Learning to Work with Orphans and Vulnerable Children

1. Learning to Work with Orphans and Vulnerable Children A Project of the Social Work HIV/AIDS Partnership for Orphans and Vulnerable Children in Tanzania Day 7 Helping HIV Infected and Affected Children and Families

2. Social Work Process for Working with Most Vulnerable Children and their Families Identifying Vulnerable Children and their Families Engaging Vulnerable Children and Families Assessing the Strengths and Needs of Vulnerable Children and their Families 4. Developing a Plan of Services for Vulnerable Children and their Families

3. Social Work Process for Working with Orphans and Vulnerable Children Affected by HIV 5. Implementing the Plan of Services • Identifying and Referral to Other Resources • Providing direct services: problem solving, support and coordination • Empowering and supporting caregivers • Addressing HIV related prevention and care concerns • Evaluating Progress, Revising Service Plan and Following Up Through Ongoing Case Management, Family Support And Advocacy

4. Objectives At the end of this day, Para Social Workers will be able to: • Demonstrate knowledge of the basic facts of HIV infection from acute infection to end of life • Describe the context of HIV in Tanzania, Sub Saharan Africa and the world • Demonstrate basic knowledge of HIV Prevention, Counseling and Testing from the perspective of the Para Social Worker

5. Objectives, continued • Demonstrate basic knowledge of Prevention of Mother to Child Transmission of HIV from pregnancy through breast feeding from the context of the Para Social Worker • Demonstrate a basic knowledge of HIV treatment and the Para Social Work skills required to support adherence and prevention for people living with HIV/AIDS

6. The Basic Facts of HIV as it Affects Tanzania and the World

7. The Definition of HIV • H Human - because this virus can only infect human beings • IImmuno-deficiency - because the effect of the virus is to create a deficiency, a failure to work properly, within the body’s immune system. • V Virus - because this organism is a virus, which means one of its characteristics is that it is not capable of reproducing by itself. It reproduces by taking over the machinery of the human cell.

8. The Definition of AIDS • AAcquired is acquired or becomes infected with • I Immune destroys the body’s immune system, which usually works to fight off disease • D Deficiency makes the immune system not work properly • S Syndrome a wide range of different diseases and opportunistic infections Acquired Immune Deficiency Syndrome AIDS is part of the spectrum of HIV, defined as end stage disease. AIDS is symptomatic and, unless treated aggressively, leads to death

10. Exercise • Talk with the person next to you • Make a list of • The ways HIV can be transmitted • The ways people think HIV can be transmitted that are not true (HIV CANNOT be transmitted)

11. Common Modes Of HIV/AIDS Transmission The main mode of transmission is sexual. Mother to Child Blood transfusion Sharing of sharp objectscontaminated with infected blood (tattooing, genital cutting)

12. HIV Stage with progressive deterioration of immune system – symptoms can occur in HIV and depend on general health state of the PLWHIV and other factors HIV/AIDS Progression stages Pre Infection Acute Infection Sero- Conversion Asymptomatic Period Periodic Health Problems Development of more severe Health Problems ART stops progression

13. AIDS ART HIV INFECTION Deterioration of CD4 Cells (T Cells) over the Course of the Disease, 10-12 years 1500 350 200 0 CD4 Cells (T Cells) Stages of Progression: HIV/AIDS

14. Definition of Terms • Viral Load= the amount of virus your body produces every day • CD4 cells or T Cell= the cells of the immune system destroyed by HIV. Normal CD4 is 600 to 1500. As the disease progresses, CD4 goes down to 0. • ARV or ART Anti-retroviral therapy= a triple combination of drugs of 3 classes usually as one combined pill • Epidemic= outbreak of disease bigger than usual • Pandemic= a worldwide epidemic of disease • Opportunistic Infection= the diseases that occur once the immune system of an HIV positive person is destroyed by HIV. There are 29 diseases designated as opportunistic for HIV/AIDS

15. The Progression of Disease • Initial infection may present as a flu-like syndrome or may not have symptoms • HIV is usually symptomless, people with HIV look and feel well. This stage may last for many years • HIV can be transmitted from one person to another AT ANY STAGE of the DISEASE unless primary and (prevention for positive (secondary prevention) is practiced

16. The Progression of Disease If treated with ARVs, HIV transmission is reduced significantly If treated effectively, people with HIV can live a normal life span and HIV becomes a chronic disease like diabetes or asthma If untreated, HIV progresses to AIDS, the life threatening form of the disease and the probability of transmission increases

17. HIV/AIDS Epidemic - 2009 Global • 2.6 million new infections in 2009 • 33.3 million living with HIV worldwide • 1.8 million died of AIDS in 2009 • 17 million orphans as a result of HIV/AIDS Sub-Saharan Africa • 22.5 million living with HIV • 1.8 million new infections • 1.3 million died of AIDS in 2009 • 90% of infected children and newly infected children reside in Sub-Saharan Africa

18. HIV and Life Expectancy in Tanzania • In 1991, the life expectancy in Tanzania for women was 54 years and 53 years for men • In 2009 LIFE EXPECTANCY is 48 years and AIDS is the leading cause of death Sources: Countryfacts Information Courtesy: CIA Worldbook, 2011; USAID. Sub-Sahara Africa. http://www.usaid.gov/locations/sub-saharan_africa/countries/tanzania/index.html(downloaded July 20, 2011)

19. HIV/AIDS Situation in Tanzania • 1.4 million people were estimated to be living with HIV/AIDS in Tanzania by the end of 2009 • The overall HIV adult prevalence in Tanzania is 5.7% of adults - more than 1 in 20 persons is HIV positive; prevalence for women 6.6%. 4.6% men. Urban prevalence is 8.7% (2008 data – GoT) • 200,000 children between the ages of 0 - 14 years were estimated to be living with HIV/AIDS (2009 GoT)

20. Social Factors Contributing to HIV/AIDS Infection • Economic • Poverty • Urbanization and lack of support network in urban environments • Social • Multiple sex partners • Alcohol intoxication • Drug and substance abuse • Sexual exploitation of women • Stigma and disclosure • Cultural • Sexual violence, rape and exploitation • Early sexual initiation • Inheritance of widows

21. HIV Transmission in Tanzania • Contributing factors • Multiple sex partners • Early sexual initiation • Low levels of condom use • Unknown HIV status • Lack of information about sexual health • High levels of other sexually transmitted diseases

22. The Biggest Risk Factor for the Transmission of HIV • In 2008, women comprised over 60 percent of people living with HIV. Among the 15-24 age group, this figure rises to 75 percent. • Women who are married having unprotected sex with only their husband are still at risk • In fact the most common transmission source for women in Tanzania may be husbands who have had sexual contact with others. Source: TACAIDS (2008, November) ‘Tanzania HIV/AIDS and Malaria Indicator Survey 2007-2008

23. Sexual Protection Remember: When you have unprotected sex, you are ALSO having sex with all the partners of your partner

24. HIV Prevention, Counseling and Testing

25. How to Prevent HIV • Abstinence • Be faithful • Condoms • Delay sex • Prevention of mother to child transmission • Treat all other sexually transmitted infections Education about HIV is needed for all of these!

26. Primary Prevention Strategies • Behaviour Change

27. Do you mind if I ask you some questions about your health? This will include your sexual health. Are you sexually active---do you have sexual or intimate contact with another man or woman? If yes, with men, women or both? Do you take disease precautions? If yes, explain. If not, why not? Do you take any recreational drugs that involve needle transmission? If yes do you share needles? How do you clean them? Do you have any questions you would like to ask me about your sexual health, AIDS or sexually transmitted diseases? Source, Linsk, 2000 Risk Assessment

28. Strategies to Address HIV Prevention • REDUCE STIGMA. Stigma may get in the way or reducing risk behaviours. • Decrease use of alcohol and other drugs that affect normal behavior • Know your HIV status

29. How does VCT help people?How does VCT help link to services Brainstorm

30. Voluntary HIV Counseling and Testing • VCT is a vital point of entry to other HIV/AIDS services including • Prevention of mother-to-child transmission • Prevention and clinical management of HIV related illnesses and treatment of tuberculosis • Psychosocial and legal support • Facilitates early referral for care and support including access to anti-retroviral therapy (ART)

31. Voluntary Counseling and Testing (VCT) • Good voluntary HIV counseling assists people to: • Learn their HIV status and make informed decisions • Explore, assess and alter risky behaviours • Cope better with their health condition(s) • Lead more positive lives and plan for the future • Help HIV infected people protect their sexual partners and families • Help learn best practices of disclosure in the social and cultural context

32. Rapid Testing for HIV • Current testing model: • Blood from a finger stick (or saliva) is tested in ten minutes. • Results are obtained in about the same amount of time as a pregnancy test. Results are also confirmed rapidly. • Safer sex techniques and linkage to care must be discussed by the counselor.

33. The Role of the Para Social Worker in VCT • Encourage people of unknown status to test, especially women of child bearing age • Develop couple and family support (e.g. husband for wife for testing) and encourage positive living • Help with the access to testing (transportation, peer support, etc) • Encourage results disclosure and help to support the communication process safely and positively

34. The Role of the PSW in VCT • Support people during the process of testing and of understanding the results • Make sure that post test counseling is provided for positive and negative • Support the process of behaviour change for people engaging in high risk practices • Multiple sex partners • Early sexual initiation • Risky sexual behaviours • Unsafe sex practices • Men who have sex with men • Intravenous drug usage and other illicit drug use

35. Family and Community Support of Prevention of Transmission of HIV from Mother-to-Child (PMTCT), Family and Community

36. The Basic Facts of Prevention of Mother-to-Child Transmission of HIV • HIV is transmitted from mother to baby during the process of pregnancy, child birth and breastfeeding • HIV transmission during can be decreased to very low level (<2%) with treatment of mother and baby as early as possible

37. Overall 20% to 45% infants will be HIV- infected if there is no intervention 5% to10% infants infected during pregnancy 10% to 15% during labour and delivery 5% to 20% infants infected during breast feeding Route of Transmission: Mother to Child

38. The Role of Para Social Workers with HIV Positive Mothers • Know the facts of Prevention of Mother-to-Child Transmission • Para Social Workers can help mothers to protect baby from the infection • Encourage mothers to get treated • Counsel women to plan pregnancy, childbirth and breastfeeding • Support women in HIV care, support their families to encourage HIV care • Provide information on safe baby feeding and baby care

39. The Role of the Para Social Worker: Pregnancy • Work with families to support HIV positive women, their babies and their families • Help mothers to plan pregnancy and birth to prevent transmission • Link pregnant mothers to care providers as early in pregnancy as possible • Help pregnant mothers to know their HIV status and to get prenatal care and HIV treatment according to national guidelines • Help pregnant mothers to get family support for testing, prenatal care and HIV care during

40. Prevention of Mother to Child Transmission: Child Birth • ART treatment during birth can prevent transmission to the baby This birth must occur in a clinic or a hospital. • Women should learn their HIV status as early as possible • Effective treatment can lessen transmission significantly

41. PSW Roles: Child Birth • PSWs should support medically appropriate care for pregnant women, women giving birth and women who are breastfeeding • Support the family, when facing the double stressors of child birth and HIV diagnosis simultaneously. Many complex family situations can erupt during this high stress period • Help the medical staff communicate complicated medical knowledge to the mother and family in a form that both can understand quickly. Time is very important. THINK EMERGENCY

42. PSW Roles: Child Birth • Knowledge of the current PMTCT protocol is required to help women understand what the doctors are telling them. • Support can include a variety of factors such as: • Mobilizing timely transportation • Testing and ARV treatment protocol acceptance • Overcoming barriers to hospital birth

43. Deciding Whether to Breast or Bottle Feed for Positive Mothers • During the first two months, a bottle-fed baby is nearly six times more likely to die from diarrhea, respiratory or other infections, compared to a breastfed child • This is mostly because contaminated water is used in mixing the formula, bottles are unclean or formula is not sufficient for infant growth • Switching between breast and bottle feeding increases the possibility of illness and HIV transmission

44. Cultural practices support breast feeding If babies are NOT breast fed, people may question your HIV status and expose both women and baby to danger, to exclusion or other stigmatization Exclusive breastfeeding for the first 6 months unless replacement feeding is AFASS Acceptable Feasible Affordable Sustainable Safe Deciding Whether to Breast or Bottle Feed for Positive Mothers

45. Breast Feeding Guidelines for Positive Women Where breastfeeding is judged to be the best option: • Exclusively breastfeed for the first 6 months, then introduce appropriate additional food and continue breastfeeding for 12 months. Wean gradually and continue to treat for at least 1 week after contact with breast milk. • At 6 months, continue breastfeeding with additional complementary food if AFASS is not met. Wean within a period ranging from about 2−3 days to 2−3 weeks

46. The Role of the Para Social Worker in Feeding Decision Making • Help the Mother and the Family to understand the facts of breastfeeding for positive mothers • Make sure that the Mother understands the procedures required for safe breast feeding, including ARV treatment for herself and her infant • Help mothers to get medical care for breast problems, along with sores or thrush in an infant’s mouth • Help the family to understand the importance of safe feeding practices for HIV positive mothers

47. HIV/AIDS MedicationsAccess to Health ServicesOther Illnesses Related to HIV

48. HIV Treatment: The Basic Facts for Para Social Workers HIV is treatable but cannot be cured HIV treatment requires at least three drugs usually taken in combination Side effects are manageable by working with the health provider If HIV medicine is not adhered to at a 90-95% level, HIV treatment will become progressively less effective Once people start HIV medicine, they cannot stop without risking their health and survival and that of others

49. Goals of Antiretroviral Therapy Reduce number of viruses in the body to undetectable level (<50 per mm3) Restore and/or preserve immune function Improve quality of life Reduce HIV-related illnesses Minimize drug resistance– when the virus mutates so the drug class is no longer effective Prevent opportunistic infections with a variety of medicines which can create better health and improve survival

50. Issues of Anti-Retroviral Treatment • Most side effects go away after a few weeks. If not need to contact health provider • Medicine is for the lifetime, unless in cases of serious side effects, e.g damage of nervous system • HIV medication requires balanced diet that basically can not be afforded by majority of Tanzanians • This can involve a lot of pills and complicated dosing schedules