SCHOOL OF SOCIAL WORK AND COMMUNITY DEVELOPMENT 2007 Dr GITA SURAJ-NARAYAN GROUP 9 PRESENTATION: SOCIAL WORK AND AIDS
207 510 060 – Munsami R 207 506 958 - Myende V. N 207 508 781 - Naicker S 207 527 463 – Naicker N. S 207 510 830 – Naidoo A. D 207 507 711 – Naidoo C 207 510 311 – Naidoo P 207 500 817 – Naidoo V 207 511 749 – Naidoo V 207 510 117 – Nayimuli A. K
14 MAY 2007
We are living in a time when the whole world is facing an epidemic of greater proportions than anyone ever imagined would be possible. At a time like this, it is important to be both informed and pro-active. Please don’t be fooled there is a certain death around you. It does not matter who you are, where you live, but you’re in daily contact with the HIV/ADIS dilemma through people round about you. The spread of this disease has accelerated and reached alarming proportions. At some level, in many ways, the society in which you live is being attacked by this killer disease. This is now a crisis that needs real and emergency solutions that work. To be condemned to certain death and not a very nice death through onslaught of opportunistic diseases through a weekend immune system is a terrible end. But what is worse, is to have to carry the thought to the end that you became infected through personal choices and behaviours. That is particularly cruel.
Round about us people are sickening and dying at an unprecedented rate. In some places graveyards are becoming full without space left to bury the dead. Families are being left in poverty without breadwinners; without fathers and, often without mothers as well. The number of destitute AIDS orphans in the world is growing so rapidly that governments do not see how they can handle the problem either now or in the future. Hospitals can no longer cope. Skilled workers are dying out in some countries there is an expectation that half of the productive workforce will be lost to AIDS in the next few years, with crippling economic consequences for the country. We need to come to terms with the fact that this is no longer some scary rumour, but a hard, stark reality that is with us in each and every community. Facing reality is not negative thinking, but mature living! There is no way in which any community is likely to escape the widening ripple of HIV/AIDS. But the good news is that the trend can be slowed down and even reversed.
What is quite startling is the extent to which ordinary people like us are closing their eyes and ears to reality. HIV/AIDS is presently a deadly disease with no permanent or guaranteed cure. Although attempts are being made to treat HIV/AIDS with medicine, it is basically not just a medical problem. It is a moral problem related to behaviour. The good news is that something can be done about behavioural issues.
The time has come when we need to be prepared for new approaches. Hoping for a short-term medical cure, or shouting about condoms as the answer or mythical beliefs about there being a cure through sleeping with a virgin or other religious practices, just haven’t worked.
You can be apart of the solution and not the problem! You don’t have to involved in sexual immorality, nor be a drug user with infected needles in your veins; nor be caught in abuse, rape, or homesexuality, where you put yourself in line to contract this deadly virus. When you come to realize the quality choices open to you, then life begins to take on new meaning. The truth is that you can hold your head up high, be a person admired by others, and still have an enjoyable, productive, positive lifestyle. It is really your choice!!!
Truth needs to be shouted from the mountaintops in our cities and towns, to the rich and poor, north and south everywhere it is the same, people need to hear and understand. They don’t have to get AIDS/HIV. It’s going to be a long time before any medical cure for AIDS reaches the masses. Even if this appears tomorrow, and even if it is affordable, it will be years before the drug reaches people in little inland villages, let alone cities and towns. It’s not being negative to say that, if you are HIV/AIDS free, you are in great danger. So are your friends and family. (Reference 1)
AIDS Acquired Immune Deficiency Syndrome
AIDS, first described in 1981, is not a single disease, but rather an increasing vulnerability to many disorders especially infections. These result from the progressive destruction of the immune system by the immunodefiency virus known commonly as HIV. The virus is transmitted when a body fluid of an infected individuals blood, semen, vaginal secretion or breast milk is absorbed into the bloodstream of a healthy person. AIDS is common among homosexual males but now the spread of heterosexuals is predominant, particularly in Africa. About one third of the babies born to HIV infected mothers will develop AIDS. Intravenous drug abusers who share needles are also at risk of contracting the disease.
Diagnostic studies and procedures
There is no direct test to diagnose on HIV infection; the tests currently available detect antibodies made in response to the virus. These antibodies are not detectable until at least six weeks after the infection. In rare cases it takes a year or more for them to develop. A negative result, therefore does not necessarily rule out the existence of an HIV infection. The most common test for HIV is a blood analysis called ELISA; this is short for, Enzyme-linked immunosorbent assay. Because the ELISA test can be falsely positive, a however a firm diagnosis also requires a positive response to another antibody test called the WESTERN BLOT TEST, which specifically detects HIV antibodies. Once an HIV infection has been confirmed, frequent blood tests to measure CD4 cell (lymphocytes in body) levels. This indicates how fast the disease is progressing, even in the absence of any symptoms in the patient.
There are no cures for Aids and there is no known way to return those who are HIV negative status. All that the treatment can do is delay the progression of the disease and extend the period of relative health. There are two main types of AIDS medications. Both act on different enzymes which are concerned with the replication of the HIV virus.
Complementary Treatments Aromatherapy Meditation Yoga
(Reference 2) Background
As we enter the third decade of the HIV/AIDS pandemic, social workers deplore the fact that millions of people are infected with HIV/AIDS and that not enough is being done to promote wellness and to stop the spread of this preventable disease.
AIDS knows no social, racial or cultural barriers. Yet the rates of infection spiral especially among the poor, the disenfranchised and among people who struggle with inequality and oppression.
Throughout the pandemic, people living with HIV/AIDS across the world have shown, and continue to show, a commitment to community-based action. They have not acted alone. Often social workers have provided essential leadership and support in mobilizing community response to HIV/AIDS. Together they have shown an unbending resolve to work toward wellness, to openly engage the communities, and to assert and protect fundamental rights. This action is a potent reminder of the duty of compassion that binds us all.
Social workers are committed to the principles of social justice. We have a "responsibility to devote objective and disciplined knowledge and skills to aid individuals, groups, communities and societies in their development and resolution of personal-societal conflict". The principles of the profession explicitly provide that we work without prejudice with regard to gender, age, disability, colour, social class, race, religion, language, political beliefs or sexual orientation. Likewise, we must be mindful and aware of the impact of oppression and marginalization with regard to gender, age, disability, colour, social class, race, religion, language, political beliefs or sexual orientation. We are obligated to uphold stringently the principles of privacy, confidentiality and responsible use of information even when a country's legislation is in conflict with this demand. Work we undertake must be consistent with these
fundamental values and nowhere may we be complicit in supporting individuals, groups, political forces or power structures that suppress their fellow human beings by terrorism, torture or other brutal means.
Through its pervasive and global scope, AIDS presents different challenges wherever it arises. In the interest of preventing further spread of HIV/AIDS and promoting health, our approach assumes a continuum of care — sexual and psycho-social health education, adequate testing, prophylactic means of prevention, counselling, support, care and treatment.
This rise of the HIV/AIDS pandemic is a call to action to social workers and social work educators everywhere to walk the critical paths that demand our attention, whether on the local, national or international level. From the most basic duty to advocate fundamental rights, through lobbying for effective and compassionate social and health policy, to advocating just and equitable protocols for research and collaboration, there is much work to be done. Human rights, social work education, social and health policy, research and partnerships all relate one to the other.
The International Federation of Social Workers and the International Association of Schools of Social Work. SOLEMNLY DECLARE:
(1) WITH RESPECT TO HUMAN RIGHTS To uphold and foster the Ethics of Social Work as set out in the International Declaration of Ethical Principles of Social Work and in the International Ethical Standards for Social Workers, and to apply them rigorously in the context of HIV/AIDS; To hold all governments accountable to the commitments set out in the Paris AIDS Summit of December 1994, regardless of whether they are one of the 42 signatories, which is to say: to advocate and defend the right to equitable treatment of all people, irrespective of culture and belief, regardless of gender, age, sexual orientation, race, religion, civil status, affiliation, route of transmission or prognosis of compliance; To pressure all governments and organizations to adhere to the principles of human rights and dignity of the person in accordance with existing Human Rights conventions and to respond compassionately to those affected by the pandemic; To advocate with vigor that all people affected and infected by HIV/AIDS have proper food, housing, education and health care and be able to exercise their rights in this regard without hindrance.
(2) WITH REGARD TO SOCIAL AND HEALTH POLICY To engage in the fight against poverty as a key element in the prevention of HIV infection;
To work actively with persons living with HIV/AIDS so that they hold their rightful place as principal partners in addressing the pandemic and as active participants in decision-making and policy implementation at all levels;
To advocate public and social health policies rooted in a solid understanding of the determinants of health, and in the context specific realities of the community, so that those policies effectively provide a continuum of care that promotes an improved quality of life for everyone affected and infected by HIV/AIDS;
To use our expertise at the macro-social level to criticize policies that harm the health and psycho-social wellbeing of all those who are touched by the pandemic, and to ensure that those who are marginalized and adversely affected are heard;
To constantly battle the stigmatization and resultant discrimination that attaches to HIV/AIDS no matter what its source and no matter what its target.
(3) WITH REGARD TO SOCIAL WORK EDUCATION To incorporate innovative, comprehensive, practical and theoretical HIV/AIDS education within social work curricula with the understanding that HIV/AIDS touches every facet of human development; To teach all students, practitioners and academicians of social work about HIV/AIDS and apprise them of the medical, physical, psycho-social, cultural, legal and economic issues involved in the pandemic; To acknowledge and work through our own fears and prejudice so we may fully foster respect for people living with HIV/AIDS; To develop an understanding of the determinants of health and the principles of the prevention-to-care continuum of care as they apply to individual and community well-being, emphasizing health promotion, prevention of infection, social and psychological care, medical treatment, counselling and support; To involve all those affected by the pandemic in the education process, through community-based organisations, NGOs or other bodies; To foster collegial attitudes that promote interdisciplinary, multidisciplinary, and transdisciplinary approaches and to ensure meaningful exchange with other professions; To integrate theory and practice.
(4) WITH REGARD TO PARTNERSHIPS To address HIV/AIDS, mindful that people living with AIDS are integral to the interdisciplinary, multidisciplinary and transdisciplinary undertakings that offer promise and hope in response to the pandemic; To enter into respectful professional relationships based on equality and equity; To overcome local, regional, national or professional concerns that might limit a broader understanding, effective intervention and inclusive decision-making;
To collaborate with all organizations or leaders mindful of the particular political, social, economic and cultural context that shapes the particular relationship.
(5) WITH REGARD TO SOCIAL RESEARCH To ensure the participation of social workers in psycho-social research to ensure a social work perspective on prevention, intervention, care, treatment and support and health promotion; To involve people with HIV/AIDS in designing, implementing and interpreting the research; To ensure that all research initiatives are driven by the fundamental values of confidentiality, informed consent, self-determination, dignity and worth of the individual; To respond to the contribution of those being studied with respect and gratitude to ensure that the results of research are imparted to those being studied and to all those implicated throughout the research process and after its completion, so that they may benefit directly from the process and the results.
WE THEREFORE RESOLVE: That the HIV/AIDS pandemic and its psycho-social, medical, legal and economic ramifications are a priority for all social workers and all social work educators throughout the world; That social workers and educators will forcefully advocate social and health policies founded on the human dignity of people with HIV/AIDS and the communities in which they live; That social workers and schools of social work will promote a continuum of care that is based on a critical understanding of the determinants of health, as well as culturally sensitive approaches to risk and harm reduction including, but not limited to, education about safer sex and injection drug use; That social workers and social work educators will be guided by a fundamental awareness that issues of HIV/AIDS awareness, education, research, treatment and care are intrinsically tied to issues of discrimination, poverty, unemployment, physical, mental and social well-being; That our duty is to work to eradicate the impediments to effective prevention of HIV transmission and to the proper care of those affected and infected by HIV/AIDS. Website 1 Case Study: World Aids Day Staff Report: Social worker seeks to raise awareness about Aids A campaigning social worker is hoping to set up an organisation to raise awareness about the menace of HIV and Aids in the UAE. Roopa Hasan said too few people knew the risks linked to the killer virus - and little was being done to improve their knowledge. The 29-year-old Indian said there are many misconceptions linked to Aids that she wants to eradicate in the UAE."I want to use my life to save at least a couple of more lives by making people aware of this deadly virus. There is a tremendous need to make people aware. "There are facts and myths related to HIV/Aids and they have to be addressed. How many people in the UAE know the difference between HIV and
Aids?" she asked. Hasan said HIV/Aids prevalence rates in the Gulf region were fairly low compared to some other parts of the world. However, she said countries have reported increases in HIV/Aids infections in recent years. ―I hope to be visiting local schools and contacting universities to organize group discussions. I will also be networking with the hospitals to see if they want HIV/Aids counselling," she added. To help fund the group, Hasan said she would be contacting major companies to see if they could offer support. In Delhi in her native India, Hasan spent three years working for a non-governmental organisation called Torch raising awareness about HIV/Aids. Website 2
SECTION IN THE BILL OF RIGHTS AND WHAT IT MEANS FOR PEOPLE WITH HIV/AIDS
THESE RIGHTS ARE IMPORTANT BECAUSE THEY PROTECT EVERYONE FROM BEING TREATED UNFAIRLY 10. Human Dignity Everyone has the right to have their dignity respected and protected. A person or institution may not insult or damage any person’s self-respect, by their words or actions.
12. Freedom and Security of the Person Includes the right to: Make decisions on reproduction – does not include decisions about pregnancy and terminations, but also things like you health during your pregnancy and the health of your unborn baby. Security and control over your body. Not to be subjected to medical or scientific experiments without informed consent.
A person has the right to take his/her own decisions about medical treatment and pregnancy, the person cannot be treated in a cruel or degrading way by any person or institution.
14. Privacy Everyone has the right to privacy. If you have HIV or AIDS, you have the right to keep the information to yourself. An employer or hospital cannot force you to tell them, or force you to have a blood test to find out this private information.
16. Freedom of Expression Everyone has the right to freedom of expression, which includes freedom to receive or give out information or ideas. This right is important, particularly as a way to ensure that proper information about how to prevent HIV is available in schools and prisons.
18. Freedom of Association Everyone has the right to freedom of association. You can join any organization you choose. You cannot be forcefully separated from other people.
21. Freedom of Movement and Residence Everyone has a right to freedom of movement and to leave the country. All citizens have a right to enter, remain in and live anywhere in the country. You are free to move around the country. You cannot be forced to live in a separate place, away from the rest of society.
22. Freedom of Trade, Occupation and Profession Everyone citizen has the right to choose their trade, occupation or profession freely. You can choose what kind of work you want to do. You may not be told that you cannot be a doctor, a teacher or a health care worker just because you have HIV.
23. Labour Relations Everyone has the right to fair labour practices. No person may be unfairly discriminated against at work
24. Environment Everyone has the right to an environment that is not harmful to their health and well-being. The right is important for people with HIV who are living in state institutions such as prisons or psychiatric hospitals.
26. Housing Everyone has the right to have access to adequate housing. No person may be evicted from their home, or have their home demolished, without an order of court made after considering all relevant circumstances. People living with HIV or AIDS may not be refused a subsidy or loan to but a house. Evicting a person from a house or flat because of their health is unlawful.
27. Health care, Food, Water and Social security Everyone has the right to have access to: Health care services, including reproductive care
Social security, including, if they are unable to support themselves, and their dependants, suitable social assistance.
No person may be refused emergency medical treatment. Hospitals or doctors cannot refuse to treat a person with HIV or AIDS. People with HIV or AIDS have the right to disability grants if they are too ill to support themselves or their families.
29. Education Everyone has the right to basic education including adult basic education. If you have HIV or AIDS, you have the same right as all people have to education. A school cannot refuse to educate you or your child because you have HIV or AIDS.
32. Access to Information Everyone has the right to have access to any information and is held by another person and that is needed to carry out or protect you rights. If you feel you are being discriminated against because of a policy, you can demand to see that policy, and then challenge it in a court. You have the same right with private institutions and information that may be kept about you. This right may also include the right of people who are held in state institutions, such as prisons, to have access to education and life-skills training on issues such as HIV/AIDS.
33. Just Administrative Action Everyone, whose rights have been negatively affected by administrative actions, has the right to be given written reasons. If you feel that you are being refused a social service for unjust administrative reasons, then you can demand these reasons in writing.
35. Arrested, Detained and Accused Persons Everyone who is detained, including every sentenced prisoner has the right to conditions of detention that protect their dignity. Prisoners cannot be treated in a discriminatory or undignified way just because of their HIV status. Rights of employees living with HIV or AIDS Right to fair labour practices. (LAW – Constitution & Labour Relations Act) Right not to be unfairly dismissed because you have HIV. (LAW – Labour Relations Act) Right not to be unfairly discriminated against on the basis of your HIV status.(LAW – Employment Equity Act)
Right not to be tested for HIV unless your employer has applied to the Labour Court for authorization. (LAW - Employment Equity Act) Right to a safe working environment. (LAW – Occupational Health and Safety Act & Mine Health and Safety Act) Right to compensation if infected with HIV at work. (Reference 5)
The ILO Code of Practice on HIV/AIDS and the World of Work • In June 2001, the International Labour Organization adopted a Code of Practice on HIV/AIDS and the World of Work. The fundamental aim of the Code is to help safeguard conditions of decent work and protect the rights and dignity of workers and all people living with HIV/AIDS. • The Code is intended to help prevent the spread of the epidemic, mitigate its impact on workers and their families, and provide social protection that can help them cope with the disease. The Code provides practical guidance to governments, employers and workers’ organizations (as well as other stakeholders) for developing national and workplace HIV/AIDS policies and programmes. • The Code addresses several important issues, including preventing infection through information, education and gender-awareness programmes, and by promoting behaviour change. It covers the protection of workers’ rights (including employment protection, gender equality, entitlement to benefits and non-discrimination on the basis of HIV status). And it deals with the challenges of care and support (including confidential voluntary counselling and testing, as well as treatment in settings where local health systems are inadequate).Website 3 Why Every Social Worker Should Be Challenged by AIDS? Acquired Immune Deficiency Syndrome (AIDS) will touch the professional lives of almost all contemporary social workers before they retire. The worried, the ill, the dying, and the bereaved will occupy social workers' caseloads and continue to touch their personal lives as well. Whole families of intravenous drug users are becoming infected and dying orphaned children with AIDS languish in inner-city hospitals; gay men die; elderly parents grieve for sons, daughters, grandsons, and granddaughters; and agency staffs are immobilized by the illness of a social work colleague repeatedly hospitalized for one opportunistic infection after another. Social Workers as Pioneers This profession can be justly proud of the often pioneering work done by social workers from the onset of the AIDS health crisis in developing psychosocial services of singular diversity and effectiveness that reach out to people infected and affected by HIV. Even before the significance of HIV was known and complete knowledge of the modes of transmission was verified, social workers began to make important contributions to all professionals' understanding of AIDS.
AIDS Work and the Social Work Tradition The history of social work and the profession's innovations during the Progressive Era and the New Deal resulted in the creation of settlement houses, playgrounds, child labour laws, visiting nurses, maternal health clinics, social security, and labour legislation. This tradition was very much in evidence as social workers pioneered the design and delivery of the first psychosocial services for people affected by AIDS. These early efforts by social workers, in many cases serving as unpaid volunteers, demanded that people with AIDS have their food trays brought into their rooms, instead of having the trays placed outside their hospital room doors, or not be left to wallow in their own excrement when nursing staffs were too fearful to change the linen. Clearly, much remains to be done, and social workers continue to make important contributions in their agencies when they recognize the challenge of AIDS. For example, one social worker in an agency for the blind reached out to people with AIDS whose sight was affected by the opportunistic infection of cytomeglovirus retinitis. Braille training brings dignity and comfort to these clients, even though their lives are foreshortened by HIV disease. AIDS tests the mettle of social workers in health care settings, whose tasks may include assisting parents through the crisis when they learn simultaneously that their son is gay and is dying from AIDS; helping a woman examine the possible consequences to herself and her child on discovering that her bisexual husband has AIDS; helping pregnant women with AIDS who have one or more children already dead or dying and who hope that this baby will be born uninfected; teaching adolescents in a family planning clinic that sexual activity must also include the use of condoms to prevent transmission of HIV; counselling newly diagnosed gay men with AIDS who are already overwhelmed taking care of dying lovers. Social Injustice and AIDS AIDS has exposed previously invisible faults in our social and economic order by pointing out the tragic inequities that exist in health and social services. The poor are less apt to know about or use advanced expensive medical procedures and participate in experimental drug trials. Poor people who get AIDS mostly intravenous drug users and inner-city minority people generally lack private health insurance and access to university medical centers where the experimental treatments are being offered. Consequently, poor people and other disadvantaged people with AIDS tend to live a shorter time and in a more debilitated state of well-being, in physical environments that foster further decline and early deaths from infection. In contrast, many middle-class gay men with AIDS now live for more than 7 years following a diagnosis of AIDS. The benefits of azidothyrnidine (AZT) and aerosol pentamidine in slowing the HIV infection and preventing pneumocystis has not been realized fully because of the slowness of Medical aid providers to accept the use and cost of newer lifesaving and life-enhancing treatments. Because of their central positions in delivering services to people with AIDS in the inner city and elsewhere, social workers will continue to have crucial roles advocating
decent care from the health care team, and they must vigorously defend services against cutback decisions made by planners and politicians. Social workers in community organizations must continue to hold large providers like Medicare, Medicaid, and private health insurance companies to the highest standards of equity for all people with AIDS. AIDS poses challenges to all aspects of professional social work by providing the opportunity to work with some of the most disenfranchised and despised segments of our society. This includes urban poor intravenous drug abusers, homeless people who are HIV infected, and sexual minorities. These opportunities challenge professionals to rise above their bigotries about "junkies" and "faggots" and learn to see clients as people who are ill and in need of empathy, compassion, and most importantly, professional expertise. Social workers working with people with AIDS need to ask themselves if their skills are blocked by blaming people with AIDS or their life-styles in effect blaming the victim. Distinguishing life-styles from the viruses and bacteria that cause disease is, for some, an overwhelmingly high barrier to cross. Simple professional ethics and humanity require such a leap. Case study: Shame and AIDS My brother died of AIDS 4 years ago. Our parents were so deeply ashamed of the fact that he had AIDS they told everyone he had lung cancer. Technically this was true, because he had Kaposi Sarcoma of the lungs. But their shame, both for themselves and for him, compounded the medical and personal tragedy. As Elie Weisel once said about victims of any tragedy who suffer in silence, "What made their being most unique was something they hid. That is most tragic -- to suffer and then to suffer for having suffered." Social workers, trained to listen and encourage clients to speak of their pain and suffering, can do a great deal to ease the isolation and suffering that accompany the stigma and shame of this illness for individuals and their loved ones. AIDS Practice and Challenging Stereotypes Meeting the AIDS challenge professionally means carefully assessing clients to see them as individuals and not categorize them as being "at risk" or "not at risk." Because anyone may become infected with the virus that causes AIDS, assumptions should not be made about a client's risk status for HIV infection. The heterosexual married man with children may also have a history of having sex with men. The stereotype of people taking drugs is that they are poor or from the inner city. Yet, middle class and wealthy people also take drugs and share drug-using apparatus, risking HIV transmission. Lesbians, supposedly the lowest-risk group for AIDS, may have a history of having male lovers, or they may have taken drugs and even worked as a prostitute at some point in their lives, thus risking HIV exposure. AIDS challenges social workers to change themselves by dealing with feelings about pain, illness, death, and the illusion of personal immortality. To continue doing AIDS work social workers must receive
skilled supervision; they must have access to AIDS support groups and periodic retraining, and at times, a collegial embrace after suffering the loss of yet another beloved client.
Assessing Clients' Risks of Exposure to HIV Before the development in 1985 of an accurate test to determine the presence of HIV in blood products, people who received transfusions or clotting factors were at risk of contracting HIV through blood they were given. Currently the vast majority of new HIV infections occur either through sexual exposure or sharing intravenous drug using apparatus. In attempting to assess whether a client is at risk for AIDS, a social worker must ascertain both the client's current sexual practices as well as what they were in past.
In attempting to do a risk assessment for high-risk behavior the social worker needs to ask questions regarding drug taking and sexual practices in an accepting, non-judgmental, matter of fact gentle way that does not incorporate the use of labels. In order to be able to engage chemically dependent individuals in AIDS prevention and treatment social workers need to learn how to talk to drug users honestly and completely about their drug use.
AIDS Prevention: Drug Use The use of alcohol and an illegal substance increases a person's vulnerability to HIV in three ways: First, a person who shares hypodermic needles or other drug paraphernalia - such as "cookers" (the container in which the drug is dissolved in water) or "cotton" (the material used to strain the drug solution as it is drawn up into the syringe) with someone infected with HIV is at risk of becoming infected. Second, a person who becomes intoxicated may lose inhibitions against risky practices, e.g., neglecting the use of a condom during a drunken or stoned sexual encounter. Third, a number of substances, such as alcohol, cannabis, amphetamines, inhaled nitrates, and cocaine, may suppress one's immune system. Heavy use of an immunosuppressive substance by HIV infected individuals can accelerate the collapse of "helper" T-cell activity.
By placing abstinence from drugs as the highest treatment priority unless the client is truly committed to achieving abstinence, will only alienate the client or cause him or her to begin a dishonest relationship with the social worker. Thus social workers attempting to engage chemically dependent clients in treatment must not confuse the goals of providing AIDS education and risk reduction with the goals of helping clients stop using drugs. One way of helping accomplish this is by clearly counseling clients as follows: If you do not want to contract AIDS, the best way to avoid it is by not using drugs. I can refer you to an agency or program that can help you to stop using drugs. If you must use drugs, do not share paraphernalia such as needles or cookers. Remember that people can look healthy and still carry the AIDS virus. If you must share paraphernalia, flush the needle, syringe and cooker with bleach, and rinse well with water or boil for 15 minutes.
To reduce the risk of contracting AIDS through sexual contact, use condoms, avoid contact with semen or blood and learn safe sexual practices.
Taking the above approach in sessions with active drug using clients does not condone drug use, but it does acknowledge the reality that people who still actively use drugs are in desperate need of AIDS education services so as not to transmit HIV to drug using or sexual partners or their children.
Sexual Practices Unfortunately the vast majority of social workers complete their graduate education and even post-graduate training with little or no education in how to talk with clients about sex and sexuality, and no training in how to take a sexual history. Discussing sexual issues can cause discomfort even for the most sophisticated worker. This is especially true if the discussion involves sexual practices that the clinician believes are immoral, distasteful, repugnant, or represent a life style or behavior with which the clinician is totally unfamiliar. The potential for countertransferential blunders is enormous when clients disclose marital infidelities, exotic or nonconformist sexual practices or beliefs. It is the moral and ethical responsibility of every clinical social worker to introduce the issue of sexual practices in relation to AIDS prevention with each individual.
Some salient points to consider are as follows: The highest risk of contracting HIV has to do with exposure to blood that is already infected. Thus sharing drug injecting paraphernalia or unprotected sex that results in exposure to blood or semen pose the highest risks. Unprotected anal sex is the next highest risk behavior, followed by unprotected vaginal sex. There is controversy about whether or not fellatio (oral sex performed on a man) without a condom is high risk. There is a growing body of evidence that suggests it is at least a potentially risky behavior, though not as high risk as either unprotected anal or vaginal intercourse. In discussing the relative risks of various sexual acts with clients social workers must be prepared to have clients get angry at them for not being able to provide definite "do's and don'ts."
HIV Risk Reduction and Social Work Practice with Diverse Clients Thus social workers who see adolescents, individuals in sexually non-exclusive relationships, newly separated, divorced or widowed adults, and any person contemplating having sex with a gay or bisexual man, current or former intravenous drug user, or transfusion recipient needs to learn about safer sexual practices. The current epidemics of all sexually transmitted diseases, including but not limited to Hepatitis, Herpes, AIDS, and treatmentresistant gonorrhea has made it appropriate, and in fact essential for clinical social workers to ask clients effective questions about their sexual practices.
Roles and functions of a social worker when dealing with Aids/HIV clients
Counseling 1. Social workers should have understandable concerns about introducing these topics. The issue of whether sexual content becomes experienced as over stimulating or "inappropriately eroticized" must be assessed on a case by case basis. Understandably, many clients do not feel comfortable discussing sexual practices and may feel intruded upon or angered by explorations of these issues. However questions concerning sexual behavior outside of marriage or the client's sexuality may raise profound feelings of relief as well as anger.
Anger may occur because any discussion of AIDS shatters the client's ability to deny that the disease can touch him or her. The anger may also reflect how vulnerable and powerless the client feels in seeking social services, and in addition may be a defense in response to having been treated in insensitive or even humiliating ways in prior interactions with social service agencies or workers.
HIV testing 2. The social worker needs to know where anonymous and confidential HIV testing is available in his or her community in order to make a referral when appropriate. One of the most commonly endorsed protections against HIV-related discrimination is the use of anonymous testing. Since even in the second decade of AIDS there is considerable stigma attached to a diagnosis of being HIV positive, the client needs and deserves assurances of the confidentiality of his or her test results. It is also useful to have developed a relationship with a specific individual at the test site to whom you can refer a client with confidence. It is also an excellent idea to know about any existing AIDS service organization and other local HIV/AIDS resources in the community, and which physicians, hospitals and medical centers are most experienced in treating people with HIV/AIDS. Social workers should also educate themselves about the stages of the illness and how its progression may present.
There are a number of situations when it is clear that a social worker needs to raise the issue of a client being tested for HIV: The client mentions that he or she has recently had or feared he/she has had a sexually transmitted disease. A client shares that he or she has discovered that their spouse has been sexually unfaithful. A client has been sexually assaulted or raped. A client's spouse is hemophiliac (person that has sex with blood) or has received a transfusion prior to the screening of the blood supply in 1985. A client reports high risk sexual or drug taking activities like sharing paraphernalia.
It is therefore urgent for the worker to remember that no matter how appropriate it may be that the client be tested for HIV, the final decision about whether or not to be tested must always be the client's.
With Counseling before and after the HIV Test Each individual planning to take the HIV test needs to receive pre and post test counseling regardless of whether he/she tests negative or positive. After introducing the topic of being tested for HIV, but prior to actually taking the test, all clients need to explore the following issues: How do they feel they will handle learning that they are HIV positive or HIV negative? How will whatever the results are change their life? Who in their life do they want to share this information with? How do they feel a positive test result will impact these relationships?
The period of time while one is waiting for test results is almost always one of heightened anxiety, which often includes somatic symptoms and sleeplessness. If a client is newly in recovery from alcohol or drug abuse, in the midst of other interpersonal or intrapsychic (being or occurring within the psyche, mind, or personality) crises, it is generally inadvisable to counsel him or her to take the test at that time. Positive test results can be emotionally devastating sometimes resulting in a psychiatric decompensation, or relapse into active use of alcohol or drugs. If a physician feels there are urgent medical reasons indicating HIV testing, then counseling needs to address this and support the medical advice. For individuals who are newly in recovery from chemical dependency, and for whom there is no medical urgency, but only a desire to learn their HIV status, it is advisable they wait until they have at least a year's sobriety to take the HIV test. Post test counseling must include information on safer sex no matter what the results are, and referrals to medical and mental health services if the client tests positive.
Once a client has learned that he or she has been exposed to HIV the social worker has a number of crucial tasks in order to help him/her adjust to living with a life threatening illness. First and foremost, the worker needs to become extremely educated about HIV disease and AIDS. The worker should establish a relationship with a knowledgeable medical professional who can explain various symptoms, treatments and options to the worker so that the client is not spending his or her time educating the worker about medical issues of the illness. Although AIDS is almost always a terminal illness, it is most often premature for clients to begin preparing for death upon learning that they have just tested positive. Clients need to hear that there is usually a period that increasingly lasts up to ten or more years where people remain asymptomatic and are only HIV positive. (People have full blown AIDS when their CD-4 cells fall below the 200 mark or they come down with one of the AIDS related opportunistic infections.) Only when other serological tests indicate that the immune system is severely damaged or the client is seriously ill
with one of the major AIDS related opportunistic infections may the client simultaneously be learning that he or she has been exposed to HIV and is at risk of dying from a serious AIDS related complication.
One reason for this is that inner city people do not generally have a primary care physician, and usually do not go to clinics or doctors for regular or preventative visits. The poor, women, children and addicts, are more apt to use the hospital emergency room for primary medical care, arriving there in run down conditions with severe HIV symptoms or in advanced stages of one of the opportunistic infections associated with a diagnosis of "full blown" AIDS. With this in mind all social workers with socially disadvantaged clients must use every opportunity to teach these individuals the concept of primary medical care, and urge them to seek regular contact with physicians for themselves and their children
Ethical, Legal Issues and Confidentiality Related to HIV Antibody Status Social workers may find themselves in a situation where there is a conflict between loyalty to one's client regarding confidentiality and other ethical concerns.
Case Study A heterosexually married man sought counseling following learning that a regular male sexual partner had been hospitalized for an AIDS related condition. These men had never practiced safer sex and my client was in a panic that he might be infected and that he might have infected his wife, with whom he was still sexually active. After testing positive for HIV antibodies, he was unwilling to share this information with his wife. I was insistent that he let her know what the situation was, especially since she needed to be tested to ascertain what her health status was. After refusing to tell his wife that he was HIV positive for two months, I gave him the following ultimatum. If he didn't tell his wife within one month and she accompany him into sessions so I could be certain that he had indeed told her about his HIV status and her possible risk, I would call her myself and tell her. I made this decision after consulting with my attorney. Based on an interpretation of the Tarasof ruling in California, she felt that she could defend my potential breach of client therapist confidentiality since there was a potentially life threatening situation involving the wife. Eventually he reluctantly agreed to tell her that he had been tested for HIV after having visited a female prostitute on a business trip and discovered that he had been exposed to HIV.
This case illustrates several points regarding legal, ethical and clinical questions of HIV testing in social work practice. Except in cases of suspected or observed child abuse, the confidentiality of a client's discussions with a social worker is an important foundation of the professional relationship.
Universality of the Issues Affecting People Living with HIV/AIDS It is virtually impossible not to be personally affected by working professionally with people who are seriously ill and dying. When social workers become educated about the relevant issues of people living with HIV and AIDS, the worker becomes better prepared to help any client face a life catastrophe. By confronting dying clients the fragility of life and the value of each day, social workers begin to confront the vulnerability of their own lives and to acquire a deeper appreciation of living. Even deeply religious people question why bad things happen to them or to the people they love and can greatly benefit from the intervention of a skilled social worker who can help them work through all the accompanying issues and feelings. An additional benefit for the worker of doing this work is that it demystifies death and dying.
When a social worker first encounters a person with HIV/AIDS or a member of their family or support system, one of the worker's tasks is to help the client balance a realistic sense of hope with practical issues inherent in learning to live with HIV and AIDS.
One of the most important functions of the social worker will be as liaison between the client and his or her family; between the client and physician or other health care providers or home care agency; and between the client and social service agencies. Families and other loved ones are often in greater denial than the client and may benefit greatly from speaking with a social worker.
Social workers can help clients who experience pain by teaching them the techniques of self-hypnosis and visualization.
Hospital social workers need to be alert to the above mentioned dynamic and be prepared to advocate for chemically dependent patients who are not being adequately medicated. Conversely, some patients who are in recovery have unrealistic expectations regarding using any drug that they once may have taken illicitly. Social workers need to remind people that they did not get sober to suffer and that taking prescribed medication to alleviate pain is not the same as abusing drugs.
Clients at the end of their lives can be empowered by social workers engaging them in a discussion about where they want to die. Many clients may not realize that whether to die at home, in the hospital or in a hospice is a decision that they and their loved ones can and should consciously make together in consultation with the physician. It can be enormously helpful if the social worker explains hospice care. Suggesting that an intake worker from hospice visit the client to describe the program in detail is one useful intervention. These discussions
are best held in at least two different sessions. The first is with the client alone to explore all of his or her feelings about this emotionally laden issue. Next the discussion needs to be continued with the people, if there are any, who will help care for the client, in order to explore all the emotional as well as logistical and practical considerations.
It can often be difficult for all concerned to acknowledge that "enough is enough." It is the role of the social worker to explore with the client his or feelings about whether or not to cease treatments or to continue fighting for extra time. It is not the worker's role to give permission for one choice or another, though the client may be asking the worker either directly or obliquely for his or her opinion about what course of action seems to be best. Dying can be a quality time both for the terminally ill person as well as those who love him or her. AIDS Practice and Challenging Stereotypes
Meeting the AIDS challenge professionally means carefully assessing clients to see them as individuals and not categorize them as being "at risk" or "not at risk." Because anyone may become infected with the virus that causes AIDS, assumptions should not be made about a client's risk status for HIV infection. The heterosexual married man with children may also have a history of having sex with men. The stereotype of people taking drugs is that they are poor or from the inner city. Yet, middle class and wealthy people also take drugs and share drug-using apparatus, risking HIV transmission. Lesbians, supposedly the lowest-risk group for AIDS, may have a history of having male lovers, or they may have taken drugs and even worked as a prostitute at some point in their lives, thus risking HIV exposure. AIDS challenges social workers to change themselves by dealing with feelings about pain, illness, death, and the illusion of personal immortality. To continue doing AIDS work social workers must receive skilled supervision; they must have access to AIDS support groups and periodic retraining, and at times, a collegial embrace after suffering the loss of yet another beloved client.
Challenging Hopelessness and Barriers to Good Practice Social workers need to be prepared to empower ill and dying clients by maximizing their options to live and to die how they want to. To accomplish this crucial clinical task with clients, professionals must feel empowered in their work. False barriers can get in the way of reaching out empathically to clients. Social workers erect these barriers for many reasons: perhaps the worker is heterosexual, and the client is gay; or the worker does not shoot drugs, and the client does; or the worker is not poor, black, or Hispanic, and the client is; or the worker does not have a lifethreatening illness, and the client does. Social workers are challenged to let go of the need to feel different from people who have AIDS. Many people with AIDS are living longer and with a better quality of life than they might have a few years ago. Social workers must learn how to empower clients with hope amid their illness. The hope may not be only for a
cure, but to stay healthy long enough for the next generation of medical breakthroughs to occur. More time allows social workers to encourage people with AIDS to hope for and work toward improved relationships with estranged family members or friends. Social Work Practice on the Cutting Edge AIDS work challenges all social workers to contribute to human betterment through their professional excellence. But, from a selfish perspective, this work rewards each person who engages in it by opening up some of the most profound questions of human existence pertaining to the value of life and relationships, and how one chooses to live. Working closely with people who have a life-threatening illness allows social workers to expand their sense of the preciousness of life. Lesbian and gay social workers have been largely the vanguard of providers since the onset of AIDS and can no longer do it alone. Many of the earliest social workers involved in AIDS work are now sick or have died. The fight for sensitive and effective services for all people with AIDS now requires the help of every social worker. Each social worker has the opportunity to help change a small portion of events by not shying away from working in the AIDS field. When the history of AIDS is finally written, let the social work response be recorded as one of the finest during this immense public health crisis. Website 4
Reference 1. Dr Madangatye, N. G. Tembinkosi. 2002, AIDS. Published by OM books SA, 2nd Edition
2. Guide to Medical Cures and Treatment. AIDS. Page 69-70
3. Website 1. http://www.ifsw.org/en/p38000241.html
Access date: 17/04/2007 (9:21 am)
Endorsed by the IFSW Officer's Committee Meeting, January 2001 international federation of social work page last updated on 07.10.2005 4. Website 2. http://www.archive.gulfnews.com/indepth/world_aids_day/more_stories/69403.html Access Date: 17/04/2007 (9:31am) 5. Aids law Project, Guidelines on HIV/AIDS and The Law for Advice and Legal Office Workers. The Bill of Rights and what it means for people with HIV/AIDS. Page 6-13. Centre for Applied Legal Studies. University of the Witwatersran 6. Website 3. http://www.un.org/ga/aids/ungassfacts/html/fswork_en.htm Access Date: 18/04/07 (7:23 am)
7. Website 4: http://www.thebody.com/content/art2489.html Access Date: 17/04/2007 (8:59) Shernoff, Michael. January 1990. HIV and Social Work: A Practioner’s Guide. Published in Social Work, V. 35. The Haworth Press, Binghamton, New York. (Website: http://www.haworthpressinc.com)