In this study, it was the opinion of all the HCWs that all positive children and adolescent should be informed of their status. Majority however taught that such information should be done when the child is mature enough to understand the implication of him/her knowing his/her status. The WHO guidelines on disclosure of HIV status to positive children recommends school age period.2 At this school age, children should be told of their HIV-positive status, and the younger ones informed in stepwise manner taken into consideration their cognitive development and emotional maturity. This was to be in preparation for full disclosure at a latter age. Sariah et al15 in their experiences with disclosure of HIV-positive status to the infected children from the perspectives of HCWs in Tanzania pointed out that disclosure can be a very complex and confusing process to HCWs, but however noted that their national guideline recommended disclosure process to begin as early as 4–6 years of age. In another disclosure study from South Africa by Madiba and Mokgatle,16 the authors noted that over half of their HCWs suggested an older age (above 10 years, range 11–18 years). This findings appeared similar to what was obtained in the present study were 8-16 years was suggested by 75% of HCWs as ideal age to disclose HIV status to infected children and adolescents. The South African study believe that at the age above 10 years most children will be mature enough, or they may become sexually active and risk reinfection with a different strain of the virus. Similar reason was also given in the present study were the HCWs equally believe that at older age (8-16years) children will be mature enough to understand the implication(s) of being HIV positive, and may also have started indulging in sexual activities with risk of not only infecting others but also reinfecting themselves with resistance strain of the virus. This current trend of disclosing to infected children at a relatively older age of 12 years and above compared to earlier suggested 6 years appeared more culturally accepted in South Africa, and other resource limited settings.14,16 Data from this study and from others underprivileged communities suggest age of disclosure to be a subjective process to be influenced by community taking into consideration the social contexts of disclosure of which HIV-related stigma, discrimination, secrecy, and fear of death plays a very crucial role.3,8,19
Lack of training on disclosure and non-availability of the guideline in our health institution contributed substantially to the lack of knowledge and less involvement of HCWs on disclosure in this study. This was reflected in the data obtained where 48 (60.0%) of the HCW said either the hospital does not have a guideline or they are not aware of any guideline in the health institution. In addition, over 85.0% of them do not know any key information on disclosure. According to WHO,2 essential elements to be added in the training for HCWs in paediatric HIV disclosure should include: the use of culturally appropriate and available resources, use of appropriate communication skills for children of different ages, providing information on HIV treatment and care to parents/caregivers/children, preparing parents/caregivers for both short and long-term emotional reactions of the children following disclosure, developing a plan for the child/parent/caregiver to disclose to others, preparing parents/caregivers to answer questions that will arise over time after disclosure, choose staff member(s) or others with whom to discuss the issues, prepare parents/caregivers to engage in life-planning with children, and reduction of stigma. Rujumba et al12 in their situational analysis of pediatric HIV/AIDS care in Ethopia noted that HCWs are still constrained by inadequate knowledge about pediatric HIV care and pediatric counselling. Fair and Walker 13 also argued that fully understanding of disclosure to HIV-infection in children was essential for HCWs involvement in the disclosure process. One of the major concerns of HCWs in many studies from resource limited settings was the 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, 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 shared responsibility of the both HCWs and parents/caregivers, because parents/ caregivers need the assistance of HCWs to disclose to their children as they see disclosure as difficult task for them to do alone. However, 18(22.5%) argued that parents/caregiver should take the lead in the process of disclosure because the children trusts the them better, and they know the right age and time to disclose. Only 4(5%) were of the opinion that HCWs should take the lead in disclosure in this study. All these findings in the present study appeared closely similar to what Madiba and Mokgatle16observed in their study where 87(42.7%) of their HCWs were of the opinion that disclosure should be a shared responsibility, 99(48.5%) argued that only the parents/caregivers should lead in the disclose process, while 18(8.8%) said is the responsibility of HCWs to lead and initiate disclosure. Other studies,7,14,16,21,22however viewed telling the children about their status as the responsibility of the parents/caregivers, because of the reasons: their close relationship with child, they are better placed to monitor 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. Few14,23 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 for 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,12and Zimbabwe19 were HCWs documented similar supportive role, ongoing counseling, and health education as their major role. The main reasons for delay disclosure by parents/caregiver from HCWs perspective in this study were fear of stigma (40.0%), fear of telling others (17.5%), and fear of hurting the child (10.0%). Similar barriers to disclose by parents/caregivers as reported by HCWs include: parents’ fear of being blamed by their children, parents feeling guilty and fear that the child will tell others,24,25 child being too young and cannot keep secret,20 and social stigma surrounding the HIV diagnosis.25 Other studies3,14,20,26,27however 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