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Counselling for Maternal and Newborn Health Care: A Handbook for Building Skills. Geneva: World Health Organization; 2013.

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Counselling for Maternal and Newborn Health Care: A Handbook for Building Skills.

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14WOMEN AND HIV/AIDS

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What is in this session?

In many countries, HIV/AIDS prevalence is increasing rapidly among women of reproductive age, and has become an important contributing factor to high maternal morbidity and mortality. All women should know their HIV status and understand the importance of HIV prevention. Knowledge of HIV status, through HIV testing and counselling, is especially important during pregnancy, childbirth, and breastfeeding, since women with HIV can transmit the virus to their infants during these times.

Talking to women about HIV/AIDS may be a new topic area for many skilled attendants. Midwives and nurses who provide services to women are already a trusted source of information and advice. Building on this foundation of trust, skilled attendants can be an important source of caring and provide supportive HIV/AIDS counselling.

IMPORTANT

It is not possible to cover in one session of this Handbook all of the skills and knowledge needed to provide comprehensive HIV/AIDS counselling. This session only provides an introduction with a focus on HIV and pregnancy. You are encouraged to discuss with your colleagues and programme managers how the services can best provide support for the different themes covered. If HIV is very prevalent in your community, you might consider discussing in your group or with your supervisor opportunities for additional training to help staff in supporting women. Tools developed by the CDC, World Health Organization (WHO), UNICEF, USAID, and partners can provide useful strategies for learning about how to address HIV. For testing and counselling for prevention of mother-to-child transmission of HIV support tools see

http://www.who.int/hiv/pub/vct/tc/en/index.html

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What skills will I develop?

  • How to motivate women to accept HIV testing and counselling, prevent HIV, and prevent mother-to-child HIV transmission (PMTCT).
  • How to help women overcome actual or perceived HIV-related stigma and discrimination and other barriers that influence their decision-making about HIV prevention and testing and use of PMTCT services.
  • Self-reflection: how to explore your own beliefs and attitudes around HIV/AIDS.
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What am I going to learn?

By the end of this session you should be able to:

  1. Explain the benefits of testing and counselling for HIV during pregnancy, the need for partner testing and counselling, and the importance of sharing HIV status with partner.
  2. Discuss ways for all pregnant women and their partners to prevent exposure to HIV.
  3. Help pregnant women understand mother-to-child HIV transmission and how to prevent it.
  4. Motivate women with HIV infection to participate in PMTCT interventions.
  5. Assist pregnant women who test HIV-positive to cope with their diagnosis and support them to make a plan to get the special care they and their infants will need.

Activity 1

Image session14fu4.jpg 45 minutes

Image session14fu5.jpg To reflect on your own attitudes, beliefs and values towards women who are HIV-positive.

This exercise is best done in a group or with another person so that you can discuss the topic. If you are working alone, try and find a colleague who will carry out the exercise with you.

  1. Is it important to know whether a woman has HIV? Why or why not?
  2. Are there certain types of women more likely to be infected with HIV or can any woman get HIV?
  3. Whose fault is it if a woman gets HIV?
  4. Should women who have HIV be allowed to get pregnant? Should they be allowed to have more than one pregnancy?
  5. Should women who have HIV get the same care or different care to women who do not have HIV? If different, how should it be different?

Think about how some of the answers you have given to these questions may impact on the way you treat and counsel women that you see. Do these present a barrier to providing appropriate care and support? Keep these points in mind as you read through the session. You may wish to review the questions and answers after you complete the session, to see if your answers have changed and to think about the barriers your beliefs and attitudes may pose.

Image session14fu6.jpg Our View

In answering these questions you will have had to explore some of your own attitudes, values and beliefs towards HIV.

Anyone can get HIV. Some people are more at risk because of the behaviours they have such as multiple sexual partners, or because they inject drugs. It should not matter how a woman or man got HIV in terms of how you treat them. All women that you see, whether they are HIV-positive or negative, should be treated with respect. As you will not know who has HIV and who does not, you should treat all women the same way and take the same clinical precautions. Women who are HIV-positive have the same human rights as all other women and they can make choices and decisions about whether to have children or not, and how many children and whether they want to breastfeed. If a woman is HIV-positive, she may need additional information, support and counselling including the possible effects of childbirth on her health status, but the decisions are still hers to make.

You may agree or you may not agree with some of the views expressed here. Whatever your views, you need to think about how they might impact the women that you treat and counsel. Are you likely to treat them differently? How could you try to overcome some of the negative attitudes that you have?

Counselling to increase acceptance of HIV testing

Identifying women with HIV infection and their partners is a “gateway” to helping women, partners and children to receive the HIV treatment and care they need. All women in high prevalence countries, especially pregnant women, should be tested and counselled for HIV. Counselling during routine antenatal and postpartum care is an important way to reach women with information about HIV/AIDS and encourage HIV testing. New emphasis is placed on providing essential HIV/AIDS information at the first antenatal care visit, to be sure that as many women as possible receive the information.

HIV COUNSELLING TOPICS

During pregnancy

  • basics of HIV transmission and prevention
  • PMTCT
  • HIV testing and counselling processes
  • benefits and risks of HIV testing
  • right to refuse testing (opt-out)
  • confidentiality
  • implications of positive and negative test results
  • identification of supportive HIV services and treatment available
  • identification of PMTCT services and treatment available
  • family planning/dual protection and provide condoms (See page 167 below for a definition of dual protection)
  • identification of sexual risks and plan for reduction of risks
  • availability and benefits of testing and counselling services for couples
  • importance of infant feeding and nutrition

Counselling after an HIV test

  • explain HIV test result and the possibility that in the first 3 months following infection the test may still come back negative (“window period”)
  • assist in understanding result/ coping with diagnosis
  • provide information to HIV-negative women on how to stay negative
  • discuss immediate concerns
  • explain available services, treatment, care and support and make appropriate referrals
  • support safe and voluntary disclosure
  • discuss best and most feasible infant feeding option
  • discuss the importance of good nutrition for staying healthy
  • explain essential PMTCT issues
  • encourage partner dialogue/disclosure
  • encourage partner testing and counselling
  • discuss family planning/ dual protection and provide condoms
  • reinforce HIV prevention/risk reduction and develop a plan to reduce the risk of HIV reinfection
  • revise the birth and emergency plan and discuss the need to give birth in a facility with a skilled attendant

In many countries, provider initiated testing and counselling of all pregnant women during ANC has become national policy. This is called “opt-out” HIV testing. In “opt-out” testing, getting an HIV test is a part of the regular ANC care package for all pregnant women, like haemoglobin tests. All ANC clients are offered the test, and counselled on the benefits and risks of knowing HIV status during pregnancy. But testing is still voluntary and women may refuse if they wish. Women are more likely to accept HIV testing if their health care provider counsels in favour of the procedure and recommends it.

If a woman refuses testing and counselling, spend a bit of extra time with her to find out why she refused (use your open questioning and active listening skills), and see if you can help her with any problems related to accepting the HIV test. But remember to present the information in a neutral, non-biased way without pressure or judgement.

Some women may be afraid to get an HIV test, do not want to know their HIV status, or do not want to discuss results with their partner. Real and perceived stigma and discrimination against those who are known to be infected with HIV is a big problem in many communities and may be a barrier to testing. Counselling women about the benefits and risks of knowing their HIV status, not only for themselves but for their infant and partner, can help to overcome the fear of stigma, discrimination and other barriers.

Allowing women to express their concerns is also important. Fear of bad outcomes is more common than actual bad outcomes for most women, and many women who disclose their positive HIV status report positive outcomes, support and understanding. When counselling, be sure to assist women to evaluate the real chances of bad outcomes and help make a plan to minimize them.

BENEFITS OF PREGNANT WOMEN KNOWING HIV STATUS INCLUDE

  • Being sure of her status, if HIV-positive or HIV-negative
  • If HIV-negative, she can learn how to remain negative
  • If HIV-positive, she can learn how to live positively and care for herself and her baby
  • Revision of her birth and emergency plan to make sure she gives birth in a facility with a skilled attendant
  • She can share HIV test results with partner and encourage him to get tested
  • Special care and treatment to prevent HIV transmission to the baby is available
  • Care, nutrition support, counselling, and follow-up is available for women infected with HIV and HIV-exposed infants
  • Long-term treatment (Anti-RetroVirals-ARVs) for women infected with HIV, baby, and family are available in many places

Assuring the confidentiality of test results can help women decide to get an HIV test

Confidentiality means that only health staff directly involved in her care will know her test results; that it is her decision if and when she wants to share her test results with anyone else. Assure women that they will get good ANC whether or not they accept HIV testing and counselling. Where available, refer women who refuse testing and counselling at ANC for specialized HIV testing and counselling.

If a woman does not accept HIV testing and counselling at her first visit, ask again at every future visit if she is ready to be tested. Briefly review with her the benefits of knowing her and her partner's HIV status, and the care that is available for HIV-positive women and their babies, at each clinic visit to help her decide.

Discussing HIV test results with HIV-negative women

Post-test counselling for a pregnant woman who has tested HIV-negative should focus on helping the woman decide how she can stay HIV-negative. Support should also be provided to help her decide if she will discuss her results with her partner, so that he can be tested and actively participate in risk assessment and risk reduction for the two of them.

The main ways to prevent HIV infection and STIs:

  • Correct and consistent use of condoms during every sexual act
  • Practising safer sex (choosing sexual activities that do not allow semen, fluid from the vagina, or blood to enter the mouth, anus or vagina of the partner, or to touch the skin of the partner where there is an open cut or sore.)
  • Reducing the number of partners
  • Sexual fidelity
  • Abstinence.

Sometimes pregnant women may need help in adopting these prevention behaviours, or in getting their partner to agree. A first step in negotiating safer sexual practices between partners is for them to do a risk assessment, to identify any risky behaviour they might currently be involved in. This requires a frank and honest discussion between partners about their own sexual practices as a couple, and any other sexual activity that might be taking place outside of their relationship.

The second step is for the woman or couple to decide what changes need to be made to better protect against HIV/STIs, and how they will make those changes. All women should consider dual methods of protection, to protect against HIV and to avoid unwanted pregnancy. (See Session 12 on family planning for more information on dual protection).

Dual protection

Many couples are successful in adopting safer sexual practices. If you have developed the appropriate skills and experience, it is often helpful to offer to counsel the couple together so they can then talk with you as a couple about these issues, to help them better understand risks, and find solutions that are agreeable to both.

REMINDER

Correct and consistent use of condoms with another family planning method for every sexual encounter is the best way to ensure dual protection against HIV and avoid unwanted pregnancy or to space desired pregnancy.

Another key to HIV prevention is partner testing and counselling. Every pregnant woman should ask her partner to get an HIV test. It is not unusual for a pregnant woman to test HIV-positive and for her partner to test HIV-negative, or the other way around. This is called “discordance”. Couples with discordant HIV test results can present a counselling challenge, as partners often have difficulty understanding how the results can be different. You may want to refer discordant couples to more specialized counselling services where available.

Retesting

Repeat testing late in the pregnancy should also be recommended to HIV-negative women if HIV is very prevalent in your community.

Health workers need to assess if condoms are easily available in the community or if there are barriers which limit their availability.

Health workers need to assess if condoms are easily available in the community or if there are barriers which limit their availability

Activity 2

Image session14fu4.jpg 1 hour

Image session14fu5.jpg To develop or improve your counselling skills so you can help women to address common barriers to HIV prevention behaviours, and to negotiate safer sex with their partners.

Remember as previously discussed, the main ways to prevent STI/HIV infection: use of condoms (including dual protection), practising safer sex, fidelity, partner reduction, or abstinence.

  1. Discuss with colleagues, women and men in the community and make a list of the different reasons why men and women do not put HIV prevention behaviours into practice. Also talk about barriers to partner HIV testing and counselling. Consider how the counselling context (e.g. culture, gender roles, household decision-making, and the social system in your community) may contribute to these barriers.
  2. Discuss possible solutions - make this into a list of things that women can do for themselves, things that health workers can implement, and things that can be addressed by the wider community.
  3. Think of ways you can help to implement the solutions you have proposed. With regards to things women can do for themselves, how can you support them to do these things? What information will they need? How can you improve your couple counselling skills to work with partners to involve them in the solutions?
  4. What work needs to be done in the broader community? Who else can support you in this effort?
  5. Finally what can health workers do? Discuss the solutions among staff and develop a plan together to improve the support you can provide.

Image session14fu6.jpg Our View

Whether women are infected with HIV or not, it is important for them to understand how to prevent HIV transmission (or reinfection). Helping a woman overcome her own or her partner's resistance to partner testing and counselling, condom-use and other safer sexual practices for example, partner reduction or abstinence, will require you to have a frank, open discussion about sexual issues. You may need to discuss sexual attitudes and practices that you have not addressed in your counselling before. You may find that women would like an opportunity to role-play condom negotiation and introduction of dual methods with you before they discuss the issues with their partners. Before they do so, make sure to provide her with condoms.

See session 16 below on women and violence will also be of use to you if you suspect there may be a problem of violence.

Discussing HIV test results with women infected with HIV

Helping a woman cope with positive HIV test results is among the most difficult counselling challenges faced by health workers today. Pregnant women who find out that they have HIV have to cope not only with their own diagnosis, but that their baby has been exposed to HIV, as well as the normal concerns all women have during pregnancy.

Post-test counselling for pregnant women who test -HIV-positive can present challenges of time, space, and privacy/confidentiality. If it is not realistic to provide counselling to women infected with HIV during the regular antenatal care session, it may be possible to ask the woman to return at a time when it would be possible for you to have more time for a more in-depth discussion, after she has had time to think over the basic information you provided her during post-counselling at ANC. Some women who test HIV-positive may want to bring their partner or a family member back to the clinic to participate in couple or family counselling. If you cannot provide counselling of this type, refer them to other available HIV counselling services.

There are several key post-test counselling topics:

  • coping with the diagnosis
  • learning the actions to take to keep a woman and her baby healthier and prevent mother-to-child transmission, including antiretroviral drugs and infant feeding
  • deciding whether to share her test results with others, especially her partner, so he can also get tested.

Helping pregnant women cope with their diagnosis is the first counselling objective and requires special skills. Factors that influence a woman's acceptance of a positive HIV test results include:

  • the content and quality of the counselling and support she receives
  • awareness of the options that are available to her for treatment, care and support
  • her perception of what the reaction of family and friends will be
  • her willingness to share her HIV status with others (disclosure).

It is important to discuss the pros and cons of disclosing her status to others from the woman's own perspective and to discuss any problems that a woman thinks she might have if she shares her HIV status with others. Help her decide who she might like to tell about her diagnosis and help her make a plan to share her results if she wants to. If a woman would like your support to disclose results, offer to participate in “mediated disclosure”. Invite family and partner to the clinic or go to their home if appropriate, to participate in the sharing of HIV test results.

Provide women who have a positive test result with multiple opportunities for disclosure. Even women who choose not to disclose when results are first given to them can later change their minds.

Remember to assure women that all discussions about HIV results and related issues are confidential. Only you and essential members of the health care team will know about her status, and that you will maintain confidentiality among yourselves.

In many settings, women infected with HIV decide not to disclose their HIV status. Fear of stigma and discrimination, real or perceived, against people with HIV/AIDS, including fear of partner violence and rejection by family, can be a major barrier to getting tested for HIV test and disclosure of HIV-positive test results. Despite efforts to change attitudes towards people living with HIV/AIDS, stigma and discrimination persist in many communities.

Some women infected with HIV who disclose test results do experience violence or some of the other negative things that can happen. Remember, as mentioned earlier, fear of bad outcomes is more common that actual bad outcomes for most women. Most women who do tell others their HIV status receive support and understanding from their partner and family. When counselling, try to determine if there is a real risk of bad disclosure outcomes, and help think of alternative sources of support for women who cannot or will not disclose to their partner, family or close friends.

BARRIERS AND MOTIVATORS TO DISCLOSURE OF HIV STATUS

Disclosure means a woman sharing her HIV status with her partner and/or family.

Barriers

  • shock, anger, denial, fear, isolation, loss, grief, guilt
  • fear of abandonment- economic and family support
  • fear of rejection/stigma/discrimination
  • fear of violence
  • blame - fear of accusations of infidelity
  • shame - to admit to family and friends, employers and embarrass them
  • fear of loss of job
  • fear of effect on her marriage, current pregnancy or implications on future childbearing
  • depression, anxiety, low self-esteem, suicidal ideas.

Motivators

  • avoiding burden of secrecy, no fear of involuntary disclosure
  • allows opportunity for treatment, partner testing and counselling
  • ability to discuss testing, prevention/protection, treatment with partner
  • ability to protect partner/ baby from transmission
  • access to emotional and practical support
  • ability to discuss symptoms and concerns
  • easier access to health care
  • easier to adhere to medication - no need to hide medication
  • easier to adhere to infant feeding style of choice.

Activity 3

Image session14fu4.jpg 1 hour

Image session14fu5.jpg To practise helping HIV-positive women to make a disclosure plan.

  1. Review the box above which lists barriers and motivators to disclosure. Think these over and discuss with colleagues, women and men in the community to make the list appropriate for your setting.
  2. Practise disclosure doing some role-plays where the counsellor will:
    • discuss advantages/disadvantages of disclosure
    • help the woman identify barriers and fears about disclosure
    • explore options to overcome fear of disclosure
    • identify readiness to disclose
    • give the woman time to think over the results and her specific needs.
  3. Continue the role-play but move on to develop a disclosure plan. Be sure to include the following elements in the plan:
    • who to inform (disclosure) and impact on family
    • partial disclosure or full disclosure - who to tell first, where, and how
    • how to break news
    • assist the woman to anticipate likely responses after disclosure
    • provide reassurance, offer to mediate (e.g. act as a go-between) disclosure to partner or others. Offer couple counselling (see session 4).
    • identify sources of support
    • develop coping strategies for managing stress of diagnosis
    • discuss risk reduction, protecting partner and baby
    • assist the woman in understanding the need for her existing children to know her status and for them to receive testing and counselling in an age-appropriate way.

Image session14fu6.jpg Our View

Taking some time to review barriers and motivators to disclosure in advance will enable you to practise your counselling skills on this topic area. Counselling women or couples who are HIV-positive can be very emotional and is a sensitive topic. With the use of plays, you can explore different ways of facilitating and supporting the decision-making process.

Develop a sheet with the different elements of the disclosure plan and keep it handy so that you can use it as a support when working with women.

Treatment for herself and her baby, including preventing mother-to-child HIV transmission (PMTCT)

The second counselling objective for HIV-positive pregnant women is to explain in detail the care that will help her stay healthier and help her prevent passing HIV to her baby, and to motivate her to accept that care. Explain the prophylaxis (preventive treatment), treatment and care that may be available for her, her infant, and her partner. Explore with her if there are any barriers she might face receiving care and treatment, such as costs, transport, or family resistance.

Efforts to prevent mother to child transmission of HIV should be as comprehensive as possible and acknowledge that both mothers and fathers have an impact on transmission of HIV to the infant:

  • Both partners need to be aware of the importance of safer sex throughout pregnancy and breastfeeding.
  • Both partners should be tested and counselled for HIV.
  • Both partners should be made aware of and provided with PMTCT interventions.
  • Both partners should be provided with condoms.

When the male partner is involved and informed, the woman is more likely to be able to participate in PMTCT interventions, including using condoms during pregnancy and lactation, and receive needed maternal and HIV services.

Some things that help prevent transmission from mother-to-child, such as exclusive replacement feeding or exclusive breastfeeding (see Session 13), can be difficult for women to adopt, especially if they do not share their HIV status with family. For example, new mothers often experience pressure from mothers-in-law or other female relatives to use breast milk substitutes or to feed babies traditional porridge early in life, in addition to breast milk. This type of “mixed feeding” is especially dangerous for HIV-exposed babies, and you should help women develop strategies to maintain exclusive breastfeeding even if there is resistance in the home environment.

Women need support to help them decide and carry out their infant feeding choice.

Women need support to help them decide and carry out their infant feeding choice

Activity 4

Image session14fu4.jpg 1 hour

Image session14fu5.jpg To improve counselling content and techniques for the special needs of HIV-positive women during pregnancy, postpartum and breastfeeding.

  1. Review the key facts about PMTCT in this session or in the PCPNC. Are there any facts about PMTCT that you yourself would like to know more about to better counsel HIV-positive women?
  2. Think about the questions you ask all pregnant women when helping them prepare a birth and emergency plan (See Session 7). Think about how counselling HIV-positive women and their families for birth and emergency planning is different. Also consider the impact of stigma and discrimination from health workers and from the community. What will you need to add to the questions you developed for birth and emergency planning to consider the needs of the HIV-positive women? How could you strengthen your current counselling techniques to help HIV positive women with PMTCT and make a birth and emergency plan?
  3. Brainstorm possible barriers that women could face trying to carry out the recommended actions for PMTCT, such as disclosure, difficulties with adherence to antiretroviral interventions, planning to give birth in a facility and infant feeding recommendations. Talk with HIV-positive women and ask them what some of the barriers are. Use the information from Activity 2 in this session.
  4. Talk with staff members who may be involved in providing care to HIV-positive women during labour, birth and the postpartum period. Get them to review their own attitudes towards HIV-positive women, and whether they treat them differently, or view them differently. You can use Activity 1 of this session to guide your discussions. Ask for their comments on how each of them could contribute to more effective counselling for birth and emergency planning for PMTCT, infant feeding support and postnatal follow-up of HIV-positive women and their infants.
  5. Using the comments from women and staff, and your insight, put together a sample “PMTCT Birth and Emergency Preparedness Counselling Session”. Practise doing it. How long does it take to cover all the key facts? Probably more time than you actually have in your busy schedule! If your focus is more on giving information than about the woman's participation and a two-way communication process, consider how you can involve her more. Think of ways to cover all the information and allow time for the woman to participate and express her concerns in less time. You may need to break it up into several sessions.
  6. Make some notes in your notebook on how working with HIV-positive women for PMTCT has made you feel. Are there any things that you and the staff think you could do to make your facility more “PMTCT Friendly”?

Image session14fu6.jpg Our View

There is a lot of information to be conveyed in PMTCT counselling. However, it is important that the counselling on PMTCT does not become information giving only. Remember the foundations of good counselling (Sessions 2 through 5) - find out what the woman already knows and build on that knowledge. Ask about her situation and share information that is relevant to her. Help her to identify solutions and together work out how she can implement them. In some cases you may feel out of your depth, or unable to provide the level of support and care a mother who is HIV-positive needs. It may be appropriate in these instances to refer women for specialized counselling.

Supportive counselling for women infected with HIV

Making sure that women with HIV continue to get the additional care and counselling they need after the baby is born, during breastfeeding and the baby's first year of life presents special challenges. New mothers who are infected with HIV continue to need supportive counselling well into the baby's first year of life, to assure better follow-up of mother-baby pairs (HIV-positive mothers and HIV-exposed infants).

As your experience in counselling women infected with HIV increases, you will be able to identify common responses to positive HIV diagnosis and living with HIV. But remember to tailor your counselling to the specific needs of each woman: careful counselling can uncover deeper issues, problems and concerns that may be unique to each woman. Supportive counselling for women infected with HIV requires confidential two-way communication to help them define the problems and challenges related to HIV and make more informed choices about treatment, care and support. Women infected with HIV with special needs such as adolescents, or women living with intimate partner violence, may need even more support.

As a health worker you can provide hope and encouragement, and help give women a sense of control so they can find practical, realistic ways to cope with lifelong care and treatment needs for a serious illness like HIV. The box on the next page can help you determine some of the issues that may need to be addressed as you counsel women infected with HIV after the birth of their baby. Keep this information as a resource and reminder.

COUNSELLING TOPICS FOR WOMEN INFECTED WITH HIV

  • practice safer sex and appropriate family planning for HIV-positive women; use condoms (See Session 12 and box below.)
  • understand care and support needs for HIV-positive women and infants and access services
  • understand ARV treatment, assess treatment readiness, and access services if available
  • identify personal strengths and resources
  • living positively with HIV, personal care and improved nutrition
  • identify additional emotional, social, spiritual support required and potential sources - family, peers, community organizations
  • identify needs for material assistance and ways to mobilize local resources
  • define and address barriers to treatment, care and support.
  • identify ways to tell other children and caregivers about HIV status.

COUNSELLING WOMEN INFECTED WITH HIV ON FAMILY PLANNING

(Refer also to Session 12 on Family Planning)

  • Explain that future pregnancies can have significant health risks for her and her baby including transmission of HIV to the baby (during pregnancy, birth or breastfeeding), miscarriage, anaemia, wasting, preterm labour, stillbirth, low birth weight and other complications.
  • If she does wish to get pregnant again, birth spacing is important. Advise her to wait at least 24 months from birth to the next pregnancy, as that is healthier for her and the baby.
  • Condoms are the best family planning method for women with HIV. Condoms provide protection from STIs/ reinfection with HIV and pregnancy. Advise on correct and consistent use of condoms.
  • With the condom, another family planning method can be used for additional protection against pregnancy (dual protection). However, not all methods are appropriate for the HIV-positive woman:
    -

    A woman who has HIV, can insert IUD. If she has AIDS, do not insert IUD. But if the woman is being treated with antiretrovirals (ARVs) and is healthy, the IUD can be inserted.

    -

    Fertility awareness-based methods may be unreliable to use if she has AIDS or is taking ARVs because of changes to the menstrual cycle and higher body temperature.

    -

    Women with HIV should not use spermicides or diaphragms with spermicides.

    -

    Women who have HIV and TB, or any women taking Rifampin for TB, should not use hormonal birth control pills, monthly injectables, implants or patches.

  • As for HIV-negative women, Lactational Amenorrhoea Method (LAM) can only be used as a family planning method in the first 6 months after birth if the woman is exclusively breastfeeding her baby (that is not giving any other foods or drinks to the baby, not even water) both day and night and her menstrual periods have not returned.
  • Counsel about permanent methods if a woman has completed desired childbearing.

Some women infected with HIV may want to have additional children. Be supportive and respect a woman's wishes but explain that pregnancy carries risks for herself and her baby. Explain that women infected with HIV may have difficulty becoming pregnant. Discuss the need to plan for care and treatment for her, and for her children if she or her partner becomes ill.

Activity 5

Image session14fu4.jpg 1 hour

Image session14fu5.jpg To help HIV-positive women plan to receive treatment for her and her baby and reduce MTCT during pregnancy, birth and in the postpartum period

It is important to help women develop a plan to seek out and adhere to treatment, care and support for themselves and their infants. This activity aims to help you to provide supportive individual or family counselling to HIV-positive women and their families after birth.

  1. Review the recommended topics for counselling HIV-positive women in the first year after birth. Identify additional information you need or counselling skills you will need to strengthen. For example, did your previous counselling experience include counselling partners and family members, or outreach to solicit support from community or religious groups?
  2. Review the clinic records of some of the HIV-positive women you have counselled during pregnancy who have now given birth. Think about the counselling and support you provided during antenatal care sessions and during labour and birth. Did it include recommending follow up for the mother and baby after routine postpartum visits are completed? What would you need to change so that supportive counselling to HIV-positive women throughout the first year after birth becomes a routine part of your counselling services?
  3. Think about the list of counselling, care and support recommended for HIV-positive women and their babies. Talk to some HIV-positive women to get their actual experiences caring for themselves and caring for a baby exposed to HIV. Make a list of the possible barriers they face. Divide this list into internal barriers (things like shame, fear, and low self-esteem) and external barriers (lack of funds or transport, no family support). Think of ways to support them to overcome each barrier. Focus on ways to provide hope, encouragement, and practical, realistic ways to cope.
  4. Decide which needs of HIV-positive women and babies you and your staff can address through counselling, and what things you will need external help to achieve. How can you create broader awareness of the problems of HIV-positive women and families? Consider the possibility of creating peer support groups, so HIV-positive mothers can share their experiences with other HIV-positive women. Will you need to recruit the support and resources of local community and government organizations?

What did I learn?

Image session14fu9.jpg

After finishing this session you should be better prepared to counsel all pregnant women about issues of HIV in pregnancy, and the importance of getting tested for HIV. You should know how to counsel women to practise safer sex to prevent HIV, and how to prevent MTCT. You can provide initial supportive counselling to women who test positive for HIV, and you have practised helping women to decide about disclosure of HIV test results, and to deal with stigma and discrimination that often results when a woman tests HIV-positive.

You have learned more about the many concerns and challenges facing both HIV-negative and HIV-positive pregnant woman and their families. Are you more comfortable talking to women about their sexual practices that may put them at risk for getting HIV? About how to adopt safer sex practices within their relationships? Are you confident you can counsel women infected with HIV without allowing any personal attitudes you might have to influence the counselling relationship?

Do you have all the necessary information you need to be able to counsel pregnant women about HIV/AIDS or to refer them to specialized counselling? If completing this session made you want to expand or formalize the basic HIV/AIDS counselling skills you learned, try to identify local sources for HIV counselling and testing in your area, such as government programs, NGOs and community- based organizations.

Write down in your notebook a summary of the key lessons you have learned in this session.

Copyright © World Health Organization 2013.

All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: tni.ohw@sredrokoob). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: tni.ohw@snoissimrep).

Bookshelf ID: NBK304180

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