Pediatric Index Testing  - PowerPoint Presentation

1. Pediatric Index Testing Module 5Ensuring pediatric index testing services are safe and ethical: Considerations for addressing intimate partner violence and violence against children

2. Index Testing Must Follow the 5CsAll HIV testing services, including index testing, must meet WHO’s 5C standards

3. PEPFAR’s Guidance for Safe and Ethical Index TestingIndex testing is a completely voluntary service offered to people living with HIV (PLHIV) to assist them with getting their partner(s) and child(ren) tested for HIV. They are free to accept or decline this service. PLHIV must be provided with all available HIV prevention, care and treatment services, regardless of their decision to participate in index testing services Services MAY NEVER be withheld from clients and clients MAY NEVER be pressured into disclosing the names and contact information of their child(ren)Index testing should be client-centered and focused on the needs and safety of the index client and his or her partner(s) and children Please see the PEPFAR Safe and Ethical Index Testing Guidance for additional information

4. What Happens When Clients Feel Coerced into HIV Testing?Sircar et. al. 2020 interviewed key and affected populations in Kenya:"Multiple interviewees felt that some providers coerce their community to test, and several felt that providers are judgmental and unlikely to respect privacy and confidentiality."Gaining insight from the client can help us provide more individualized and human rights-based services that ensure the concerns of the client are center stage

5. Maintaining Confidentiality Is a Key Part of Safe and Ethical Index Testing ServicesIndex testing providers need to give their clients an assurance that what is said will be kept in confidence. It is the provider’s duty to never reveal information that clients tell them outside of shared confidentiality with other relevant staff Personal Identifiable Information (PII) of all family members should always be kept confidential As part of the consent process, discuss with the client:what protections will be put in place to protect the confidentiality of the information they share about themselves and their contacts, who will have access to their information, andwith whom their information may be shared and for what purpose.

6. Data Sharing Agreement for Shared Confidentiality Clinical partners should have a data sharing agreement in place with OVC and community partners BEFORE beginning services This agreement should include a description of how both organizations will maintain the confidentiality of client information For more information see the OVC Job Aid or the PEPFAR Solutions Safe & Ethical Index Testing Toolkit. 

7. Protecting Children and Adolescents from HarmChildren are considered a vulnerable population due to:Dependence on adults, due to age and developmental stageLow social status, especially girls and children with disabilitiesEconomic dependenceLegal status The result is that violence against children (VAC) is often surrounded by secrecy and stigma and seen as a private matter, especially if the perpetrator is a family member. Photo source: Children in Adversity Strategy, p2: Photo credit: Rosalie Colfs, Handicap International, TEAM CONGO project 

8. Guiding Principles for Working with Children and Adolescents12. Evolving capacities of the child or adolescent1. Best interests of the child or adolescent3. Non-discrimination4. ParticipationSource: 1989 UN Convention on the Rights of the Child

9. Special Considerations for Survivor-Centered Care for Children Survivor-centered care empowers the survivor of violence by prioritizing their rights, needs and wishes and ensures they have access to appropriate and good quality servicesCore principles of survivor centered care:Do No HarmMaintain Privacy and Confidentiality Meaningful Engagement of Survivors and PLHIVAccountability

10. Applying the Principles of Survivor Centered Care for Children at Risk for or Experiencing ViolenceDo no harmUnderstand how to recognize signs and symptoms of potential violence against children (VAC)Be aware of increased VAC risks for sub-groups of children and adolescents, especially children with disabilitiesKnow where to access further support within and outside the health facilityHave written information about where to go for VAC and GBV support

11. Do’s and Don’ts of Identifying VAC in Clinical SettingsWHO recommendation 1: Health care providers should be alert to the signs and symptoms of child maltreatment and associated risk factors and assess for child maltreatment without putting the child at increased risk.WHO recommendation 2: Health care providers should not use a universal screening approach (e.g., a standard instrument, set of criteria, or questions asked of all children in health care encounters) to identify possible of child maltreatment.WHO Clinical Guidelines: Responding to Children and Adolescents Who Have Been Sexually AbusedIn addition to health care providers, community actors such as OVC case managers and community health workers should also know the do's and don'ts of identifying VAC. 

12. First-Line Support for Children Who Are Experiencing ViolenceSource: First-line Support for VAC module of the 4Children VAC Training

13. First-Line Support for Violence Against Children (VAC)Whenever you suspect violence or neglect, or whenever a child or adolescent discloses experience of violence or neglect, provide age-appropriate first-line support using the LIVES approach. Never ask about experience of violence or discuss violence with anyone else in the room, including a parent or caregiver, as they may be or know the perpetrator. Every site should have a trained focal person for managing cases of confirmed or suspected violence or neglect. If you have a concern that a child is facing risk to life or serious harm, keep the child safe and bring in support immediately.If in doubt, assume that a child is at serious risk and contact the focal point.  

14. First-Line Support for Violence Against Children (VAC)Have a set of simple ‘keeping safe’ instructions for a child who may be at risk but does not appear to be in immediate harm. Ongoing referrals and support are essential. Referrals should be made to the OVC program, as well as clinical and/or non-clinical violence response services, including child protection and psychosocial support services. Listen respectfully and empathetically to the information that is provided by the child or adolescent and their caregivers.Offer a non-judgmental and validating response – reassuring the child or adolescent that they are not to blame for the abuse and that they have acted appropriately in disclosing it.

15. What Do I Do After I Obtain Consent for Testing?Before HIV testing for children where parents have given consent, prepare parent/adolescent for the HIV test outcome:Let’s talk about how you are feeling about getting your child testing for HIVWhat are some reactions/steps you will take if the test is positive? negative?Do you have any concerns about the reactions of others in your family or household if the child is positive? Do you have any concerns about the reactions of those in your community if the child is positive? Do you have any concerns about the child’s safety or about the child being accepted and loved at home after the test? Describe available options for additional support including the OVC program, family counseling, adult or child support groups:Living with HIV especially when you are just finding out for the first time about the diagnosis can be challenging. Do you have someone who will support you and the child if the result is positive?See the Safety Check Flowchart. 

16. What Do I Do If the Testing Referral or Consent Is Declined?If referral for index HIV testing of biological child is refused or consent is not given, discuss the following questions to determine if adverse effects are a barrier to testing:Do you feel unsafe going to the clinic to have your child tested?Let’s talk about how you are feeling about getting your child testing for HIV?Do you have any concerns about the reactions of others in your family or household if the child is positive? Do you have any concerns about the reactions of those in your community if the child is positive? Do you have any concerns about the child’s safety or about the child being accepted and loved at home after the test? Discuss testing options, create a plan, and share with clinical/OVC team (as outlined in the OVC and clinical job aids) Work together to assure safety of child/parent from harm, neglect, abandonmentSee the Safety Check Flowchart. 

17. What Do I Do if I Have Concerns about the Safety of the Child or Caregiver?If the parent/adolescent indicates that they have concerns about the child’s safety based on the test or the test results, take action to ensure the child and parent will be protected. recommend that the parent/adolescent meet with a social worker or VAC point of contact and/or make a referral to appropriate resources in the community where the parent or caregiver can go to get the help and support they need. Proceed with HIV testing only when safe. Refer to the VAC and IPV sections of this training as well as other VAC and IPV trainings (e.g., LIVES training and 4Children materials).

18. How Can I Enhance the Safety of Children Who Are at Risk of or Experiencing Violence?Make sure that there are no negative consequences for the child or family.Confidentiality is essential. The most important thing to help a child be safe is to listen to the child, validate the child’s experiences, and ensure that the child has had the chance to say what they are comfortable saying. It is not necessary to encourage, nor should a child or adolescent be forced, to disclose experience of violence. You can offer LIVES and a referral to the VAC focal point even without a disclosure of violence.Always have easy-to-access information available for sharing with children (e.g., Child Helpline, if available, and other sources of local support. Conversations should be age-appropriate.  

19. Safety Check FlowchartThis flowchart reviews the steps for ensuring that index testing services remain safe for children living with HIV and their caregiversIt includes sample questions and scripts for counselors and providers to useThis job aid can be adapted for the country-specific context so OVC and community-based staff have a step-by-step process to follow to support children and families throughout the pediatric index testing process.Let’s review this flowchart together

20. Technical Resources for Routine Enquiry of Intimate Partner and Family Based ViolenceKeesbury, Jill, and Jill Thompson. (2010). A step-by-step guide to strengthening sexual violence services in public health facilities: Lessons and tools from sexual violence services in Africa. United States Agency for International Development. http://www.popcouncil.org/uploads/pdfs/2010HIV_PEPFAR_SGBV_Toolkit.pdfWorld Health Organization. (2013). Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. World Health Organization. http://apps.who.int/iris/bitstream/handle/10665/85240/9789241548595_eng.pdf?sequence=1World Health Organization. (2014). Health care for women subjected to intimate partner violence or sexual violence: a clinical handbook. World Health Organization.  http://www.who.int/iris/handle/10665/136101World Health Organization. (2016). Guidelines on HIV self-testing and partner notification: Supplement to consolidated guidelines on HIV testing services. World Health Organization. http://apps.who.int/iris/bitstream/handle/10665/251655/9789241549868-eng.pdf;jsessionid=E3EB194F380FFEFB97F86E66751FF829?sequence=1

21. VAC-Related Technical ResourcesWHOWHO. Caring for women subjected to violence: A WHO curriculum for training health-care providers. (2019) https://www.who.int/reproductivehealth/publications/caring-for-women-subject-to-violence/en/ WHO. INSPIRE: Seven Strategies for Ending Violence Against Children. (2016) https://www.who.int/publications/i/item/inspire-seven-strategies-for-ending-violence-against-childrenAIDSFreeAIDSFree.  Clinical management of children and adolescents who have experienced sexual violence. (2013) https://cdn.ymaws.com/www.forensicnurses.org/resource/resmgr/Education/PEPFAR_Clinical_Mngt_of_Chil.pdfAIDSFree.  Strengthening linkages between clinical and social services for children and adolescents who have experienced sexual violence: A companion guide. (2016) https://publications.jsi.com/JSIInternet/Inc/Common/_download_pub.cfm?id=18965&lid=34ChildrenLVCT Health. Integrating Violence Against Children Prevention and Response into HIV Services - Training for health care providers. (2019) https://www.crs.org/our-work-overseas/research-publications/integrating-violence-against-children-prevention-and-0Together for GirlsTogether for Girls. Resource Bank. https://www.togetherforgirls.org/resources-bank/