Health Care Providers Perception and Practice of HIV Disclosure to Sero-Positive Children and Adolescents in a Tertiary Health Facility in Abuja, Nigeria

Background: Ideally, disclosure of HIV status to infected children and adolescents should involve both health care workers and parents/caregivers. Most studies on disclosure in children have focus mainly on parents/caregivers with little information on health care workers. We conduct this study to evaluate the practice, perception of the healthcare workers in our health facility on disclosure to infected children and adolescents. It is envisaged that such information will help in the design of better strategies on disclosure in our environment. Methods: A cross sectional hospital based study was conducted among health care workers at the special treatment clinic, and heart to heart unit of the University of Abuja Teaching Hospital, Gwagwalada from January to March 2017 for the above objective. A structured questionnaire was used to collect information on disclosure among the healthcare workers, which include among others: their bio-data, knowledge, perception, and practice on disclosure in the two service areas of the hospital. Results: Of the 80 health care workers interviewed, 60(75.0%) were females, 11(13.8%) were doctors, 9(11.3%) nurses, 17(21.3%) monitoring/evaluation/record clerks, and 16(20.0%) were either voluntary counseling and testing counselors or adherence counselors. Their mean age and duration in service in the two areas were 39.70±7.10 and 7.93±4.99 years respectively. Over half 48(60.0%) of the health care workers were unaware of the hospital having guideline on disclosure, 64(80.0%) have not been trained, and 68(85.0%) does not know any key information on disclosure. While all 80(100%) felt that disclosure was a good practice for better adherence, only 16(20.0%) had actually disclosed, with 6(37.5%) not seeking any formal permission from parent/caregivers before disclosing. Ages 8-16 years was recommended by 60(75%) as the appropriate age to disclose, however 28(35.0%) recommended age 14-16 years. Over half of the respondents 58(72.5%) admitted that disclosure should be a shared responsibility between themselves and the caregivers, most however perceive their role as only preparing the parents/caregivers for disclosure, and providing ongoing counseling to both the parents/caregivers and the children and adolescents. Lack of training on disclosure, and none availability of guideline in the health institution were major setback on the ability of the healthcare providers to fully participate in disclosure process. Conclusion: While healthcare providers support the idea of disclosing at mid and late adolescent, their perceived role was that of support and provision of ongoing counseling. Lack of training and none availability of disclosure guideline affects their perceived role. There is need to train and retrain healthcare workers on disclosure guideline, and making such guideline available in the health facilities. DOI : 10.14302/issn.2324-7339.jcrhap-18-2202 Freely Available Online www.openaccesspub.org | JCRHAP CC-license DOI : 10.14302/issn.2324-7339.jcrhap-18-2202 Vol-3 Issue 3 Pg. no.2 Introduction With successful use of antiretroviral therapy (ART), infected children are now surviving into adolescents and adulthood. Disclosure of human immunodeficiency virus (HIV) sero-status to them becomes a very crucial issue to address. It has remained one of the greatest psychosocial and emotional challenges facing parents/ caregivers and healthcare workers (HCW) of these children. Disclosure is a controversial and emotionally charged issue amongst both the HCWs and parents/caregivers. It involves disclosing to the child about a potentially life threatening, stigmatized and transmissible illness that many parents/caregivers fear that such information may create psychological and emotional distress for the child. HCWs are often challenged by the complicated issues facing HIV-affected families. They are faced without support of definitive evidence-based policies and guidelines on when, how, where, and under what condition(s) infected children should be informed about their own or their caregivers’ HIV status. Consequently, many HCWs around the world are uncertain how to counsel clients about the disclosure process. This lack of disclosure ultimately and adversely affects the well-being of the child, including access to paediatric HIV treatment care and support and adherence to ART. Increase adherence to treatment with reduced risk of death is one of the major health benefits of disclosure. Other benefits include: higher self-esteem, fewer symptoms of depression, higher CD4, better ability to seek for social support, improved coping skills, and practice of safer sex to prevent secondary transmission. There is little evidence of psychological or emotional harm; however stigmatization remains a major barrier, and often delays the decision to disclosure. As a result of this, significant numbers of children and adolescents in most developing nations of the world on ART are not fully informed about their HIV status. The American Academy of Pediatrics (AAP) recommended counselling to the caregivers to be provided by healthcare providers, it should be on-going process, individualized putting into consideration the child’s cognitive ability, and developmental stage. Its recommendation also insisted that adolescents should know their HIV status, and be fully informed in order to appreciate the consequences of their health including sexual behaviours and issues around their treatment. However, in many developing countries, HCWs still lack the support of policies and guidelines on when and how to start counseling of parents/caregivers of infected children about their HIV status or their caregivers’ HIV status. Guideline was developed by the WHO 2 for assisting HCWs to support caregivers on disclosure in resource-limited settings, however such valuable information are usually not available in many health care facilities in such areas. Nigerian national guidelines on paediatric HIV and AIDs treatment also recommends early commencement of disclosure and to be done overtime, such practice is also not routinely done. HIV disclosure rate in high prevalence regions need to be evaluated and improved upon drastically in order to reduce the risk of acquiring new infections, improve adherence to ARTs, and practice of safe sexual behaviors. Unfortunately, limited body of work exists on the prevalence and practice of disclosure by HCWs in sub-Saharan Africa (SSA). Most studies on disclosure have focused on parents/caregiver with little information on HCWs. HCWs in the sub-region are either not trained or unaware of existent of guideline in their various health facilities. The aim of this study is therefore to determine the HCWs knowledge, Corresponding author: Okechukwu AA, Department of Paediatrics, University of Abuja Teaching Hospital, Gwagwalada, E-Mail: nebokest@yahoo.com


Introduction
With successful use of antiretroviral therapy  3 Consequently, many HCWs around the world are uncertain how to counsel clients about the disclosure process. This lack of disclosure ultimately and adversely affects the well-being of the child, including access to paediatric HIV treatment care and support and adherence to ART. 3 Increase adherence to treatment with reduced risk of death is one of the major health benefits of disclosure. Other benefits include: higher self-esteem, fewer symptoms of depression, higher CD4, better ability to seek for social support, improved coping skills, and practice of safer sex to prevent secondary transmission. [4][5][6][7][8][9] There is little evidence of psychological or emotional harm; however stigmatization remains a major barrier, and often delays the decision to disclosure. 10,11 As a result of this, significant numbers of children and adolescents in most developing nations of the world on ART are not fully informed about their HIV status. 10,11 The American Academy of Pediatrics (AAP) recommended counselling to the caregivers to be provided by healthcare providers, it should be on-going process, individualized putting into consideration the child's cognitive ability, and developmental stage. 5 Its recommendation also insisted that adolescents should know their HIV status, and be fully informed in order to appreciate the consequences of their health including sexual behaviours and issues around their treatment. 5 However, in many developing countries, HCWs still lack the support of policies and guidelines on when and how to start counseling of parents/caregivers of infected children about their HIV status or their caregivers' HIV status. 2, [12][13][14][15][16] Guideline was developed by the WHO 2 for assisting HCWs to support caregivers on disclosure in resource-limited settings, however such valuable information are usually not available in many health care facilities in such areas. Nigerian national guidelines on paediatric HIV and AIDs treatment also recommends early commencement of disclosure and to be done overtime, 17 such practice is also not routinely done. HIV disclosure rate in high prevalence regions need to be evaluated and improved upon drastically in order to reduce the risk of acquiring new infections, improve adherence to ARTs, and practice of safe sexual behaviors. 8,9,10,18 Unfortunately, limited body of work exists on the prevalence and practice of disclosure by HCWs in sub-Saharan Africa (SSA). 15 Most studies on disclosure have focused on parents/caregiver with little information on HCWs. HCWs in the sub-region are either not trained or unaware of existent of guideline in their various health facilities. The aim of this study is therefore to determine the HCWs knowledge, perception, and practice on disclosure to infected children adolescents in our health facility. Such information as envisaged will be relevant in the development of culture sensitive counseling strategies to improve our disclosure rate.

Methods
The study was cross sectional hospital based study conducted in the two service areas where HIV infected/exposed children and adults are tested, treated, monitored/evaluated, and followed up (special treatment clinic, and heart to heart unit) of the university of Abuja teaching hospital (UATH) from January to March 2017.
Special treatment clinic (STC) is an out-patient clinical service area where HIV infected/exposed children (paediatric special treatment clinic) and adults (adult special treatment clinic) were followed up for treatment, care and monitoring. Heart to heart unit (HTHU) is an arm of STC, and a unit of the mental health department

Discussion
In What is the right time to disclose?

What is health workers perception about telling HIV status to infected children
For the child to take his/her drugs 32(40.0) So that they will be responsible for their medications 18 (22.5) For them to understand the disease 6(7.5) To know why they are taking medication regularly 10 ( Why should health workers take the lead in the disclosure?(4) Because they are more qualified and more skillful 2(50.0) They will provide ongoing support 1(25.0) They will provide ongoing counseling 1(25.0) What is health workers understanding why parents/caregivers delay disclosure?  Provides information about importance of disclosure 2(2.5) Facilitates initiation of disclosure 14 (17.5) Prepares the child for disclosure 4(5.0) Assist health workers to disclosure 6(7.5)

What is the role of health workers in disclosing to HIV-infected children
Support the caregiver through the disclosure process 32(40.0) Provide health education to children to take care of themselves 15(18.8) Provide ongoing counseling to caregivers to manage disclosure 17 (21.3) Provide information about the importance of disclosure to assist caregivers 10(12.5) Monitor the reaction of the child after disclosure 2(2.5) Encourage and assist parents/caregivers to disclose 4(5.0) What support is needed by the health workers to facilitate disclosure to a child?
In service education and training on disclosure 24(30.0) Workshops and training on disclosure 36(45.0) Provision of guideline on disclosure 14 (17.5) Counseling to be able to deal with HIV infected children 6(7.5) lack of formal guidelines and training on child counseling to guide on how to support caregivers to disclose to children. [12][13][14][15][16]20 The recently published WHO disclosure guidelines for children have not yet been adopted and utilized by HCWs in many health facilities across sub-Saharan countries. HCWs in these areas are hardly ever trained in pediatric HIV and in disclosure counselling to children, and hence lacked skills to assist caregivers to disclose. [12][13][14][15][16]20 Training workshops on childhood disclosure will not only improve HCWs skills and knowledge on disclosure, but will also increase their confidence in assisting parents/caregivers to disclose as well as support infected children to understand the disease. 1,7,12,20 Over 70.0% of HCWs in this study were of the opinion that disclosure to positive children should be a the child's reaction to the disclosure, the child trusts them better, they knows the right age to disclose, they will support the child to adhere to the prescribed treatment plan, they will support the child to cope with disclosure, and child will be comforted by them. Few 14,23 however were the opinion that disclosure should be responsibility of HCWs alone because HCWs are better skilled to prepare the children psychologically before disclosure, and are in position to deal with negative reactions from disclosure.
HCWs see their role in disclosure as supportive to parents/caregivers, providing health education to children, and provide ongoing counseling to parents/ caregivers to manage disclosure in this study. This is in keeping with current findings from a study in Kenya, 17 in South Africa, 12 25 Other studies 3,14,20,26,27 however reported different reasons which include: fear of the child crying, fear of being very sad, fear of the child run away, and fear of him or herself losing hope.
Some parents/guardians resorted to deception as a way of coping with questions from their children until they deems they are ready. 28

Conclusion
Healthcare workers support disclosure of HIV sero-status to infected children and adolescents at mid and late adolescent. They perceive their role as mainly supportive and provision of ongoing counseling to parents/caregivers/children. However lack of training and none availability of disclosure guideline in the health facility hinders these perceived roles, hence training and provision of guideline tailored toward culture-sensitive approach will be a better approach.