Counselling

A child with suspected HIV generally means a family with suspected HIV. Counselling therefore has to take into consideration the mother and, if possible, the father. Until recently there have been few specific treatment options to offer the child and family when a child tests HIV-positive.This has made raising the issue of testing difficult. However, the increasing availability of antiretroviral treatment is likely to encourage HIV testing. Also, parents often want to know the cause of their child's illness. See Chapter 6 for the issues for discussion with adults with suspected HIV.

Pretest counselling

It is important to counsel the mother before testing her child for HIV. Her consent is necessary before testing her blood (if the child is under 18 months) or the child's blood (if the child is over 18 months) for HIV. If her child tests HIV-positive, then it is extremely likely that she is the source of infection and is HIV-positive.

Consider the implications for the mother when she hears that her child may have HIV infection:

° her child may have an incurable and fatal disease; ° she herself may have HIV; ° her husband may have HIV; ° any future children may have HIV.

Her decision to have a test or not is difficult. She will need time and support while she considers the advantages and disadvantages of a test. If she knows she is HIV-positive, the main advantage is that she can plan for the future. On the other hand, she may be fearful that her husband will beat her or leave her if she tells him that she is HIV-positive. She may also be concerned that if her child tests positive, the health workers will no longer provide good care for her child.

The mother may like to bring her husband for joint pretest counselling. It is usually easier for a woman to tell her husband she may be HIV-positive than to tell him afterwards that she is HIV-positive.

Post-test counselling

Chapter 6 lists the issues for discussion relevant to anyone who tests HIV-positive.There are other issues specific to a mother who tests HIV-

positive. These include the poor outlook for the child and the risk of future babies being HIV-infected. About one-third of children born to HIV-positive women are also HIV-infected (in the absence of interventions to prevent mother-to-child transmission).

When counselling women who are breastfeeding or who have delivered recently, it is important to discuss breastfeeding. There is risk of HIV transmission by breastfeeding. However, in many low-income countries, breastfeeding is still a safer alternative to bottle-feeding. For example, a child whose mother is HIV-positive and who lives in an environment where there is no clean water is probably at higher risk of dying from diarrhoea if bottle-fed than from AIDS if breastfed.

It is also important to consider PCP prophylaxis with cotrimoxazole for infants born to an HIV-infected mother. PCP is a very common cause of death in HIV-infected infants especially before 6 months of age. The recommended cotrimoxazole dosage for PCP prophylaxis is 150 mg TMP/750 mg SMX per m2/day given 3 times per week.Thus, appropriate dosage for infants 2-6 months (usually 3-6 kg) would be 40 mg TMP/200 mg SMX once a day three times per week. If only cotrimoxazole tablets are available, then give half a crushed tablet (80 mg TMP/400 mg SMX) on Monday,Wednesday and Friday.

I I SUGGESTIONS FOR FURTHER READING I I

Lepage P Spira R, Kalibala S, et al. Care of human immunodeficiency virus-infected children in developing countries. The pediatric infectious disease journal, 1998, 17:581-586.

Marum LH,Tindyebwa D, Gibb D. Care of children with HIV infection and AIDS in Africa. AIDS, 1997, 11 (Supplement B): SI25-SI34.

Joint UN Programme on HIV/AIDS. Provisional WHO/UNAIDS Secretariat recommendations on the use of cotrimoxazole prophylaxis in adults and children living with HIV/AIDS in Africa. Geneva, 2000. (Available at http://www.unaids.org).

Temmerman M, Ndinya-Achola J, Ambani J, Piot PThe right not to know HIVtest results. Lancet, I995, 345: 969-970.

Joint United Nations Programme on HIV/AIDS, AIDS epidemic update: December 2002. Geneva.

World Health Organization, Counselling for HIV/AIDS: a key to caring. Geneva, 1995.

World Health Organization, Scaling up antiretroviral therapy in resource-limited settings. Guidelines for a public health approach. Geneva, 2002 (includes a clinical staging system for HIV and HIV-related disease).

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