HIV testing in schools is a minefield

South Africa is preparing to take HIV testing into the classroom as part of its national voluntary HIV testing and counselling (VCT) campaign, but testing kids is controversial and implementing the programme is fraught with challenges - just ask those already doing it.

Government departments, together with the South African National Aids Council, are holding nationwide consultative meetings with members of the education, children's rights and HIV sectors to formulate a national policy for school-based HIV testing, as well as guidelines and recommendations for the country's nine provinces.

Activists from the Durban-based Yezingane Network of children's organisations met with national Health Minister Aaron Motsoaledi and identified consent and confidentiality as two of the main challenges.

15 million to be tested

Launched in April 2010, South Africa's VCT campaign is seeking to test 15 million South Africans by April 2011. A schools-based component was included from the outset, but public debate did not erupt until the Department of Health (DoH) announced it had pushed back the February 2011 start date for student testing to allow it and the Ministry of Basic Education to formulate a child-sensitive VCT strategy.

About 3% of South African children 18 years and younger are HIV-positive, according to a 2010 report by South African research body, the Human Sciences Research Council.

Around 13% of those aged 12 to 14 reported having had sex in the last year, and just over a quarter of girls 12 to 18 years old reported having had cross-generational sex with men who were at least five years older - an HIV risk factor.

Earlier access to care

Advocates for school-based testing have argued that getting kids to be tested young would allow those living with HIV to access care sooner. Most would test HIV negative, which could help destigmatize testing, create a pattern of repeat testing, and drive home safer-sex messages.

"Effective sexuality education needs to happen before the age of 16, and [VCT] is a great way of making that discussion real," said Peter Fenton, former chief education specialist and manager of life skills and HIV/Aids programmes in Western Cape Province. "Simply stated, if we want to stem the tide of HIV for future generations we cannot pussy-foot around this issue."

A matter of consent

Some student and teacher unions are opposed to school-based testing, arguing that children as young as 12 years old may not be psychologically or emotionally prepared to deal with an HIV-positive diagnosis.

Persons younger than 18 years are still considered minors in South Africa, but amendments to the Children's Act in 2008 make special provisions for HIV testing, lowering the age of consent to 12 years, provided they demonstrate an understanding of the test's benefits, risks and social implications.

The DoH has indicated that VCT services will only be offered to high school students, which effectively excludes children under the age of 12. Nevertheless, testing children for HIV is controversial, and has led service providers and schools to negotiate some level of parental involvement.

25,000 students tested each year

Fenton said Western Cape had tested about 25,000 students per year since 2007 as part of its HIV/Aids strategy, and most were tested with the prior knowledge or consent of parents.

Shout-It-Now, an HIV education and testing NGO operating in Western Cape, has been using a mobile computer lab paired with a testing unit to teach kids about HIV. Bruce Forgrieve, the chairperson, said the organisation gave learners letters for their parents in their home languages prior to testing, but would go farther to obtain explicit parental consent if asked to do so.

"The law [regarding consent] here in South Africa is very specific," Forgrieve told IRIN/PlusNews. "We asked for a legal opinion and were basically told that if we prevent children from testing, then we would be infringing upon their human rights. That said, we work in close cooperation with schools. if a school says, 'We want you to get parental consent', we do."

In KwaZulu-Natal Province, a health and education NGO, Mpilonhle, has an agreement with the provincial government to provide monthly HIV testing services to schools. The organisation's executive director, Dr Michael Bennish, said they sent letters and also met with parents, who had the power to veto on-site HIV screening through their representation on school governing boards.

These boards, comprising school principals, teachers and parents, have the final say over much of how national and provincial education policies are implemented, especially in the controversial area of sex education, which falls under the "Life Orientation" heading in the South African curriculum.

At schools that have allowed HIV screening, both Shout-It-Now and Mpilonhle reported an HIV testing uptake by students of at least 90%.

Confidentiality before and after

Confidentiality and support for pupils found to be HIV-positive have been the leading concerns raised by the public and the DoH. Organisations working in the field said systems would have to be in place to ensure both requirements were met.

Shout-It-Out and Mpilonhle said initial HIV education took place in a group setting, but children were counselled and tested individually. Bennish said Mpilonhle had even taken steps to ensure other students did not know who has elected to test.

After a general health lecture with their peers, every student at a school serviced by Mpilonhle sees a youth counsellor to discuss issues like access to social grants, substance abuse, tuberculosis and HIV, then they are offered VCT. The individual sessions all last about an hour, making it hard for other children to guess who has opted for the test.

Ensuring that students cannot identify who tests positive for HIV is even more important. When a learner tests positive for HIV, there is a lot to do - dealing with emotions, linking children to care, discussing which adults children might disclose to for support.

"The first thing we do is make sure the person understands the diagnosis, but we also try to contain [their reaction] because it's a bad piece of news. It's not a death sentence by any means but, you can imagine how traumatic that is, regardless of the age group you're working with," Forgrieve told IRIN/PlusNews.

"[Shout-It-Now has] a process that never 'outs' any child. We keep them out of class in a way that they won't be missed," so as not to arouse suspicion among peers that could lead them to identify newly diagnosed students, Forgrieve said. "This is something that we've worked really hard at, and it's our best kept secret."

'S' is for support

Both Shout-It-Out and Mpilonhle use care coordinators to escort children to nearby clinics for confirmatory HIV testing and a CD4 count, which measures immune system strength and determines whether a patient should start taking antiretroviral (ARV) medication.

"We hold their hand the whole way and we don't let go until we know someone at that clinic is holding the other hand," Forgrieve said.

Both organisations also have counsellors available to go home with children if they need help breaking the news to caregivers. "We arrange to talk with the family if the client allows - they need a support structure in place and this can be quite challenging," Mpilonhle's Bennish said. "Our sense is that kids who test positive may be more likely come from socially disadvantaged and chaotic homes, but [those dynamics] create extra obstacles."

Forgrieve said even linking children to care wasn't always easy, as many learners already knew which clinic they would like to go to, and it was often not the one nearest the school either because of maintaining confidentiality, or perceptions of the care available. Luckily, the number of learners who tested positive was low and allowed staff to give learners intensive support and follow-up.

Revival of the school health programmes

According to a statement by the Yezingane Network, the DoH scale-up of school testing would be linked to a revival of school health programmes, but there were questions as to who would implement the new VCT, and concerns that school staff would not be in a position to give HIV-positive learners the kind of follow up care they needed.

"A mass-based approach [to VCT], especially if facilitated by teachers who are not health specialists, and who are generally not trusted by learners when it comes to confidentially, would not be the right approach," Fenton told IRIN/PlusNews.

"There are not yet sufficient psychosocial support mechanisms in place, and without thorough preparation the rights of children may be trampled on in the process."  - (PlusNews, February 2011)