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

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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