|Counselling and Voluntary HIV Testing for Pregnant Women in High HIV Prevalence Countries - Elements and Issues (UNAIDS, 1999, 24 p.)|
|4. Counselling and voluntary HIV testing: a prerequisite for action|
Pre-test information and counselling for HIV-positive women: a summary
· Information about therapy options, including costs
· Information and referral for support, services and positive living
Information and counselling about therapy
Obviously, a positive test result is a prerequisite for the two interventions thought to be most effective in reducing transmission of HIV from mother to child: antiretroviral therapy and avoidance or abbreviation of breastfeeding. Where antiretroviral therapy is available, counsellors should explain its benefits and the importance of adherence to the regimen. They should also make clear that, while research continues, it is thought that the benefits of antiretroviral drugs may be diminished if a woman goes on to breastfeed her infant. Unless antiretroviral drugs are provided free, counsellors should discuss the cost of the therapy and help a woman assess her familys ability to bear the cost of a full regimen.
Information and counselling about infant feeding
Full information about infant feeding options is essential for all HIV-positive mothers-to-be, regardless of whether antiretroviral drugs are available. Pregnant women should be reminded that less than half all babies born to HIV-positive mothers and breastfed will be infected with HIV. Of those that do become infected, at least a third are likely to have contracted the infection while being breastfed. Women should also understand that breastfeeding protects against a wide range of other childhood diseases. Women should be given information about the alternatives to breastmilk, and what two years of substitute feeding is likely to cost. The importance of access to clean water, fuel and feeding implements if they choose substitutes to breastmilk should also be discussed.
Counsellors should discuss the possibility that choosing substitute feeding might label a woman as HIV-positive in the eyes of her family or her community. Counsellors should help a woman analyse her social situation and family resources and weigh up the best feeding option for her baby. A mother must decide what the best option is in her own situation; counsellors should provide all possible support for a womans decision.
Information and counselling about fertility regulation
In many high HIV prevalence countries, bearing healthy children provides social status and access to family resources - access denied to women whose HIV-infected children sicken and die. To that extent, interventions to reduce HIV transmission from mother to child can help a woman consolidate her social position, despite her HIV infection.
While women and couples should be free to make their own decisions about child-bearing, counsellors should ensure that women are aware of the risks inherent in any future pregnancies, as well as the risk of passing on the virus during unprotected sex. Counsellors should make it clear that even where interventions are available, all pregnancy carries some risk of HIV transmission from mother to child. And the risk of transmission grows as the mothers infection progresses, so it is likely to grow from one pregnancy to the next. What is more, the effectiveness of anti-retroviral therapy in successive pregnancies is unknown.
Women who choose to avoid pregnancy in the future because of their HIV infection should be referred to family planning services. Women who choose two years of replacement feeding should also receive advice on contraception to replace the birth-spacing effect of breastfeeding. If they choose to bear more children, they should be encouraged to delay the pregnancy for at least two years.
Counselling about shared confidentiality
While health service providers must guarantee confidentiality of test results, they should recognize that the burden of secrecy can be detrimental to peoples ability to live positively with their infection. Counsellors should help HIV-positive clients decide who, if anyone, to share information about their status with. Counsellors should never themselves disclose test results to anyone else except at the express request of the client.
Counsellors should discuss the potential pluses and minuses of sharing test results with other people. Sharing a positive test result with a partner may expose a woman to ostracism. It may, on the other hand, allow her to make otherwise impossible choices about childbearing and care. Sharing results with other family members can provide psychological support as well as necessary care and help in planning for the future. Sharing results with other health care workers can ensure that a woman receives the best information and care possible for herself and her child over the course of her pregnancy and eventually her illness. Sharing results with other HIV-positive people in support groups can contribute to knowledge and coping skills.
Information to prevent the further spread of HIV
Information on preventing the sexual transmission of HIV is every bit as important for HIV-positive as for HIV-negative clients. Staff counselling HIV-infected women should reinforce information provided in pre-test counselling, stressing the risk of passing infection on to present and future sexual partners, discussing negotiation of safer sex with those partners and providing information about sources of free or affordable condoms.
Information about the natural history of HIV infection, well-being and care
In many countries, a positive HIV test result is equated in peoples minds with near-immediate sickness and death. Correcting this misconception is an important aspect of counselling. Counsellors should discuss the natural history of HIV infection including the long latency period and common opportunistic infections.
Counselling and voluntary testing services attached to reproductive health services are an important entry point to the continuum of care. But it must be recognized that HIV-related counselling is not the primary objective of these services. They are unlikely to be able to provide as much follow-up counselling or support as clients need. Counsellors at reproductive health facilities should therefore provide referrals to support groups or other sources of information about care and about living positively with HIV.