Download VCT for MARA Manual - National AIDS Control Programme

Voluntary
Counseling and Testing
Training Manual
for
Most-at-Risk Adolescents
2008
ii
Voluntary Counseling and Testing
Training Manual for Most-at-Risk
Adolescents
2008
National AIDS Control Programme, Family
Health International, and UNICEF
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This training package was prepared on behalf of the National AIDS Control Programme,
UNICEF and FHI PAKISTAN by Kathleen Casey of Family Health International, Asia-Pacific
Regional Office, Bangkok.
Acknowledgements
Many individuals and organizations have contributed to the development of this HIV Counseling
for MARA Training package. Sincere thanks are due to following people for their technical input
and reviews:
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Dr. Mubarik Ali, Pakistan Society
Anne Bergenstrom, UNICEF-EAPRO
Dr Siobhan Crowley – WHO/HQ
Dr Wendy Holmes – Burnett Foundation
Kanwal Qayyum, FHI Pakistan
Dr. Nadeem Shahid, PACP Quetta
Dr. Khurram Shahzad, FHI Pakistan
Bushra Rani, Nai Zindagi, Lahore
Bettina T. Schunter, UNICEF Pakistan
Naila Tahir, Child Protection Welfare Bureau, Pakistan
We would like to acknowledge that we have used and adapted the many useful resources
provided by the Child Grief Organization. http://www.childgrief.org/suicide.htm
Cover photo: Giacomo Pirozzi/UNICEF
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Manual Contents
Introduction and How to Use the Manual
1
Guidelines for Preparation for Training
3
Sample Training Schedule
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Module 1 HIV Testing and Counselling (HTC) of Most-at-Risk Children and Adolescents
Lecture Notes
Session Plan
14
24
Module 2 Psychosocial Care - Counseling Across the Disease Continuum
Lecture Notes
Session Plan
Counseling Tools
26
38
41
Module 3 Talking about Grief, Loss and Death with MARA
Lecture Notes
Session Plan
Counseling Tools
44
57
60
Module 4 Substance Use, HIV and MARA - Special focus: Solvents and Inhalants
Lecture Notes
Session Plan
Counseling Tools
68
78
80
Module 5 MSM Sexuality and MARA Sexual Assault Survivors
Lecture Notes
Session Plan
Counseling Tools
85
92
94
Module 6 Supervision and Case Management
Lecture Notes
Session Plan
98
105
Activity sheets for all modules
107
Overhead projection masters
123
HIV Counseling for MARA Post Training Evaluation
124
PowerPoint Presentations
127
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Introduction and How to Use the Manual
Particular challenges include: the emergence of modern socially and more liberal youth
populations who are poorly informed of the attendant risks; the link between commercial sex and
the trafficking of humans; and the likelihood that rising rates of syphilis and other sexually
transmitted infections will form a bridge by which HIV can spread rapidly through sexual contact
from injecting drug users to the wider population. A number of interventions, as for example
condom use, STI control, preventing mother-to-child transmission and harm reduction among
injecting drug users, were proven effective in decreasing HIV transmission. High quality HIV
testing and counseling (HTC) not only enables and encourages people with HIV to access
appropriate care but has been demonstrated to be effective in HIV prevention. Equitable access to
HTC services should be considered a priority intervention in the fight against HIV.
There is clear evidence that HIV testing and counseling has several benefits such as: facilitating
planning for the future; orphan care; will making; acceptance and coping with one's sero status;
facilitating behavior change in sero-negative and sero-positive people thus keeping HIV negative
those who test negative; reducing mother-to-child transmission. HTC is also the platform for
facilitating early management of HIV-related infections and STI’s, identifying the need for
prophylaxis and effective/safe use of HIV antiretroviral therapies. It also enables psychosocial
support through referral to social and peer support and increases the visibility of HIV in the
communities. This fosters the enhancement of destigmatization of those with HIV/AIDS as HIV
will be seen as a problem faced by many normal people in the community. This process can
promote normal attitudes to the disease, which is known as ’normalization’ of HIV/AIDS. It is
therefore important that HTC services be made available on a much larger scale than at present.
Important Pre-requisite knowledge required for this training.
This course is not a stand-alone course:
This course assumes and builds on the training provided in the HIV Voluntary Counselling and
Testing course.
Trainees (Participants) should undertake this training prior to participation in this training to
ensure that they are familiar with the concepts and terminology and information provided therein.
Overall objectives of the training are:
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Describe the rationale to scale up HTC services for Most-at-Risk Children and
Adolescents in Pakistan
Demonstrate that HTC is an effective HIV transmission reduction strategy
Improve the technical capacity of health workers to provide HTC to most-at-risk
children and adolescents
While no training manual can be exhaustive, this package attempts to outline the key activities
and information involved in training HTC counselors. This package assumes that the trainees
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have completed the basic VCT training package and are aware of the processes and procedures
involved in VCT for adults. It is essential that trainees are provided this training prior to attending
this training.
The trainer’s manuals
The printed trainer’s manual is divided into six modules with clearly stated objectives and session
plans.
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Module 1: Testing and Counseling of MARA
Module 2: Psychosocial Care- Counseling Across the Disease Continuum
Module 3: Grief and loss counseling for MARA
Module 4: Substance Use, HIV and MARA special focus on Solvents & Inhalants
Module 5: MSM sexuality & MARA sexual assault
Module 6: Supervision and case management
The printed manual contains all the training resources. This form provides the module numbers,
the title of the sessions and the corresponding numbers of the associated:
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Session plans
PowerPoint presentations
Handouts
Case studies
Activity instructions
Counseling tools
At the end of the trainer’s manual a sample training evaluation form is also included.
The PowerPoint presentations, handouts and case studies for course participants, referred to in the
manual, can be found on the CD ROM under the various module and sub module numbers.
The participant folders
Should be organized on a module basis:
 Trainees only receive Lecture Notes, PowerPoint Handouts, and Counselor Tools.
 Activity sheets and Cases are ONLY to be handed to trainees during the activities. They
should NOT be included in the participant folders.
Disclaimer: The training programme requires supervised skills rehearsal; therefore the manual
is not suitable for use as a self-directed learning tool. You are further advised that only persons
who have successfully completed the course should use this manual. It is not recommended that
this manual be used by clinicians/trainers who have not participated in the specific training
activities - to do so may compromise the quality of training provided.
Plan of training & the time required for training
This is a 3-day training programme and builds on knowledge and information provided in the
NACP-FHI HIV Voluntary Counseling and Training Course (VCT).
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Guidelines for Preparation for Training
Important Pre-requisite knowledge required for this training.
This course assumes and builds on the training provided in the HIV Voluntary Counselling
and Testing course.
Participants should undertake this training prior to participation in this training to ensure that
they are familiar with the concepts and terminology and information provided therein.
a) Key considerations for the development and delivery of effective training
It is important to identify the combination of skills that counseling staff and supervisors will need
inThis
ordercourse
to support
each other,
so that
togetherun
the entire staff at a voluntary counseling and
builds
on prior
learning
testing site will be able to deliver high-quality services to their clients.
Making sure that supervisors also receive counseling training as well as counseling supervision
training is critical to maintaining the quality of clinical service and to strengthening the
management of the program. Supervisors must see their roles as educative and supportive (as
well as being able to provide appropriate challenge where necessary), but not interrogative.
Training for counselors should be “competency-based”, bearing in mind the realities of the field
situation. This means that before training programs can be designed, the relevant competencies
must be defined. Careful consideration must be given to the procedures which counselors should
follow and the skills they require.
The most important method in any situation depends on: the nature of the learning objectives (the
learning of facts requires different teaching methods from the learning of communication skills);
local cultural factors; and, the style of teaching which learners are familiar with and capable of
using.
Example: Even though trainees may be most familiar with lectures, this method cannot be
used to teach communication skills.
The competencies identified with regard to training in counseling depend on communication
skills. There will also be a need to develop attitudes and skills for coping with fear, anger and
embarrassment. Learning objectives in these areas are only achieved when the teaching methods
are interactive and involve the trainees in practicing communication skills and in expressing their
feelings.
Effective training of counselors always has a closely-supervised practical component.
Therefore counseling training programs should be designed in such a way that ample opportunity
is provided for this practical training both within the field and classroom settings.
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Group size
Group size for classroom counseling training should not exceed 24 participants. An ideal number
is 12-21. The smaller the group, the more quality time and opportunity is afforded for trainees to
practice their skills. As a number of group activities require splitting the trainees into groups of
threes, it is suggested that course trainee numbers are divisible by three.
Interactive training strategies
This course employs interactive training methodologies, allowing instruction, practice and
feedback to take place is crucial to address the sensitive and confidential issues discussed during
HIV pre- and post-counseling.
The methodologies include:
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Role-play exercises (including those which can be audio or videotaped);
Focused discussions;
Educational games; and,
Case-based small group learning activities.
Trainers can consider using any of the following strategies:
 Visual Aids
Visual aids can be used to highlight oral presentations or points. For examples, key points can be
noted on the blackboard and questions for debate or discussion (and responses) can be written on
the board. The use of the board in this way promotes discussion and interaction. These materials
should be clear, readable, and should not be filled with too many details.
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Equipment required for training includes:
- Whiteboard or large sheets of paper (e.g. flip chart)
- Photocopied trainees handouts arranged in a folder
- Transparencies used with an overhead projector
- PowerPoint and LCD projector
- Videotapes
- Posters/photographs
 Presentation
A presentation is used to give information. Key points can be illustrated using visual aids.
Trainers can promote interaction by:
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The use of partially individual/group exercise handouts which trainees complete,
Encouraging questions from the group following the presentation,
Group work to discuss and answer questions, or
Assigning issues or tasks to small groups.
 Rapporteur sessions
Following group discussions, the trainer can develop a list of points made which can be used to
summarize the presentation. Alternatively, the trainer can call upon a trainee to be a rapporteur
to document a list of summary points that can be derived from the use of brainstorming lessons
learned from the presentation.
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 Large Group Discussions
These should be led by the trainer and involve the whole group. The advantages of such
discussions include:
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the trainees are involved in problem-solving;
the trainees are active participants, which stimulates interest;
the learning process becomes more personal, requiring the trainer to provide feedback on
individual opinions and ideas;
the trainer is able to evaluate the trainees’ understanding and absorption of material; and
the trainees have an opportunity to share already established expertise and skills.
Large group discussions require a skilful trainer who:
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asks questions or suggests topics, maintains objectivity, and directs the discussion to keep
it relevant to the learning objective,
stresses confidentiality,
ensures that all group members have equal opportunities to participate and that no one
person (including the trainer!) dominates the discussion,
perceives and responds to differences in the group, such as skill level, education, and
comfort with the topic,
is aware of cultural and gender issues,
encourages trainees to answer questions and share expertise,
needs to be flexible if the group begins to explore other relevant issues,
is respectful and non-judgmental of the trainees’ ideas and opinions in order to allow for
open expression of concerns,
keeps to the time, leaving adequate periods for discussion,
obtains feedback and responses from the group to provide evaluation mechanisms for the
session, and,
provides an appropriate balance of supportive and challenging facilitation in which to
foster learning.
 Small Group Discussions
These are usually groups of 4 to 6. Some of the advantages of such discussions are:
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trainees have more opportunity to talk and are less likely to be embarrassed than if they
were in a large group,
the atmosphere is more conducive to a discussion of feelings,
trainees gain self-confidence through sharing information, and,
more ideas come from the group.
The trainer does not lead the group, but must be skilful in structuring the discussions so that the
trainees accomplish the stated objectives. It is important to provide clear guidelines at the
beginning of the discussion such as:
- Which topics are to be discussed?
- Will the group draw conclusions or make decisions?
- Can opinions or feelings of the trainees be shared beyond the small group?
- Will the group be expected to report its discussions to the larger group?
- How much time does the group have?
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The trainer may also ask the group to appoint a facilitator and a rapporteur. Small group
discussions and/or work with pairs should be followed by a large group discussion so that general
conclusions can be drawn.
 Working in pairs
Working in pairs can also be effective when in-depth sharing or analysis of particularly personal
or sensitive issues is required. Individuals may feel freer to disclose their attitudes and opinions
with one trainee rather than within the larger group.
 Role-play
Role-play can be organized to play the parts of identified people and act out a scene. This is
useful when practicing skills such as counseling, and for exploring how people react in specific
situations. Role-play has the following advantages:
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allows for safe rehearsal of skills and activities and provides practical preparation for
genuine situations,
the trainees are able to experience activities and to relate theory to practice,
allows for full expression and interpretation of concepts.
Some individuals may feel intimidated by role-playing. The trainer must be skilful in ensuring
they are relaxed and should:
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keep the role-play appropriate to the learning context,
emphasize that the characters are “in role” and that group observers are looking at the
character and their reactions, not the individual people playing them.
Implementing role-plays
Ideally, role-plays should be arranged by dividing trainees into triads. Each triad should
nominate a “counselor”, a “client” and an “observer”. Trainees should be rotated between these
three roles so that they have an opportunity to experience each role. Accordingly there should be
three rounds of cases with one case being conducted per round.
The trainer should only hand the cases to the trainees who are playing a client. Counselors and
observers should not be permitted to read the cases. The trainer should inform clients that they do
not wish them to share the cases with either counselors or observers in order to make the roleplay as realistic as possible.
Counselors are to practice applying the knowledge and skills learned through the lectures and
other activities by completing the nominated task. If during the role-play they become confused
or uncertain they should be instructed to refer to their notes, review their material and
recommence when ready. They should not ask for assistance from their client or observer. If
necessary, they should be instructed to put up their hand for assistance from a facilitator. At the
conclusion of the role-play the counselor should discuss what they were happy with in their
practice and what things they would have liked to have done differently.
Clients are to play the role of the case outlined in the case study. They should attempt to allow
the counselor to practice obtaining the information rather than simply reading out what is written
in the case study. Facilitators should instruct the clients to inform the counselor if they are roleplaying a person of different gender e.g. if a trainee is female and playing a male client she should
inform the counselor that she is a male client. Clients should provide feedback to the counselor at
the conclusion of the role-play.
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Observers are to observe the process of the role-play and provide feedback to the counselor at the
conclusion of the role-play. Observers should be asked to first give positive feedback and then
constructive criticism. This helps to increase confidence and avoids discontent between trainees.
Facilitators should remind observers that they are not to interrupt the role-play.
Five minutes should be allowed at the conclusion of each round for discussion and feedback
within the triad.
This is to be followed by requesting the class to form three small groups. One small group should
comprise all the trainees who played counselors for that round, another group should comprise all
the trainees who played clients and another group should comprise all the trainees who played
observers.
A facilitator should be allocated to debrief each small group. One facilitator will debrief the
counselors, one facilitator will debrief the clients and one facilitator will debrief the observers.
The small group facilitators should ask the trainees to share their role-play experiences
and guide the discussion to the following three questions:
i.
ii.
iii.
What made clients feel comfortable?
What micro skills were particularly important for the counselor to employ?
How did counselors manage to balance provision of information with being
responsive to the needs of the client’s emotions?
The small group debriefing should last no longer than 10 minutes each round.
Trainees should then return to their triads and swap roles. Different case studies should then be
provided to the trainees who swap to being counselors.
If only one or two facilitators are available then the debriefing should be performed as one large
group following each round. Following the triads debriefing each other, the trainees should be
asked to return to one large group. Trainees should be asked to share their role-play experiences
and discussion should focus on the three questions above.
Finally, it is important to remind the trainees that they are in the process of learning. Whilst they
may feel overwhelmed at the beginning, each time they use the knowledge and skills they are
acquiring they will become more confident and improve their abilities.
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Overview of role-play process:
Trainees divide into triads
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Each triad nominates a “counselor”, a “client” and an “observer”
Each round
Clients receive case study Case 1 round one Case 2 round 2 case 3 round 3
Conduct the role-play exercise
Debrief within the triad for 5 minutes
Debrief within small groups of counselors, clients and observers for 10 minutes
- What made clients feel comfortable?
- What micro skills were particularly important for the counselor to employ?
- How did counselors manage to balance provision of information with being responsive to the
needs of the client’s emotions?
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Trainees should then return to their triads and swap roles for rounds 2 and three.
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Counselors should become observers
Observers should become clients
Clients should become counselors
 Case Studies
The case studies are designed to give counseling trainees an understanding of the effect of HIV
infection on the individual, and to enable them to deal with problems they may encounter in the
practice setting. The trainers need to develop case studies that are specific to the local setting.
Where included, case studies are located in the session plan for each individual sub-module; some
of these are followed by a discussion of key points pertaining to the case study. Case studies for
printing and providing to trainees are found in a separate section of this trainer’s manual.
The case studies provide a detailed description of an event, different characters and settings. The
case studies may be followed by a series of questions that will challenge the trainees to discuss
the positive and negative aspects of the event.
The case studies prepared for use in the Individual Pre HIV test counseling sessions should not
be included in the participant folders. They have been designed to be handed out to the trainees
during the activities. (Refer to the Session Plan).
Trainees who role-play “counselors” in these activities should not see the cases prior to the
commencement of the activities. This will ensure that the “counselor” gains experience in
acquiring information from “clients”. In “real life” situations clients do not send all their details
to the counselor in advance; rather the counselor uses their counseling micro-skills to gain
information from the client. Conducting role-plays in this way ensures training approximates real
life situations.
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The advantages of case studies are that they allow an examination of a real or simulated problem
that mirrors the outside world and allows trainers to develop confidence and problem solving
skills.
 External trainers/Guest speakers
Use of a range of external trainers or guest speakers presents both advantages and disadvantages.
Some of the advantages include:
 Trainees have access to “experts” in their respective fields
 Trainees establish important linkages to external individuals and agencies that will assist
them in their clinical work
 External presenters add variety to the programme of regular trainers.
Some of the disadvantages of using external trainers or guest speakers include:
 When inadequately briefed, speakers may launch in to their standard lecture response
 Speakers may present non evidence based or erroneous information
 Speakers may pitch their presentation inappropriately in terms of language used and
target audience
 Some speakers may be uncomfortable with the use of more interactive learning
methodologies
 Speakers may not adhere to the time frame provided.
To maximize the use of external trainers or guest speakers:
 Ensure they are adequately briefed, verbally as well as in writing, in terms of what is
expected of them. Provide a guideline that specifies the content to be covered, the
style of methodology to be used, the level and type of language, and the timeframe by
which to adhere. In addition, clearly describe the type of trainees they are working
with and the overall aims of the training programme.
 Choose speakers who are known to be effective for your goals. Alternatively,
“groom” them to attain the desired outcome.
 Ensure that the regular trainer remains present where possible whilst the external
speaker presents. This ensures continuity if there are any issues arising. In addition,
regular trainers are also able to thus observe and provide useful feedback to the
external trainer/guest speaker.
 Always ensure that external trainers/guest speakers are given feedback from both the
organization and trainee evaluations in order to continue to improve their sessions.
b) Assessing knowledge levels
Prior to the training sessions, the trainees’ knowledge of HIV/STDs and the counseling process
should be assessed with Pre-test using objective questions. This information can be used to tailor
the training sessions to the understanding of the trainees. After the sessions are completed, these
same questions can be used to determine how much trainees have learned and how effective the
training has been. For populations that are not familiar with questionnaires or where some of the
trainees may be illiterate, focus groups may also be utilized to assess knowledge levels.
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c) Assuring quality
However, for these training sessions to be successful, the trainees must use this knowledge in the
actual counseling setting. Consequently, it is important to observe whether the guidelines are
implemented in the actual practice situation to assure the quality of the service to the client.
d) Checklist of what is needed for the Training (Supplies and Space)
Sample Checklist of Materials/Advance Preparation
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Timetable
Room
Adequate seating
Personnel (trainers, resource persons, administrative support)
Participant notebooks and pens
Flipchart paper and stand
Markers
“Sticky stuff”/cello tape
Newsprint/handouts
Manuals/resource books
Copies of activity sheets have been made to hand out to each trainee
Overheads
Overhead projector and markers
Box for collecting written questions trainees have felt unable to ask
Box for collecting evaluation forms
Condoms (allow two per trainee)
Penis and vagina models for condom demonstrations
Male and female dolls
Colored pencils & crayons
Magazines for cutting out pictures – collage and art work
Injecting equipment ( needle, syringe, two small bowls, red food coloring and water)
e) Key considerations for ensuring successful training

Ensure that the Training Materials Outline is close at hand for easy reference. This
can avoid using the wrong handouts or case studies for accompanying presentations.

All trainees must be present for the ENTIRE training. It is suggested that certificates
are not provided to trainees who do not attend the entire course. In the event of an
emergency arising and trainee cannot complete the course, the trainer should negotiate
with the trainee to complete the missed segments at a future course and then obtain the
certificate. Note this is critical to ensuring quality of counseling. If a trainee misses any
segments, the trainer should brief the trainee when they return about what they have
missed. This will ensure that they do not disadvantage their role-playing partner when
they do role plays or other activities.
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Ensure training sessions commence on time. Request all trainees should arrive on
time. There is much material to be covered each day, and it can be very disruptive to
have trainees arrive at the training sessions once the sessions have already begun.

Discussion of sensitive issues. Trainers must recognize that discussions of sex, sexuality,
HIV and STI’s can be difficult. It is important for trainers to make a statement about this
potential discomfort to trainees at the commencement of the course and invite the course
trainees to discuss their concerns with you on an individual basis. The training group
must respect a trainee decision to pass on a specific question or activity.

Encourage trainee to use the question box. Questions of a sensitive nature can be
written down on a piece of paper and placed into the question box. The questions shall be
drawn out at the end of each day and discussed during the “Question and answer” session
before the close of the day.
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It is important to maintain confidentiality at all times, especially if counselor trainees
refer to their own personal experiences or those of their clients. Trainers are urged to ask
trainees to all agree to maintain the confidentiality of all fellow trainees.

Encourage trainees to respect individual differences. Trainees frequently come from
different ethnic and cultural and lifestyles, beliefs, personal experiences and expertise.
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Encourage trainees to listen carefully and with empathy, and respect to each other’s
contributions, opinions, and experiences. Explain that it is important in the training,
and as professionals, to practice active listening by allowing each other to share their own
experiences and opinions with the group.
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Create an environment in which each participant feels comfortable asking
questions. Trainees need to be able to ask questions about what they do not understand.
Again the Question box can be a useful tool.
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Due to the constant change in transmission patterns, treatment, perceptions and
attitudes etc, trainees should be reminded to consistently update their information
regarding HIV and AIDS. As providers, it is important that we keep abreast of changing
information. With the latest information, resources and treatments available, we can
provide better services to our clients.
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Ensure you get the right trainees. Establish clear criteria for participation and
communicate these criteria to not only the trainees but also their employers.

Ensure an evaluation form is distributed to trainees at the end of every session.
These need to be completed by the trainees and placed in the ‘Evaluation Box’ to be
collected by the trainer once all forms have been submitted. These evaluation forms can
help provide valuable feedback to the trainer about their styles, presentation skills and
apparent knowledge of the subject area.
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Consider the advantages of providing meals to the trainees. The training course
follows a very strict timetable. It is therefore essential that the sessions commence and
conclude at the nominated times. The provision of morning tea, lunch and afternoon tea
at the site of the training has the advantage of ensuring all trainees promptly return from
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breaks. It also creates flexibility within the program should there be a need to shorten
breaks or complete work within a break. Further, it tends to contribute to the general
satisfaction of trainees and allows them to focus on the material being learned to a greater
degree.
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Sample Training Schedule
Sample 3 day schedule
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This course assumes trainees have completed the VCT course.
The schedule assumes strict adherence to the specified break times: 15 minutes each for
morning tea and afternoon tea; 1 hour for lunch.
Day 1
08:00
08:15
08:15
10:15
Welcome and registration
HIV Testing and Counseling (HTC) of Most-at-Risk children and adolescents
–Module 1
Lecture and role plays
10:15
10.30
10:30
13.00
Break
13:00
14:00
16.30
16:45
14:00
16:30
16.45
17.45
HIV Testing and Counseling (HTC) of Most-at-Risk children and adolescents
–Module 1
Role plays and review
Lunch
Across the disease continuum – Module 2
Afternoon Tea
Across the disease continuum – Module 2
Day 2
8:30
10:30
10.45
11:45
12:45
13:45
10:30
10:45
11.45
12:45
13:45
15:45
15:45
16:00
16:00
17:20
Grief and loss counseling for MARA Module 3
Break
Grief and loss counseling for MARA Module 3
Substance Use, HIV and MARA special focus on Solvents & Inhalants - Module 4
Lunch
Substance Use, HIV and MARA special focus on Solvents & Inhalants Module 4
Afternoon tea
MSM sexuality & MARA sexual assault - Module 5
Day 3
8:30
10:30
10:45
12:30
13:30
15:45
16:00
16:45
10:30
10:45
12:30
13:30
15:30
16:00
16:45
17.30
MSM sexuality & MARA sexual assault - Module 5 continued
Break
Supervision and Case management – Module 6
Lunch
Supervision and Case management – Module 6
Afternoon tea
Conclusions & Next steps
Certificates
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MODULE 1: Lecture Notes
HIV Testing and Counselling (HTC) of Most-at-Risk Children and Adolescents
Session Objectives:
At the end of the training session, trainees will be able to:
 Review of HIV diagnosis in Infants;
 Review of PPTCT counseling with focus on MARA;
 Demonstrate an understanding of the key principles and processes for counseling
children and adolescents
Every day nearly 1,500 new HIV infections occur among children under 15 years of age i. In
South and South-East Asia, an estimated 140,000 children between 0-14 years of age were
infected with HIV as of 2007.ii About 90 per cent of infections in children are associated with
parentiii-to-child transmission, which can occur in utero, during delivery, or after birth during
breastfeeding. The transmission mode for the remaining 10 per cent of HIV infections in children
includes injecting drug use or sexual activity, sexual abuse or, occasionally, via blood transfusion.
As the HIV epidemics continue to grow in most parts of the world, the HIV infection rate among
children is also increasing. Without antiretroviral treatment the majority of HIV infected children
will die within two years of life.iv However, if provided with pediatric treatment the length and
quality of life of HIV-infected children can be significantly increased. In one cohort in Thailand,
50 percent of HIV infected children on ARVs were still alive at age five.v While in 2005 some
35,000 HIV positive children were in need of antiretroviral treatment only less than one per cent
were receiving it. At present, children comprise of only an estimated four per cent of people in
treatment in Asia.vi
One of the reasons for limited access to pediatric treatment in resource-limited countries is lack of
access to infant and child testing diagnostic services. Some reasons for lack of early diagnosis of
HIV infection in infants and children in resource-limited countries include:




Poor follow up of infants exposed to HIV through maternal HIV infection resulting in
limited rate of diagnosis of HIV in HIV exposed infants.
Complex or costly diagnostic protocols for HIV testing in infants.
Higher cost and expertise required to perform tests that can reliably detect infection in
infants and children aged less than 18 months.
Health system requirements for specimen collection and transport to referral laboratories,
which deter programmes from establishing services to ensure early diagnosis of HIV
infection.
In addition, there is a lack of specifically trained child counselors and psychologists in Pakistan.
There is a need for significant scaling up of access to counseling and testing services for infants
and children in order to enable more children to benefit from antiretroviral treatment, care and
support, and thus increased quality of life. Most-At-Risk Young children and infants are unlikely
to seek counseling and testing for HIV and are more likely to be counseled and tested as a result
14
of provider initiated or caretaker initiated testing process. Given this context, issues of informed
consent and rights-based approach are of particular importance. In general, testing of infants and
children occurs in a number of specific circumstances, including:





After birth for early diagnosis of HIV
Diagnosis of an ill infant or child
In cases where the child has been, or potentially exposed to HIV through:
o Parent (Mother)-to-child transmission
o Sexual activity
o Injecting drug use
o Sexual abuse or rape
o Exposure within a health care setting (e.g. contaminated needle stick injury, or
receipt of potentially infectious blood)
Upon admission to an orphanage, drug rehabilitation centre, or other such institution
Children living or working on the streets
Early diagnosis of infants and young children has the following potential advantages:







Early identification, and access of, HIV-infected infants and children to optimal
treatment, care and support
Access to information and services to prolong life, for example by improving nutrition
and taking exercise
Facilitates decision-making regarding infant feeding
Eliminates anxiety and stress of parents of HIV negative infants, and among HIV positive
children relief of knowing the truth rather than being worried about the unknown
Reduces potential stigma, discrimination and psychological distress among those
diagnosed HIV negative
Facilitates life-planning for parents and/or children who are HIV-infected
Among older children who are HIV positive, facilitates understanding of the importance
of prevention further transmission, including practice of safe behaviors to avoid infecting
others
HIV testing of children, who are HIV positive, may have the following disadvantages:



2.
Not fully understanding the situation, or only understanding the negative implications
Disclosing their status without being aware of the possible negative ramifications, such as
stigma and discrimination
Feelings of anger, resentment, anxiety, hopelessness and depression
Diagnosis of HIV in children under 18 months
Maternal antibodies may be present in the neonate for up to 18 months. Therefore, children born
to HIV infected mother may test sero positive when tested with ELISA or simple / rapid testing,
however, it does not necessarily mean that they are HIV infected. Because of the possible
presence of maternal antibodies for up to 18 months of age serological assays used for HIV
diagnosis in adults are not reliable for diagnosis of HIV in infants under 18 months of age. While
maternal antibodies can persist as long as 18 months usually they clear by 9-12 months. HIV
diagnosis can be confirmed at 18 months of age. Under the age of 18 months virological testing
(PCR) is the required method of diagnosis of HIV infection in infants. Virological testing can be
conducted at any time from 6 weeks of age, with > 98 per cent sensitivity. Performance of one
15
early virological detection test at six weeks of HIV exposed children will identify the majority of
children infected prior, during or after delivery, and enable them to go onto ART.
Available laboratory based HIV diagnostic methods for detecting HIV in infants and children
include:
1. HIV DNA Polymerase chain reaction (PCR) for diagnosis in infants < 18 months of age
2. HIV RNA assays (PCR and other nucleic acid detection techniques) for diagnosis in
infants < 18 months of age
3. Ultra sensitive ICD p24 antigen, in infants between 9-18 months of age
4. HIV Antibody Test (ELISA), for infants between 9-18 months of age. A negative test
during 9-18 months suggests absence of HIV, while a positive result in infants aged 9-12
months or older usually indicates HIV infection.
Both DNA and RNA technologies are relatively complex and expensive methods which require
equipment, space and trained technicians. However, HIV RNA assays are increasingly becoming
available commercially and for HIV DNA PCR standardized equipment is commercially
available. The HIV Antibody Test is inexpensive and increasingly available.
Occasionally a clinician may suggest testing of a symptomatic child to help with medical
management. The possibility of a sero positive diagnosis in an infant or young child may be the
first indication of HIV sero positivity in the mother and/or father and siblings(s). If the infant tests
positive, it is almost inevitable that the mother is also HIV positive and that the father will also be
infected. It also raises the possibility that a sibling(s) may be HIV infected. Occasionally,
parent(s) may refuse HIV testing of infants based on this reason or other related reasons.
3.
Legal and ethical considerations in testing infants and children
The Convention on the Rights of the Child (CRC) provides an important framework which guides
HIV and AIDS prevention, treatment, care and support responses for children. The CRC states
that counseling and testing is “fundamental to the rights and health of children” and should be
made accessible along with protection of their rights. The provision of counseling and testing
should follow a rights-based approach grounded in the principles of consent, counseling and
confidentiality. HIV testing of infants and children should only be supported when it is in the best
interests of the child. The potential benefits and harms associated with testing of a child should be
balanced, along with the reasons for the request or suggestion for testing.
The participants need to be aware of the following considerations in the context of testing infants
and young children include:
 Under what circumstances is testing of infants and young children conducive and to
whom?
 Once the results are known, how and what benefits are available for the infant or child
who tests HIV positive
 How will the knowledge of HIV positive sero status be used to ensure access to care and
support for the infant or child?
 Role of health care providers and counselors in supporting parents / guardians through
16
Consent and confidentiality
In general, HIV testing should only be conducted once an individual is informed of the benefits
and risks and voluntarily agrees to test.vii Children in general, and under 10 years in particular,
present special circumstances for seeking consent, both of which may be affected by national
policies, provider judgment and the maturity of the child. Though parents and guardians
frequently give consent for medical procedures, including HIV testing, on behalf of their children,
children have a right to “participate in decisions affecting his or her life”.viii Mandatory testing of
children should not be undertaken in any circumstances and HIV testing or HIV status must not
be used to deny access to education, health care or housing.
The age of consent when a child or adolescent can consent to testing without parental / guardian
permission varies from one country to another. While most countries have national laws and
policies related to counseling and testing for adults, most laws and policies are unclear or
ambiguous about HIV testing of minors, in particular about whom is authorized to give informed
consent and under what conditions. At times, they contradict age of consent for marriage,
termination of pregnancy or voting rights. Laws and policies on consent do not often give
consenting rights to informational caretakers or medical staff, an issue in terms of HIV testing in
case of orphans, abandoned infants and street children.
Counselors should be aware that the age of consent is a contentious issue that frequently
confounds the provision of counseling and testing and care and support for children
The Convention on the Rights of a Child grants every child has the right to have his / her privacy
respected. In context of HIV testing, every child has a right to have his / her HIV test result
maintained confidential. Furthermore, “information on the HIV status of children may not be
disclosed to third parties, including parents, without their consent”.ix Counselors, along with other
health care providers must be clear about the national laws and policies on counseling and testing
of children, and about whom, when and how best to inform or disclose a child’s HIV status.
Summary of key policy and legal issues for Pakistan– VCT and minors
(1) Voluntary written informed consent shall be obtained on a prescribed form before any
HIV screening or pre-test counselling is undertaken.
(2) The informed consent in writing may be given by using a coded system.
(3) No persons, including children, should be screened for HIV when they are lodged in a
governmental establishment, including but not limited to, a crisis centre, an orphanage,
darul aman, or similar other centres and facilities.
(4) The age of consent for HIV testing will be eighteen years. Children under this age will
need the consent of their parents or guardians. In special cases, children living
independently, who are not in contact with parents and who do not have a guardian, will
be able to consent for HIV testing after they have been provided with age-sensitive
information and counselling.
Source: Page 27 of the document „THE HIV & AIDS PREVENTION, AND TREATMENT ACT,
Draft 2007"
17
4.
Counseling children
Counseling must be available for any child undergoing HIV testing, including post-test
counseling for the child and the parent(s) / caretaker(s). Counseling children infected or affected
by HIV and AIDS requires the following skills:
 Assessing maturity for understanding benefits and risks of testing and for providing
consent
 Age-appropriate communication
 Disclosure
 How to inform a child of his / her HIV status
 Counseling for adherence of HIV medication
 Talking to children about death
 Assessment of sexual abuse and rape
 Parent / caretaker counseling
 Ongoing psychosocial counseling
Counseling children involves:
 Creating a friendly and private environment
 Establishing a relationship with children and gaining their confidence and trust
 Helping children to tell their story
 Listening to children in an active manner
 Giving children correct and appropriate information at his / her level of development
 Recognizing that the HIV test may raise different issues for children of different ages
 Giving honest answers without hiding information, even if difficult
 Helping children to make decisions
 Preparing older children and adolescents for safe sexual (and/or injecting practices), to
prevent co-infection with another strain of HIV, and onwards transmission of HIV to
their sexual or injecting partners
 Helping children to recognize and build on their strengths and to develop a positive
attitude towards life
The foundation for a relationship between a counselor and a child is good communication.
Children should never be forced to tell their “story” and there may be good reasons for when
children cannot communicate about something. In order for a counselor to help children to
communicate freely they can use one or more of the following creative and non-threatening tools:




Drawing
Storytelling
Drama and role-plays
Plays
18
Creating a child friendly environment

Create boundaries of safety.
-You can give an approximate time to the child about how long the session will last.
-If the parents/guardians are not in the room, inform the child exactly where the
parents/guardians will be. Show the child where they are sitting.
-Whatever you want to tell me (the counsellor) you can. I will not discuss what we
talk about with your parents unless you give me permission or the law requires me
too. The only time that rule changes is if you hurt yourself or tell me that you want
to kill yourself, then I will speak to your parents/guardian so that we can help you
-The child is informed that this is “a safe place”. That this is a place where the child
can relax, talk, and play. For the counsellor, the rule is that the counsellor cannot hurt
the child, and the child cannot hurt the counsellor.
5.

Focus on the child. Show an interest in their life and their daily activities. Be curious.
Appreciate who they are. Find the uniqueness in each child. Find out what is
interesting or special about each child that you see.

Have toys and objects that the child likes and that are age appropriate. (See appendix
for a sample playroom) Have toys and objects that will help you illustrate your
discussion about HIV and what will happen during an HIV test.

Use age appropriate language

Be calm and unhurried. Follow the child’s lead. What they want to talk about and do
you encourage it, as long as it is not destructive or dangerous. Then you can bring
them back to the main topic if they are not talking about it or showing it in their play.
Counseling of parents / guardians as part of HIV diagnosis
Many MARA will not have had recent contact with parents or families; others will be having
some form of either regular/irregular contact.
The majority of HIV infected infants and young children acquired HIV from the mother. In view
of this it is pertinent to cover the following issues with parent(s) of infants born to HIV positive
mothers:
o
o
o
o
o
o
o
o
Information and referral to ARV treatment
Information on infant feeding options and the benefits and risks of breastfeeding
Information on family planning methods, safer sex, including condom use to prevent HIV
and STI transmission
Information on safer injecting practices, among those who disclose injecting drug use
Parent(s) anxieties, fears and coping mechanisms
Support mechanisms and potential for shared confidentiality
Information about infant diagnosis for HIV, and pediatric treatment options
Disclosure issues for the mother, including disclosure to spouse and/or significant others
19
o
o
Information and referral to care and support services for the mother, infant and partner
Planning for future, including emotional, spiritual, financial and legal support
Where the child is under guardianship then some of these issues should be addressed with the
guardian and substitute carers.
6.
Infant feeding counseling1
Most-at-risk HIV infected pregnant women need information and advice to help them to make an
informed decision about whether to breastfeed or not. Special advice should be sought in
relationship to infant feeding in the context of substance use. Aside from HIV transmission risks,
many substances can be transmitted to the infant.
They need help to assess and weigh up the risks to their baby in their particular circumstances.
Then they need support so that they feel confident about their decision, and advice about how to
feed their baby as safely as possible. To be able to do this, counselors need careful training in
both lactation management and issues related to HIV and infant feeding. Training materials for
HIV and infant feeding counseling are available from WHO and UNICEF.
Weighing the risks has been difficult in resource-poor settings because we know little about the
safety, affordability and practical problems associated with alternatives to breastfeeding. This,
and the difficulty in studying the timing of transmission of HIV from mother to baby, have made
it very difficult for policy makers to develop clear and consistent guidelines.
In a counseling session on HIV and infant feeding the counselor has three main tasks:
 To convey information
 To help a mother to assess the risks for her baby in her own situation
 To give the mother confidence in her choices
A locally appropriate checklist can help with these tasks.
Counseling about HIV and infant feeding choices is likely to need more than one session. The
post-test counseling session is not a good time to talk about infant feeding decisions. A woman
does not need to make all decisions about how she will feed her baby at the first session. She
might want to discuss the decision with her husband, other family members or a friend. While
she is pregnant she needs to decide whether she will breastfeed at all or not. But she does not
need to decide when she will stop breastfeeding until later. She does not need information about
safe weaning foods until the baby is older. However it is best to mention that it is important to
ask about these issues later.
Begin by explaining the purpose of the discussion. The counselor should present the benefits of
breastfeeding on the one hand, and the risk of HIV infection through breastfeeding on the other,
and explain that there are ways to lower the risks. At this point the counselor could ask the
mother what option she would like to talk about first. The counselor needs to pause often to check
whether the mother understands and has any questions. She should not continue to give
information to a woman who is upset or very anxious. She should listen to what is troubling her
and empathize. She can tell her that she can make the decision later so that she does not feel
under pressure.
1
This material was sourced from Dr Wendy Holmes, Burnett Institute, Australia.
20
Weighing the risks
The idea of weighing up risks can be difficult for a woman to understand. Her choice is not a
simple one of deciding whether the risk of death for her baby is greater if she breastfeeds than if
she does not. Her decision will be influenced by many factors. Some she may tell the counselor;
some she may keep private. For example, the woman may know that at home she will not be able
to replacement feed exclusively. For this reason it is important that the woman makes the decision
and not the counselor.
Q.
What do we mean by the terms acceptable, feasible, affordable, sustainable
and safe?
A.
To help the woman to decide whether she will breastfeed or not the counselor can ask
her to consider whether replacement feeding will be:
 Affordable?
Can her family afford to pay for replacement feeding? What will be the effect on the family
budget? Babies need 40 x 500gm tins of commercial infant formula for six months. Home-made
formula (see slide 19) will require 92 liters of animal milk in the first six months. A lactating
woman needs an extra 500 calories a day – so breastfeeding is not without cost – but it is much
cheaper than providing a substitute.
 Sustainable?
Will the family continue to be able to afford adequate replacement feeding for at least six
months? Will formula or animal milk continue to be available and accessible without
interruption?
 Feasible?
Will the mother have the time, space and fuel to prepare replacement feeds at home, during the
day, and at night? How will she cope when she is traveling or working? Is there anyone who
will be able to help her to feed the baby?
 Acceptable?
What will her husband; mother-in-law, other relatives, friends and neighbors say if she does not
breastfeed? How will she feel herself if she does not breastfeed? Breastfeeding is highly valued
and is regarded as an important part of mothering by the whole community. Women may find it
very difficult not to breastfeed. Girls grow up expecting and looking forward to breastfeeding, a
source of pleasure for the mother as well as the baby. A woman who does not breastfeed may
meet with frequent social disapproval for not breastfeeding her baby. People may start to
associate replacement feeding with HIV infection, so the woman and her family may be
stigmatized for this reason. But if the woman who decides to give replacement feeds also
breastfeeds sometimes, she is likely to increase the risk of both HIV transmission and diarrhoeal
disease.
21
 Safe?
Will replacement feeds prepared by the mother be free of contamination and nutritious? Does she
have access to clean water? Is the formula or milk she can obtain of good quality? Is she able to
store milk safely? If the woman believes that replacement feeding will not be affordable,
feasible, acceptable, sustainable and safe it is best for her to choose to breastfeed. Reassure her
that there are ways to minimize the risk of transmission of HIV through breastfeeding.
Q.
A.
What advice should we give an HIV positive woman who wants to
breastfeed about how to do so more safely?
There are four things she can do to breastfeed more safely:
 Exclusive breastfeeding protects the baby against infections and may have a lower
risk of HIV infection than mixed feeding.
 Breast problems, such as mastitis or breast abscess, increase the risk of HIV
infection for the baby. Early, frequent suckling, good attachment, and feeding the
baby on demand help to prevent breast problems.
 The baby might become infected with HIV at any time during the months of
breastfeeding. The baby benefits from breastfeeding most in the first few months.
The mother might consider stopping breastfeeding early to lower the risk of HIV
infection.
 The risk of transmission of HIV to the baby will be lower if the mother cares for
her own health when breastfeeding. Poor nutrition and new infections increase the
amount of HIV in the blood. The husband also needs to know that his wife needs
good food, rest and to be protected from STI.
We can also explain that although we know that mixed feeding carries a risk of HIV
infection, the risk for a baby who breastfeeds exclusively for up to six months and
then stops breast feeding, may be no higher than for a baby who is never breastfed at
all.
i
WHO. 2006. Recommendations on the diagnosis of HIV infection in infants and children. Draft
for public review (ver 6), July 2006.
ii
UNAIDS 2008 Report on the Global AIDS Epidemic
iii
In Pakistan the term “Parent to Child Transmission” is used preferably over Mother to Child
Transmission to be culturally more sensitive: the blame should not be given to mothers since
mostly women are married in Pakistan and contract HIV from the husbands.
iv
Newell, M.L., Coovadia, H., Cortina-Borja, M., Rollins, N., Gaillard, P., Dabid, F. (2004).
Mortality of infected and uninfected infants born to HIV-infected mothers in Africa: a pooled
analysis. Lancet, 364 (9441). 1236-1243.
v
Tim Brown & Neff Walker. Satellite Session on Establishing Effective Responses for
Children Affected by HIV/AIDS in Asia 7th ICAAP, Kobe, Japan July 3, 2005
vi
WHO. Early Detection of HIV Infection in Infants and Children. Guidance note for
development of round 6 GFATM proposals and the Technical Review Panel to direct gap analysis
and consideration of options for selection of technology for early diagnosis of HIV in infants in
resource-limited settings.
22
vii
UNAIDS & WHO (2004). UNAIDS/WHO policy statement on HIV testing.
FHI. 2001. Voluntary counseling and testing: a reference guide – responding to the needs of
young people, children, pregnant women and their partners.
ix
UN. 2003. Convention on the rights of the child general comment no. 3: HIV/AIDS and the
rights of the child.
viii
23
MODULE 1: Session plan
HIV Testing and Counselling (HTC) of Most-at-Risk Children and Adolescents
Session objectives:
After participating in this session trainees will be able to:
 Discuss the specialized testing procedures required to diagnose infants;
 Provide advice related to Counseling for PPTCT for MARA;
 Demonstrate an understanding of how to adapt adult Pre and Post HIV test
counseling to the needs of MARA.
Time to complete module: 4 1/2 hours
Training materials
Activity sheet (AS01)
Activity sheet – Cases (AS01.1) – handed out during activity
PPT 01, LCD projector
PPT01 – Printed in Handout view distributed in participant folders.
Lecture Notes (LN 01) - distributed in participant folders.
Content
Diagnosis of HIV in infants
HIV Testing and Counseling Consent issues for minors
Review of PPTCT counseling with focus on MARA
Adapting adult HCT processes and procedures to MARA
Session instructions
1. Commence by explaining to participants that we will need to adapt the processes and
procedures that we employ for testing adults to the context of testing MARA.
24
2. Ask the class to consider standard VCT _ Pre-test counseling and ask them what they feel
would need to be changed to meet the needs of this population{ Answers to include:
issues such as process for obtaining consent, simplified explanations of medical
information, use of different counseling micro-skills e.g., sitting on the floor with child
clients, using drawings, dolls etc to assist the child understand health information related
to their body etc
3. Ask the class to again consider what may be the challenges they would encounter doing
HIV post test counseling with MARA {Answer to include: difficulties informing a child
or their parents/guardians they are HIV positive, unattached minors without emotional,
social or financial support requiring follow-up treatment and care; issues related to
disclosure to families etc}.
4. Lecture using the PowerPoint presentation until you reach the activity. Ensure you
actively involve the trainees, and check for understanding by directing questions
randomly to class members.
5. Activity Instructions
 Divide the class into groups of threes (triads) – handout to each trainee Activity sheet
(AS 01). Ask them to read the activity sheet.
 Call all of the Round 1 “clients” to the front of the room and hand out Case Study 1.
Remind them not to show the case to either the observer or counselor.
 Follow the following pattern.
Trainees divide into triads

Each triad nominates a “counselor”, a “client” and an “observer”
Each round
Clients receive case study (round 1=Case 1; Round 2=Case 2; Round 3=Case3)
Conduct the role-play exercise 30 minutes
Debrief within the triad for 10 minutes
Debrief within small groups of counselors, clients and observers for 15 minutes. Each of these
groups should be facilitated by a co-trainer.
iv.
What are the key counseling issues for the client?
v.
What micro skills were particularly important for the counselor to employ?
vi.
How did counselors manage to balance provision of information with being
responsive to the needs of the client’s emotions?
vii.
How would you adapt adult VCT to the needs of this client?

Trainees should then return to their triads and swap roles.
-
Counselors should become observers
Observers should become clients
Clients should become counselors
At the conclusion of the session summarize the key points covered in the session. This may be
done by asking the trainees what they consider the key point addressed in the session.
25
MODULE 2: Lecture Notes
Psychosocial Care - Counselling Across the Disease Continuum
Session objectives:
At the end of the training session, trainees will be able to:
 Identify common psychosocial issues of MARA living with HIV
 Identify the link between VCT and post-diagnosis psychosocial care
 Develop a psychosocial care plan for MARA clients
HIV disease is not only a medical issue, but a psychosocial one as well. Infection and the
subsequent progression of this disease present the client with a broad range of personal
experiences to negotiate. The changes in the health of people with HIV disease progress demand
constant behavioral and psychological adaptation. People living with HIV (PLHIV) develop new
patterns of coping as the disease changes. At the same time, the person's condition may trigger a
variety of reactions from others such as family members, significant others, employers, coworkers, and rehabilitation counselors and other helping professionals. It is these psychosocial
issues that will be addressed in the following pages. It is very important for counselors to
understand the underlying psychosocial issues and stages of HIV disease and AIDS to provide the
most effective services possible. Before proceeding with this module, it is important that
rehabilitation counselors and other personnel be familiar with the medical stages of HIV disease.
The World Health Organization (the WHO) Staging System is an effective way to monitor HIV
progression.
You have covered this in your VCT training, however by way of review, you should recall that
the medical stages include the following: Acute/Primary; Early Stage (Chronic) Asymptomatic;
Early to Middle Stage Symptomatic; Advanced HIV; Late Stage Disease.
HIV-ASSOCIATED
SYMPTOMS
Asymptomatic
Mild symptoms
Advanced symptoms
Severe symptoms
WHO CLINICAL
STAGE
1
2
3
4
Early Stage (Chronic) Asymptomatic
Once the HIV virus enters the individual’s body it infects and commences replication within the
body’s immune system (CD4 T cells and macrophages). The immune system then produces
antibodies specific to HIV in an attempt to defend the body against the HIV infection. This
period is commonly referred to the “window period” and can last for between 2-12 weeks.
During this period the individual is highly infectious however the antibody tests designed to
detect the virus may fail to detect an antibody response and therefore fail to detect HIV infection.
26
During this phase between 30-50% of infected individuals will experience what is known as an
acute “Sero-conversion illness” with symptoms including acute flu like illness, lymphadenopathy
(swelling of lymph glands) night sweats, skin rash, headache and cough. A small percentage of
persons may experience intense, transient neurological symptoms such as hemiplegic.
Individuals infected with HIV remain infectious throughout their lives.
Initial diagnosis is of HIV is often accompanied by feelings of shock, anger, disbelief even denial.
A review of the literature reviewing psychological morbidity of patients post recent diagnosis
suggests that during the adjustment phase that is of mild to moderate intensity, however is of
limited duration. However, there is evidence indicating that some individuals will suffer a
significant adjustment disorders in adolescent and adults. Whilst early research indicated patients
newly diagnosed suffered more serious psychological disturbance than those patients who had
presented for testing and received HIV negative results. Clinical depression, anxiety disorders,
substance use and psychoses may be noted in newly diagnosed patients. Some of these conditions
may actually precede infection and could be what put the individual at risk of acquiring HIV.
Suicide is not uncommon during this phase of the disease continuum. Researchers have the
incidence peaks at, or around diagnosis, and a second peak at the time of an AIDS diagnosis.
Indeed most research does indicate a bimodal distribution of suicide across the disease continuum
with peaks in incidence immediately post diagnosis and during late stage disease. Other
conditions noted in individuals during this phase of illness include post-traumatic stress disorder,
particularly individuals who were sexually assaulted, common among MARA.
Chronic phases of HIV illness - Symptomatic
The second and third phase occurs typically within the five to ten years after initial infection, and
commonly reported symptoms include generalized painless swelling of lymph glands and other
symptoms such as drenching night sweats, chronic diarrhea, loss of body mass, and persistent
infections such as Candidiasis, herpes and sign skin infections may appear. These symptoms can
reoccur chronically for many years, often increasing in severity as the immune system
progressively deteriorates.
Comparative studies with HIV negative and HIV positive asymptomatic persons reveal the
individuals experience significantly higher psychological morbidity in the third phase of the
disease continuum, the symptomatic disease phase. Higher levels of anxiety, depression in
particular are noted in this population .Other common diagnoses in this phase include organic
brain syndromes such HIV dementia, HIV Minor neuro-cognitive disorder; delirium related to
opportunistic infections and substance dependency and misuse. Mood disorders related to
metabolic disturbances may also be observed in patients at this stage, chronic pain and related
constitutional illnesses are not uncommon during this period. HIV related sexual dysfunctions are
more likely to be reported during this phase of the illness and these may present challenges to
HIV transmission risk reduction with MARA. The most common sexual dysfunction being
erectile maintenance (condoms may slip off with loss of erection) and retarded ejaculation
(difficulties with ejaculation may result in clients prefer to increase stimulation by not suing
condoms).
Chronic phases of HIV illness – Acquired immune deficiency syndrome (AIDS)
AIDS represents the final stage of the disease and the mean survival rate without antiretroviral
medication is around two years after diagnosis of an “AIDS defining illness”. An AIDS diagnosis
is made by the presence of one or more pre defined opportunistic infections. The three most
commonly reported opportunistic infections in South East Asia are tuberculosis (TB),
Pneumocystis carinii pneumonia (PCP) and extra pulmonary cryptococcosis (usually meningitis).
27
In this phase of the illness organic brain syndromes such as AIDS Dementia Complex, HIV
Mania, Organic mood disorders may be the dominant presenting problems in psychiatric
consultations. During this phase clients may experience adjustment disorders related to disease
onset, loss of autonomy, grief and loss and increased suicide ideation. Psychological assessment
diagnosis in HIV demands that the practitioner is able to consider the relative contributions of,
metabolic disturbance, constitutional illness, pre-morbid conditions, iatrogenic effects, and
psychosocial factors in mood and behavioral disturbance.
HIV counseling across the disease continuum and impact on children and adolescents
Chronic illness tends to impact on many different areas of a child's/adolescent’s life, including
school, family, social, and psychological adjustment. Research examining the psychological well
being of chronically ill children has been mixed, but the general consensus is that chronically ill
children are at a greater risk for developing adjustment problems. These adjustment problems
have included an increased risk for depressive symptoms, behavioral problems, academic
difficulties, and feelings of isolation and withdrawal. Although chronically ill children appear to
be at increased risk for developing psychological symptoms, there are a large number of
chronically ill children who adjust well to their illness. Given that chronic illness may increase
risk of impairment, but it does not by itself guarantee adjustment problems, the trend in recent
research has been to examine variables that may moderate risk for emotional difficulties. Factors
that have been shown to predict adaptation to chronic illness include family stress, cohesion, and
expressiveness. Additionally, socioeconomic status, coping style, attributional style, and social
competence have been shown to predict emotional and adjustment difficulties.
The expression of HIV infection in the central nervous system (CNS) is variable across
children/adolescents and within children/adolescents across time. Documented symptoms of CNS
involvement include attention and concentration difficulties, language problems (particularly in
expressive language), motoric skills deficits, lagging social development, and failure to achieve,
or loss of, major milestones. Children/adolescents with HIV/AIDS have been reported to exhibit
a number of behavioral and psychosocial difficulties including hyperactivity, attentional deficits,
social withdrawal, and depression. It is oftentimes difficult to ascertain whether symptoms of
these disorders are behavioral/emotional or neurological in nature. Cognitive deficits, learning
disabilities, and developmental delay related to CNS symptoms of HIV infection can directly
impact academic performance. It is unclear to what extent the behavioral, neuropsychological and
developmental deficits are also related to social circumstances such as maternal HIV infection,
impoverished environment and chronic illness in general. Careful assessments must be used to
tease apart cognitive, social and neurological contributions to these problems. Counselors and
mental health personnel may find that a considerable amount of their work involves guiding
carers and families in using appropriate behavior management and parenting/care skills.
Casework support planning
MARA frequently will have difficulties in negotiating health services, and social and legal
services that may arise in relationship to their health status and life situation. A key role for
counselors is brokering all of the services for the client, and supporting them in communicating
with the relevant referral points. This is referred to as “Case work” sometimes referred to as
“Case-Management” and involves the following:
 Identification of issues
 Assessment of needs – Psychological, social and physical care
 Development of individual action plans in consultation with other service providers
28


Referral as required and appropriate
Coordination of follow-up services
To adequately develop case management plans counselors require:
 A rapport and trusting relationship with the client
 An up-to-date knowledge of HIV/AIDS and related issues
 An up-to-date knowledge of available government supports, non-government supports and
other referral agencies
Facilitating Psychological adaptation to living with HIV
The counselor needs to assess as best they can the coping style that the person used before
becoming infected with HIV. In addition, it is also be important to note the following: The
coping style changes as the child/adolescent progresses through the disease. Many street-children
and adolescents will display a history of understandable, yet maladaptive, approaches to coping
with life stressors. These coping strategies are likely to be exacerbated when they are diagnosed
with HIV. It is important to assess what is the child or adolescent’s vision of what successful
coping is?
In counseling younger children the counselor could ask the child to draw a picture or tell a story
about how children live with HIV, in older children it may be possible to ask this directly. It is
important that the counselor highlights the advantages of developing positive coping strategies.
Positive peer role models and participation in peer support activities with other children or
adolescents can be helpful and should be facilitated by the counselor. Information on Positive
Living (health living) should be provided.
Developing Self-Efficacy
Bandura (1977) described self-efficacy as a belief in one's sense of control, one's ability to
perform some action or to control one's behavior or environment, to reach some goal or make
something happen. Self-efficacy is affected by one's entire history of experience in mastering
tasks and overcoming obstacles. The beliefs one holds about their own capabilities affect the
effort they exert, the choices they make, the perseverance they can maintain in the face of
obstacles, their thought patterns, their mood, and their stress levels. An additional aspect of a
person's sense of control is the concept of locus of control. There is internal and external locus of
control. A person with internal locus of control believes that things happen to him because of
what he has done himself. This person feels more in control. A person with external locus of
control believes they have no control over what happens to them. Control for them is located in
others or in the system. Research has shown that people with a low sense of self-efficacy and a
higher feeling of helplessness are more likely to become depressed and ill. Self-efficacy is often
found to be situation specific, meaning a person could have high self-efficacy in one situation and
not in another. For example, feeling embarrassed or uncomfortable asking a partner to use a
condom would show low self-efficacy in that one area only.
Clients can be asked to have a “provisional try” of a strategy for asking partner to use the
condom. It is important that these new behaviors are presented as experiments “let’s try and see
what happens” allows for failure, disclosure of failure and re-trying in a different way.
Developing Self-Esteem
29
Self-esteem is a concept that includes a person's sense of self, of their competence, and their
acceptability to others. It encompasses their internal self-scheme based on their past experiences
of success or failure and their interpersonal experiences of acceptance or rejection. In regards to
HIV, low self-esteem may be a factor in not self-protecting themselves or others from HIV. No
one has been able to measure a drop in self-esteem as a result of becoming infected because selfesteem may have been low to start with. However, with stigmatization, guilt, loss of a positive
body image, loss of roles, loss of work, and loss of social network, it seems natural to assume that
self-esteem would be threatened.
Counselors can help clients gain self worth by helping them to see the positive things that they
have achieved in their lives no matter how seemingly challenging their lives have been. Children
living on the streets rarely have the chance to have their survival strategies and their strengths
acknowledged. Asking children to draw pictures or make up story about things they have
achieved or they are proud of is important. Similarly adolescents can be challenged to think of
ways they have overcome challenges that they have faced in life. Often MARA have experienced
criticism from health workers and so this is the first step in building their self esteem and self
efficacy.
Coping Defense Mechanisms
In order to maintain self esteem, people may use the following defense mechanisms to cope with
HIV and AIDS:
Coping Defense Mechanisms:
 Denial: Negating the reality of situation
 Avoidance: Attempting to ignore ramifications of situation
 Regression: Becoming more dependent, more passive, more emotional
 Compensation: Counteracting limitations in one area and gaining proficiencies in other
areas
 Rationalization: Excusing oneself for not reaching expectations
 Diversion of feelings: Channeling unacceptable feelings into socially acceptable behavior
(can be constructive).
Denial can be an important mechanism for fostering faith in survival. Confronting the denial of
people living with HIV and AIDS may not serve positive purposes because constructive denial
allows for needed cognitive and emotional breaks from living with the disease. Counselors need
to assess the child or adolescents coping defenses and gently challenge those that put the client’s
health and the safety of others at risk e.g. a persistent belief that HIV diagnosis was wrong and
that they cannot infect others.
Addressing Family Issues and Care Issues
It is important to realize that many families are coping not only with HIV-related issues, but also
with additional stressors related poverty in rural areas or to inner-city living. These include
poverty, violence, and drug abuse. Other concerns reported by families dealing with HIV and
AIDS involve interacting with the medical environment and addressing medical concerns.
Families must negotiate financial and insurance difficulties and learn to communicate effectively
with physicians. Additionally, they are coping with hospitalizations, clinic visits, and important
medical decisions. Caregivers are often required to manage their children's medical condition as
well as their own, and possibly, that of other family members. The medical regimen associated
30
with HIV and AIDS can be notoriously difficult to follow. Not only must caregivers adhere to
their own medication regimen, they must convince their children to comply with medication that
tastes bad and pills that are difficult to swallow because of their large size.
Isolation
Another unique aspect of HIV and AIDS is the secrecy, stigma, and isolation that accompany it.
Despite improvements in understanding of HIV and AIDS, those who are infected continue to
face possible fear, rejection, and prejudice if and when their diagnosis becomes known. Stigma
and discrimination may already be experienced by many children and adolescents who live on the
streets and engage in illegal or socially disapproved activities. Children and adolescents who
cannot disclose their status may experience an internal sense of isolation. Children and
adolescents whose status is disclosed may experience stigma and isolation as a result of the
disclosure.
Facilitating Disclosure of HIV status
Cultural issues may impact communication patterns, attitudes toward HIV infection, and
willingness to access social and psychological support systems. Children and adolescents are
often not told of their own HIV infection, or that of caregivers, parents and siblings.
Parents/caregivers have indicated that they are uncomfortable discussing HIV status with children
for a variety of reasons. One of these is the fear that children/adolescents will be unable to keep
the diagnosis a secret from peers and other community or family members resulting in social
rejection of the child and the family. Parents/caregivers also report a desire to protect the child
from the knowledge that the parent and/or child have the illness. This is especially true if one or
more close family members or friends have already died from AIDS. Additionally,
parents/caregivers report that they are uncomfortable and uncertain how to address questions
regarding how the virus was transmitted to parent and/or child. Parents may feel guilty or
ashamed about the method by which they contracted HIV. Mothers, especially, may be trying to
cope with their own feelings in having transmitted the virus to their child. There is a large body
of literature in pediatric psychology addressing the question of disclosing disease status to
pediatric patients. A great deal of this literature has been conducted in the area of pediatric
oncology. In general, it has been well established that children/adolescents have better emotional
adjustment if they are told of their diagnosis and allowed to discuss their condition openly with
their family and medical caregivers. This is true even in situations where the child is terminally
ill.
Unfortunately, there is little research regarding disclosure of diagnosis specific to pediatric HIV
and AIDS. Specifically, research has not been conducted to assess whether concerns about social
ostracism and related psychosocial effects outweigh the need to discuss the child's/adolescent’s
(or other family member's) HIV and AIDS diagnosis. There is some preliminary evidence that
children/adolescents with HIV or AIDS who were not told of their diagnosis exhibited increased
levels of social isolation as compared to children who knew their diagnosis. Adolescents who are
likely to be sexually active should be aware of their HIV status and receive information and
support in reducing transmission risk behavior.
Counselors should attempt to provide families/caregivers with information regarding the benefits
and consequences of disclosing HIV status to a child/adolescent. Open communication about
health status is generally considered optimal, but this must be weighed against a family's concern
about social rejection. Additionally, families may request help formulating an explanation that is
31
developmentally appropriate and answering difficult questions about disease process, prognosis,
and transmission. Situations involving cognitive or developmental delay may not be appropriate
for disclosure if a child's/adolescent’s ability to keep the diagnosis private, or their ability to
understand the situation is impaired. Additionally, disclosure should be undertaken in an
environment that is supportive with adults ready to provide appropriate information and
reassurance.
The child’s own HIV status and informing the child of their parents HIV status
There are no guidelines for the most appropriate age or most appropriate methods for telling a
child his / her HIV status. A study conducted in US found that caregivers believed the best time
to tell a child his / her HIV status is around 10 or 11 years of age, in particular if the child has
been asking questions about taking medicines or clinic visits. More than 90 per cent reported they
wanted to be involved in making the decision to disclose and 70 per cent said they would want to
disclose the diagnosis to the child themselves. In cases where the parent preferred not to disclose
the main reason was belief that the child was not “ready”.x As concrete guidance on disclosure is
currently not available, parent(s) / caregiver(s) need to decide for themselves if, when and how
they will disclose taking into consideration potential benefits of disclosure to the child. The
potential benefits of disclosure may include:
 Helping a child to cope with his / her illness through addressing fears and concerns with
the support of parent(s) or caregivers
 Facilitate the child’s involvement in planning their care, educational and psychosocial
needs
 Enable an adolescent to learn about safe sex practices and to take responsibility
 for prevention of further transmission, if sexually active or injecting drugs
Informing a child of their HIV or health status:
 Use age-appropriate language and concepts that the child can understand
 Ask the child what he / she is thinking and what they know about HIV and AIDS
 Use words, pictures and drawings to explain about HIV
 Ask the child if he / she has questions and answer them honestly and directly
Non-disclosure may lead to anxiety, fear and depression and also deprives the child from support
and referral to psychosocial support and activities.
Potential disadvantage of disclosing to a child include possible experiences of stigma and
discrimination, and in extreme cases, harm by others. Experience in some sub-Saharan countries
has indicated that older children prefer parents to tell them if one or both parents have HIV. It is
thought to be beneficial for older children to learn about their parents HIV positive status before
the onset of illness, though at present most children only learn about their parents’ HIV status
much later on. When to disclose the parent’s HIV status to a child depends on the child’s age and
maturity, but ultimately is the choice of the parent. It is inevitable that disclosure of an HIV
positive sero status to a child will have a significant psychological impact on the child. This will
be compounded should both parents, and / or siblings, be infected.
Yet, the truth of the child knowing about his / her HIV status, or that of a parent, can be less
threatening than fear of the unknown. In cases where the child is not informed, he / she may
already “know” because of having overheard conversations, or noticed a difference, at home.
Children may make up their own explanations for what is happening. Frequently parent(s) avoid
32
talking to their children about illness and death in order to “protect” their child from upsetting
news.
A detailed guide to disclosure of HIV to children has been included as a tool in Module 1 of this
training package.
Cognitive and Behavioral Concerns
Neuropsychological and developmental impairment associated with HIV infection has been
clearly documented in the literature. The expression of HIV infection in the central nervous
system (CNS) is variable across children and within children across time. Documented symptoms
of CNS involvement include attention and concentration difficulties, language problems
(particularly in expressive language), motoric skills deficits, lagging social development, and
failure to achieve, or loss of, major milestones.
Children/adolescents with HIV and AIDS have been reported to exhibit a number of behavioral
and psychosocial difficulties including hyperactivity, attentional deficits, social withdrawal, and
depression. It is oftentimes difficult to ascertain whether symptoms of these disorders are
behavioral/emotional or neurological in nature. Cognitive deficits, learning disabilities, and
developmental delay related to CNS symptoms of HIV infection can directly impact academic
performance. It is unclear to what extent the behavioral, neuropsychological and developmental
deficits are also related to social circumstances such as maternal HIV infection, impoverished
environment and chronic illness in general. Careful assessments must be used to tease apart
cognitive, social and neurological contributions to these problems.
Unsafe sexual and injecting practices may increase in response to these mood and neurological
changes. Counselors need to be cognizant of this potential and continually assess the individual’s
capacity to engage in transmission risk reduction behavior.
Preparing children and adolescents for hospital visits & medical procedures
Sometimes parents/guardians are uncomfortable telling their child about going to hospital or that
he or she needs an operation. Parents might feel protective or anxious about their child's reaction.
'Parents/ guardians should be advised by the counselor that “You can protect your child from the
information but you can not protect them from the experience'”. At the very least it is important
that the child knows that he or she is actually going to hospital. It can also be helpful if the child
knows the reason why (e.g., an outpatient check-up or assessment or an inpatient medical
procedure, operation or treatment).
The child/adolescent should be provided some basic information about what will happen when
they are at the clinic or hospital.
Managing anxiety related to hospitalization or clinic visits.
The child/adolescents level of development determines the approach:

Young infants (new-borns to 8 months) - when the baby is going to hospital or having an
operation, it is normal for parents to find it more stressful than the child will. Young
infants usually separate easily and can be comforted quickly by the care staff in the
Hospital. Parents/carers should be advised of this by the counselor. Often parents/carers
33
can provide a familiar rug or soft toy so that the child can derive comfort from this.
Where a substance dependent mother has delivered a child who is showing signs of
substance withdrawal the mother will require support and counseling in relationship to
feeling of guilt and distress with the fact that the infant needing specialist drug
withdrawal treatment.

Older infants & toddlers (8 months to 2 years) - Most children of this age group will have
some difficulty separating from their parents and older infants can initially behave poorly
with care staff. As the parent knows their child best, they can tell the nurses and doctors
how they think their child will react and what they can do to help their child cope better.
Parents are advised that they could start telling their toddler about going to hospital or
having an operation a day or two before.
Often the parents of MARA will have limited ability to negotiate with hospital staff and
therefore counselors can provide support to parents in communicating with hospital staff
and assisting them with managing administrative procedures. This may be particularly
important where parents are drug users or sex workers and have had past poor
experiences in navigating health systems and dealing with health professionals.

Pre-school & young school-aged children (3 to 6 years) - Most children of this age group
can understand simple explanations about their illness and/or operations and may need
time to express their feelings, draw or play and ask questions. Parents/guardians could
start telling your child a few days to a week before. Playing games like nurses or doctors
with dolls etc can be helpful. Especially the child could role play the doctor or nurse and
give the child an injection. Counselors can provide a syringe without a needle for this
purpose and work with parents/guardians to help them prepare the child

Older school-aged children (7 to 11 years) - Most children of this age group are able to
understand the reason for an operation or hospital stay and what is going to happen to
them. Children of this age may have fears about waking up during medical procedures or
operations, about pain and changes in their body. Plenty of reassurance, talking time and
play practice on teddy bears or other toys, or drawing can help. You could start telling &
preparing a week or more before. Children who have been living on streets and who are
normally projecting a “streetwise” demeanor may regress to quite dependent and fearful
behavior. Having treatment support buddies or other supportive carers visit will assist the
child in adjusting to this environment.

Adolescents (12 to 17 years) - Most adolescents have a good understanding of what is
going on in their bodies and the reason for Hospital visits or operations. Including them
in discussions or decisions about their care and treatment can increase their sense of
control and reduce anxiety. Adolescents often have several worries about going to
hospital. They may be concerned about the impact of an illness or medical procedure on
their appearance, the reactions of friends, independence and privacy or sexuality issues.
Also, be prepared to discuss the adolescent's fears about dying or disability. The
adolescent may need time to think about it, gather information and read, discuss it with
you in more detail, talk to other teenagers with HIV, and make plans to be absent from
school work and social life. Counselors’ are advised to discuss this issue with
parents/guardians are advised to start telling & preparing your adolescent a few weeks in
advance.
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When adolescents are unaccompanied minors they should be encouraged to develop links
with peer support groups prior to hospitalization. In some circumstances “hospital buddy
support systems “can be developed so that the adolescent will have the opportunity to
have visitors and supports whilst in hospital.
Helping parents/caregivers talk about the hospitalization
Often a parent can feel nervous about what to say to his or her child. The counselor could practice
with the parent to increase their confidence. Also, role-playing can be good ways to trouble shoot
for those unexpected questions and reactions. In many circumstances you will be dealing with
family where the child or adolescent has left home or come and gone on a regular basis, often
their will be family resentments.

Brothers & sisters - If the child has brothers or sisters, the other children may also need
explanations, reassurance and an opportunity to express their feelings. The counselor’s
role is to identify

Grandparents - Grandparents are often closely attached to their grandchildren and can
be a very important part of the child's life. Involving grandparents (or other members of
the child's extended family) in the preparation and hospital stay can be a big help to the
child. This can let your child avail of multiple social supports and provide a sense of
normality.
Talking about medical procedures with younger children
It is most helpful to tell the child in simple, clear language with words that you know they
understand.



'special pictures' could mean x-rays or scans
'special medicine or drink' could refer to medication or tonics
'Special creams' could be cream-based medications.
Counselors can be a great help to the parents, nurses and medical staff by finding more childfriendly ways to explain other common hospital words such as injections, drips, plaster,
bandages/dressings or monitors.
Giving information about the hospital or clinic in advance
After you or the parents/guardians have gathered information, you may need to spend time
talking to the child about the hospital or clinic itself to “desensitize” the child. You could try
some of the following ideas:

You could give a description of the hospital/clinic (e.g. a place/big building or house with
lots of children in it). An advance visit to the hospital/clinic might help.

You could tell the child/adolescent about the people who work in the hospital/clinic (e.g.
Doctors are men & women who help children who are sick or have a problem). It is
useful to have a child-friendly sentence prepared to describe the other staff your child
might meet such as the Nurse or Lab tech.
35

Talk about what hospital/clinic staff might look like (e.g. the different colored uniforms,
tissue hats in the operating theatre, name badges etc.)

Talk about what the hospital ward may be like (e.g. a big room with lots of smaller rooms
with children of all ages in them, or the daily routine). Also, explain that your child might
have to share or change rooms with other children while in hospital/clinic. This can
prevent problems of non-compliance and resistance.

Talk about what the food may be like.
Giving the child a personal reason for the hospital visit or medical procedure can motivate him or
her to comply with treatments and help your child make sense out the experience (e.g. being able
to run for longer without getting tired, wear special garments so legs will look better etc.). The
reason would depend on the illness or health problem being treated and your child's level of
understanding. Tell parents of custodial carers that “It is important to encourage the child to talk
about the hospital/clinic and his or her ability to cope with it”.
Counselors, parents or a guardian telling a child that they disliked hospital themselves is often not
helpful. Parents should be advised that in general, it's best to answer all questions even if this
means saying 'I don't know but I will find out'. Try to remember to come back later with the
answer! Even if it is difficult for you, try to answer questions openly and honestly. Parents
should be advised that reassurance is vital. Parents should reassure the child that they and other
members of the family will visit as frequently as possible. The reassurance that the family will be
there close-by can help the child cope better and separate easier during absences. Sometimes
children's hospitals have some form of parent's accommodation so that parents can arrange to stay
overnight. Telling the child that you will be doing this can also be reassuring. Parents are advised
to try to stay calm. Parents should be advised that their child may pick up on their own level of
fear and concern, and be frightened by this.
Counseling for Pain management
Dealing with pain can be difficult for parents and children. Pain can be a feared experience
associated with hospital and medical procedures. Parents/caregivers should be advised that if
their child asks will a medical procedure hurt, which telling your child/adolescent that it won't
hurt when it does hurt is not helpful. This false reassurance tends to have the effect of diminished
trust, increased anticipatory fear, and reduced compliance. Often children/adolescents can
tolerate more pain when prepared for it, know what to expect, have words to describe it and are
reassured in advance about ways of coping with the pain. Breathing techniques to “blow away
the pain” can be taught to the child/adolescent by a parent or the counselor.
Being prepared for the experience of pain can also improve the child's sense of pain control. In
addition to medical treatments, most hospital's/clinics have some for pain management. Children
may find it hard to describe pain and so they will need assistance. Smiling and growl faces can
help children express how bad pain is.

NO pain

feel better


not sure
pain is there

very strong pain
36
Alternatively a picture of the body can be provided and children draw the parts where the pain is:
37
MODULE 2: Session Plan
Psychosocial Care - Counselling Across the Disease Continuum
Session objectives:
At the end of the training session, trainees will be able to:
 Identify and develop developmentally appropriate strategies to common psychosocial
issues of MARA living with HIV
 Identify the link between VCT and post-diagnosis psychosocial care
 Develop a psychosocial care plan for MARA clients
 Consider and address treatment adherence challenges in MARA
Time to complete module: 3 ½ hours
Training materials






PowerPoint Presentation (PPT 02) and Handout of PPT ( Handout view 6 per page)
Activity sheet(AS02)
Learning Notes (LN 02) Enclosed in trainee folders
Counselling Tool (LN 02) Enclosed in trainee folders
4 copies OHP masters _ key Issues strategies
Question box
Content





HIV-related psychosocial issues across the disease continuum
Case-work support planning
Psychological interventions
Counselling to support HIV disclosure
Preparation for in-patient treatment
Session instructions
Commence the PowerPoint Presentation pausing at the Activity 1 (Total time 30minutes)
 Form 4-5 small groups and handout the Activity sheet (AS02) and ask participants to read
AS02.
38

Each person is required the description of the stages of HIV disease in you
Lecture Notes( LN 02) down to and including the section entitled c support
planning. (10 minutes personal reading time)
 The in your small groups discuss the key presenting psychosocial problems you
are likely to see in MARA at each stage. Give specific examples. Record this
information on a sheet of paper (10 minutes small group) discussion.
 In the large group discussion provide your answers in the large group
discussion(10 minutes)
 Facilitate a large group discussion working through the stages of disease progressions
progressively, call for feedback from each of the groups. Ensure all of the issues
discussed in the Lecture Notes are considered from a MARA perspective.
 Continue to lecture with the PowerPoint pausing to ask the class to briefly share their
experiences related to the points raised in the lecture.
 Introduce Activity 2 by forming four groups (1 hour)
30 minutes small group activity
5 minute group feedback to class
10 minute trainer feedback
In your allocated groups
 Review the allocated cases on your activity sheet
 Case 1=Group 1
 Case 2=Group 2
 Case 3=Group 3
 Case 4=group 4
Identify the key counselling issues
The list the specific counselling strategies you will use
Record your discussion on the supplied OH transparency sheet or flip chart
Ask participants to follow the format. Handout the OHP master for this to each table
group
Key Issues
•
Key strategies
Present your findings to the large groups
Cases for the four groups are as follows:
Case 1 –Your client is an 11 year old boy who works with truckers. He came to the
clinic today and reports he is sick. He moves in and out of home. When he runs away
from home he lives with his friends on the streets. He steals, and has “played with men
for money.” He has a sore on his penis and claims it hurts him to urinate. His family is
poor. He has not had a HIV test. He does not know about HIV. He appears to be
affected by a substance however he denies he uses drugs.
Case 2 – Your client is 14 year old girl involved in prostitution. She has run away from
home claiming her father beats her and her mother. She lives with a man and a woman
39
whom she says looks after her. She has had a HIV test about two months ago and tells
you she is HIV positive. She claims she cannot use condoms with the clients as they say
they are paying for the service.
Case 3 – Your client works in a local hotel. He cleans and does odd jobs and frequently
has sex with male guests for money. He is sixteen years old, and was diagnosed HIV
positive last year. He presents at the clinic with signs of advancing HIV. He needs
hospitalization form management of an opportunistic infection. His family has no money
and pressures him to keep working at the hotel. His family does not know he has HIV.
He has told nobody.
Case 4 - A young adolescent IDU 18 comes to the clinic. He informs you his girlfriend
works as a sex worker, and he says she is pregnant. He admits he was diagnosed HIV
positive 2 years ago. He indicates he has not told her. He does not use condoms as he
thinks she must already have HIV from her work because the doctor who diagnosed him
told him that you get if from sex and drugs.
 Activity 3(total time 1 hour)
Timing breakdown: 30 minutes for group work and 20 minutes for group feedback and
10 minutes for trainer comments.
Ask participants to read Activity 3 in their activity sheets. Remind this group that they
will need to draw upon information they learned in the VCT Adherence treatment
module.
Allocate tasks accordingly.
(1) Instructions to Groups 1 & 2
Draw a picture to describe HIV transmission and prevention to a 12 year old street
child. Discuss how you would explain this.
(2) Instructions Groups 3 & 4
Describe the importance of treatment adherence to STI and HIV treatments to a 16
year old that intermittently uses drugs. Include discussion of HIV re-infection,
resistance and drug interaction (treatment and recreation).Discuss how you would
explain this.
Inform the groups that each group is to nominate one person to present the activity to the
class and this individual address the class as the class were the client using diagram or
explanations aids that they would use with the client.
 Finalize the session by brainstorming the key topics covered. Remind the class to read
the handout in detail including the tool.
40
MODULE 2: Counseling Tools
Psychosocial Care - Counselling Across the Disease Continuum
How to use this tool:
This may be provided to a parent it is letter to parents who are considering disclosing their HIV
status to their children, or inform a child of their status. It is by a HIV positive mother, by Amy
Buch.
It can also be used to facilitate your counseling session. I would like to share with you the
experience of one parent. Your situation may be different but we can talk about the issues this
raises for you. It may help you to focus your concerns, and help us plan what you would like to
do.
It is suggested that you ask the parent to read it and highlight points they would like to discuss
further with you. If the parent cannot read the counselor may read it to them saying.
When thinking about talking to your children about your HIV status or your children’s status, you
might feel overwhelmed by different emotions. It is normal to feel frightened, anxious, or guilty.
It may help to discuss your feelings and how and what you will say with someone you trust, such
as a doctor, counselor, family member, or friend. You may also want to share your disclosure
plans with those who know your HIV status, so they’ll be prepared to give accurate, reassuring,
calm responses if the children bring it up with them. Take some comfort in what you know: how
your children learn new information, what your children may already know about HIV, and what
feels most supportive to your family. Use this knowledge to decide how to disclose about HIV to
your family. While there may not be an exact best way to disclose, there are some steps you can
take to prepare.
Telling Children about Their HIV Status
Before talking, think about why you want your child to know. Perhaps your child has been in the
hospital, taking medications, or asking questions. Whatever your reason, make sure that you are
okay with your child knowing. If it is not okay with you, it may not be okay with your child.
Have some HIV-related information ready before you get started. (Look for materials that have
an optimistic tone.) Children might want to know if they are going to die, how they got infected,
or if they will become sick. Know how you will answer these questions. Also, consider your own
feelings about these concerns. You may choose to wait to have the conversation until you get
some emotional support.
Children will need different types and amounts of information depending on their age. Begin with
some simple ideas that you think are most important. Very small children may be too young to be
told the name of the disease or many details, but try to be as honest as possible. Disclosure can
occur little by little in age-appropriate ways as the children get older. Young children need
information mostly about things that affect them right now. School-aged kids may need some
basic information about what to do if they bleed. (All children should be taught that it’s not a
41
good idea to touch anyone’s blood.) Teenagers will require more information about prevention
and transmission. All children should know they cannot infect friends or family through casual
contact.
It may take a long time for children to absorb the information. Let your children know that they
can always speak freely to you. You want your children to see you as a trustworthy adult so they
will feel comfortable coming to you with more questions in the future.
Your children may feel isolated, angry, scared, or depressed by their HIV status. It may help if
there is someone else they can talk to. Arrange a support network consisting of heath care
providers and trusted family and friends.
While laws protect HIV+ people from discrimination, you may not want your children to let
everyone know their HIV status. You can tell your children that HIV is a private family matter
and that you will decide as a family who to tell and how they should be told.
Letting Your Children Know You Are HIV+
Telling your children that you are HIV+ is also extremely difficult. Prepare yourself by thinking
about how your children will react and what they will want to know based on their age and
maturity. Your children will probably ask about your health. However, their main concern may
be what will happen to them if you were to get sick. They will need reassurance that they will be
taken care of if something happens to you. Children might also want to know how you got HIV
and if they might get it too. Depending upon their ages, they will have different questions. They
also might not have any questions at all.
Your children might already suspect something. Older children or teenagers might learn about
HIV in school. They might see you taking medications or going to the doctor more often than
some of their friends’ moms. If your children already suspect something, they may feel angry that
you have kept this from them. On the other hand, they will probably benefit from being able to
talk about HIV openly. If your children have already learned something about HIV at school or
through the media, you can use that as a chance to build on what they already know.
Let your children know who they can talk to about your status. Tell them who else you have
already told. (Be prepared that they might feel disappointed if a lot of people knew before they
did.) Your local NGO HIV service organization may have a kids group where they can talk with
others in similar situations. Your health care provider may also have a counselor who can talk
with your children.
Taking Care of Yourself
While it can be extremely difficult to disclose HIV information to children, it is better to tell your
children as early as you can, especially once they start asking questions. It is usually easier to tell
the truth than try and cover up the diagnosis. Once children know, the family can start discussing
things openly and dealing with the feelings that come up. Following the tips listed below may
make disclosure easier for you and your children:
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Deal with your own feelings first. Gain control over your own emotions and learn to live
with the diagnosis.
Build a strong parent-child relationship.
Seek out support for yourself both before and after disclosure from friends, social
workers, counselors, and others.
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Prepare by gathering HIV-related information, creating an appropriate environment, and
arranging supports for your children.
Find a time to disclose that is free from interruptions and appointments.
Try to be as relaxed as possible before the conversation begins. Your children might
notice if you are feeling anxious, sad, or angry.
Disclosure is a process. Even if your children do not react the way you hoped right away,
with time, support, and information, they may be more accepting.
Encourage your children to ask questions as they come up.
Give reassurance and hugs!
43
MODULE 3: Lecture Notes
Talking about Grief, Loss and Death with MARA
Session objectives:
At the end of the training session, trainees will be able to:
 Provide developmentally appropriate grief and loss counseling to MARA
 Provide appropriate advice to parent, guardians and caregivers about grief and
loss issues impacting on MARA
 Develop communication strategies to discuss death with MARA
This module will focus on talking about loss, grief and death with MARA. Children express loss
and grief in a different way than adults. They tend to move in and out of intense feelings, rather
than sustaining high levels of one emotion for long periods of time. When adults see a grieving
child playing or laughing, they may mistakenly believe that the child is "over it". This perception
may influence how much grief support a child receives.
MARA and the Experiences of Loss
Children living on the streets may have already experienced considerable losses including the loss
of families where parents have made them leave home either for work, or leave because of
behavior problems. Children who lose a parent must cope not only with grief over their loss, but
possibly with significant disruptions to their home and family life such as placement in foster care
or the home of another relative. This loss may be further complicated by a child’s unexpressed
past resentment over deceased or a surviving parent’s lifestyle e.g. a sex worker or drug using
parent.
Children living with substance using parents or close friends may experience different types of
losses. This type of loss may be either direct loss through accidental or deliberate overdose or
what is referred to as an ambiguous loss. This type of ambiguous loss occurs when a family
member is either physically or psychologically absent in the case of a parent’s chemical
dependency (alcohol and drug addiction). Children who experience abduction and incarceration
also experience significant grief loss issues. MARA may have lost friends to HIV or drug
overdose or other illnesses common to those living on the streets. The impact of loss of street
peers should not be underestimated. For many children living on the streets they regard there peer
network as alternate families. Frequently, street children experience multiple losses and exhibit
signs and symptoms of disordered mourning. Social support and increased age has been
associated with improved grief outcomes, and pediatric HIV and AIDS patients may be lacking
on both counts.
Often counselors have to work with the family members of MARA. Families dealing with HIV
and AIDS are faced with concerns of separation and grief. Grief and mourning may be
complicated by feelings of guilt, or anger over the lifestyle of the child or adolescent’s lifestyle.
In the event of a parent's death, the grandmother or other extended family members may be called
upon to raise the children. These grandmothers experience grief regarding the loss of their own
children, as well as the stress of assuming parenting responsibilities at a late age. Additionally,
44
families are experiencing multiple losses. HIV is unique in its ability to strike multiple members
of the immediate family as well as the larger community, thus severely compromising traditional
social support systems. Pediatric HIV and AIDS patients who die may leave behind not only
grieving parents, but also grieving siblings. The topic of children's reactions to sibling death is
one that does not receive widespread attention, but there is evidence that the sibling relationship
is one of the most important social relationships. Better family adjustment following the death of
a child has been shown in the oncology literature to be related to open communication and social
support. Siblings and parents of deceased pediatric HIV infected people may be at risk due to the
social isolation associated with HIV.
Understanding Common Emotional Responses in Children
Sadness may be observed in others in a variety of ways. Crying is the most obvious indication
that something is disturbing someone. It can be a great relief for the griever to have an
opportunity to share tears with another or even solitude to release the tears. Children report that
there will be moments when in a classroom that they will feel overwhelmed with feelings of loss,
but they don't want to cry in front of peers. Providing an option for newly bereaved students to
go to a quiet spot in the school to release their feelings creates a safer emotional environment.
Sadness may manifest in other ways, such as through deep sighing.
Anger – Grief isn't just about crying. Anger is common among those who have lost someone
important in their life. They may feel that it just isn't fair, that life is unjust. The loss may be
understood as preventable, giving rising to blaming and outrage. There are many possibilities of
carelessness, neglect, and deliberate intent to kill that bring tragedy into the lives of children and
their families. A child may be angry at the one who died. Displaced anger arises when the energy
of anger is directed at someone or something other than the true source of pain. It may be easier
for a child to express anger than sadness because there is less perceived emotional vulnerability in
being angry verses being sad. Acknowledgement of anger can be an effective way of deescalating
the intensity of anger.
Irritable - The bombardment of unpleasant feelings of loss can create a sense of irritation.
Feelings of anger over the loss may not come out in explosive ways, but in a general sense of
irritation.
Guilt and self-reproach - Because children are ego-centric (the cause and effect world revolves
around them), they are likely to feel like they are the cause of the loss regardless of the
circumstances around the death. Children may believe that “if only I had” ….put my toys away,
made better grades, helped around the house more, asked her to wait five minutes more, not
talked back to my mom, etc, etc, etc. their loved one would still be alive. There are times when
these thoughts may be the only sense of power and control the child feels. At other times, these
beliefs may be carried into adulthood, contributing to difficulties in later life.
There are times when a child may be responsible for a death, such as the tragic stories of teen
drivers who are involved in fatal accidents due to reckless driving, or road conditions for which
they were unprepared, accidental shootings, falls, etc. Under these circumstances, it is likely that
these feelings may need to be addressed by a grief therapist.
Anxiety, Insecurity and Fear - After the loss of a loved one, a child's world may feel unfamiliar
and unsafe. The question, “Who is going to take care of me?” is important to answer. Family
circumstances may have changed dramatically. The remaining parent is required to take on the
45
responsibilities left by the other parent. This leaves less time for nurture and care of the children
in the family. This further destabilizes grieving children. In these cases, we see either an overly
“parentified" child, one who takes on adult mannerisms and responsibilities, or attention-seeking,
often disruptive behavior. Even negative attention is better than no attention at all. The same can
be a feature seen in unattached minors on the streets.
In addition, the loss of a loved one creates high loss awareness. To the child this means that since
this happened once, the reality of potential future losses is underscored. Children express concern
over what will happen to them if the remaining caregiver dies. There are times when children lose
both parents simultaneously, or within a brief period.
When a sibling or street peer dies, the child or adolescent may wonder if he or she is next. This
further complicates feelings of anxiety.
Abandoned - The absence of a loved one may contribute to a feeling of abandonment regardless
of whether the loss appears to the child to be caused by the one lost, is accidental or the result of a
lengthy illness. This feeling may attack the child's sense of self-esteem. The cry, “Why did you
leave me?” is common in both children and adults.
Worried - Children have concerns about many things. They may worry about other family
members or friends who are grieving, finances, and the overall welfare of the family. These
worries may be grounded in true difficulties facing the family. Children will often hide their pain
from family members to try to “protect” others. In children on the streets this worry may be
“masked” by an “acting tough”.
Lonely - When a significant loved one is removed from a child's life, a pervasive sense of
loneliness often sets in. The talks, emotional interactions, and activities once shared are also lost,
leaving a void in the child's life. Extended family members, aunts, uncles, cousins, grandparents,
and friends may help by spending time with the child, but the special role of the one lost is still
missing. In today's society, many families are far from extended family, so the needed support is
lacking.
Yearning - Longing for and seeking the lost one is common in the first year or two following a
loss. Life adjustments are in progress, but aching and longing for the loved one remains. During
this time, children may talk with the deceased, have vivid dreams about interacting with the
person, or think they see the person in a public place. A smell, song, phrase or other sensory
experience may throw the griever into a place of acute yearning and sense of loss.
Helplessness and Powerlessness - The child who cries out, “I WANT MY DADDY BACK!” is
faced with the continued absence of Daddy. No matter what she says or does, Daddy does not
return. She has no impact on engaging the return of her father. She is powerless to change this
critical issue so vital to her emotional and physical health. It is important for the child to find
areas that allow her to produce her desired outcome.
Shock - Shock may work as a defense against the loss, shutting down mental and emotional
circuits that are overloaded with feelings and loss. This is a time when feelings of numbness and
being “out of body” may happen. Shock is more likely to occur following an unexpected death,
but happen even when a death is anticipated. Children who loose a parent through a sudden drug
overdose or witness friends die on the streets frequently experience shock and helplessness and
even a sense of self blame.
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Numbness - Absence of feeling can create a surreal sense for the child. No feelings replace
intense feelings about things and people before the loss. This experience does not usually last
more than a few months, but can be disconcerting and confusing while it lasts. This sense of
numbness may become chronic in children who have sustained multiple losses.
Emancipation -There are times when a relationship is so painful that there is relief when the
person is gone. There may have been physical, emotional, or sexual abuse. While there may be
conflicted emotions following a loss, the sense of freedom from the abuser can be exhilarating for
the griever.
Relief -When someone has suffered through a lengthy illness, families may be relieved that the
suffering is over for their loved one. This feeling is most common in an anticipated death. A
child may be at peace about feeling relief, or may question his loyalty to the loved one and feel
guilty for feeling relieved.
Turmoil - A melting pot of emotions can create inner turmoil as children try to sort through the
feelings. A child is not likely to tell you, “I'm feeling inner turmoil.” She, however, may
demonstrate it through chaotic artwork, disorganization, forgetfulness, and disruptive behavior in
the classroom.
Physical Sensations
Grief is about more than emotions. Feelings of loss have physical components as well. These
feelings may be frightening to a grieving child and his or her family.
After medical causes have been ruled out, the following physical symptoms may be attributed to
normal grief reactions:
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Fatigue
Stomach pains
Appetite changes
Headaches
Tightness in throat, chest
Short of breath
Weakness
Low energy
Dry mouth
Sensitive to noise, light, alcohol
Understanding Common Thought patterns
Denial -“I can't believe it happened” is a defense that allows the unprepared bereaved person time
to absorb the reality of the loss. When someone first learns of an unexpected death, the first
response is often “NO!” This response changes over time as a person is psychologically able to
tolerate the loss without being completely overwhelmed. One should not attempt to convince the
bereaved of what they are denying. Allow the natural process of grief to unfold this defensive
thought.
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Confusion - Short term and long term memory may be impacted for a period. This can be
disconcerting to students. They may or may not have done their homework, and cannot
remember anything about it. This is frustrating to the teacher, parents, and disheartening to the
student.
Thoughts about deceased - Shortly after a death, it is common to think about the deceased almost
constantly. It is also common for the bereaved unconsciously to adopt behavior characteristics of
the deceased. This will diminish over time. If not, referral to a grief therapist is appropriate.
Sense of presence of the deceased - Children and adults alike may experience a sense that their
loved one is watching over them. One child said that his mom was in the walls of his room and
would come out at night to visit him. This sense of presence may help the bereaved cope or may
be disturbing. When a group of about 15 bereaved children was asked who had seen their loved
one since the death, all but one responded that they had.
Difficulty concentrating - In the first few months, most bereaved individuals find that it is
difficult to stay focused on a task. Intrusive thoughts about the deceased and moments of
overwhelming feelings contribute to these lapses of concentration.
Nightmares -Nightmares are common for children. When safety and security are threatened,
thoughts and feelings are likely to be expressed in the form of frightening dreams.
Understanding Common Behaviors
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Eating changes, more or less
Absentmindedness
Withdrawal from others
Avoiding places or people who remind one of deceased
Searching and crying out for the deceased
Sighing
Crying
Talking about death and dying with children and adolescents
Children and Adolescents go through stages of awareness of death as they pass along the
developmental path. The interventions we use should be guided by these stages. Stage of depth
conceptualization should always be assessed. Adults are often reluctant to talk about death and
dying with children however children are aware of death through fairy tales, games, TV,
overhearing adult conversations, religious instruction, and attendance at funerals. If we permit
children to talk about death we can prepare then for crisis, and help them when upset, and address
any fears.
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We can make it easier for them if we are honest and open.
What children sense or overhear may be worse than the truth.
At each developmental stage, the child’s perceptions and concepts of death change because he or
she reaches a different level of cognitive development, possesses a greater storehouse of
experience, and has new ideas about the world.
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Assessing death conceptualization in children and adolescents
Prior commencement of either grief or loss counseling or telling a child about their impending
death it is essential to counseling it is important that the counselor assess the child’s
conceptualization of death.
Key questions:
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“What does dead mean?”
“Can dead people come back to life again?”
“Tell me what you know about dying or dead people”
“Can dead people get hungry?”
“Can dead people feel things like pain”
Give examples of each.
Additional questions to ask children:
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‘Have you heard adults talking about death? What did they say about it?’
“Have you ever had someone close to you or a pet die?” “What happened?”
“Does everybody and animal die?”
“Why do things die?”
Summary of Developmental stages and death conceptualization:
Infant death conceptualization
Up to age two - no formal concept of death
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Infant’s awareness of the world is narrow – awareness of mother, physical being and
separation.
Needs for warmth, physical contact and consistency
Infants grieve the loss of a loved one they were used to being with. Before children can talk, they
communicate with sounds of crying, cooing, body language, and physical symptoms such as colic
and fretfulness. Grieving babies can be difficult to console. If a surviving parent or family
members are grieving, too, chances are that the baby will sense their distress. It may also be
difficult for them to remember all the needs of an infant when they are upset. Counselors can
help in these circumstances with looking at supports for families. Ask, friends or your groups or
religious or NGO community to help with a toddler's or baby's care whilst the family is in crisis.
Death conceptualization -Pre-school age (2-4)
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Fear of abandonment
Preoccupation with physical function –
“How does he play now he is dead” “He will get hungry if mummy can’t feed him”
Death is impermanent, reversible
Confusion with sleeping ( fear development)
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As children learn to utilize our symbolic language of words, they can begin to share feelings
verbally. They learn what sad, mad, and scared mean. They communicate about the concrete
world: what they can see, touch, hear, taste and smell. The future, the idea of “never”, is outside
their understanding. They fully expect the return of their loved one.
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“If I am a good boy my mummy will come back”
Children will seek out the dead people – continually ask where that person has gone
and may even look for them.
Death conceptualization – 5-9 years
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15% of children think about death at night and believe people die at night.
Death comes from an external source – a monster, ghost, or angel that takes people
away.
Death is something that can be “outwitted” or escaped
Often exposure to death has been on TV or seeing a dead animal.
Death is associated with “mutilation” and horrible images.
Children will often shock adults with detailed questions about decayed bodies and
mutilation of bodies.
Death is seen as a punishment
Children will try to make bargains with death. “If I do a certain thing mummy will
not die or I will not die”
Key fears around death:
- Fear of losing another parent or family member
- Fear I will die at same age as the deceased
- Fear of going to sleep
- Fear of separation
- Fear of protection loss
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Children often show an interest in burial and ceremonies associated with death.
Death conceptualization – (9-12 years)
Majority of children realize death is the end of life and is permanent.
Death is increasingly seen as a biological process.
More conscious of the consequences of death e.g. “Will my bother be lonely” “Will I
have to move when mum and dad die?”
Around the age of six, children begin to understand that the loved one is not returning. This can
bring about a multitude of feelings at the time of other significant changes in a child's life,
including entering first grade. Children who do not remember their parent may feel an acute sense
of loss as they see peers with their parents and hear their family stories. Children at this age are
increasingly interested in biological processes about what happened to their loved one. Questions
about disease processes and what happens to the body are of keen interest. When asked questions,
it is important to clarify what it is the child wants to know.
Children's worlds are sometimes messy and have a high level of energy. Grief is also messy
sometimes. It does not always take a form that makes adults comfortable. Parents and caregivers
should be informed that allowing your child to express feelings through creative, even messy,
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play can be helpful (i.e. finger painting, making mud pies and throwing them, etc). The counselor
or parents may want to join in the creative play.
Death conceptualization –Adolescents
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Understood as an abstract concept by teenagers
Death is distant
Fear of death
Testing mortality “driving fast” etc
Adolescents are more likely to engage in high-risk behavior, especially after a death loss. One
young person expressed that her friend was always careful and followed all the safety rules, but
died anyway. She asked, “Why should I be careful?”
Teenagers are usually in a place of growing independence. Teenagers living on the streets for
many years will have often a veneer of adult toughness. They may feel a need to hide their
feelings of grief to show their control of themselves and their environment. Teens often prefer to
talk with peers rather than adults when they are grieving.
Basic Principles of Informing a Child of a Death
 Keep it simple. Use “died”, not “He is sleeping.”
(I.e.: “Tanveer, there was an accident on the street today. Your best friend was walking on
street and was hit by a car and he fell down to the ground. The fall was so far and so hard
that he died.”)
 Allow the child/adolescent to express raw feelings freely or ask questions
 Answer questions honestly and simply. Do not go into detail, unless asked. Offer only as
much detailed information as is requested.
 If the death was due to a violent crime, explain how the child/adolescent can remain safe.
 If the body is suitable for viewing, allow the child/adolescent to see the deceased loved
one, if requested. Prepare the child/adolescent for what he or she will see.
 Tell the child/adolescent what will be happening in the next few days.
 Give the child/adolescent choices in what to do. Some children want to go to school, or
continue to work or engage in their normal social activities the day of the death. Familiar
routines are comforting. Inform the school, or NGO that the child/adolescent attends of
the death before the child attends returns.
 Reassure to the child that he or she will be cared for and explain the plan.
Counseling Tasks and Interventions
There are four key tasks that children work through as they mourn a loss. These tasks include
understanding, grieving, commemorating, and moving on. One of the first questions asked when
a person has experienced a loss is “Why?” During the task of understanding, a child or adolescent
seeks to determine what caused the loss and why it happened. The task of grieving means
allowing children and adolescents to experience the painful feelings associated with a loss. In
commemorating a loss, children and adolescents are encouraged to develop a personally
meaningful way to affirm and remember the lost person or object. The last task in the process of
mourning is the task of going on. During this task children and adolescents discover new ways to
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“maintain an inner connection with and representation of the deceased as they develop other
friendships, attend school, play, and perform all the things that shape their daily lives”
Several interventions have been found to be useful in helping children and adolescents tackle the
tasks of mourning that they are faced with. Activities such as using loss genograms 2; play
therapy; narrative therapy, such as a “Letter to Loss”; art therapy, such as drawing a picture of
“What happens when someone dies?”; or assisting the child or adolescent to commemorate the
loved one or object by creating a CD, tape, journal, or scrapbook are just some of the
interventions we have found to be effective with this population.
Appropriate communications
Offering support to a grieving child can begin with a simple statement or open-ended question.
Here are some conversation starters:
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I’m sorry your mom/dad/sister/boyfriend/girlfriend/husband/wife has died.
What was your mom/dad/sister/boyfriend/girlfriend/husband/wife like?
Tell me about your__________.
What was his/her favorite food?
What do you miss the most?
What is the hardest part for you?
What is the hardest time of day for you?
I cannot know how you feel, but I remember how I felt when my __________ died.
I care about you.
I care about how you are feeling.
Would you like to talk about it?
I’m available at this time, if you would like to come by to talk.
Whenever you want to talk about it, I’m here for you.
I’m thinking about you especially today because I’m aware that today is your friend’s
birthday (anniversary of the death, your birthday, etc).
I’m here to listen if you want to talk, or just spend time together if you don’t want to talk.
Avoiding words that can hurt
The following are a few of the potentially harmful comments that are often offered to
children/adolescents grieving the loss of someone who is important to them
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2
I know just how you feel.
I know just how you feel…my dog died last year.
Lick your wounds and move on.
You’ll get over it.
It will be okay.
Don’t think about it.
You are better off without him.
Don’t cry.
It’s your fault.
You drove your father to drink.
The genogram is a map of family process.
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If only you had ___________________.
Tears won’t bring her back.
Be strong.
Forget about it.
You are the man/woman of the house now.
You should feel…. (proud, relieved, happy, sad, etc.)
Suicide and Grief
The death of a loved one through suicide is very difficult to face. This painful loss leaves many
questions for adults and children. Often the child/adolescent left behind may wonder what signs
they missed or how they might have prevented it. They may be feeling very angry, deeply hurt or
guilty. They need to hear from the counselor that suicide of a loved one or friend is not their fault.
When counseling adolescents we can offer the following information about suicide:
“People who have come close to completing suicide say that in those moments the mental pain or
anguish is overwhelming. They cannot see beyond the pain to consider how their actions might
hurt loved ones. Research studies clearly indicate the biochemical components of depression (a
physical reaction inside the body). While not all deaths by suicide may be associated with
depression, many are”
It is reasonable to explain to a child that a death by suicide is the result of illness that is hard to
understand. It is important for a child to understand that the loved one was not thinking clearly.
He or she just wanted the pain to stop. At the time a parent completes suicide he or she is very
likely not thinking that their children and other loved ones will feel abandoned and betrayed.
You may be reluctant to tell a child that a loved one completed suicide. Most children can handle
the truth about a death.
Conclusions
Counselors need to work carefully to address the Grief and Bereavement counseling needs of
MARA. Too often adults take the street toughness as a sign of a child/adolescents adjustment to
a death. Disordered mourning results from a lack of psychological processing of normal grief
reactions. Disordered mourning has been associated with suicide, increased HIV transmission
risk behavior, increased substance use and accidental overdose. Disordered mourning has also
led to children/adolescents being increasingly vulnerable to physical, emotional and sexual abuse.
The following two pages include some a summary of age/developmentally appropriate
interventions.
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How to Help Someone Suffering from Loss
DO let your genuine concern and caring show.
DO be available... to listen or to help with whatever else seems needed at the time.
DO say you are sorry about what happened and about their pain.
DO allow them to express as much unhappiness as they are feeling at the moment and are willing
to share.
DO encourage them to be patient with themselves, not to expect too much of themselves and not
to impose any “shoulds” on themselves.
DO allow them to talk about their loss as much and as often as they want to.
DO talk about the special, endearing qualities of the person they've lost.
DO remember they continue to need your caring and support after the first few weeks or months
have passed.
DON'T let your own sense of helplessness keep you from reaching out.
DON'T avoid them because you are uncomfortable (being avoided by friends adds pain to an
already painful experience.)
DON'T say that you "know how they feel". (Unless you've experienced their loss yourself you
probably don't know how they feel.)
DON'T say "you ought to be feeling better by now" or anything else that implies a judgment
about their feelings.
DON'T tell them what they should feel or do.
DON'T change the subject when they mention their loss or their loved one.
DON'T avoid mentioning their loss out of fear of reminding them of their pain (You can be sure
they haven't forgotten it.
DON'T try to find something positive (e.g. a moral lesson, closer family ties, etc.) about the loss.
DON'T point out “at least they have their other …”
DON'T say they “can always have another ...”
DON'T suggest that they “should be grateful for their so-and-so...” DON'T make any comments
which in any way suggest that their loss was their fault (there will be enough feelings of doubt
and guilt without any help from their friends).
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MODULE 3: Session Plan
Talking about Grief, Loss and Death with MARA
Session objectives:
At the end of the training session, trainees will be able to:
 Provide developmentally appropriate grief and Loss counseling to MARA
 Provide appropriate advice to parents, guardians and caregivers about grief and loss
issues impacting on MARA
 Develop communication strategies to discuss death with MARA
Time to complete module: 3 hours
Training materials
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PowerPoint Presentation (PPT 03) and Handout
Activity sheets(AS 03) to be handed out during session
Learning Notes (LN 03) included in participant folders
Counseling Tool (T 03)
Flip chart paper, color pencils and crayons, dolls
Question box
Content
Common types of loss experienced by MARA
Common emotional, physical & psychological responses to loss in MARA
Developmental concepts related to death
Talking about loss, grief and death with MARA
Counseling strategies for grief and bereavement
Session instructions
 Commence PowerPoint presentation pausing briefly after the first PPT to ask the group
for other unlisted common types of loss experienced by MARA then continue with the
presentation actively involving the group in discussion until you reach Activity 1
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 Activity 1 (Total time is 20 minutes)
Instruct the class to read the Lecture Notes section “Navigating Children’s Grief” and to
discuss in their table groups the behaviors, emotions and physical reactions with MARA.
Discuss any additional manifestations of grief that they have seen in these clients.
 Continue with the PowerPoint presentation until you reach Activity 2.
 Activity 2 (Total time 45 minutes)
Allow 20 minutes=small groups discussion; 25 minutes large discussion
Ask the groups to review the Lecture Notes in the section “Avoiding Words that Hurt”.
Instruct the group to look at each item mentioned and to discuss and consider what the
potential psychological and/or behavior consequences of using each of these remarks to
be.
 Activity 3 (Total time 1 hour)
30 minutes=group work
30 minutes feedback =5 minutes feedback to the class for each group and then final
comment from trainer.
Form four groups and assign one case per group. Provide the following instructions. Ask
the groups to nominate one person to present the group findings to the group
Explain that the task is to discuss what needs to be discussed in relationship to death and
dying for the specific case.
Add any drawings or describe activities you wish to use to provide developmentally
appropriate information and techniques (Drawings, stories, activities)
Cases provided on activity AS03:
Group 1 – You are working with an adolescent girl 14 years old from a poor urban
family whose father a former trucker has died of AIDS. The girl has become involved in
sex work to help support her grieving mother who is also ill. The girl is dismissive of
any grief reaction saying she now has a lot of friends and that her life is ok. She
acknowledges the sex work places her at risk however she says she has no choice. She
says that we all will die anyway.
Group 2 – You are providing counseling to a street youth18 who has HIV and requires
hospitalization for palliative care. He is in late stage HIV and asks is he going to die. He
tells you that he is frightened, and that his family rejected him a long time ago when they
found he was having sex with other boys. He lives on the streets and relies on begging
and stealing to survive.
Group 3 – Your client is 8 years old boy. His father died 1 year ago and his mother a
former sex worker is currently ill with HIV. The child spends a lot of time on the streets
with older youth and has come to the attention of your service. After meeting with his
mother she asks you to prepare him for her possible death. She was initially resistant to
58
this but when the boy refused to live with her parents and ran away from home she
agreed he should be told.
Group 4 – Your client is a 16 year old girl whose older husband is dying from AIDS.
She was forced to marry this man. He did not disclose his HIV status to her parents or to
her. He frequently forced her to have unprotected sex with him. She reports he
frequently abused her as he complained she was a poor wife. She feels she should have
looked after him better. She has been shunned by people in her village and relies on
begging for food. She has been getting sick herself and fears she will die. She asks will
she die soon. She is too afraid to seek medical assistance.
 Summarize the session on the key learning points.
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MODULE 3: Counseling Tools
Talking about Grief, Loss and Death with MARA
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MODULE 4: Lecture Notes
Substance Use, HIV and MARA - Special focus: Solvents and Inhalants
Key learning points:
At the end of the training session, trainees will be able to:
 Conduct a drug use assessment;
 Identify clients who may be using volatile substances;
 Educate clients about the links between volatile substances (inhalants and solvents);
 Educate clients about life saving procedures for drug overdose management.
HIV counseling and Injecting Drug Use
Counselors who work in HIV and other health services may work with injecting drug users in a
number of different ways including:
 Providing counseling associated with HIV testing;
 Providing counseling to facilitate transmission risk reduction, including counseling and
referral to assist clients modify of their drug use;
 Supporting clients, their partner and families to adapt to living with HIV;
 Supporting the client to achieve HIV and other medical treatment adherence;
 Offering palliative counseling to clients who are in the final stages of their life.
In order to offer effective counseling support to clients, counselors will need to address drug use
and drug dependency as well as the psychosocial issue that confront drug users at these various
points of service.
Counseling for behavior change
It is important that counselors conduct a drug use history as this will provide you with important
information that will assist you with making appropriate referrals and providing appropriate
counseling interventions.
It is critical to assess how motivated the client is to change his/her drug use. Each individual will
be at a different “readiness” to change. Some clients may not feel their drug use is a problem and
they may wish to continue using drugs. Others may want to stop using drugs and may be more
ready to start treatment for their drug use. Clearly, a client’s attitude will determine what type of
intervention is appropriate and will influence the outcome of this intervention. By encouraging
the client to talk about his/her drug use and examine the impact it has upon his/her life the
assessment process itself can form the first part of the intervention and can help promote or
68
initiate a change in the client’s drug using behavior. It is important to make the most of this
opportunity.
Recognizing drug use - sign and symptoms:
Drug use is commonly under-reported and can be missed if not asked about specifically. Drug
use, especially dependent drug use, can have a significant impact upon a client’s health and can
complicate the treatment of other conditions. A client who is drug dependent is more likely to
adhere to HIV transmission risk reduction or HIV/STI/TB treatment regime if he/she is receiving
treatment for his/her drug dependence. Drug use, and in particular injecting drug use, is a major
risk factor for blood borne virus transmission. A counselor should be aware of a client’s drug use
so he/she can provide his/her client with information and advice on how to reduce this risk. It is
important that a drug use assessment is carried out in pre HIV test counseling as part of risk
assessment, and in any behavior change counseling session, and in supportive post diagnosis
counseling sessions. Drug use and adherence transmission risk reduction adherence requires
ongoing supervision and support across the disease continuum. It is important to focus on all
aspects of drug and alcohol use and not simply on a clients injecting drug use. Clients should
also understand the relationship between sexual transmission and all types of drug use. Different
people use drugs in different ways. A client may also use drugs in different ways at different
times of his/her life. To get a clear idea of a client’s drug use it is necessary to determine the
following:
 What drugs a client currently uses
 What drugs a client has used in the past
 How a client has used these drugs, including a client’s pattern of drug use
 Whether the client is dependent upon these drugs
 Whether this drug use is causing problems in the clients life
 How the client feels about his/her drug use and whether or not he/she wants to change
his/her drug use behavior.
Because of the stigma associated with drug use a client may be reluctant to disclose his/her drug
use:
 A client may feel embarrassed about his/her drug use and may fear being judged because
of it.
 A client may be scared that he/she may receive inferior treatment after admitting that
he/she uses drugs.
 A client may be scared that admitting to drug use during a consultation may be
incriminating (i.e. result in suffering legal consequences).
 A client may not see his/her drug use as a problem or may believe that it is not important
to mention it to a doctor.
Overcoming reluctance to disclose drug use:
To gather the information needed for a complete drug use history it is important to overcome a
client’s reluctance to talk about drug use.
The client must feel that they can trust the counselor and that it is safe for them to be open and
honest. To achieve this, a counselor should:
 Maintain a non-judgmental attitude
 Acknowledge to the client that drug use can be difficult to talk about
 Assure the client that the consultation is confidential
 Obtain the client’s informed consent before taking a drug use history
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Identifying drugs used:
Drug use is common. Use of some of drugs may be legal – use of others may be illegal. People
who use drugs commonly use, or have used, more than one drug. Certain drug using behaviors
may not be problematic – but use of any drug may be problematic for some people. It is important
to identify all drugs, legal and illicit, injected or non-injected that a client has used. This includes
drugs that he/she uses currently and any used in the past. It is important to ask about specifically
about all the drugs listed below otherwise it is possible to miss identifying the client’s use of a
drug. Ask: “Have you ever used [name of drug] before?”
 Alcohol (beer, wine, spirits etc.)
 Tobacco (cigarettes, chewing tobacco etc.)
 Cannabis (marijuana, hashish, charas, kif etc)
 Opiates (Opium, heroin, methadone and other opioids)
 Meth-amphetamine and amphetamines
 Other amphetamine type substances such as ecstasy (MDMA)
 Cocaine (coke, crack cocaine etc.)
 Hallucinogens (LSD, hallucinogenic mushrooms, PCP, ketamine etc)
 Inhalants (nitrous oxide, petrol, glue etc)
 Sedatives or sleeping pills (benzodiazepines, barbiturates etc)
 Any other substances – If a client has used any other substance not listed above have
him/her specify what it is.
Determining the pattern of drug use:
Because people use drugs differently over time it is important to gain an understanding of a
client’s pattern of drug use. The pattern for each drug used should be determined. Drug use
patterns can be asked about as follows:
 How old were you when you first used [name of drug]?
 How long did you use [name of drug] like this?
 When did that change?
 What was the pattern after that?
 How long did you use [name of drug] like this…etc…
 How often and in what amounts have you used [name of drug] in the last three months?
 When did you last use [name of drug]?
Assessment of drug use
Here is a checklist that can be administered by a counselor or done as a self checklist:
 Are you using more drugs or alcohol than you used to get the same effect?
 Are you using drugs or alcohol more frequently than you used to?
 Do you use drugs or drink alcohol on your own?
 Do you lie about your using - i.e. how much, how often etc. - to your family or
friends?
 Has your drug or alcohol use ever caused you any money problems? Problems at
work?
 Do you regularly take more drugs or alcohol than you originally intended?
 Have any of your family or friends voiced concern about your drug use or drinking?
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Have you ever made any effort to cut down or stop your drug or alcohol use? Did it
fail?
Are you using drugs or drinking alcohol more or less continuously now?
Do you think you have a drug problem?
If answered "yes" to ANY of these questions - then it's quite likely that the client is dependent on
drugs or alcohol.
Volatile substance use (Inhalant-solvent)
Use also has a potential adverse impact on the health status of HIV infected individuals and
reduces HIV treatment adherence. It is essential that counselors consider the client’s use of
inhalants when assessing client support needs. Most of the people who use solvents and aerosols
are young - between 10 and 16 years old. Many try inhalants only once or twice, or use them only
on occasion. But some people use heavily and may continue using into adulthood. Chronic
solvent users are usually in their 20s. Solvent use is associated with poverty, difficulty at school,
and lack of opportunity, problems at home and a high incidence of substance use in the family.
Inhalant abuse or Volatile substance abuse (VSA)

Do include questions about inhalants3 or ‘sniffing’ ("Samad Bond" glue seems to be very
popular) as one possibility when you are talking with young clients about drug and
alcohol use. Your clients may not consider substances that they inhale as “drugs.”
However, inhaling the fumes from domestic and industrial products creates a strong
intoxication and, over time, can cause permanent damage to the body and brain. The
practice is becoming increasingly common in Pakistan. 4

Common users of inhalants are working or street youth – the youth who are also
vulnerable to STIs including HIV. Just like drugs and alcohol, inhaling may contribute to
behaviors risky for STI or HIV infection.

Working or street youth may be strongly influenced by their ‘gang’ or network. Inhaling
is frequently a group activity, with youth pooling money to buy substances. Participation
may also be a ‘requirement’ for continued acceptance by a group. Group acceptance may
also include unprotected sex with group ‘leaders’ or others in the hierarchy.
Substances commonly inhaled include:
1. Volatile solvents: Liquids that evaporate quickly at room temperature.

Industrial or household solvents or solvent-containing products, including paint thinners
or paint removers, degreasers, dry-cleaning fluids and fast drying glues and adhesives
3
The name "inhalants" describes any chemical that is inhaled through the mouth or nose for the
purpose of getting "high."
4
See “Solvent Abuse among Street Children in Pakistan.” The United Nations System in
Pakistan, Islamabad. 2004.This document can be downloaded from
http://www.un.org.pk/undcp/glue%20sniffing.pdf
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
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Paint-on correction fluids, permanent felt-tip-marker fluid, and electronic contact
cleaners
Nail polish remover, lighter fluids, cleaning products
Petrol and petroleum products
2. Aerosols: Anything that comes from an aerosol can.

Household aerosol propellants such as those in spray paints, hair or deodorant sprays,
fabric protector sprays, and aerosol computer cleaning products
3. Gases
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
Gases used in household or commercial products, including butane lighters and propane
tanks, whipped cream aerosols or dispensers (whippets), and refrigerant gases
Medical anesthetic gases, such as ether, chloroform, halothane, and nitrous oxide
("laughing gas")
 Helium, Freon (gas from air conditioners,
refrigerators or other cooling equipment)
4. Nitrites include nitrates or gases used in medical
anesthesia or some household products.
 Amyl nitrite is a prescription drug to treat
angina. The nitrites are sealed in capsules
and are "popped" to release the vapors and
are referred to as "poppers" in street
language.

Volatile nitrites are often sold in small
brown bottles and labeled as "video head
cleaner," "room odorizer," "leather cleaner
“or” liquid aroma."
In South Asia, three of the most widely abused
inhalants are superglues manufactured, toluenes (in
paint thinners), petrol and Iodex, a muscle stress
relieving balm.
Youth working in transportation centers such as bus
or truck stands will have easy access to solvents,
fuels and paints that can be inhaled.
Many youth will be using more than one substance,
depending on preferences and availability and costs.
How are these substances used?
Inhalants may be sniffed directly from an open
container or inhaled from a rag soaked in the
substance and held to the face. As an alternative,
open containers or soaked rags can be placed in a
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bag where the vapors can concentrate before being inhaled.
Inhalant users inhale vapors or aerosol propellant gases using plastic bags held over the mouth or
by breathing from an open container of solvents, such as gasoline or paint thinner.
Nitrous oxide gases from spray products such as aerosol hairspray are sprayed into plastic bags;
some users may filter the aerosolized particles out with a rag. Some gases such as propane and
butane gases are inhaled directly from the canister. Permanent drawing markers can be put into a
plastic bag and then stepped on and crushed to breathe the vapors. Vapors from pocket lighters
are inhaled through the nostrils.
What are the desired effects of inhaling?
Inhaling these chemicals generally produces a feeling similar to alcohol intoxication. Users
describe feelings of warmth, emotional distance and relaxation.
Nitrites are known for the speed and intensity of their effects: A nitrite rush is near-instantaneous,
but fades almost as quickly, leading most users to inhale more -- and often, more and more. Some
substances also produce hallucinations.
How do inhalants ‘work’ in the
body?
The solvents or gases are inhaled into
the lungs and are quickly absorbed by
the capillary surface of the lungs. The
substance
rapidly
enters
the
bloodstream and the brain and cause
effects by working directly on the
brain/central nervous system.
The intoxication effects can occur so
quickly that the effects of inhalation
can be similar to the intensity of
effects produced by intravenous
injection of other psychoactive drugs.5
The intoxicating effects are short-lived
but intense. Since the effects do not
last long, repeated inhaling is needed
to maintain the effects.
Nitrites affect the body somewhat differently than other solvents:
Nitrites act primarily to dilate blood vessels and relax the muscles.
5
http://www.usdoj.gov/dea/concern/concern.htm
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While other inhalants are used to alter mood, nitrites are used primarily as sexual enhancers.
Use of inhalants can cause brain, nerve, liver and other damage to the body.
How inhalants, or any drugs, affect an individual depends on a number of factors:

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
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

the age
how sensitive s/he are to the drug
how much is used
how long and how often s/he has been using it
the method you used to take the drug
the environment the person functions in
whether or not the individual has certain pre-existing medical or psychiatric conditions
if the individual has taken any alcohol or other drugs (illicit, prescription, over-thecounter or herbal)
What are the signs or symptoms or inhalant abuse?

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Paint or stains on body or clothing
Spots or sores around the mouth
Red or runny nose
Watery, red eyes
Chemical breath odor
Drunk, dazed or dizzy appearance
Drowsiness or unconsciousness
Reduced attendance in school, Lower
grades or poor attendance at or
attention to work
Anxiety, excitability, irritability
Inability to concentrate
Substance odor on breath and clothes
Poor muscle control
Change in sleep patterns
Prefers group activity to being alone
Nausea, loss of appetite
Loss of interest in normal daily
activities
Long term effects:6
Most inhalants are extremely toxic and chronic use of inhalants
has been associated with a number of serious health problems.
The most significant toxic effect of chronic exposure to
inhalants is widespread and long-lasting damage to the brain
and other parts of the nervous system: memory impairment,
attention deficits, and diminished non-verbal intelligence and
even severe dementia.
Extensive exposure to inhalants can also cause loss of feeling,
vision and hearing and difficulties in coordination of
movement or limb spasms, all due to damage to areas of the
brain.
Sniffing glue and paint thinner causes kidney abnormalities,
while sniffing the solvents toluene and trichloroethylene cause
liver damage. The heart and lungs may also be affected.
6
http://www.starliterecovery.com/inhalants.asp [picture of brain]
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Although some of the damage to the nervous and other organ systems may be at least partially
reversible when inhalant abuse is stopped, many of the problems are irreversible.
In addition, research indicates that inhaling nitrites depletes many cells in the immune system and
impairs immune system mechanisms that fight infectious diseases.
Frequent or long-term use of nitrites can pose additional risks, including:
 Glaucoma leading to blindness: Nitrites increase pressure in the nerves and blood vessels
in the eyes.
 Blood Cell Damage: Nitrites damage red blood cells and may cause an often-fatal anemia
in which blood can no longer transport oxygen. This type of poisoning happens most
often to users who swallow (rather than sniff) the chemical and requires immediate
medical treatment.
Death from Volatile Substance Abuse (VSA)
Prolonged inhaling of the highly concentrated chemicals in solvents or aerosol sprays can cause
irregular and rapid heart rhythms and lead to heart failure and death within minutes of a session
of prolonged sniffing. This syndrome is known as "sudden sniffing death." This can result from a
single session of inhalant use by an otherwise healthy young person.
Sudden sniffing death is particularly associated with the abuse of butane, propane, and chemicals
in aerosols.
Inhalant abuse also can cause death by:7

Asphyxiation - from repeated inhalations, which lead to high concentrations of inhaled
fumes displacing the available oxygen in the lungs. This is especially a risk with
heavier than air vapors such as butane or gasoline vapor.

Suffocation - from blocking air from entering the lungs when inhaling fumes from a
plastic bag placed over the head

Convulsions or seizures - caused by abnormal electrical discharges in the brain

Coma - the brain shuts down all but the most vital functions

Choking - from inhalation of vomit after inhalant use

Fatal injury - from accidents, including motor vehicle fatalities, suffered while
intoxicated

Spraying butane directly into the throat, the jet of fluid can cool rapidly to –20 °C by
expansion, causing prolonged spasm of the larynx (throat) and suffocation.

The anesthetic gases present in the inhalants appear to sensitize the user to adrenaline.
When intoxicated, a sudden surge of adrenaline (e.g., from a frightening hallucination
or run-in with the law), can cause a fatal cardiac arrhythmia (disturbances regularity of
heartbeat).
Actual overdose from the drug does occur, however, and indeed inhaled solvent abuse is
statistically more likely to result in life-threatening respiratory depression than intravenous use
of opiates such as heroin.8
7
http://www.nida.nih.gov/ResearchReports/Inhalants/Inhalants4.html
8
http://www.drugabuse.gov/pdf/monographs/148.pdf
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Withdrawal
While not considered physiologically addictive, young people who stop using may experience
emotional ‘withdrawal’ symptoms. Depending on the substance, these may include:
 Anger,
 Irritability,
 Generalized aches and pains
Drug and alcohol interactions, including ARVs
There is no literature describing interactions of inhalants and medications, including ARVs.
However:
 Liver and kidney damage – inability to clear drugs normally, build up to toxicity
 Confusion and intoxication – forgetting to take medications on schedule
 Inhaling nitrites depletes many cells in the immune system and impairs immune system
mechanisms that fight infectious diseases.
 Researchers believe that nitrites may impair immune response and contribute to the onset
of secondary infections often seen in people with AIDS
Other problems: poor nutrition due to nausea, loss of appetite. Young people may be using
inhalants to overcome feelings of hunger when they can’t afford food. In many settings it will be
easy to have ‘free’ access to inhalants.
The methods of sharing do not pose any risk of blood-borne infection such as occurs through
sharing injecting drug solutions and equipment.
Individuals who abuse nitrites to enhance sexual function and pleasure may be more likely to
engage in unsafe sexual practices that greatly increase the risk of contracting and spreading such
infectious diseases as HIV/AIDS and hepatitis.
Referring for help for VSA rehabilitation
Unfortunately, few, if any, of the drug rehabilitation services in Pakistan deal with VSA.
Programs in other countries often focus on life skills and anger management.
Providing advice on harm reduction
It is critical counselor discuss the following way to reduce serious harm with clients who use.
Particularly dangerous practices include:
 Putting a plastic bag completely over the head
 Spraying directly into the mouth
 Having lighted cigarettes around due to risk of catching fire
 Mixing volatile substances with other drugs/alcohol
 Using alone
Providing advice on handling common emergencies
Emergencies generally relate to unconsciousness or cessation of breathing. Cardio Pulmonary
Resuscitation (CPR) skills are rare among the public. Peers should be taught to check for
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breathing, call for help and to place anyone who is unconscious in the ‘recovery position shown
below. This will prevent choking on vomit and prevent the tongue dropping back and causing
suffocation.
The recovery position for semi and unconscious individuals:
1. Make sure mouth is empty and there are no foreign objects in the mouth (e.g. loose dentures,
vomit) otherwise remove it
2. Open the airway by tilting the head back and lifting the chin. Straighten their legs
3. Place the arm nearest to you at right angles to their body
4. Pull the arm furthest from you across their chest
5. Hold the leg furthest from you above the knee and move it upward across their leg
6. Make sure the back of their hand is placed against the cheek nearest to you
7. Keep their hand pressed against their cheek and pull on the upper leg to roll them towards
you and onto their side
8. Tilt their head back to make sure they can breathe easily
9. Ensure the hip and knee of their upper leg are bent at right angles
The Recovery Position
If the person is conscious:

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
Make sure there is enough fresh air
Stay calm and keep the person calm
Don’t argue or struggle with the person
Remember: the effects of solvents generally pass quickly. After 5-20 minutes, they should
recover.
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MODULE 4: Session Plan
Substance Use, HIV and MARA - Special focus: Solvents and Inhalants
Session objectives:
At the conclusion of this module, trainees will be able to:
 Conduct a drug use assessment;
 Recognize signs and symptoms of use and withdrawal;
 Educate clients about the links between volatile substances( inhalants and solvents)and
HIV acquisition, transmission and disease progression;
 Educate clients about life saving procedures for drug overdose management
Time to complete module: 3 hours
Training materials
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PowerPoint Presentation (PPT 04) and Handout
Activity sheets(AS 04) to be handed out during session
Learning Notes (LN 04) included in participant folders
Counseling Tool (T 04)
OHP blank transparencies and blue and black marker pens
Question box
Content
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Drug use assessment review;
Types of volatile substances;
Use of volatile substance in Asia and Pakistan;
Methods of use;
Signs and symptoms of use and withdrawal;
Relationship between volatile substance use and HIV;
Client education
Session instructions
 Commence by lecturing with PowerPoint presentation (PPT04) until you reach the
activities.
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Activity 1
 Divide the class into groups based on geographical areas (province, districts etc).
 Handout the activity sheet (AS04). Ask trainees to carefully read the instructions for
activity 1.
 Provide each of the groups a blank OHP transparency sheet and marker pens
 Ask each group to appoint a group facilitator for the group discussion, one person to
record information on the OHP and another to present their answers to the large group.
 Debrief asking each group to report on their activities. Ask the other trainees to comment
on the presenting groups answers.
Activity 2: total time=1 hour
10 minutes for self study
20 minutes for group discussion
30 minutes for large group feedback
Activity 2 – Self study and group work (30 minutes)
Refresh your memory about the Stages of Model of counseling for behavior change. You first
studied this in a VCT training course. A summary has been reproduced here in the Counseling
Tool for this module (T4). Read it and reconsider how you would use different strategies at
different stages of client readiness for change.
Group work
Your client is a 13 year old boy who works with truckers. He has been sniffing petrol with
increasing frequency. He reports to you that all of his friends do it but that he can handle it and it
helps him get through the nights he spends on the streets. He has lost weight and admits he
doesn’t eat as much as he used too. He thinks sometimes he should not do it as it makes him a bit
sick. He thinks that he will get sick one day and then he will stop. He has only ever stopped
using once He stopped for two days only. He stopped using after being very intoxicated and was
beaten up on the street. He started sniffing again when he went on a long trip with the trucker he
works with.
Discuss in your groups
1. What stage of change is this boy likely to be at? Discuss your reasons for identifying this
stage.
2. What would be the appropriate counseling interventions to use at this stage? Be specific!
3. What are potential relapse triggers if he did stop again
Large group discussion: Ask each group to present their findings to the class. Encourage the
class to direct comments and questions to the presenting group.
a. Call for final questions prior to the end of the session.
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MODULE 4: Counseling Tool
Substance Use, HIV and MARA - Special focus: Solvents and Inhalants
Motivational Interviewing and Behaviour Change
Motivational interviewing is a counselling approach based on the principle that all human
behaviour is motivated. It acknowledges that many people experience ambivalence when
deciding to make changes – they both want and don’t want to change. It also acknowledges that
people can perceive both the advantages and disadvantages of changing, or continuing, with their
current drug use behaviour. The aim is not to immediately focus on the action of changing, but
working to enhance motivation to change.
What underlies the power of the motivational interviewing technique is that the client talks
herself or himself into changing the behaviour, rather than having it suggested or advised by
someone else.
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People may progress in these stages in a set order; however this is the exception rather than the
rule. Most people move within the cycle. When changing behaviours, people might relapse and
return to an earlier stage several times before they achieve their goals. Each time this happens
they will gain new information about their behaviour and will be able to apply that information in
the next attempt.
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Matching the intervention to the client’s “Stage of change"
Clients Stage of Change
Pre-contemplation
The client is not yet considering change or is
unwilling or unable to change.
Contemplation
The client acknowledges concerns and is
considering the possibility of change but is
ambivalent and uncertain.
Preparation
The client is committed to and planning to
make a change in the near future but is still
considering what to do.
Action
The client is actively taking steps to change but
has not yet reached a stable state.
Maintenance
The client has achieved initial goals such as
abstinence and is now working to maintain
gains.
Appropriate motivational strategies
 Establish rapport, ask permission, and
build trust.
 Raise doubts or concerns in the client
about. substance-using patterns
 Express concern about impact on
health and life style and keep the door
open for discussion.
 Normalize ambivalence about change.
 Help the client "tip the decisional
balance scales" toward change using
evidence from client life and health
information.
 Elicit and summarize self-motivational
statements of intent and commitment
from the client.
 Elicit ideas regarding the client's
perceived self-efficacy and
expectations regarding behaviour
change and treatment.
 Explore behaviour change treatment
expectancies and the client's role.
 Clarify the client's own goals.
 Negotiate a change--or treatment--plan
and behaviour contract.
 Consider and address barriers to
change.
 Help the client enlist social support.
 Engage the client in treatment and
reinforce the importance of remaining
in recovery.
 Acknowledge difficulties for the client
in early stages of change.
 Help the client identify high-risk
situations through a function analysis
and develop appropriate coping
strategies to overcome these.
 Support lifestyle changes.
 Affirm the client's resolve and selfefficacy.
 Help the client practice and use new
coping strategies to avoid a return to
use.
 Develop a "fire escape" plan if the
client resumes substance use.
 Review long-term goals with the client.
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Key Motivational interviewing techniques include:
1. Exploring importance: The positive and negative consequences. This can be called
decisional balancing which gives the client a more complete picture of their drug use. It
can also be a positive experience for the person as the worker is interested in what they
enjoy about their substance use ‘What are the good things about your cannabis use?’
‘What are some of the less good things?’
2. Scaling questions: The focus of these questions is to see how important the drug use is
to the person and how confident they are to change. Some may think it is important to
give up their drug use but not feel confident to do it. Others may feel confident they can
give up their drug of choice but see it as not important to them. (Pre-contemplators). Ask
questions such as: ‘On a scale of 0–5 how important is it for you to give up using
amphetamine?’ ‘On a scale of 0–5 how confident are you about giving up? Use scaling to
help quickly identify the most important areas to work on. You can then use this
information:
‘Why is it a 5?’ (Even if a ‘1’ ‘Why isn’t it a zero?’)
‘What will help keep you at this level?
‘What will help you move higher?’
‘How high does it have to be before you make an attempt to change?’
‘What can I do to help?’
3. Summarise and invite action: ‘Where does that leave you now?’ Don’t try to provide
solutions — invite the client to collaborate in providing a solution. The onus is then on
the client, not the worker, to make a decision to change. Express empathy, especially
about the difficulty of changing. Emphasise personal choice and control. Statements that
a client makes can be reframed slightly to create a new way of looking at change. 'I’ve
been to a counsellor before and they didn’t do anything for me.' The reply could be
'Maybe their approach did not suit you. Is there anything I can do to help?'
4. Building confidence: Ask questions to allow the client to build confidence in their
ability to change. ‘In the past, what has been helpful when you have tried to change your
drug use?’ 'Do you know anyone who has changed their drug use?' ‘Is there anything you
can learn from these past attempts?’ ‘Is there anything you can learn from other people’s
attempts to change?’
5. Exchanging information: .Providing information can be a useful strategy to provoke
thinking about change and to correct misconceptions about risks associated with drug
use. For example some people may be at a contemplation stage for needle sharing
practices but be pre-contemplators with regard to using condoms. It is important to
explore the personal implications of the information for the client. The worker wants to
raise doubts and to increase the client’s perception of the risks and problems associated
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with drug use. Do not use the information as evidence to push the client into change - this
is not the aim. 'How much do you already know about the risks of injecting?’ ‘Some
people find that …how about you?’ ‘How do you see the connection between your
amphetamine use and your sleeping problems?’ ‘Is there anything more you’d like to
know about injecting? Always follow up feedback of exchanging information by seeking
the client’s response.
6. Set goals: Goals are very important motivators. The more realistic, specific and
attainable the goals are, the greater their emotional impact will be. Since goals belong to
the client and can promote their feelings of self responsibility and confidence, goal
setting needs to be a collaborative process between worker and client. Effective goal
setting is:
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Consistent with the client’s ‘stage of change’ (e.g. a ‘pre-contemplator’ may
resist a goal of total abstinence, but may embrace reducing the risk of infection)
Negotiated with the client so they are more likely to commit to them.
Positive. Changing behaviour will be more successful if couched in positive
terms, (e.g. increasing the number of days without heavy alcohol use as opposed
to decreasing the number of drinking days).
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MODULE 5: Lecture Notes
MSM Sexuality and MARA Sexual Assault Survivors
Session Objectives:
After participating in this session participants will be able to:
 Discuss the relationship between sexual identity and HIV transmission risk
 Provide appropriate counseling to clients experiencing sexual identity issues
 Respond with appropriate strategies for counseling male sexual assault survivors
 Make appropriate referrals for male sexual assault survivors
 Exploring the psychosocial care issue of MSM are living with HIV
It is critical that MSM feel they can access health care throughout the disease continuum. Ability
to access health services alone however is not sufficient. MSM must feel that they can discuss
their sexual behavior, the social impact of the disease, difficulties with partner disclosure etc
without fear of discrimination and rejection by health providers. Clients need to feel that their
health providers can maintain confidentiality and provide non-judgmental services.
Definitions and Identities of Men who have Sex with Men (MSM)
The term men who have sex with men or MSM is meant to address all men who have sex with
men, regardless of their sexual identities. It is used because only a minority of men involved in
same sex behavior self-define as gay, bisexual or homosexual but may more aptly self-identify
using local social and sexual identities and behaviors. They do not consider their sexual
encounters with other men in terms of sexual identity or orientation. Many men, who have sex
with men self-identify as heterosexual rather than homosexual or bisexual, especially if they also
have sex with women, are married, only take the penetrative role in anal sex, and/or have sex with
men for money or convenience.
MSM includes various categories of men who may be distinguished according to the interplay of
variables such as:
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Their sexual identities, regardless of sexual behavior (gay, homosexual, heterosexual,
bisexual, and transgender, or their equivalents, and other identities)
Their acceptance of and openness about their non-mainstream sexual identities (open or
closeted)
Their sexual partners (male, female, and/or transgender)
Their reasons for having these sexual partners (natural preference, coercion or pressure,
commercial motivation, convenience or recreation, and/or being in an all-male
environment)
Their roles in specific sexual practices (penetrative, receptive, or both)
Their gender-related identities, roles and behavior (male or female, masculine or
feminine/effeminate, cross-dressing or gender-concordant dressing)
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Sexual orientation and sexual identity formation
There are several theories that describe the sexual orientation development of gay and lesbian
individuals. One of the widely quoted and respected theories of gay and lesbian identity
development was developed in 1979 by Vivian Cass. Cass described a process of six stages of
homosexual and lesbian identity development. Knowledge of these stages should guide the
counselor’s understanding of the clients’ thoughts, feelings, and behaviors, and therefore guide
the appropriate interventions. While these stages are sequential, some people might revisit stages
at different points in their life. HIV transmission risk behavior can be either directly or indirectly
related to the client’s sexual identity, it is therefore critical that counselors appreciate and assist in
psychologically processing their sexual identity.
A general guide to this can be located in Counseling Tool 5 in this module.
Let us examine descriptions of the six stages and their relationship to HIV transmission risk
behavior:
1. Identity confusion
•
•
•
•
An awareness of being different
Conscious denial common and avoids behavior that represents “gayness”
Where behavior was not avoided – discounting of behavior “it was just a kiss
between friends etc”
Risk related to not being prepared for sexual encounters e.g. not carrying
condoms
2. Identity comparison
•
•
•
•
Feelings of alienation, self loathing
Beginnings of a sense of loss of sense of self and the future ( e.g. being a father
etc)
Acknowledging that I am probably gay or bisexual
Risk taking may relate:
– To not being prepared (not carrying condoms because it “means” you intend
to have sex with men)
– Engaging in lots of sex with different female partners to publicly or
personally assert “masculinity” or “normalcy”
– Using substances such as alcohol to cope with feelings of attraction or having
sex with same sex
3. Identity tolerance
•
Cost-benefit evaluation of sexuality is subject to influence of other MSM &
heterosexuals.
– I may be gay and maybe I deserve to get infected!
– If I am gay it is inevitable that I will get infected anyway!
•
Lack of confidence about attractiveness can lead to doing whatever your partner
wants!
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–
He is really attractive and experienced at this type of sex, I better do
whatever he wants I may not get another chance.
–
Maybe I can afford to take some risks with the women I have sex with.
4. Identity acceptance
•
•
•
•
Increased association with gays & lesbians
Increased disclosure of sexuality to others who are viewed as supportive
Feelings of distress when others do not accept
Risk is related to need to feeling accepted by MSM and others
5. Identity pride
•
•
•
Heterosexuality can be devalued.
Judgmental attitudes to other less confident MSM
Potential risks
– Increased sexual risk taking with multiple partners to assert sexuality
– Making judgments that MSM partners are no risk because they mainly have sex
with women or are married
6. Identity synthesis
•
•
•
Level of anger and frustration is less and others acceptance or non acceptance matter less
Now sees self as gay but also as part of society
Less risk taking behavior may be possible as focusing on self and right to exist in society
Male Sexual assault, Sexual Identity and HIV
Many young men and women in Pakistan, particularly children living away from home on the
streets are a risk of sexual assault. Surveys have demonstrated that significant numbers of men
have been assaulted. Whether you're a man or a woman, sexual assault is a trauma. The trauma of
sexual assault involves losing control of your own body and possibly fearing death or injury.
There are certain ways that human beings react to trauma that are the same for men and women.
"Rape trauma syndrome" is a term that mental health professionals use to describe the common
reactions that occur for both men and women after sexual assault. "Rape trauma syndrome" is not
an illness or abnormal reaction but it is a normal reaction to an abnormal, traumatic event. In the
context of HIV the impact may be magnified, especially where an individual has become infected
as a result of sexual assault. Even where an individual’s infection cannot be attributed to the
assault the individual may perceive a connection. Though each person and situation is unique,
this checklist will help you to know the range of reactions that are normal to expect. Of course,
there are also ways that men are affected differently than women by sexual assault. Following the
list of universal reactions to sexual assault, we'll delve into some of the reactions to sexual assault
that are more unique to men.
Counselors have a duty to explore the potential for sexual assault with all of their clients
irrespective of gender. Counselors should address the many myths that surround male sexual
assault with their male clients.
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Counseling strategies – Addressing Myths
Counselors should directly address mistaken beliefs about male sexual assault with the survivor
and uncover the realities behind the myths. You could say let me share with you some common
beliefs other men and society in general have about male sexual assault. Let’s discuss them one
by one.
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Men can't be sexually assaulted - Men are sexually assaulted across many
socioeconomic, racial and age groups.
Only gay men are sexually assaulted – Current or future sexual orientation.
Heterosexual, gay and bisexual men are equally likely to be sexually assaulted.
Gay men sexually assault other men. Most men who sexually assault other men identify
themselves as heterosexual. This fact helps to highlight another reality -- that sexual
assault is about violence, anger, and control over another person, not lust or sexual
attraction.
Men cannot be sexually assaulted by women. Although the majority of perpetrators are
male, men can also be sexually assaulted by women for entrapment or financial gain.
Having erection or ejaculation during a sexual assault means you were aroused and
therefore not sexually assaulted or consented to sex. – The counselor should inform the
client that both “erection and ejaculation” are physiological responses physical
stimulation or even fear. Some perpetrators are aware how erection and ejaculation can
confuse a victim of sexual assault - this motivates them to manipulate their victims to the
point of erection or ejaculation to increase their feelings of control and to discourage
reporting of the crime.
Addressing fears that men who have been molested will themselves become perpetrators:
Some clients or relatives and friends may have heard and express fears that the sexually abused
will themselves become abusers. It is important for counselors to reassure the client or their
family that indeed most male victims of child sexual abuse do not become sex offenders. Often
sexual assault perpetrators will have grown up in families or experienced circumstances where
they experienced other types of physical violence or extreme psychological abuse. Sexual abuse
is rarely about sexual gratification but rather a form of control, degradation and physical abuse.
Checklist of Universal Reactions to Sexual Assault
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Emotional Shock: I feel numb. How can I be so calm? Why can't I cry?
Disbelief and/or Denial: Did it really happen? Why me? Maybe I just imagined it. It wasn't really rape.
Embarrassment: What will people think? I can't tell my family or friends.
Shame: I feel completely filthy, like there's something wrong with me. I can't get clean.
Guilt: I feel as if it's my fault, or I should've been able to stop it. If only I had...
Depression: How am I going to get through the next day/year etc? I'm so tired! I feel so hopeless.
Maybe I'd be better off dead
Powerlessness: Will I ever feel in control again?
Disorientation: I don't even know what day it is, or where I'm supposed to be. I keep forgetting things.
Flashbacks: I'm still re-living the assault! I keep seeing that face and feeling like it's happening all over
again.
Fear: I'm scared of everything. What if I have herpes or AIDS? I can't sleep because I'll have
nightmares. I'm afraid to go out. I'm afraid to be alone.
Anxiety: I'm having panic attacks. I can't breathe! I can't stop shaking. I feel overwhelmed.
Anger: I feel like killing the person who attacked me!
Physical Stress: My stomach (or head or back) aches all the time. I feel jittery and don't feel like eating.
From:http://www.utexas.edu/student/cmhc/booklets/maleassault/menassault.html#anchor997204
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Suicide risk in MSM and MSM Sexual assault survivors
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Suicide is a major risk in cases of depression. About 50% of people who kill themselves
are suffering from some form of depression. Men are around three times more likely to
kill themselves than women (although women attempt suicide more often).
Suicide is more common among men who are separated, widowed or divorced, and it's
more likely if they are heavy drinkers.
Over the last few years the suicide rate among men has increased globally, especially in
the 16–24 age group and in those working in agriculture.
Family, friends and even doctors are often reluctant to talk about suicide to someone who
is depressed in case it makes them more likely to attempt it, and the depressed person
him/herself often has the same concern. However, there's no evidence that this is the case.
In fact, a person with suicidal feelings normally finds sharing these a relief, not least
because it signals to those around them just how bad they feel – which increases the
possibility of getting some help.
Same-sex attracted (SSA) young people are at greater risk of family conflict; rejection by family
and friends particularly after ‘coming-out’ attempted and successful suicide; mental illness;
substance use and abuse; homelessness; victimization at school; truanting and not completing
school. The dynamics of family relationships often make it difficult for young people to feel safe
about ‘coming out’ instead preferring to keep their feelings hidden which can result in suicide
ideation and attempted suicide.
Persons identifying as homosexual are 2 to 7 times more likely than heterosexual comparison
groups to attempt suicide; between 31 and 63% have attempted suicide, with those living in rural
areas at higher risk. The risk is believed to be particularly high for adolescent gays at the time of
acknowledging their sexual orientation, and exacerbated by being subjected to community
violence, loss of friendship or family rejection. While there appears to be a link between sexual
orientation and suicide risk it should not be assumed that identifying as SSA is a mental illness or
will lead to mental illness.
MSM and Suicide risk in HIV
There are two periods when people with HIV are more likely to attempt suicide.
The first is when the person is initially diagnosed and suicide may occur as an impulsive response
to the emotional turmoil that follows.
The second period of high risk occurs late in the course of the disease when the central nervous
system complications of AIDS develop, capacity to earn income declines, and people feel they
are a burden of family members and carers. During the late stage of HIV infection people
experience adjustment issues associated with this stage of the disease, impairment of thinking,
and the possible complications of underlying changes in brain chemistry.
The psychosocial needs of HIV infected boys and adolescents who engage in male-to -male
sex
Whilst all individuals infected with HIV and their relevant support networks, such as family,
friends and partners, can experience profound emotional, social, behavioral and medical
consequences, young MSM experience these issues often at a time when they are coping with
issues related to their sexuality. Both the disease and the issues of sexuality disease have
significant implications for adjustments in family life, for sexual and social relations, for work
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and education, for spiritual beliefs and needs, for legal rights, and for civil rights. The
psychosocial issues are dynamic and are often different at different stages of the disease
continuum. The HIV disease demands from the infected individual and their significant others,
and health workers constant adaptation and adjustment.
Whilst all of the issues discussed in Module 2 Counseling Across the Disease Continuum will
need to be considered there are some additional issues to be considered for MSM.
Primary HIV infection (acute retroviral syndrome)
Researchers across many countries the risks of suicide in HIV found peak at or around diagnosis
and a second peak at the time of an AIDS diagnosis. MSM may be already dealing with issues
related to their sexuality prior to diagnosis and have experienced suicidal feelings related to their
sexuality, once diagnosed these feelings may be reactivated or exacerbated. Similarly many
MSM may feel isolated and stigmatized by the fact they have sex with other men. These feelings
may be exacerbated once they are diagnosed with HIV. Feelings of guilt related to sexuality may
be compounded by thoughts such as “I deserve this infection because I did something bad and
abnormal“. “I would not be infected if I did not have sex with men”. It may also make disclosure
to families difficult as they may want to know how the individual became infected.
During this stage it also possible that the men will experience some form of sexual dysfunction
such as lack of sexual desire or difficulties obtaining an erection. These problems typically do not
have a physical basis; rather they are a psychological reaction to the diagnosis or related
relationship difficulties indirectly or directly to the diagnosis. Some clients will respond to their
diagnosis by using indulging in excessive intake of alcohol/drug use.
Chronic phases of HIV illness - Asymptomatic
MSM may experience “denial of infection” in the absence of physical symptoms. Denial will
also be a strategy for coping with the realities of living life on the streets or in the difficult
circumstances that encounter MARA living in Pakistan who have many competing health and
urgent socioeconomic needs. Denial or “safe sex” fatigue may lead to unsafe sex and other
practices.
Chronic phases of HIV illness - Symptomatic
In this phase MSM may be acutely conscious of changes to personal appearance including
increased in dermatological complaints, muscle wasting and weight loss. Often MARA will start
to experience signs and symptoms of HIV and will respond to this by increasing the use of nonprescribed drugs to control symptoms or cope with the increasing psychosocial consequences of
infection.
During this stage HIV infected youth may experience HIV related sexual dysfunctions. The most
common sexual dysfunctions at this state include erectile maintenance problems and difficulty
with sexual climaxing (known as retarded ejaculation). Both of the dysfunctions make it more
difficult to use condoms. In the case of erectile maintenance the individual may be initially
aroused however during sex the erection subsides and the condom slips off! In the case of
“difficulty with climaxing” (retarded ejaculation) the individual is most likely to be come
frustrated and remove the condom in order to increase stimulation in order to ensure ejaculation
(climax) occurs. In addition, if either of these dysfunctions occurs on one occasion then clients
will be discouraged from using condoms on subsequent occasions. HIV also may have significant
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impact on individual’s capacity to derive income from sex-work and many MARA may require
referral to income generation scheme.
AIDS (clinical stage 4)
Within the Pakistan context often MSM experience abandonment at this stage. MSM who have
worked in sex work and have been living on the streets have few treatment care or support
options. If their same –sex behavior has become common knowledge those who are married may
have been rejected by female partners or their extended families, others will be living with
partners or children they have infected. The anticipatory grieving for further health decline and
loss of life at this at this stage is often compounded by other losses such as rejection and
loneliness.
Typically the HIV counselor’s casework will be dually focused on supporting the client in issues
related to sexuality and MARA lifestyle as well as focusing on HIV psychosocial issues.
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MODULE 5: Session Plan
MSM Sexuality and MARA Sexual Assault Survivors
Session objectives:
After participating in this session trainees will be able to:
 Discuss the relationship between sexual identity and HIV transmission risk;
 Provide appropriate counseling to clients experiencing sexual identity issues;
 Respond with appropriate strategies for counseling male sexual assault survivors
 Make appropriate referrals for male sexual assault survivors
 Exploring the psychosocial care issue of MSM are living with HIV
Time to complete module: 3 hours 20 minutes
Training materials
Activity sheet (AS05) handed out during activity
PPT 05 loaded into computer
PPT05 – Printed in Handout view distributed in participant folders.
LCD projector/screen
Overhead Projector
Lecture Notes (LN 05) - distributed in participant folders.
Counseling Tool (T05) – included in participant folders
OHP Master (OHP05) 3 one for each small group
Content
MSM same-sex behavior in Pakistan;
The relationship between sexual identity and HIV transmission risk;
Counseling male sexual assault survivors
HIV psychosocial care issues for MSM – the MARA perspective
Session instructions
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 Commence the PowerPoint presentation (PPT05)pausing at Activity 1
 Activity 1 Handout the module activity sheet (AS05).
Total time 20 minutes
10 minutes in small group
10 minutes large group discussion
Ask all the table groups to consider the various HIV transmission risk factors associated
with sexual identity (give example of a married man who has bought sex from other
men); sexual practices of MSM in Pakistan, and other critical issues demonstrated in the
survey (e.g. arrested during last six months time in prison, having unprotected sex with
other men in prison detention and getting out and then having sex with girlfriend).
 Continue with lecturing using PowerPoint presentation (PPT05). Until you reach
Activity 2.
 Activity 2(30) minutes total time)
Ask the class to read their Activity sheet. Activity 2
15 minutes small group
20 minutes large group discussion 4 Groups each 5 minutes presentations)
Provide the following instructions:
1. Nominate a group facilitator, a recorder and a presenter for the large group discussion
2. Discuss the potential impact of sexuality on the sexuality acceptance process.
3. Discuss the key messages about assault and sexuality that counselors should offer
clients who have been assaulted
4. Present your findings to the large on the overhead transparency provided.
a.
Continue with the PowerPoint presentation until you reach Activity 3.
b.
Activity 3( 30 minutes total time)
Large group discussion. Ask the group to respond to the following questions
1. What are the types of sexual assault perpetrated on young boys and
adolescents in Pakistan?
Discuss the setting in which the assaults occur;
What makes MARA vulnerable in each of the various settings?
The most common types of sexual assault (e.g. receptive anal; oral etc)
2. Discuss what services are available to sexually assaulted boys and
adolescents
 Continue with the PowerPoint presentation ensuring that you ask questions through out
your presentation to clarify trainee understanding. Stop at Activity 4
 Activity 4 Total time: 1 hour
30 minute small group work
30 minute large group feedback (10 minutes for each group)
Form 3 table groups allocate a case to each group. Provide the following instructions
1. In your table groups review the case allocated to your group.
2. Nominate a group facilitator, a recorder, and a presenter to present the findings to
the large group
3. Discuss the key issues and strategies. Using the following format record your
answers on the supplied OHP master
At the conclusion of the small group time call each group to present their findings to
the group. At the conclusion of the presentation call for comments from the class.
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MODULE 5: Counseling Tools
MSM Sexuality and MARA Sexual Assault Survivors
Same Sex Behavior and Commonly Asked Questions and Answers
American Psychological Association
Source: http://www.apa.org/topics/orientation.html#whatcauses
What Is Sexual Orientation?
Sexual Orientation is an enduring emotional, romantic, sexual or affectional attraction to another
person. It is easily distinguished from other components of sexuality including biological sex,
gender identity (the psychological sense of being male or female) and the social gender role
(adherence to cultural norms for feminine and masculine behavior).
Sexual orientation exists along a continuum that ranges from exclusive homosexuality to
exclusive heterosexuality and includes various forms of bisexuality. Bisexual persons can
experience sexual, emotional and affectional attraction to both their own sex and the opposite sex.
Persons with a homosexual orientation are sometimes referred to as gay (both men and women)
or as lesbian (women only).
Sexual orientation is different from sexual behavior because it refers to feelings and self-concept.
Persons may or may not express their sexual orientation in their behaviors.
What Causes a Person To Have a Particular Sexual Orientation?
There are numerous theories about the origins of a person's sexual orientation; most scientists
today agree that sexual orientation is most likely the result of a complex interaction of
environmental, cognitive and biological factors. In most people, sexual orientation is shaped at an
early age. There is also considerable recent evidence to suggest that biology, including genetic or
inborn hormonal factors, play a significant role in a person's sexuality. In summary, it is
important to recognize that there are probably many reasons for a person's sexual orientation and
the reasons may be different for different people.
Is Sexual Orientation a Choice?
No, human beings can not choose to be either gay or straight. Sexual orientation emerges for most
people in early adolescence without any prior sexual experience. Although we can choose
whether to act on our feelings, psychologists do not consider sexual orientation to be a conscious
choice that can be voluntarily changed.
Can Therapy Change Sexual Orientation?
No. Even though most homosexuals live successful, happy lives, some homosexual or bisexual
people may seek to change their sexual orientation through therapy, sometimes pressured by the
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influence of family members or religious groups to try and do so. The reality is that
homosexuality is not an illness. It does not require treatment and is not changeable.
However, not all gay, lesbian, and bisexual people who seek assistance from a mental health
professional want to change their sexual orientation. Gay, lesbian, and bisexual people may seek
psychological help with the coming out process or for strategies to deal with prejudice, but most
go into therapy for the same reasons and life issues that bring straight people to mental health
professionals.
What About So-Called "Conversion Therapies"?
Some therapists who undertake so-called conversion therapy report that they have been able to
change their clients' sexual orientation from homosexual to heterosexual. Close scrutiny of these
reports however show several factors that cast doubt on their claims. For example, many of the
claims come from organizations with an ideological perspective which condemns homosexuality.
Furthermore, their claims are poorly documented. For example, treatment outcome is not
followed and reported overtime as would be the standard to test the validity of any mental health
intervention.
The American Psychological Association is concerned about such therapies and their potential
harm to patients. In 1997, the Association's Council of Representatives passed a resolution
reaffirming psychology's opposition to homophobia in treatment and spelling out a client's right
to unbiased treatment and self-determination. Any person who enters into therapy to deal with
issues of sexual orientation has a right to expect that such therapy would take place in a
professionally neutral environment absent of any social bias.
Is Homosexuality a Mental Illness or Emotional Problem?
No. Psychologists, psychiatrists and other mental health professionals agree that homosexuality is
not an illness, mental disorder or an emotional problem. Over 35 years of objective, welldesigned scientific research has shown that homosexuality, in and itself, is not associated with
mental disorders or emotional or social problems. Homosexuality was once thought to be a
mental illness because mental health professionals and society had biased information. In the past
the studies of gay, lesbian and bisexual people involved only those in therapy, thus biasing the
resulting conclusions. When researchers examined data about these people who were not in
therapy, the idea that homosexuality was a mental illness was quickly found to be untrue.
In 1973 the American Psychiatric Association confirmed the importance of the new, better
designed research and removed homosexuality from the official manual that lists mental and
emotional disorders. Two years later, the American Psychological Association passed a resolution
supporting the removal. For more than 25 years, both associations have urged all mental health
professionals to help dispel the stigma of mental illness that some people still associate with
homosexual orientation.
Can Lesbians, Gay Men, and Bisexuals Be Good Parents?
Yes. Studies comparing groups of children raised by homosexual and by heterosexual parents
find no developmental differences between the two groups of children in four critical areas: their
intelligence, psychological adjustment, social adjustment, and popularity with friends. It is also
important to realize that a parent's sexual orientation does not dictate his or her children's.
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Another myth about homosexuality is the mistaken belief that gay men have more of a tendency
than heterosexual men to sexually molest children. There is no evidence to suggest that
homosexuals are more likely than heterosexuals to molest children.
Why Do Some Gay Men, Lesbians and Bisexuals Tell People About Their Sexual
Orientation?
Because sharing that aspect of themselves with others is important to their mental health. In fact,
the process of identity development for lesbians, gay men and bisexuals called "coming out", has
been found to be strongly related to psychological adjustment—the more positive the gay,
lesbian, or bisexual identity, the better one's mental health and the higher one's self-esteem.
Why Is the "Coming Out" Process Difficult for Some Gay, Lesbian and Bisexual People?
For some gay and bisexual people the coming out process is difficult, for others it is not. Often
lesbian, gay and bisexual people feel afraid, different, and alone when they first realize that their
sexual orientation is different from the community norm. This is particularly true for people
becoming aware of their gay, lesbian, or bisexual orientation as a child or adolescent, which is not
uncommon. And, depending on their families and where they live, they may have to struggle
against prejudice and misinformation about homosexuality. Children and adolescents may be
particularly vulnerable to the deleterious effects of bias and stereotypes. They may also fear being
rejected by family, friends, co-workers, and religious institutions. Some gay people have to worry
about losing their jobs or being harassed at school if their sexual orientation became well known.
Unfortunately, gay, lesbian and bisexual people are at a higher risk for physical assault and
violence than are heterosexuals. Studies done in California in the mid 1990s showed that nearly
one-fifth of all lesbians who took part in the study and more than one-fourth of all gay men who
participated had been the victim of a hate crime based on their sexual orientation. In another
California study of approximately 500 young adults, half of all the young men participating in the
study admitted to some form of anti-gay aggression from name-calling to physical violence.
What Can Be Done to Overcome the Prejudice and Discrimination the Gay Men, Lesbians,
and Bisexuals Experience?
Research has found that the people who have the most positive attitudes toward gay men, lesbians
and bisexuals are those who say they know one or more gay, lesbian or bisexual person well—
often as a friend or co-worker. For this reason, psychologists believe negative attitudes toward
gay people as a group are prejudices that are not grounded in actual experiences but are based on
stereotypes and prejudice.
Furthermore, protection against violence and discrimination is very important, just as it is for
other minority groups. Some states include violence against an individual on the basis of his or
her sexual orientation as a "hate crime" and 10 U.S. states have laws against discrimination on the
basis of sexual orientation.
Why is it Important for Society to be Better Educated About Homosexuality?
Educating all people about sexual orientation and homosexuality is likely to diminish anti-gay
prejudice. Accurate information about homosexuality is especially important to young people
who are first discovering and seeking to understand their sexuality—whether homosexual,
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bisexual, or heterosexual. Fears that access to such information will make more people gay have
no validity—information about homosexuality does not make someone gay or straight.
Are All Gay and Bisexual Men HIV Infected?
No. This is a commonly held myth. In reality, the risk of exposure to HIV is related to a person's
behavior, not their sexual orientation. What's important to remember about HIV/AIDS is it is a
preventable disease through the use of safe sex practices and by not using drugs.
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MODULE 6: Lecture Notes
Supervision and Case Management
Session objectives:
After participating in this session trainees will be able to:
 Assess their personal risk factors for counselor burnout
 Understand the relationship between burnout and quality of client care
 Discuss the various support strategies available to a counselor
 Demonstrate an ability to provide a formal case presentation to a supervision group
 Demonstrate an ability to participate in a peer supervision group
Counselor burnout – an impact on the counselor and the client services
It is important to acknowledge that HIV counseling can be stressful and entails giving a lot of
yourself, not just in time and energy, but emotionally in compassion, understanding and hope.
HIV prevention counselors, as well as other human service providers, encounter many life and
death issues in attending to their clients that can affect them physically, mentally and spiritually.
It is necessary to find a balance personally and professionally, in order to sustain health and
continue working in this field. It is important to encourage counselors to be aware of signs that
they are overworking or not coping well. It is important to consider the whole person when using
the personal approach for taking care of oneself. The ‘whole person’ we define here as the body,
the mind and the spirit. Frequently providers will only consider one aspect of their ‘whole’
person. They might focus on the body aspect, which is their physical health; or the ‘mind’ aspect,
which can be their attitude, or the ‘spiritual’ aspect, which is their sense of peace. These three
entities—body, mind, spirit—are connected to each other. There needs to be a balance between
these entities: all parts need to be equally nourished. For example, a physically well-nourished
person should not neglect their spiritual and mental needs.
Counselors must also be aware that they are not expected to help clients deal with all of their
needs. It is important to establish clear boundaries between our understandings of who we are,
who the client is, and what needs we both bring to the interaction. In assessing the client’s needs
it is important for the provider to think about and ask, “what can I accomplish here?” and “what
am I not able to accomplish?” Clients may be referred to outside agencies in the community as
needed: it is important that counselors be familiar with these resources.
If we as providers know that it is our task to establish clarity about our own role and expectations
as a counselor, we can help the client to establish their own clarity as well. In many situations, it
is the combination of a provider’s sense of high commitment, the stress of the job, the lack of
adequate support, and the isolation they might feel, that can lead to what is called 'burnout.’ In
order to maintain a sense of balance and establish his/her continuity or longevity in this field, it is
important for counselor to:
 Ask for help when they need help
 Know their personal limits and be able to say “no”
 Be able to separate the personal from the professional
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Use supervision or peer support to discuss their concerns about the work
Be aware of their own biases and stereotypes
Learn to be assertive and to set limits with other staff and with clients
Continue learning new skills and requesting feedback on their work
Support groups for counselors should be instituted and supported by employers. Counselors
should also be given adequate time off and “mental health days” when needed.
Counselor support
Counselors should think about their network of colleagues, friends, family, and supervisor etc to
see how they can meet the following needs:
 Sharing your work issues in a confidential manner
 Obtaining feedback/ guidance
 Developing professional skills, ideas, information
 Venting emotions if you are angry, fed up, discouraged
 Acknowledging feelings of distress, pleasure, failure etc
 Feeling valued by those you count as colleagues
 Increasing your physical, emotional or spiritual well being
Some ideas for support include: Workers, boss, partner, friend, husband, wife, uncle, auntie,
cousin, grandmother, weekend workshops, university, support group, counseling, massage, work
team, consultant, religious leader, staff meetings, coffee breaks, distance learning, dog/cat/pet,
clients, students, children, in-service training, television, radio, sport, prayer, meditation, music,
dance, literature etc.
Conducting a personal self-inventory
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How do I know when I am under stress? (This can include physical, emotional, and
behavioral signs.)
What are the signs of stress that others recognize in me?
What are the most frequent sources of stress for me at work? (This can include clinical
and administrative issues.)
What are some strategies that I currently use to decrease stress?
What are some other strategies that I would like to use to decrease stress?
Counseling supervision and support
Counseling is a discipline that requires ongoing practice as well as monitoring of the use of such
skills by a competent supervisor. The counselor who wishes to provide a therapeutic outcome for
clients can only do so after much self-examination, practice of counseling skills and an
understanding of counseling theory.
Definition of counseling supervision:
This represents the exchange of information and describes a supportive relationship between
counselor and a senior counselor. The objective of this alliance is to enable the supervisee to gain
ethical competence, confidence and creativity so as to give his/her best possible service to his/her
clients. Therefore, supervision is for the protection of the client and for on-going accountability
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and professional development of the supervisee. Supervision also provides an opportunity to
prevent burn out from occurring.
The supervisor can only work with what the counselor brings. It is essential that the counselor
intends to use supervision well and knows how to do this. There is a need to train counselors as
supervisors at the individual country level.
The supervisory relationship is educational by nature. The supervisor is there for challenge and
support. The supervisor helps the supervisee discover and unlock his/her own resources.
The supervisor-supervisee relationship contains all the elements of the counselor-client
relationship although supervision is not counseling.
The supervisory relationship:
 Is purposeful
 Ensures that the supervisee’s concerns are explored
 Facilitates change
 Is confidential (as per the contractual agreement)
Autonomy is promoted in terms of:
 Choices
 Decisions
 Responsibilities
 Actions
The relationship ensures:
 Trust
 Honesty
 Warm acceptance
 Empathy/Understanding/Communication
Purpose of supervision
1. Ethical
Supervision is an ethical requirement for practicing counselors. HIV counseling is somewhat new
to many countries in the region and discussion is required in order to regulate and make
professional the practice of counseling. Supervision is a way of attempting to maintain
accountability between and among those who offer their services as counselors to the public.
This is the way that our profession seeks to ensure that we are working responsibly and to the best
of our abilities.
2. A necessary resource
Supervision is a requirement for all counselors no matter how experienced or talented.
Counseling is often work which is of a highly personal and taxing nature:
 We may be working with people when they are at their most vulnerable, distressed and
needy.
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We may become hardened or burnt out without realizing it, which will reflect on our
work.
We may work with clients who leave us puzzled or confused.
We may get out of date and need to be encouraged to continue our professional
development.
We may exploit our clients without realizing it.
Supervision provides an opportunity for counselors to:
 Explore the way you work
 Stand back and get different perspectives on your clients and the way you are working
with them
 Become more aware of the way you affect and are affected by your clients
 Discharge emotions and recharge energies and ideals
 Feel supported in your competence and confidence as a professional person
 Receive feedback and challenge the quality of your practice
 Monitor and develop ethical decision making
Propositions:
 The success of counseling supervision is dependent on the active and responsible
participation of the counselor.
 A supervisor will usually have professional experience and expertise at least equal to the
counselor. In this respect he/she will bring knowledge, understanding and intuition to the
relationship. However, in situations where there are no counselors of greater experience,
it is possible for an experienced counselor to use a less experienced counselor as
supervisor. Alternatively, peer supervision can be created.
 A working agreement is mutually and individually contracted as to roles, rights and
responsibilities.
 The counselor is also a facilitator. As such she/he has a responsibility to foster the
conditions that encourage her/his supervisor to provide their best efforts.
Our assumptions that relate to the "best practice" of counseling:
 Ongoing supervision helps to enable, and as far as possible - ensure the optimum service
for a client or clients collectively.
 Supervisees are able to engage actively and usefully in the supervision relationship
according to their level of skills, experience, assertiveness and self awareness.
 It is the supervisor's responsibility to offer to supervisees appropriate:
– Information
– Skills
– Support
– Challenge
– Or, alternatively to point them in a direction where these are available
 Many difficulties in supervision spring from supervisors and supervisees not appreciating
the risks and vulnerabilities involved in honest reflection and "adult learning" in a
personal context, and therefore not talking openly about them.
 There are some situations where a counselor may be stressed or distressed due to life or
work pressures. This may affect their skill and sensitivity in their counseling and they
require support at such times. This may also include the need to terminate counseling
practice for a given period of time.
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Some trainees and some counselors do not develop sufficient confidence or competence
to offer "effective enough" counseling. Some may be temporarily debilitated, and a
supervisor may need to determine whether this is the case and take appropriate action.
Supervisors may refuse to continue to work with a supervisee whom they consider being
continually ineffective or who is judged to be harmful to clients.
Supervisors assume that building a mutually respectful, empathic and genuine
relationship with the supervisee will result in a unique working relationship. This
relationship will allow the optimum facilitative environment for this counselor to learn,
discover and develop.
Supervisors believe that by seeking to create an environment of safety and trust they will
be enabling the counselors to offer such a relationship to clients.
Responsibilities of supervisor and supervisee
1. Supporting, enabling, ensuring
The supervisor has the responsibility for creating a working relationship through which the
counselor is supported as a person working:
 With clients who may be challenging
 With clients in distress
 In situations which may be confusing
 As a developing counselor
 In a profession that is taking seriously the task of monitoring the ethics of his/her practice
and who will act, if necessary, within contracted boundaries to ensure the protection of
the client
2. Bringing, Reflecting, Using
As a counselor in supervision with the help of your supervisor, you should be able to:
 Bring your work to your supervisor and share it freely and accessibly
 Be clear about your needs from supervision
 Be open to feedback, and be prepared to monitor your practice
 Use the available supervision time to the best advantage for your counseling and your
clients
 Monitor your use of supervision and take responsibility for giving feedback to your
supervisor about its usefulness for you and your clients
Stages of development as a counselor
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Beginning trainee counselor: Trainee with no experience of counseling clients.
Practicing trainee counselor: Trainee who has worked with/is working with clients.
Beginning counselor: Practicing counselor.
Experienced counselor: Counselor with a developed range of client experience.
"Expert": Counselor recognized by colleagues as able to pass on thinking and practice to
others in the role of supervisor, trainer or consultant.
Learning is an ongoing activity. Supervision is a learning opportunity.
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Values and assumptions about good and bad counseling
In preparing to supervise we may need to be clear about our beliefs about good and bad practice
in counseling. We are undertaking to be the person to whom a counselor is accountable for
his/her work.
As such, we have to agree with the supervisee what we are expecting of him/her and be prepared
to challenge practice which we believe to be incompetent, unethical or less than helpful.
Peer Group supervision
Group supervision is a working alliance between a supervisor and several counselors in which
each counselor can regularly offer an account or recording of his/her work, reflect on it, and
receive feedback and where appropriate guidance from his/her supervisor and colleagues. Group
supervision should enable each counselor to gain in ethical competence; confidence and creativity
so as to give his/her best possible service to clients.
Advantages and disadvantages of group supervision:
Advantages:
 There is richness in having access to and hearing other peoples work.
 For people working in isolated ways the group provides interaction with colleagues and a
sense of belonging.
 It allows fuller feedback and reflection of who you are as a counselor.
 If safe enough, it's the place where you can be authentic, take risks and disclose failure or
vulnerability and be helped to do something about it.
 It is possible to receive support and challenge at the same time.
 You can rest as well as be active.
 There is opportunity to learn to supervise others - and practice.
Disadvantages:
 It may feel highly dangerous to be authentic, which invites competition.
 There is less time for individual presentation.
 Different people will experience different emotions and ideas to the same stimulus.
 Family patterns often surface in groups -rivalry etc
 Dynamics can get messy.
 Issues of confidentiality can be tricky - with regard to client, counselor and agency.
The peer group case management
Peer group case management a useful strategy to assist the counselor in managing challenging
cases. Client confidentiality must be maintained. During the drafting of the case material or
during presentation the counselor must not identify the client by name or in a way that others may
identify the client. Prior to the commencement of the presentation in the supervision session all
group members must agree not to repeat the contents of this case discussion to other then group
members.
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The case presentation and management follows the following format:
 Gender, age and sexuality of the client;
 Clients HIV status;
 How they most likely came to be at risk/infected;
 Information on the family and partners of the client;
 Whether the client has disclosed;
 Work and educational background of the client;
 Current financial situation.
1. Describe what you see is the core problem the client is facing?
2. Counselor actions: Describe what you have done with the client so far?
3. Counselor self analysis: How does the problem impact on the counselor’s life? What factors
in the counselor’s life impact on the way they assist the client?
4. Group now has the opportunities to ask clarifying questions.
5. Group engages in group problem solving. The presenting counselor makes notes on the
advice.
6. The group facilitator now summarizes the session.
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MODULE 6: Session Plan
Supervision and Case Management
Session objectives:
After participating in this session trainees will be able to:
 Understand how to conduct peer supervision using a case management format.
 Appreciate the importance of examining their own attitudes, beliefs and emotions when
responding to challenging casework scenarios
Time to complete module: 3 hours 45 minutes
Training materials
Activity sheet (AS06) handed out during activity
PPT 06 loaded into computer
Lecture notes in participant folders (LN06)
PPT06 – Printed in Handout view distributed in participant folders.
LCD projector/screen
Overhead Projector
Content
Preparing for a formal case presentation
How to conduct peer supervision using a case management format
The importance of counselors evaluating the impact of their own attitudes beliefs and emotions
Session instructions
 Commence the PowerPoint presentation (PPT06) Indicate that the lecture notes(LN06)
contain more detailed information on counseling supervision
 Ask all trainees are to spend 20 minutes preparing a rough draft case presentation. It
should be either a current client situation that the trainee experiences difficulties with; or
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a past client case that they found that they experienced difficulties with. Instruct them to
prepare this in writing paper and follow steps 1, 2, 3, and 4 on their activity sheets. {If
trainees have not previously worked as a counselor as them to try to think about a client
scenario that they would find difficult to manage}.
 Assert that that client confidentiality must be maintained. Trainees should not identify
the client by name or in a way that others may identify the client. All group members
must agree not to repeat the contents of this case discussion to other then group members.
 In the large group nominate a group facilitator, and a case presenter this should be
somebody who has actually worked with a client in the past, or who is currently working
with a client.
 Case presentation process
1. Presenter describe the background of the client including:
Gender, age and sexuality of the client;
Clients HIV status;
How they most likely came to be at risk/infected;
Information on the family and partners of the client;
Whether the client has disclosed;
Work and educational background of the client;
Current financial situation.
2. Presenter describes what they see is the core problem the client is facing?
3. Presenter describes their actions: Describes what they have done with the
client so far?
4. Presented offers self self-analysis: Describes how the problem impacts on
their personal and working life? What factors in the personal life impact on
the way they assist the client?
5. Group is then provided the opportunities to ask clarifying questions.
6. The group facilitator leads the group in group problem solving. The
presenting counselor makes notes on the advice.
7. The group facilitator now summarizes the presentation.
 This process may then be repeated with other cases prepared by class members.
Depending on remaining time.
 Complete the session by summarizing with the class the key things that they have learned
from the session
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Activity Sheets
Activity Sheet (AS 01): HIV Testing and counseling of MARA
Objectives of Activity:
At the completion of this activity will be able to:
 Consider the ways in which they will have to adapt HIV Pre and Post test counselling
to meet the needs of MARA;
 Be able to identify and develop a counselling plan for the support of MARA in HIV
Testing and counselling.
Instructions to trainees
This activity requires that you use the skills processes and procedures you have learned in
your VCT training course and adapt them to the needs of this adolescent client. Please use the
Pre-test counselling form attached when you are the “counsellor”.
Each triad should nominate a “counsellor”, a “client” and an “observer”. You will be rotated
between these three roles so that you will have an opportunity to experience each role.
Accordingly there should be three rounds of cases with one case being conducted per round.
ONLY trainees who are playing a client will receive a case. Do not share the cases with
either counsellors or observers in order to make the role-play as realistic as possible.
Counsellors are to practice applying the knowledge and skills learned through the lectures
and other activities by completing the nominated task. If during the role-play you become
confused or uncertain you are instructed to refer to your notes, review your material and
recommence when ready. You should not ask for assistance from your client or observer. If
necessary, you may put up their hand for assistance from a facilitator. At the conclusion of
the role-play as the counsellor, you should discuss what you were happy with your their
practice and what things you would have liked to have done differently. Ensure you use
communication strategies appropriate to the development age and educational background of
your client.
Clients are to play the role of the case outlined in the case study. You should attempt to
allow the counsellor to practice obtaining the information rather than simply reading out what
is written in the case study. Inform the counsellor if you are role-playing a person of different
gender e.g. if you are a female and playing a male client she should inform the counsellor that
you are a male client. Clients should provide feedback to the counsellor at the conclusion of
the role-play.
Observers are to observe the process of the role-play and provide feedback to the counsellor
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at the conclusion of the role-play. Do not to interrupt the role-play. Observers should are
asked to first give positive feedback and then constructive criticism. This helps to increase
confidence and avoids discontent between trainees. .
Ten minutes should be allowed at the conclusion of each round for discussion and feedback
within the triad.
Class de-briefing
At the conclusion of this you will be asked to form three small groups. One small group
should comprise all the trainees who played counsellors for that round, another group should
comprise all the trainees who played clients and another group should comprise all the
trainees who played observers.
A facilitator will be allocated to debrief each small group. One facilitator will debrief the
counsellors, one facilitator will debrief the clients and one facilitator will debrief the
observers.
The small group facilitators will ask the trainees to share their role-play experiences and guide
the discussion to the following three questions:
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ix.
x.
xi.
What are the key counselling issues for the client?
What micro skills were particularly important for the counsellor to employ?
How did counsellors manage to balance provision of information with being
responsive to the needs of the client’s emotions?
How would you adapt adult VCT to the needs of this client?
The small group debriefing should last no longer than 15 minutes each round.
Trainees should then return to their triads and swap roles. Different case studies will then be
provided to the trainees who swap to being counsellors.
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Pre Test Counselling Form -
Site Name: ______________________
1. No names should be recorded on this form. In situations of confidential testing, names and contact
details are to be stored in a separate location.
Additional identifying data ( could be a client logo etc):
2. Number of previous HIV test:
Last test date/time:
Result: HIV Positive  HIV Negative  Indeterminant
_ _/ _ _/ _ _
 Cannot remember
Last test was conducted within three months of exposure risk 
3. Individual risk assessment:
Client has regular partner9: 1=Yes,
2=No
Is any regular partner HIV positive:
1= Yes,
2= No,
3=
Unknown
In case of minor: HIV status of mother  1= HIV Positive, 2= HIV Negative 3= Unknown
HIV status of father  1= HIV Positive, 2= HIV Negative 3= Unknown
Please indicate code and date of most recent potential exposure.
Sex with men women or both 
Exposure (only tick when there
Last occasion when this risk
Window period (only tick if within
is exposure risk)
occurred
the window period):
Occupational exposure10
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9
Regular partner could be husband/ wife/boyfriend or girlfriend or even regular sex client seen over a period of time.
Partner may be more than one.
10
This does not refer to sex work but rather exposure to blood borne pathogens in the course of work e.g.
nurse, doctor, ambulance, police, cleaner etc sustaining a needle stick injury or muco-cutaneous exposure.
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Tattoo, scarification, piercing 
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Blood products/organ
Vaginal intercourse
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Oral sex
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Anal intercourse
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Sharing injecting equipment


Client requires repeat HIV test due to window period exposure:
YES/ NO (please circle) If Yes, date for repeat test: _ _/ _ _/ _ _

Client risk was with a known HIV positive person
Client is pregnant

If Yes, stage of pregnancy:
Client’s partner is pregnant

 1- 3 months  4 – 6 months  >7 months
Client is using contraception regularly

Family planning referral required: Yes  No
Client’s partner is using contraception regularly

Have you ever been forced to have sex without your
Referral required: Yes  No
consent 
Client code:
Laboratory no:
Date:
Client indicates history and/ or STI infection

Treatment referral required:
Yes  No
Client’s partner has history and/or STI infection

Treatment referral required:
Yes  No
Client reports symptoms of TB

Treatment referral required:
Yes  No
Client’s partner has symptoms of TB

Treatment referral required:
Yes  No
110
4. Brief statement of self reported medical history of client.
Write brief note here regarding past significant or current illnesses that may affect diagnosis: e.g.
Hepatitis B or C
5. Assessment of personal coping strategies:
(Please indicate code 1=Yes, 2=No).
Client indicates history of/current depression
Prior history Current
Note:
Client indicates history of/of anxiety
Prior history Current
Note:
Client indicates history of substance use/disorder
Prior history Current
Note.
Client indicates history of other psychiatric disorder( specify)
 Note:
Client indicates suicide intent if test result is HIV positive
 Note:
Client has prior history of self harm or suicide attempt
 Note:
Client indicates intent to harm another if test result is HIV positive
 Note:
Client indicates potential risk of violence if discloses to partner
 Note:
Client has adequate personal support network
 Note:
6. Orientation on Condom Use:
1. Verbally 
2.Written leaflet given 
Number of condoms provided to the client:
3.Demonstration 
4. Client practice 
7. Orientation on HIV prevention for injecting drug user
1. Verbally  2.Written leaflet given 
3.Not applicable 
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Counsellor interventions performed this visit
(Please tick appropriate boxes)
I certify that the following activities were performed this counselling session.










Build rapport and introduce your role to the client, explain about service
and record keeping
The confidentiality and privacy that you can offer the client
Basic information about HIV and transmission
Conduct clinical risk assessment and provide feedback on client risk
Behaviour change counselling following ABC model and Condom/safe
injecting education/demonstration
Assess client’s readiness to learn sero status
Exploration of what the client might do if the test is positive, and the
possible ways of coping with a HIV-positive result. This may include a
suicide risk assessment if indicated.
Exploration of potential support from family and friends
Basic information about the test and result provision procedure
Informed consent to undergo HIV and test obtained
Other notes
________________________
Counsellor Name
____________________
Counsellor Signature
__________________
Date:
Cases:
Case No 1:
E.K 15 years old has been living on the streets of Lahore for 7 years. Right from his appearance
on the street life he joined a group of transgender which apparently used to dance in functions to
earn their living while the senior members of the group were regular at selling sex and often
motivated/forced the little boys also to sell sex. EK, initially unwillingly, but to survive remained
part of these activities for three years and ultimately discontinued working with them due to
increased physical and sexual abuse by the leader of group resulting in increased vulnerability of
physical abuse by the police and fear of being deprived of every belongings, poor physical
hygiene, blade cuts and strong stigma and discrimination. EK became to know about the HIV
from NZ street outreach workers who also educated him about safer sexual practices. EK still has
to exchange sex with place to sleep food and drugs. His was penetrated by a male partner (a male
client) in his anus without condom one week ago. 3 days back he oral sex with a street kid
wearing a condom.
Cut here ………………………………………………………………………………………
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Case No2:
Activity Sheet (AS 02): Counselling across the Disease Continuum
Objectives of Activities:
Participants will:
 Identify and develop developmentally appropriate strategies to common psychosocial
issues of MARA living with HIV
 Identify the link between VCT and post-diagnosis psychosocial care
 Develop a psychosocial care plan for MARA clients
 Consider and address treatment adherence challenges in MARA
Instructions:
Activity 1(Total time is 30 minutes)
–
–
–
Each person is required the description of the stages of HIV disease in you
Lecture Notes( LN 02) down to and including the section entitled c support
planning. (10 minutes personal reading time)
The in your small groups discuss the key presenting problems you are likely
to see in MARA at each stage. Give specific examples. Record this
information on a sheet of paper (10 minutes small group) discussion.
In the large group discussion provide your answers in the large group
discussion(10 minutes)
Activity 2 (Total time 1 hour)
30 minutes small group activity
5 minute group feedback to class
10 minute trainer feedback
In your allocated groups (time for small group work 30 minutes)
• Review the allocated cases on your activity sheet
•
Case 1=Group 1
•
Case 2=Group 2
•
Case 3=Group 3
•
Case 4=group 4
• Identify the key counselling issues
• The list the specific counselling strategies you will use
• Record your discussion on the supplied OH transparency sheet or flip chart
Use the format:
Key Issues
Key strategies
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•
Present your findings to the large groups (5 minute per groups 10 minutes for trainer
comments =30 minutes in total.
Cases for Group discussion( Activity 2 continued)
Case 1 –Your client is an 11 year old boy who works with truckers. He came to the clinic
today and reports he is sick. He moves in and out of home. When he runs away from home he
lives with his friends on the streets. He steals, and has “played with men for money.” He has
a sore on his penis and claims it hurts him to urinate. His family is poor. He has not had a
HIV test. He does not know about HIV. He appears to be affected by a substance however
he denies he uses drugs.
Case 2 – Your client is 14 year old girl involved in prostitution. She has run away from home
claiming her father beats her and her mother. She lives with a man and a woman whom she
says looks after her. She has had a HIV test about two months ago and tells you she is HIV
positive. She claims she cannot use condoms with the clients as they say they are paying for
the service.
Case 3 – Your client works in a local hotel. He cleans and does odd jobs and frequently has
sex with male guests for money. He is sixteen years old, and was diagnosed HIV positive last
year. He presents at the clinic with signs of advancing HIV. He needs hospitalization form
management of an opportunistic infection. His family has no money and pressures him to
keep working at the hotel. His family does not know he has HIV. He has told nobody.
Case 4 - A young adolescent IDU 18 comes to the clinic. He informs you his girlfriend works
as a sex worker, and he says she is pregnant. He admits he was diagnosed HIV positive 2
years ago. He indicates he has not told her. He does not use condoms as he thinks she must
already have HIV from her work because the doctor who diagnosed him told him that you get
if from sex and drugs.
Activity 3(total time 1 hour)
Timing breakdown: 30 minutes for group work and 20 minutes for group feedback and 10
minutes for trainer comments.
Drawing on what you have previously learned in your VCT course on HIV transmission and
Adherence counselling adapt the information to the following contexts
• Groups 1 & 2
– Draw a picture to describe HIV transmission and prevention to a 12 year old
street child. Discuss how you would explain this.
• Groups 3 & 4
– Describe the importance of treatment adherence to STI and HIV treatments to
a 16 year old that intermittently uses drugs.
– Include discussion of HIV re-infection, resistance and drug interaction
(treatment and recreation).Discuss how you would explain this.
Each group is to nominate one person to present the activity to the class and this
individual address the class as the class were the client using diagram or explanations
aids that they would use with the client.
114
Activity Sheet (AS 03): Talking about Grief, Loss and Death with MARA
Objectives of Activities:
At the end of the training session, trainees will be able to:



Provide developmentally appropriate grief and Loss counselling to MARA
Provide appropriate advice to parent, guardians and caregivers about grief and loss
issues impacting on MARA
Develop communication strategies to discuss death with MARA.
Instructions
Activity 1(Total time is 20 minutes)
 Please read the Lecture Notes section “Navigating Children’s Grief”
 Discuss in your table groups behaviours, emotions and physical reactions with
MARA that you have worked with.
 Discuss any additional manifestations of grief that you have seen in these clients.
Activity 2 (Total time 45 minutes)
20 minutes=small groups discussion
25 minutes large discussion
In your groups to review the Lecture Notes in the section “Avoiding Words that Hurt”. Look
at each item mentioned and discuss and consider what the potential psychological and/or
behaviour consequences of using each of these remarks to be.
In the large group discussion offer your answers.
Activity 3 (Total time 1 hour)
30 minutes=group work
30 minutes feedback =5 minutes feedback to the class for each group and then final comment
from trainer.
Form four groups. Nominate one person to present the group findings to the group
 Your task is to discuss what needs to be discussed in relationship to death and dying.
 Add any drawings or describe activities you wish to use to provide developmentally
appropriate information and techniques ( Drawings, stories, activities)
Group 1 – You are working with an adolescent girl 14 years old from a poor urban family
whose father a former trucker has died of AIDS. The girl has become involved in sex work to
help support her grieving mother who is also ill. The girl is dismissive of any grief reaction
saying she now has a lot of friends and that her life is ok. She acknowledges the sex work
places her at risk however she says she has no choice. She says that we all will die anyway.
Group 2 – You are providing counselling to a street youth18 who has HIV and requires
hospitalization for palliative care. He is in late stage HIV and asks is he going to die. He tells
115
you that he is frightened, and that his family rejected him a long time ago when they found he
was having sex with other boys. He lives on the streets and relies on begging and stealing to
survive.
Group 3 – Your client is a 8 years old boy. His father died 1 year ago and his mother a
former sex worker is currently ill with HIV. The child spends a lot of time on the streets with
older youth and has come to the attention of your service. After meeting with his mother she
asks you to prepare him for her possible death. She was initially resistant to this but when the
boy refused to live with her parents and ran away from home she agreed he should be told.
Group 4 – Your client is a 16 year old girl whose older husband who is dying from AIDS.
She was forced to marry this man. He did not disclose his HIV status to her parents or to her.
He frequently forced her to have unprotected sex with him. She reports he frequently abused
her as he complained she was a poor wife. She feels she should have looked after him better.
She has been shunned by people in her village and relies on begging for food. She has been
getting sick herself and fears she will die. She asks will she die soon. She is too afraid to
seek medical assistance.
116
Activity Sheet (AS 04): Substance Use, HIV and MARA – Special focus on
Inhalants and Solvents
Objectives of Activities:
 Conduct a drug use assessment;
 Identify clients who may be using volatile substances;
 Educate clients about the links between volatile substances( inhalants and solvents);
 Educate clients about life saving procedures for drug overdose management
Instructions
Activity 1 – Group work ( 40 minutes)
Each group should nominate a discussion facilitator, a recorder, and somebody to present the
information to the large group.
Allow 20 minutes discussion
Five minutes for each group to feedback to large group (4 groups X 5 minutes=20 minutes)
1. Discuss the names and “nicknames” of solvents abused in different regions of
Pakistan
2. Discuss the common signs and symptoms of their use ) (one by one)
3. Discuss how solvent use may be related to HIV transmission
Activity 2 – Self study and group work (1 hour)
10 minutes for self study
20 minutes for group discussion
30 minutes for large group feedback
Self study
Refresh your memory about the Stages of Model of counselling for behaviour change. You
first studied this in the VCT training course. A summary has been reproduced here in the
Counselling Tool for this module (T4). Read it and reconsider how you would use different
strategies at different stages of client readiness for change.
Group activity
Read the following case:
Your client is a 13 year old boy who works with truckers. He has been sniffing petrol with
increasing frequency. He reports to you that all of his friends do it but that he can handle it
and it helps him get through the nights he spends on the streets. He has lost weight and
admits he doesn’t eat as much as he used too. He thinks sometimes he should not do it as it
makes him a bit sick. He thinks that he will get sick one day and then he will stop. He has
only ever stopped using once He stopped for two days only. He stopped using after being
very intoxicated and was beaten up on the street. He started sniffing again when he went on a
long trip with the trucker he works with. Answer the following questions in your groups and
117
write the responses on the OHP sheet provided.
Discussion questions:
4. What stage of change is this boy likely to be at? Discuss your reasons for identifying
this stage.
5. What would be the appropriate counselling interventions to use at this stage? Be
specific!
6. What are potential relapse triggers if he did stop again
You will be asked to feedback the results in a large group discussion.
118
Activity Sheet (AS 05 Supp): MSM Sexuality and MARA Sexual Assault
Survivors
Instructions:
Activity1: Large Group Activity (total time 20 minutes)
10 minutes in small group
10 minutes large group discussion
In your small groups review the data and discuss and then be prepared to address the
questions in a large group discussion. Consider the various HIV transmission risk factors
associated with sexual identity (e.g. a married man who has bought sex from other men);
sexual practices of MSM in Pakistan, and other critical issues demonstrated in the survey
(e.g. arrested during last six months time in prison, having unprotected sex with other
men in prison detention and getting out and then having sex with girlfriend).
HIV/ AIDS Surveillance Project, 2006
Age during first intercourse: R= 10-21; Mean 14.8 ;2 SD
Freq
%
Forced sex during last 6 months
39
39.7
Arrested during the last 6 months
37
37.8
Used alcohol during sexual intercourse 46
in the last 6 months
46.9
Used intoxicant during the last 6
months
82
83.7
Sold blood for money during last 12
months
14
14.3
Injected drugs during last 6 month
9
9.2
Bought sex from a man
31
31.6
Module 5
Activity 2: Small group discussion( total time 30minutes)
15 minutes small group
20 minutes large group discussion 4 Groups each 5 minutes presentations)
5. Nominate a group facilitator, a recorder and a presenter for the large group
discussion
6. Discuss the potential impact of sexuality on the sexuality acceptance process.
7. Discuss the key messages about assault and sexuality that counsellors should
offer clients who have been assaulted
8. Present your findings to the large on the overhead transparency provided.
119
Activity 3: Large group discussion
1. What are the types of sexual assault perpetrated on young boys and adolescents in
Pakistan? Discuss
 The setting in which the assaults occur;
 What makes MARA vulnerable in each of the various settings;
 The most common types of sexual assault (e.g. receptive anal; oral etc)
2. Discuss what services are available to sexually assaulted boys and adolescents
Activity 4
30 minute small group work
30 minute large group feedback (10 minutes for each group)
1. In your table groups review the case allocated to your group.
2. Nominate a group facilitator, a recorder, and a presenter to present the findings to
the large group
3. Discuss the key issues and strategies. Using the following format record your
answers on the supplied OHP master
Key Issues
Key counselling strategies
4. Present your findings to the large group
Case study 1: Asymptomatic
A 19 year old IDU has been recently diagnosed with HIV and syphilis. He is currently injecting
various crushed pills. He says his life is over and that he has nobody except his street friends who
are using. He is destitute, has no skills and is living on the streets. He has been surviving by
stealing and performing sexual favours for food and accommodation. He says he doesn’t like and
cannot afford condoms.
Case study 2: Symptomatic
Eight months ago a 13 year old male had a rash on his body for that would not go away. A doctor
tested him for HIV and he was diagnosed HIV positive. At the time of his diagnosis he lived at
home with his mother, father, and two sisters. When they found out through local gossip that he
had HIV his father told him to leave the house. He is now living with his friends who do not
know his HIV status. These friends work very little and spend their time sniffing volatile
substances. He has been losing weight, though admits to not eating regularly. He has had a
persistent rash and feels chronically tired. He tells you he occasionally works with truckers and
has been molested on several occasions by his employers
120
Case study 3: AIDS
A 19 year old gay identifying male found out that he had HIV three years ago. He has had many
opportunistic infections in the last three years. He has been very distressed by his recurrent
periods of illness and has felt a burden to his family. He is currently in hospital with tuberculosis
and a second episode of pneumonia (PCP). Doctors have recommended antiretroviral (ARV)
treatment and OI prophylaxis but he is poor and has no money to buy expensive medicine. The
doctors are not sure he will recover from this infection and believe he may be too ill to return
home again. His family is by his bed when the doctors tell him the bad news.
121
Activity Sheet (AS 06): Supervision and Case management Counsellor
Instructions:



All trainees are to spend 20 minutes preparing a rough draft case presentation. It
should be either a current client situation that you experience difficulties with; or a
past client case that you have experienced difficulties with. If you have not previously
worked try to think a bout a client scenario that you would find difficult to manage.
Prepare this in writing paper and follow steps 1, 2, 3, and 4 described below. Client
confidentiality must be maintained. Do not identify the client by name or in a way
that others may identify the client. All group members must agree not to repeat the
contents of this case discussion to other then group members.
In the large group nominate a group facilitator, and a case presenter this should be
somebody who has actually worked with a client in the past.
Provide information on the following:
8. “Describe the background of the client including:
Gender, age and sexuality of the client;
Clients HIV status;
How they most likely came to be at risk/infected;
Information on the family and partners of the client;
Whether the client has disclosed;
Work and educational background of the client;
Current financial situation.
9. Describe what you see is the core problem the client is facing?
3. Counsellor actions: Describe what you have done with the client so far?
10. Counsellor self analysis: How does the problem impact on the counsellor’s life?
What factors in the counsellor’s life impact on the way they assist the client?
11. Group now has the opportunities to ask clarifying questions.
12. Group engages in group problem solving. The presenting counsellor makes notes on
the advice.
13. The group facilitator now summarizes the presentation.
122
Overhead Masters
Module 2 and again Module 5
Key Issues
Key counselling strategies
123
HIV Counseling for MARA Post Training Evaluation
Please circle the most appropriate response.
1. The training provided me with knowledge to conduct HIV testing and counseling (HTC) with
MARA
Very much
disagree
Somewhat
disagree
Don’t know
Somewhat
agree
Very much
agree
2. The training provided me with skills to conduct HTC with MARA:
Very much
disagree
Somewhat
disagree
Don’t know
Somewhat
agree
Very much
agree
3. The teaching methods used were helpful in developing practical skills:
Very much
disagree
Somewhat
disagree
Don’t know
Somewhat
agree
Very much
agree
4. Most of the trainers demonstrated that they knew the material:
Very much
disagree
Somewhat
disagree
Don’t know
Somewhat
agree
Very much
agree
Somewhat
agree
Very much
agree
5. Most of the trainers had good presentation skills:
Very much
disagree
Somewhat
disagree
Don’t know
6. Most of the trainers demonstrated that they had practical experience in HIV counseling of
MARA.
Very much
disagree
Somewhat
disagree
Don’t know
Somewhat
agree
Very much
agree
7. On a scale of 0-10, to what extent has your knowledge of the following areas changed as a
result of the training.
(Please indicate your response by placing a cross on one of the numbers).
 Module 1 HIV Testing and counseling of MARA
0
1
2
3
4
5
6
7
8
9
10
/……... /……... /…….../……… /……... /……... /……... /……... /……... /……... /
Not
A Little
A Lot
At all
124
 Module 2 Psychosocial Care – counseling across the Disease continuum
0
1
2
3
4
5
6
7
8
9
10
/……... /……... /…….../……… /……... /……... /……... /……... /……... /……... /
Not
A Little
A Lot
At all
 Module 3 Talking about Grief, Loss and Death with MARA
0
1
2
3
4
5
6
7
8
9
10
/……... /……... /…….../……… /……... /……... /……... /……... /……... /……... /
Not
A Little
A Lot
At all
 Module 4 Substance use, HIV and MARA/A special focus on MARA
0
1
2
3
4
5
6
7
8
9
10
/……... /……... /…….../……… /……... /……... /……... /……... /……... /……... /
Not
A Little
A Lot
At all
 Module 5 MSM Sexuality and MARA Sexual Assault Survivors
0
1
2
3
4
5
6
7
8
9
10
/……... /……... /…….../……… /……... /……... /……... /……... /……... /……... /
Not
A Little
A Lot
At all
 Module 6 Supervision and Case Management
0
1
2
3
4
5
6
7
8
9
10
/……... /……... /…….../……… /……... /……... /……... /……... /……... /……... /
Not
A Little
A Lot
8. What did you find were the three most useful parts of the training?
9. What did you find were the three least useful parts of the training?
125
10. List 3 changes you could implement in your work as a result of completing this training?
11. Is there any other information you would like to have included in this training?
12. Do you have any other recommendations for changes to the training?
126
Powerpoint Presentations
127