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Volume 2, Number 3
mdi\sOF
HEALTH SERVICES
HIV Counselor
PERSPECTIVESWritten and Produced by the UCSF AIDS Health Projectfor the California Department of Health Services, Office of AIDS
Inside This IssueResearch Update
Health of Infants with HIV
Implications for CounselingCase Study
Test Yourself
Discussion Questions
PREGNANCY & HIV
1347
88
8
of pregnancy. Recent studies alsosuggest transmission may occurat the time the baby is delivered,perhaps through contact with themother's blood. For instance, onestudy showed that the first-bornin a set of twins was far more likelyto be infected than the secondborn, indicating transmission mayhave occurred when the first twinwas exposed to blood upon entering the cervix and birth canaLS
In some cases, physicians haveperformed Caesarean sections inan attempt to reduce mv transmission risk. However, babies delivered by this method, a surgicalprocedure that reduces contactwith the mother's blood duringdelivery, have also been infectedwith HIV. Therefore, Caesereansection delivery is recommendedonly if it is medically indicated forfactors other than HIV.
A woman can be infected whilepregnant, and the fetus can thenbe infected. Therefore, it is necessary for pregnant women to avoidunsafe risk behaviors.
A few cases of HIV diseaseamong women have been linkedto donor, or alternative, insemination. Sperm "banks," which freezeand store sperm for later use, arerequired by California law to per-
form an HIV antibody teston donated semen. However, physicians, who use freshsperm by taking it directlyfrom a man and inseminating it into a woman, are notrequired to screen for HIVantibody. Clients using either of these methods areurged to obtainwritten doc-
*T-helper cells are white blood cells that fightdiseaseand are reduced in numberas HW spreadsand the immune system is suppressed. P24 antigen is an agent produced byHW that often can bedetected through laboratory tests in people withsymptoms of disease.
stages of illness.2*It is not possible to determine
if a woman with HIV will bear aninfected child. A woman's historyof giving birth to children with orwithout infection is not an indicator of whether future children willbe infected. A small study showedthat children born to women whoseroconverted during pregnancywere at no greater risk of HIVinfection than children born towomen who were seropositive atthe time they became pregnant.4
Methods of TransmissionMuchremains unknown about
the specific ways in which HIV istransmitted from a woman to afetus or child, but most research-
. ers assume that transmission occurs through more than one route.
Researchers have speculatedthat transmission can occurthroughout pregnancy at the timeof conception or at some pointduring the embryonic or fetal stage
RESEARCH UPDATE
Probability of TransmissionWhile early studies of perina
tal HIV transmission showed thatas many as 60% of childrenborn toa mother with HIV were themselves infected, more recent research has found this high rate tobe inaccurate. Studies in 1991 and1992 have commonly found transmission rates of about 25%. Onestudy reported a transmission rateas low as 14%.2 Clinicians generally indicate that children born towomen with HIV have a 25%chance of being infected.3
Several factors may affect transmission rates. Research has suggested thattransmission rates may behigher for women with relatively low T-helper cellcounts, those in whom p24antigen is present, and thosewho are at more advanced How to Use PERSPECTlVES
It is estimated that as many as80,000 women of reproductive agein the United States might be infected withHIV.l Epidemiologistsbelieve that each year from mid1988 to mid-1990, there were 6,000births to HIV-infected women inthe United States.
HIV can be transmitted perinatally, that is from awoman to afetus duringpregnancy or from a mother to a childduring delivery or immediately followingbirth. Perinatal transmission is also referred to as vertical transmission.
PAGE 2 PERSPECTIVES
Rates per 10,000 Women Who Gave Birth
*Based on HIV antibody tests of 135,808 newborns in the third quarter 1988.
HIV in California Childbearing Women21*
Progression of Disease
Preliminary studies haveshown that pregnancy did not affect disease progression in women with HIV.8 Studies comparingpregnant,HIV-infected women touninfected pregnant women havefound little or no difference in therate of clinical and immune system deterioration.8
However, HIV symptoms andopportunistic infections can bemore serious when they occurduring pregnancy compared tooutside of pregnancy. Fatigue,anorexia, weight loss and shortness of breath are symptoms ofboth HIV infection and pregnancy. When these symptoms occuras a result of pregnancy, the added presenceofHIV can make themmore serious. Also, because theyare common symptoms of pregnancy, clinicians may not see themas signs for HIV, and thereforemay fail to take steps to preventfurther HIV disease progression.
Studies have found no significant differences in delivery termsor pregnancy complications between asymptomatic HIV-infected women and uninfected women. In a study comparing infantsborn to HIV seronegative motherswith those born to seropositivemothers - without regard to themother's health status - therewere no significant differences inbirth weight or size.9 However,one small study found that HIVinfected women were more likelythan uninfected women to havepremature labor and to give birthto lowbirth-weight infants.10 Moreresearch is being conducted.
Treatments and Pregnancy
In initial studies, pregnantwomen have responded as well asother HIV-infected people to treatment with AZTY While one report suggested that recommended doses ofAZT are not harmful towomen or fetuses,12 the long-term
1510
ter birth, a baby may continue tohave its mother's antibodies, regardless of whether the child isinfected with HIV. After this peri0d, a baby loses its mother's antibodies and, if infected, developsits own.
However, a recently developed test may offer promise atdetermining infant infection asearly as six months after birth. Thistest measures proteins called IgAantibodies, which, unlike antibodies measured by standard HIV antibody tests, do not travel acrossthe placenta to the fetus. This simpleand relatively inexpensive test,which costs about $50, may revealthe child's, rather than the mother's, response to HIV.7 In addition,the experimental and costly polymerase chain reaction (peR)laboratory test can detect the presence of HIV in infants at least sixmonths old.
5 10
35+
5
Infection Rates by Age
25-34
Under 25
Los Angeles
San Francisco Bay Area
Other California Areas
All Women
tHowever, the World Health Organization doesrecommend that breast-feeding by HIV-infectedwomen be promoted in parts of the world whereinfectious disease and malnutrition are leadingcauses ofinfant death. In these areas, risk ofHIVinfection from breast-feeding is likely to be lowerthan risk of death from other causes if a baby isnot breast-fed.
umentation from service providers that semen has been screenedfor HIV antibodies.
While early studies did notindicate a risk of HIV transmission from breast-feeding, studieshave since shown that, once born,a child can be infected throughbreast-feeding from an infectedmother.6 Because of this, breastfeeding is generally not recommended for women with HIV.t
Detecting HIV in Infants
Traditional antibody testingmethods are not reliable in detecting HIV infection in newborns.During the first 12-15 months af-
PREGNANCY & HIV PAGE 3
effects of the drug in pregnancyare not known, and an early studyof AZT at high concentrations inanimals found fetal damage. Someresearchers have speculated thatAZT can prevent HIV transmission from mother to fetus, but thishas not been proven.
Most other drugs, includingantiretrovirals such as ddI, ddCand therapies for opportunistic infections, have not been well-studied among pregnant women, andcaution is urged in using them.J3
Testing and ReproductiveDecision-Making
Most groups, including thefederal Centers for Disease Control(CDC),recommend voluntaryHIV counseling and testing for allwomen of childbearing age whoare at risk for HIV infection.
The American Medical Association (AMA) issued policyrecommendations stating thatHIV testing for women of childbearing age is often advised.
However, theAMA has stated that,"A policy of mandatory screeningfor pregnant women is not justified based on traditional publichealth criteria or other grounds."14
The AMA's recommendations alsoreject counselingand screening policies that are directive and that interfere with women's reproductivefreedom.
Studies have found that a woman's HIV status is not the mostimportant factor to influence decisions to continue or terminate apregnancy.15,16 Decisions are basedon many factors, including familyand social relations, cultural andreligious beliefs, economic circumstances and childbearing history.Factors that influence one womanto continue pregnancy may influence another to terminate. For instance, one woman may view thepossibility of having a child as adanger to her physicalhealth, whileanother may see the presence of achild as beneficial to her psychological health.
One study of injection drugusing women found that motherchild separation was the most consistent predictor of a woman's decision to continue or terminatepregnancy. Women who did notlive with their children, after children had been removed by socialservice workers, were more likelyto continue pregnancy than women who lived with their childrenYIn addition, women who terminated pregnancy were more likelyto have known about their infection for a longer time than womanwho chose to continue pregnancy.
Some women with HIV maybelieve that because of their infection they cannotbecome pregnant.Injection drug users ODU), in particular, may believe this becausedrug use and related medical problems may result in irregular menstrual periods. However, there isno reason to believe that womenwith HIV are less likely than uninfected womento become pregnant.
A Related Issue: Healthof Infants with HIV
Through March 1992, children under the age of13 represented nearly 2%, or 3,692, of the 218,301AIDS cases reported in the United States.18 In California, children under age 13 represented .07%, or279, of 41,042 AIDS cases. Most of the children'scases nationally and in California were attributableto perinatal transmission.
On average, HIV disease progresses more rapidly in infants than in adults. About 20% of infantswith HIV develop a serious HlV-related illnesswithin the first 18 months of life, and many dieduring this period. However, infants may live formanyyears without symptoms. Newborns infectedthrough perinatal transmission have a shorter lifeexpectancy than those infants infected throughblood transfusions.
Bacterial infections are common among infantswith HIV, while infections like toxoplasmosis andcryptococcalmeningitisappear less frequently than
they do among adults. Kaposi's sarcoma (KS) rarely affects children, but children often develop lymphocyticpl1eumonia,which rarely occurs in adults.
Childrenalso develop pneumocystiscariniiPneumonia (PCP) and other severe infections at muchhigher T-helper cell levels than adults.19 In onestudy, children; all less than 40 months old, survived a median of only two months after a diagnosis of PCP.
The Food and Drug Administration (FDA) hasapproved AZT therapy for children and infants atleast three months old who show symptoms ofdisease Or abnormal laboratory testxesults. R~
searchers report AZT works as well for children asfor adults. Similar side effects are also reported.
Preventive treatments generally begin at muchearlier stages of disease progression in childrenthan in adults. For example, children may receivePCP prophylaxis at less than a year old regardlessof their T-helper cell count. Fewer drug studies arebeing conducted in children compared to adults,though an increasing number of trials are availablefor children.
PAGE 4 PERSPECTIVES
*Numbers given are averages. Differences are not statistically significant.
Infant Health at Birth9
Babies Bornto SeropositiveWomen (n=63)
8.BerrebiA, Kobuch WE, PuelJ, etal. Influenceof pregnancy on human immunodeficiency virus disease. European Journal ofObstetrics, Gynecology, and Reproductive Biology. 1990; 37:211217.
IMPLICATIONS FORCOUNSELING
20.Adapted in part from Berlin M. HIV in pregnancy: reproductive decisionmaking. San Francisco Department of Public Health, AIDSMonthly Grand Rounds. February 26,1992.
21.CapellFJ, Vugia DJ, Mordaunt VL. Distribution of HIV type 1 infection in childbearingwomen in California. American Journal ofPublicHealth. 1992; 82(2): 254-256.
Reproductive issues are complex and highly specialized. Theyare best discussed in depth withphysicians and family planningand other counseling specialistswho have experience and trainingto deal with these issues. WhileHIV test counselors cannot takeon the role of family planning providers, reproductive issues are arelevant and essential topic formany test counseling sessions.HIV test counselors can providebasic information, offer referralsfor follow-up counseling and care,encourage clients to learn moreand help them understand the importance of making decisions affecting reproductive issues. Counselors must refrain from makingvalue judgments or responding inany way that might inhibit clients'choices.
The contact between counselors and female clients with reproductive concerns can be especiallyvaluable because, regardless ofantibody status, many women ofchildbearing age do not have regular contact with medical or public health workers. Most womenwho give birth to antibody positive children discover their ownantibody status after delivery, andgenerally only after an infectedchild becomes sick.
The BasicsMany clients know little about
the relationship between HIV andpregnancy. Even an HIV-infectedwoman who has had several children may be unaware that she can
2,878
47.94
32.77
Babies Bornto SeronegativeWomen (n=57)
with human immunodeficiency virus and uninfected control subjects. American Journal of Obstetrics and Gynecology. 1990; 163(5 pt 1): 15981604.
11.Lopez-Anaya A, Unadkat JD, Schumann LA,et al. Pharmacokinetics of zidovudine(azidothymidine). III. Effect of pregnancy. Journal ofAcquired Immune Deficiency Syndromes.1992;4: 64-68.
12.5perling RS, Stratton P, O'Sullivan MJ. Asurvey of zidovudine use in pregnant womenwith human immunodeficiency virus infection.New England Journal of Medicine. 1992; 326(13):857-861.
13.Coleman R. Treatment during pregnancy.AIDSFILE. 1991; 5(3): 6.
14.Working Group on HIV Testing of PregnantWomen and Newborns. HIV infection, pregnantwomen, and newborns: a policy proposal forinformation and testing. Journal of the AmericanMedical Association. 1990; 264: 2416-2420.
15.5elwyn P, et al. Knowledge of HIV antibodystatus and decisions to continue or terminatepregnancy among intravenous drug users. Journal of the American Medical Association. 1989;261 (24): 3567-3571.
16.Johnstone FD, Brettle RP, MacCallum LR, etal. Women's knowledge of their HIV antibodystate: its effect on their decision whether to continue the pregnancy. British Medical Journal. 300:23-24.
17.Pivnick A, Jacobson A, Eric K, et al. Reproductive decisions among HIV-infected, drugusing women: the importance of mother-childcoresidence. Medical Anthropology Quarterly. 1991;5(2): 153-169.
18.Centers for Disease Control. HN/AIDS Surveillance, March 1992.
19.Pizzo P. Practical issues and considerations inthe design of clinical trials for HIV-infected infants and children. Journal of Acquired ImmuneDeficiency Syndromes. 1990; 3(Suppl. 2): 561-563.
2,811 *
47.91
33.23
Weight (in grams)
Length (in centimeters)
Head (in centimeters)
ReferencesI.Gwinn M, PappaioanouM, GeorgeJR. Prevalence of HIV infection in childbearing womenin the United States: surveillance using newborn blood samples. Journal of the AmericanMedical Association. 1991; 265(13): 1704-1708.
2.European Collaborative Study. Risk factorsfor mother-to-child transmission ofHIV-1. Lancet. 1992;339: 1007-1012.
3.Unpublished data. Based on personal conversations with Bonnie Dattel, MD,March 1992.
4.Tovo PA, Palomba E, Gabiano C, et al. Human iminunodeficiency virus type 1 (HIV-l)seroconversion during pregnancy does not increase the risk of perinatal transmission. BritishJournal of Obstetrics and Gynaecology. 1991; 98:940-942.
5.Ehrnst A, Lindgren 5, Dictor M, et al. HIV inpregnant women and their offspring: evidencefor late transmission. Lancet. 338: 203-207.
6.Ryder RW, Manzila T, Baende E. Evidencefrom Zaire that breast-feeding by HIV-lseropositive mothers is not a major route forperinatal HIV-1 transmission butdoes decreasemorbidity. AIDS. 1991; 5: 709-714
7.LandesmanS, Weiblen B,MendezH.Clinicalutility of HIV-IgA immunoblot assay in theearly diagnosis of perinatal HIV infection. Journal ofthe American Medical Association. 1991; 266:3443-3446.
9.Butz A, Hutton N, Larson E. Immunoglobulins and growth parameters at birth of infantsborn to HIV seropositive and seronegativewomen. American Journal ofPublic Health. 1991;81(10): 1323-1326
10.MinkoffHL, Henderson C, Mendez H, et al.Pregnancy outcomes among women infected
PREGNANCY & HIV PAGE 5
transmit HIV to an unborn child,or that she can give birth to anuninfected infant.
During pre-test counseling,make clients aware of the following information related toHIV andreproduction. Reiterate this information in post-test counseling.
• HIV can be transmitted froma mother to a child. Currently, it isbelieved that a child born to aninfected mother has about a 25%chance of being infected. Asidefrom the risk of transmission, HIVdoes not appear to affect the courseof pregnancy or the outcome ofdelivery, though this issue is stillbeing studied.
• Pregnancy does not generally have an adverse effect on thehealth of a woman with HIV,though this too is still being studied.
• HIV disease usually progresses more rapidly in infantsinfected perinatally than in adults.
• HIV does not appear to affecta woman's ability to become pregnant.
• A woman has the right todecide whether she wishes to continue or terminate pregnancy. Termination becomes increasinglycomplicated after the 12th week ofpregnancy, and some clinics refuseto provide such services to women with HIV. Physicians and family planning specialists can helpclients understand their options.
·There are signs and symptoms of HIV disease, and while itisalways important for people withHIV to monitor these, it is especially important to do so duringpregnancy.
Allow clients to ask questionsabout these topics. Acknowledgethat many issues related to reproduction and HIV, including specific methods for perinatal transmission, are unresolved.
Detail the benefits of knowingHIV antibody status for the healthofthe mother and herunbornchild,
including the ability to implementearly intervention and the value ofbeing emotionally prepared. Resist viewing the test as more imperative for clients who are pregnant or considering pregnancythan for other clients; it is important that counselors remain objective and support whatever testingdecisions these clients make.
Remember that sexual transmission of HIV remains an issuefor a woman even if she is havinga child. Reinforce safer sex messages, and discuss the relevance ofsafer sex to HIV and reproduction.
Decision Making
In post-test counseling, encourage clients to explore the roleof reproductive issues in their livesand outline reproductive optionsin a judgment-free environment.Discuss specific options only if clients wish to discuss them.
In post-test counseling, as wellas in pre-test counseling, encourage clients to avoid making decisions about continuing or terminating pregnancy during the counseling session. At this time, clientsmay be overwhelmed by information about reproduction and HIVand by the disclosure of a positivetest result. Most often they willbenefit from being able to make adecision over time, and after further counseling from a physicianor specialist. If a client appears tohave made a decision before thecounseling session, respect this.
The counselor's role at this timeis to establish an atmosphere inwhich clients will feel comfortablediscussing how they feel abouttheir positive test results and aboutreproductive issues. This may bethe first time the client is able tofocus on herself and her needs. It isimportant to help the client separate her needs from the potentialneeds of a child.
In general, a primary role ofHIV test counselors is to directclients to prevent HIV transmis-
sion. Because of this, a counselormay feel a responsibility to offerdirective counseling to a seropositive pregnant woman who is atrisk for transmittingHIV to a child,without realizing the other issuesthat are relevant.
In helping clients explore reproductive options, consider thefollowing factors:2o
• Belief systems. Personal beliefs, especially religious, moraland ethical attitudes about reproductive issues, influence a person'svalues and perceptions of acceptable risks.
• Relationships. The dynamicsof relationships with friends andlovers or spouses affect many areas of decision making, includingthe extent to which people makedecisions independent of othersand others' expectations. A supportive partner may make it easierfor a mother with HIV to copewith raising an infected child.
·Societal role. The extent towhich a person feels her role insociety is to reproduce or raisechildren can affect feelings of responsibility, personal pride or status in the community. While oftenviewed as beneficial, this can be adrawback if a woman feels pressure to conform to a societal roleshe does not embrace.
• Feelings of self worth. Childbearing, and the process of carrying an embryo to the point of having a baby, may provide affirmation that the client is healthy orthat she is fully a woman.
• Reproductive history. Thenumber of children and the number of terminations a woman hashad can influence her desire tohave children. Some women withHIV may choose to terminate afirst pregnancy, but decide to havea child during a subsequent pregnancy. Or, a woman who has achild with HIV may believe thechances are good thatanother childwill not be infected.
PAGE 6 PERSPECTIVES
• Personal perceptions of risk.Perceived risk often depends onthe types of risk, illness or loss aperson has experienced. For instance, while some clients mayconsider a 25%chance of perinataltransmission to be high, for othersthis risk may not be as significant.
• The health effects of havingand raising a child. Childbirth andraising a child can have both negative and positive effects on awoman's health and on her abilityor willingness to take care of herhealth.
• Health of a child. Considerations related to the health of anHIV-infected child include the ongoing needs of a child with HIVand an infected parent's ability tomeet his or her child's specialneeds.
Explore various factors thatmay influence a woman's decision-making by asking about herfeelings toward having a child andknowing that the child might beinfected. Then ask abouther feelings about potentially caring for an infected child.
Other FactorsBecause women often take re
sponsibility for caring for othersand may put such responsibilitiesahead of taking care of themselves,
A. Counselor'sjPER~PECTIVE
'ilt,simpoftaht· th$t}apregnant! flntipg(jy pQsit~pe
..... womanfindsom~otlein ·h.er:life she can talk to about net.... conc~nsap sqonasposqib.l.eafter sh.eleaves the tes.ttounselin~ Se$s~on.rbe~i~pr~:-teste~~dpos~\test$esqion$.·.try£'ffg fa help th~dientsee
. who she can...talk.to;antlivhqwillJisten andlJesupportiv€}and non-directive." ...
it is important that women withHIV, especially pregnant women,recognize this potential imbalance.Encourage these clients to make acommitment to seek medical care,eatwell, rest properly, exercise regularly and take the time to plan fortheir future.
Parents with HIV disease, menand women, must consider thelives of their children before theyare born. Begin this process byposing questions, such as who willcare for children if parents becomeill? And, who will be able to carefor the child and take on financialresponsibility if the child becomesill? Encourage clients to discussthese questions with friends, family members, medical providersand social workers.
Women should consider theeffects of treatments on themselvesand their children. The antiviraldrug AZT is probably safe for pregnant women while posing littlethreat to the developing fetus, butthe long-term effects of AZT arenot known, and other treatmentsmay be harmful. Asymptomaticwomen may be unsure whether tobegin treatments either before orafter having a child. Researchersbelieve that many treatments havesimilar effectiveness and safety inchildren as in adults, but most treatments have been studied for a relatively short time.
Encourage clients to talk tophysicians and pediatricians whoare knowledgeable a150ut HIV andpregnancy, and can discuss the effects of treatments on pregnantwomen. Finally, teach pregnantwomen how to detect signs andsymptoms of HIV infection, andadvise them to promptly reportsymptoms.
Reproductive Concerns ofAntibody Negative Women
As with all clients, encourageretesting for seronegative womenwho have engaged in unsafe behaviors over the prior six months-
A Counselor'sPERSPECTIVE
"HIV antibody positivewomen1flhoarepregnantm£i.yJacevalue judgzuents byso'ci8.ty>A lot of clients mayhavefellthese before tht!Y.came for their test results orthey'll experienc8.themafterthey leave. Sotuihen they'rein my counselitt;g session, Imust go out of my way to befree ofjudgment: 'I
the "window period" for developing HIV antibodies - or those clients who believe themselves to beat risk for infection. For pregnantwomen, however, clinicians urgethat this retest be performed nolater than the 26th week of pregnancy. Termination is not performed beyond this point.
Many women seek HIV antibody testing because they are considering pregnancy. For those whotest negative, be prepared to talkabout their risk offuture infection.It is important that they and theirpartners retest antibody negativeoutside the infection window period.
Remind clients wishing to become pregnant through vaginalintercourse that their health andthe health of their unborn child isdependent on the degree to whichthey trust their partners' declarations that they have tested negative and have not engaged in unsafe sex with others in the past sixmonths.
ReferralsBecause of the complex tech
nical and personal nature of reproductive issues, it is importantthat counselors provide relevantreferrals of people who are familiar with HIV in pregnancy. Giveclients referrals to counselors at
PREGNANCY & HIV PAGE 7
Case StudyMargaret is a 22-year-old who is two months
pregnant and has just been told in the post-testcounseling session that her HIV antibody test result is positive. Shewants to continue herpregnancy and have a baby, but says she is scared. She isafraid of the possible reactions of her friends andfamily. Her boyfriend is unaware of Margareespregnancy, but has said before that he does notwish to be a father. Margaret is also scared thatwithout support from others, no one will care forher childif shebecomes ill. Another concern is thatshe and her family have little money to care for aninfected child.
Counseling Intervention
Margaret may be trying to answer too manyquestions. Help her understand that her questionsand concerns are significant, and can be overwhelming, but they do not all need to be answeredimmediately.
Help slow Margarees pace by taking her backto basic topics. Concentrate on what her feelingsare for herself at the moment, and what her antibody status means to her. Make sure she understands the reliability and meaning of her result.
Continue by discussing the basics of reproductive issues presented in the Implications for Counseling section, including the potential risk to thefetus. Assess Margarees stage of pregnancy. Taking sufficient tip:1ewith basic topics,tp.ay helpMargaret feelgreater control. At this point,however, Margaret may be emotionally H shut downH as aresult of the many issues she is attempting to dealwith, including an antibody positive test result.
Consider other issues with Margaret. Ask herwhat it means for her to have a babYI and what itwould mean if her baby has HIV. Such questionsare designed to help Margaret understand theissues that may affect her as she begins to makedecisions. Looking at these questions in the safetyof the counseling session may giveMargaretmoreconfidence in her decision-making ability.
Help Margaret understand that her concernsare significant, and that her feelings are valid. Lether know that it is all right to feel disappointmentand fear. And reemphasize that sheis entitled tomake her oWl:"ldecisions regardingpr~gl"\Cl,l:"lcy,
EmphasiZe that it is importantfor¥argaret tobe able to talk about her feelings, thoughts andconcernswithsomeonewho will supportherwithout attempting to direct her decisions or makedecisions for her. Begin to consider others whoMargaret trusts, and who shebelieves will listen toher. Among possible candidates are a friend, family member, medical provider, nurse practitioner,counselor or social worker. If Margaret does nothave a person already in her life to talk to, provideher with at least two referrals who can listen andhelp. As the test counseling sessioncontinues, shemay think of someone she can talk to.
Ask Margaret where she plans to go after thetest counseling session. Help her see the potentialvalue of disclosing her status to another person,either someone in her life already or a social service or family planning provider.
State tQ Margaret the importance o~Bfotectil"lg
her health, and the importance ofcarifig fOJ; herself. Make sure she understands behaviors thattransmitHIV, and stress that shecantransmit HIVto others.
family planning clinics, obstetricians/gynecologists and nursepractitioners so they can receiveinformation to make decisions andreceive ongoing care. Also, offerreferrals to social workers, privatetherapists and support groups.Counselors can learn about thenature of counseling provided byspecialists by calling service providers and asking them to describetheir counseling approach withpregnant women who have concerns related to HIV.
Health care for pregnant women with HIV is available throughspecialized primary care clinicsand high-risk prenatal clinics insome areas of the state. To learnmore about these providers, call aregional AIDS hotline. In Southern California, call (800) 922-2437.In Northern California, call (800)367-2437.
It can be valuable for antibodypositive women who are pregnantto discuss their concerns withsomeone they trust to be support-
ive and non-directive. Help clients identify other people in theirlives - friends or family members or social service or healthcare providers - who can provide this support. Discuss howthe client might tell that personand how the client can prepare forvarious reactions. If the client hasno one in her life she feels will besupportive, offer an additional referral to a health care or socialservice provider who can servethis role.
PAGE 8 PERSPECTIVES
TEST YOURSELF
1. In the United States, how manywomen of reproductive age are believed to be infected with HIV? a)5,000, b) 1,000,c) 80,000,d) 4million.
2. True or False: Clinicians generallystate that children born to HIV-infected women have a 25% chance ofbeing infected themselves.
3. True or False: Studies have foundthatyoungerwomenaremore likelythan older women to transmit HIVto a child.
4. True or False: Researchers speculate that perinatal HIV transmission occurs at what period? a) conception, b) during delivery, c) afterconception but before delivery, d)all of the above are possible.
5. True or False: An infant can testantibody positive without actuallybeing infected with HIV.
6. Recent research finds that pregnancy has what effect on womenwith HIV? a) it greatly speeds progression, b) it is believed to havelittle effect on progression, c) itstops progression.
7. True or False: Women should nottake the drug AZT because thisdrug has conclusively been foundto cause human fetal damage.
8. True or False: One small studyfound that women with HIV whoterminated pregnancy generallyhad known about their infectionfor a longer period than womenwho continued pregnancy.
DISCUSSIONQUESTIONS
• Counselors may hold strongpersonal views on continuing or terminating pregnancy in the face of HIVinfection. How can counselors ensurethat these views are not expressed tothe client?
• The Case Study presented awoman who wished to continue herpregnancy. How would the counseling intervention be different for a client who wished to terminate pregnancy?
• Some women may enter pretest counseling, but may not wish tobe tested. To what extent should testing be encouraged? What counselingcan be offered to these clients?
• Because risk reduction is a primary role for counselors, it may bedifficult not to provide definite instruction to a client in making a decision around continuing or terminating pregnancy. How can counselorsbe successful at this?
• Women who are not infectedwith HIV may wish to become pregnant, but fear being infected whenthey are attempting to conceivea pregnancy. What can be said to such aclient?
• Clients are likely to come incontact with people who have definite views related to HIV and pregnancy. How can counselors prepareclients to deal with these individualsand make decisions on their own?
Answers to Test Yourself:
1. C. As many as 80,000 women ofreproductive age in the United States might beinfected.
2. True. Studies have found the rate of infection from mother to child is generallyabout20% to 25%.
3. False. Studies have not found a link between perinatal transmission and age.
4. D. It is not conclusively known when HIVis transmitted. Researchers speculate itmay occur at the time ofconception, time ofdelivery, or some period in between.
5. True. Becausean uninfected babycan carryits mother's antibodies for up to the first 15months after birth without being infected,the child can test antibody positive in theabsence of infection.
6. B. It is believed that pregnancy has littleeffect on HIV disease progression in pregnant women.
7. False. AZT has not been shown to causefetal damage.
8. True.
How to Use PERSPECTIVES;
PERSPECTIVES is designedas an easy-to-read educationalresource for antibody test counselors and other health professionals.Each issue explores a single topicwith a "Research Update" andan "Implications for Counseling"section.
The Research Update reviewsrecent research re.lated to the topic.In Implications .for Counseling, theresearch is applied to the counseling session, and a case study ispresented. PERSPECTIVES alsoincludes two sets of questions toconsider yourself or discuss withothers.
Volume 2, Number 3
Director, AIDS Health Project: James W. Dilley, MD.
Writer and Editor, PERSPECTIVES: John Tighe.
Clinical Consultants: JD Benson. MFCC; MarciaQuackenbush, MFCC; Jaklyn Brookman, MFCC.
Publications Manager: Robert Marks.
Technical Production: Leslie Samuels; Joseph Wilson.
Administrative Support: Roger Scroggs.
HIV Counselor PERSPECTIVESPERSPECTIVES is an educational publication of the Califor
nia Department of Health Services. Office of AIDS. and is writtenand produced by the AIDS Health Project of the University ofCalifornia San Francisco. Reprint permission is granted. providedacknOWledgment is given to the Department of Health Services.
Information in PERSPECTIVES is based in large part on inputfrom antibody test counselors and other health professionals.Among those who had a significant influence on this issue are:Graciela Morales, Bonnie Coates. Michelle Berlin, Bonnie Dattel,Barbara Garcia and Amanda Newstetter.
This issue of PERSPECTIVES pUblished in June 1992.
PERSPECTIVES is printed on recycled paper.
Department of Health Services, Office ofAIDS. P.O. Box 942732. Sacramento. CA94234,(916)445-0553; AIDS Health Project, Box 0884,San Francisco. CA 94143, (415) 476-6430.
_THE_AIDSHEALTHPROJECT
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