AIDS AND PLAYWORK
These notes are intended to advise those who work with children in play projects and activity, and managements of such activities about AIDS (Acquired Immunity Deficiency Syndrome) and HIV (Human Immunity Virus) as these matters affect play work. This is a contribution within the specialist area of play work to the general campaign to encourage a common sense and caring approach to what is a most serious public health and social issue.
This concern covers:
(i) Children with AIDS or ARC or who are HIV positive;
(ii) First aid and other health precautions involving all children, play workers and public;
(iii) Play workers who develop AIDS or ARC or who are HIV positive;
(iv) Screening of prospective play workers.
The term "play worker" covers all who work with children in play, whether paid or unpaid.
"AIDS is not one disease, but a syndrome, a collection of illnesses, caused by the same problem - an impaired immune system. The medical definition of AIDS is a narrow one. Only if a person is suffering from one or more of a very specific range of illnesses can they be said to have AIDS. ARC is the name given to a group of symptoms that can affect some HIV infected people who do not have the major infections or tumours seen in AIDS. Because of the very special clinical definition of AIDS a person may seem quite unwell but, if they are not suffering from one of the defined disorders such as Kaposi's sarcoma, they cannot be said to be suffering from AIDS: they have ARC.
"What most people are concerned to find out is whether they have contracted the AIDS virus. There is a test for this, of an indirect kind, called the HIV Antibody test .... if a person has HIV in their bloodstream, it will show signs of this by its antibody content .... If the HIV antibody is found in the blood, you are 'seropositive'. This means only that your immune system has reacted at some time to the presence of the virus. It does not mean that you will certainly get AIDS."
Many other pamphlets, TV and radio programmes, articles etc deal with the cause and incidence of AIDS and HIV so this Guide concentrates on the play work aspect, either assuming a very wide understanding of the general issues or referring the reader to the key contacts for general information:
e.g. The Terence Higgins Trust, BM AIDS, London WC1N 3XX. Helpline: 020-7242 1010.
The national UK free-phone Helpline is 0800-567123.
This Guide draws on advice issued to schools by the Department of Education and Science because of its relevance to working with children. It was checked with the Terence Higgins Trust and also comments from the ILEA Gay and Lesbian Youth Work Group were taken into account for this revision.
(a) to ensure that all children continue to have full access to play facilities and opportunities;
(b) to spread good practice concerning health safety and hygiene relating to AIDS/HIV in play projects;
(c) to help secure the acceptance and support of all who have AIDS or ARC or who are HIV positive especially those involved in play work and to ensure play projects play their part in the general public concern not only to halt the spread of the virus but to deal as a civilised society with those who have AIDS or ARC or who are HIV positive.
As AIDS/ARC/HIV is transmitted principally by penetrative sexual activities or exchange of blood, semen, or other body fluid there is no known danger of its being spread by e.g.
- normal social contact
- airborne droplets from coughing or sneezing
- sharing washing or toilet facilities, eating and drinking utensils, or living/working in the same space (though there are sensible health precautions which should be present in any play project irrespective of AIDS/ARC/HIV).
Q. How does a play project know a child has AIDS or ARC or is HIV positive?
A. It is unlikely that in future this information will be widely broadcast. It should always be treated as confidential information though this may sometimes break down. Current experience of the essential lack of risk from a child with AIDS or ARC or who is HIV positive together with prejudice likely in the community has demonstrated the need to operate a strict "need to know" principle by parents, teachers, social workers etc. That is, as few people as possible should know. It may be that play project managements will wish to consider advice to parents on whom, if anyone, in the project could be relied upon to receive such information and treat it with a guaranteed degree of confidence. They also will need to know why and if it is advisable that someone in the project should be in the know.
If a play project should become aware of a child using its facilities having AIDS or ARC or being HIV positive it is strongly suggested that this information be subjected to the same, strict "need to know" principle and that under no circumstances should a project be the means by which other children and adults get to know of a child's affliction, whether deliberately or inadvertently. It is also suggested that consideration be given to making such disclosure without authorisation firstly of parents and then of the project a disciplinary offence of the same magnitude as any other improper disclosure of personal information about children.
Where disclosure is authorised by parents, and with the child's consent, the project management and play workers will need to discuss appropriate methods of disclosure to other children and adults who inter-act with the project, if any is justified.
Q. How can a child develop AIDS or ARC or become HIV positive?
A. Children can either develop AIDS or ARC, or they can become HIV+. There are four main paths:
(a) The child has received infected blood or blood factors e.g. in a transfusion procedure; this applies to some children with haemophilia who were treated with contaminated Factor VIII and IX preparations (for clotting), mainly from abroad. A majority of haemophiliac children have been screened for HIV antibodies and 35% are antibody positive. The problem of contamination of blood factor supplies is now well tackled both in terms of supplies from abroad and screening out the problem from blood donated in this country. As such children grow up, some will develop AIDS or ARC, others will become HIV+. It is a problem which will diminish for play work as this generation of haemophiliac children reach adulthood.
(b) The child was born with the HIV in its cells because its mother was already infected or became so in pregnancy. The virus can be transmitted from mother to foetus. There will be children destined to develop AIDS or ARC through this route, who will die young. Others will be HIV+. The extent of this problem will depend on the extent to which current public health campaigning is heeded for if adults remain uninfected, children born of their relationships will also remain free of it.
(c) The child is having or has had sexual contact with a carrier of the virus. This would be penetrative vaginal or anal intercourse in the main. Apart from the appalling consequences of a child contracting AIDS or ARC or becoming HIV+, there is also the legal matter of the age of consent. For girls and heterosexual intercourse, this is 16; for boys and heterosexual intercourse there is no minimum age given; for men and homosexual acts of any kind it is 21, "in private"; for girls and lesbian behaviour there is no legal age specified.
It should be noted that HIV antibodies are not indicators of AIDS or ARC by themselves. The HIV test is not a test for AIDS but one which indicates the presence of immune problems of which HIV antibodies are a symptom.
Play workers, being adults in whom children may confide, should be prepared to consider the counselling needs of a child who reveals he/she is engaged in sexual activity. Fears about clause 28 of the 1988 Local Government Act should not deter counselling of children and young people e.g. about their sexuality. Added to the usual considerations (moral, legal and social) the AIDS factor must now be taken into account when counselling. Realistically, play workers often have been unable to convince a child by saying "don't do it" even though this may be very sensible advice which any adult friend of a child could and should give. Counselling could include advice on "safer sex"; on persuading a child to speak up where there is unlawful sexual abuse within the family, by a neighbour or within e.g. a club etc.
The play worker like all who work with children may be faced with the child's implored promise of confidentiality. In consulting beyond the child, the play worker ought not to broach matters with the police, parents or social services directly but refer it through management. In reaching a decision whether to breach confidence the play worker may take stock of the risk to the child and the degree to which personal counselling of the child might induce a satisfactory change in behaviour. Where management is involved, the welfare of the child whether with respect to abuse or to the risk of AIDS/ARC (or any other disease) will be a prime factor in making a decision to inform any authorities.
(d) The child is using contaminated needles through drug abuse. Initial experimentation, perhaps as a result of peer group pressure, may lead to sharing needles. In counselling children, the AIDS factor must now be considered along with the other social and legal aspects. There is emphasis in schools on combating drug abuse, and play projects will be playing their part in this work through general education and personal counselling.
Q. Is it harmful or risky to a child affected by AIDS/ARC or who is HIV+ to attend play facilities?
A. No! The child with AIDS is susceptible to serious illness due to the immune deficiency. However, there is no evidence that the child will be put at any greater risk because of attendance at a play facility than being involved in any other normal daily routine. Every child needs to play, and benefits from it; all kids benefit from good, organised play facilities run by sympathetic and caring adults giving their time and skills. This applies even more so for the child who has AIDS or ARC or who is HIV+ who will need every support and appearance of normality to cope with the effects, medical and social.
The risks are not sufficient to deny the child the much greater benefits of acceptance at and use of such facilities. Children who develop AIDS would be susceptible to a specific range of infections which humans normally shrug off because their immune system can overcome them. It should also be borne in mind that the child's family may be under great stress and trauma so acceptance is important for them as well as a relief from caring for a while. The acceptance of the child is support for them too.
The child with ARC, like the child with AIDS, will feel unwell in a number of generalised ways - extreme tiredness, fever and night sweats, loss of weight, persistent diarrhoea, mouth infections such as oral thrush, persistent swollen glands and so forth. The child with ARC is not at risk from utilising play facilities and needs play as much as his AIDS counterpart and for the same additional reasons. In both situations, stress in the family will also be a factor.
The child who is HIV+ will show no symptoms or ill-effects - the need to play remains as important.
If a child's illness from AIDS or ARC or HIV positive status does become widely known, there may be worry expressed by other children, or prejudice manifested. Such concern needs tactful, and where necessary, firm handling especially children who are at the centre of any "hassle" for an infected child. Play workers may get questions from children about AIDS. It is suggested that "a straight bat" is maintained, that is questions are answered directly and simply, according to age. Play workers will be aware, however, of parental rights in matters of instruction about sexually-related matters. But the comparative open-ness adopted by Government in its campaign on the issue is an indication of the serious long-term nature of AIDS concern. Children and young people will need careful advice and counselling. This must include a concern for the social treatment of those who are infected, and thus in the education of public opinion from an early age. Concern about clause 28 of the 1988 Local Government Act should not prevent counselling of children and young people about AIDS/ARC or HIV.
If a child using a play facility does develop AIDS, he/she will at some stage begin to develop serious illnesses as a result of the immune deficiency. Up to that stage, the child may lose strength, and his/her isolation from normal everyday activities begin. Because it is an illness (not a moral judgement), the child will need as much contact and comfort from normal aspects of his/her life as any other sick child. Where appropriate play workers may consider visits to the child's home, or to hospital/hospice if parents and doctors agree. The parents also will need support and comfort throughout, a period possibly of feelings of guilt and of social ostracism.
Whilst still able to play at a project's facilities, the child may find some activities more difficult than before, or no longer possible to perform. The play worker should be prepared to help the child tackle his/her sense of frustration.
Because of the child with ARC feeling unwell quite a bit of the time, some of the above points about physical ability will be relevant, and the child will need a lot of support as may his family.
Where the child is HIV+ there will be no sign of illness but there may be family stress and the child may not be aware of the fact.
The issue of impairment of mental functions amongst those with AIDS or ARC or who are HIV positive is one not yet fully understood and there is no evidence to date that children or young people have been affected but play workers and managements might keep an eye on media reports to follow this aspect as more knowledge becomes available.
Q. Are other children at risk from a child who has AIDS or ARC or who are HIV positive?
A. No. There is no evidence at all that unaffected children are at risk from the presence on a project of a child with AIDS or ARC or who are HIV positive. Casual person-to-person contact such as occurs in school or at play facilities presents no risk of spreading the HIV. Even intimate contact within a family where a child is infected (e.g. haemophiliacs) has not led to infection spreading in the family.
Q. How should the situation of a child's having AIDS or ARC or being HIV positive becoming revealed be handled?
A. If a rumour spreads about a child to an extent where it might seem to have some basis, or where a child's health is deteriorating with an implication of AIDS, there will be obvious concern for the child by play workers who know him/her. But the issue of finding out must be handled with the utmost tact. In the end, it must come down to a voluntary decision by the parents that the project should know. Whilst a play project with good links to the family concerned may find the parents "opening up", the crucial issue is that this should only be to find out for the child's sake, and care should be taken never to suggest that this is a first stage to exclude a child. Indeed, perhaps the only reasons to need to directly enquire might be connected with resisting pressure from e.g. other parents that a child be excluded. No child should be excluded from any play facility because of such pressure or because he has AIDS or ARC or is HIV positive.
Many projects, however, will not need to find out if specific children are infected. The adoption of appropriate first aid and hygiene measures for dealing with all children who use a facility will allow for this approach which may well be the best general one to adopt.
Those authorities dealing with children infected with HIV have all adopted a strict "need to know" criterion about the release of information about the child. This is a sensible criterion for play projects, their managements and play workers to adopt also. Often the point of contact will be a play worker on session and he/she should consider who in the project really needs to know. It may be worthwhile having discussion on a fixed line and defined area of communication. For example, perhaps just the chair of a management committee should know in addition to a play worker and his/her supervisor/ leader. It may be that a project will consider that all play workers should be aware of the situation but this should be counterbalanced against the general principle of who it is essential must know.
If parents of other children do pressure about a child with AIDS or ARC or who is HIV positive using facilities, an important task will be their re-assurance that the child's presence poses no threat to the well-being of other kids, and that general health precautions adopted anyway by projects would be safeguard enough.
This applies to all children not just where AIDS/HIV is known - it is precautionary.
Incontinence - this requires observance of the hygiene measures set out below.
Sucking, chewing and putting things in mouth - putting toys, pencils, felt tips, pens etc in mouth is not considered a risk so far as spread of HIV is concerned. But normal hygiene measures should be carried out of course, e.g. the disinfection of musical instruments with mouth-pieces.
Biting - this habit could cause a problem where skin is broken. It is most likely to be commonest amongst those with severe mental handicap or serious behavioural problems. In such cases, local medical authorities should be consulted about procedures. Where any child bites another child or a play worker etc in the usual 'rough and tumble', apart from the usual strictures appropriate for any child who does this, it would be advisable that the person is referred to their GP - in the case of another child, a note sent home to parents with a recommendation that the child sees a doctor within 24 hours.
Materials soiled with e.g. blood, vomit, faeces etc should be disposed of as set out below.
'Blood brothers/sisters' - games involving children cutting or pricking skin to draw blood and mingle it should be discouraged and not simply overlooked as 'something they get up to'.
Ear-piercing and tattooing - many children nowadays will pursue either of these without parental consent. There is a case for counselling them, should they express intent to a play worker to do so, that even if they are not going to heed their parents, they should at least be aware of the dangers of using facilities where hygiene is poor and thus there is a risk of infected tattooing needles etc, particularly given the added risks of AIDS/HIV. Most establishments giving such services will claim to be hygienic but perhaps the child (or parent if he/she consults the play worker for advice) might be advised to contact the local environmental health inspectors for any advice/information concerning such local establishments before having the work done. There is also the practice by children and young people of carrying out ear-piercing on one another (e.g. with a needle and bottle cork), and of tattooing with a pin/needle and indelible ink. There is a need for counselling and health education to warn them of the risks involved.
Drugs, sexual behaviour - these aspects have been covered above in terms of advice to children and young people.
If during the course of working on a play project a child's information given in confidence is at variance with the requirement of law, or with an equally-demanding moral imperative to pass on the information to e.g. parents or the legal authorities, this will present the play worker and/or management with possible dilemmas as to the right course of action. There can be no hard and fast rule, each situation is individual and unique and the solution of such a conflict of duties will also be unique. But, where there is added to existing problems such as drug use or sexual abuse, the danger of passing of HIV to a child, and perhaps that child's passing the virus him/herself, this will be a factor to be taken into account. In many ways, it might be safer to avoid promising a child confidentiality, though this may be very difficult or even impede the child's candour. Or it may be appropriate and sometimes necessary to inform the child that one is able to accept their terms of confidentiality on the condition that the playworker is allowed to consult one other person whom both the child and the playworker trusts e.g. chairperson or AIDS /general counsellor. It will be a tight-rope for play workers to walk but it is not a new issue. The approach to training adopted by the Samaritans and Marriage Guidance counsellors would be relevant in this regard.
First aid and hygiene precautions should be carried out with all children, play workers and other adults in mind. This should be as a matter of course - observance will be part of the general effort to halt the spread of AIDS.
Razors, toothbrushes and other implements which could be contaminated with blood should not be shared.
Minor cuts, open or weeping skin lesions and abrasions should be covered with waterproof or other suitable dressings.
Sanitary towels should be incinerated or treated as for all waste disposal - see below. Tampons may be flushed down the toilet.
Accidents involving external bleeding, vomit, faeces etc.
Normal first aid procedures should be followed, and should include the use of disposable gloves. Projects are advised to include this equipment as an adjunct to their normal first aid kits.
Wounds should be washed immediately and copiously with soap and water - apply a suitable dressing, and a pressure pad if needed.
Where a child or other person splashes blood, vomit etc onto another person, the secretion should be wiped off immediately with soap and water.
Where blood, vomit etc splashes into another person's eyes or mouth, it should be washed out immediately with a copious supply of water.
All play projects ought to keep some form of accident and incident register where all such events should be recorded, no matter how trivial-seeming.
Medical advice should be sought quickly by the Project Leader where this seems advisable or where there is uncertainty.
All play projects should ensure first aid kits are properly maintained and restocked. They also should ensure that at least one worker is a trained first aider with a current certificate.
Normal cleaning methods and supplies are sufficient. No special disinfectants are necessary for toilet or washing facilities.
Individual paper towels should be treated as waste to be disposed as recommended below.
Clothes and linen stained with blood, vomit, faeces etc should be washed in a washing machine at 95 degrees centrigrade for 10 minutes or boiled for handwashing.
Crockery and cutlery can be cleaned as usual by handwashing with hot, soapy water or in a dish-washer or dish steriliser.
Play workers giving physical care to children AIDS or ARC or who are HIV positive should ensure any cuts etc on the child are covered, and that any cuts play workers or other kids may have also are covered with a suitable dressing.
General hygiene measures, e.g. washing of hands, after use of WC and prior to eating should be followed.
Urine and faeces should be disposed into the toilet as normal, and potties should be washed and dried out with paper towels. Disinfect toilets etc in the usual manner.
Soiled disposable waste should either be burned or, if this is not possible, placed in a suitable disposal sack. The local authority responsible for the disposal of such waste will advise on the supply of suitable sacks and on its collection. Such sacks should be securely sealed.
Other waste can continue to be disposed in the usual manner.
If a play worker develops AIDS or ARC or who becomes HIV positive, this will present specific problems for play projects. The first issue is how will the fact come to light? The next is what are the implications for a project? One is certain - if the general climate on AIDS/ARC/HIV develops along hysterical and prejudiced lines, the incentive to reveal that one has the HI virus will be much reduced. Managements and play workers should encourage an atmosphere in which any one who finds themselves in the position of being HIV-infected can come forward without fear of loss of employment or of isolation and rejection. In our view it is not valid for employers to ask if an employee has AIDS or ARC or is HIV positive
Factors which projects will wish to consider in facing up to a colleague staff member/volunteer having AIDS or ARC or being HIV positive will include:
(a) the rights and well-being of children using the project;
(b) the civil and employment rights of all play workers including the affected person
(c) the views of parents and public.
Because of the special responsibilities of working with children, play projects should consider counselling all of their play workers in the soundness of the advice on AIDS concerning sexual hygiene and safe sexual practices. This will be in the interests of children, themselves and everyone else in general terms, and protective of the reputation of a project.
If a Play worker should contract AIDS or ARC or become HIV+, the first need is for the person to feel confident he/she can reveal it to colleagues. There may be concern as to how he/she contracted it, but any tendency within managements or amongst individual colleagues to take advantage to promote personal religious or moral or political standpoints about AIDS ought to be resisted at the most authoritative level. It might well be a concern that the infection did not arise as a result of some hitherto unknown and unlawful activity, such as sexual behaviour with under-age persons or drugs abuse, which would render him/her ineligible/unsuitable to work on a play project. But the vast majority of situations will arise from behaviour which is both lawful and innocent such as the partner in a relationship who has been infected by their partner but who has thought they were engaging in safe sex.
If the management maintains confidence in the play worker in such terms, it may still have to come terms with a fact about the worker it was not aware of before e.g. being gay. Whilst other people within the project may have personal views about e.g. sexual issues, there is no reason known, regarding the safety and health of children, why an HIV-infected person should not work with children.
However, for the person with AIDS or ARC or who is HIV positive , there is the development of the disease there it takes this course. The play worker with AIDS will need especial support, as would any other seriously/perhaps terminally ill colleague. He/she may reach a stage where he/she can no longer work on every aspect of the project as before. This will require no less adjustment, counselling and support as for any other illness. Eventually, the person will cease working altogether. Colleagues will often also be friends and support will be valuable both at work and at home. Amidst all fears of other people about AIDS, a real worry for the person with AIDS is that he/she may die and that must come first. The person could suffer fear, anguish, isolation, abuse, rejection and despair. Good play practice is about the total opposite of these. And a compassionate management will grant a play worker every help and support as they would a worker with any serious illness.
The fact of person being HIV+ may not come to light at all unless he/she reveals it. But if simple procedures are carried out as above, children and adults will not be at risk.
Despite the "crawling out of the woodwork" evident in too many places, the AIDS issue must not be permitted to foster prejudice and discrimination against play workers who are gay or lesbian. Where projects know of or find out/are told of a play worker's being gay, there is no reason why the presence and contribution of that person should be called into question because of that fact. Sexual orientation is not a matter for prying. There is no evidence that gays are interested in young boys or lesbians in young girls or will breach the laws of consent any more than their heterosexual counterparts. (Home Office evidence (1987) shows that 96% of all sexual offences are committed by 'straight' males.)
As for AIDS/HIV risk, whilst so far many cases of AIDS/ARC have occurred in the gay community, there is evidence that the gay community in Britain is now ahead of its heterosexual counterparts in its understanding of the need for safe sex behaviour to counter-act the spread of HIV. Lesbians are the lowest-risk category of all so far as AIDS is concerned. First aid and hygiene precautions will cope with almost all risk of contracting HIV at the work place from where-ever the potential source, child or adult, or heterosexual or homosexual, so the presence of homosexual adults in play projects need not and should not prompt moves to dismiss them, despite clause 28.
Public concern may be a factor projects will have to confront. It would be one thing for re-assurance, explanation, and education to explain why a person known to have AIDS or ARC or who are HIV positive remains employed, or why a homosexually-orientated person is no risk to children on the project, but the integrity and unity of a project may become undermined, and people's civil liberties infringed, if public pressure and prejudice is allowed to dominate management and prerogatives and basic play work principles because of fears about AIDS.
In recent times, the screening requirements concerning those who are applying to work with children have become much more rigorous and stringent and more tightening of this is in train - all playworkers (paid or unpaid) should have prior screening before they work with children. By this time most play projects will have adopted or revised enquiry procedures and these will relate e.g. to past criminal convictions involving minors, care orders, removal of child-minding registration etc. There may be a tendency to include enquiries of candidates and of referees and medical authorities concerning AIDS etc given the emphasis on the disease in the media etc. But it would be no more reasonable to ask this question about AIDS/ARC/HIV than any other non-infectious and not easily communicated disease. So managements are cautioned to take account of the nature of AIDS and the question must be whether inclusion of AIDS-related questions is justified. We would advise that it is not right that employers ask such questions.
If AIDS/HIV questions are a controversial area, any related to non-criminal but minority sexual behaviour are likely to be oppressive, destructive of a candidate's civil liberties and in any case hardly relevant to either preventing the spread of AIDS or good play practice.
The community play project is an important element in the life of a well-balanced community. Play is important for every child, whether well or ill. The person with AIDS or ARC or who is HIV positive, child or adult, poses no threat or risk to the well-being of other children and adults especially if sensible and general first aid/hygiene precautions are observed. The play worker should expect to consider him/herself under obligation to lead a responsible personal lifestyle, irrespective of his/her sexual orientation. The play world, as part of society at large, can give an example of compassion and fairness. Children will have to cope with the reality of AIDS as they grow up and the play project and worker can give a positive lead to them concerning their attitudes towards the disease, its sufferers and prevention within the context of the play work they carry out.