by Kirsta Grapentine and Beverly Belcher

With recent reports indicating that the HIV infection rate may be on the rise, it makes sense that this disturbing trend will eventually impact the child welfare system. Though this is not intended to be an "everything you wanted to know about AIDS" discussion, it is hoped that this article will provide workers with basic information about HIV and AIDS, and issues related to the adoption system.

AIDS (Acquired Immune Deficiency Syndrome) is a disease caused by a virus known as the Human Immunodeficiency Virus (HIV). HIV works by attacking and killing CD4 (or "T") cells, a key component of the immune system. Once the CD4 count in the blood falls below a certain level, the body's ability to fight off disease is severely impaired. Infections and/or diseases that an otherwise healthy person would be able to fight can be extremely critical, even deadly, for a person infected with HIV. This condition is known as AIDS. Its onset is often marked by fatigue, diarrhea, night sweats, weight loss, skin rashes and swollen glands. Full-blown AIDS may include cancers, infections, and pulmonary difficulties.

HIV can be transmitted through blood, semen, vaginal fluids and breast milk. It is most often passed from one person to another through sexual intercourse (anal, vaginal, and oral), or sharing "dirty" needles with persons infected with the virus. It can also be transmitted from an infected mother to her unborn child during pregnancy, through child birth itself, or during breast feeding.

Outside the body, HIV is a relatively weak virus and dies quickly. It is therefore nearly impossible to pass it on through shaking hands, hugging, kissing, eating utensils, drinking fountains, toilet seats, swimming pools, or mosquito bites. In the United States, blood products are screened for HIV and tainted blood is destroyed, virtually eliminating the risk that HIV will be passed on through transfusions.

Testing for HIV is accurate and inexpensive, and can detect the virus within six months of exposure. The test is designed to detect antibodies to HIV. If antibodies are present, the test is considered "positive," meaning that an individual has been infected. Negative results indicate that no HIV antibodies were detected; however, individuals who test negative and who still may have been exposed to HIV within the past 2-6 months should be re-tested after an additional six months in order to confirm the validity of the initial test. An infant who tests positive at birth may eventually revert to a negative status as its own immune system matures. If this happens, it will normally occur by the time the child is 18 months of age.

A person can be HIV infected and exhibit no symptoms for several years. A healthy lifestyle (proper diet, exercise, plenty of rest, and avoidance of high risk behaviors) can help boost the immune system, thereby delaying the onset of more serious symptoms. Although there is no cure for HIV, there are some drugs which can reduce the amount of virus in an individual's blood stream, keeping a person free of symptoms for a longer period of time. Some common infections and cancers among AIDS patients are treatable; however, the disease is ultimately terminal.

The World Health Organization estimates that 22 million individuals throughout the world are infected with HIV. The United States accounts for 7% of those infected. In Michigan, there were 8,429 reported AIDS cases and an estimated 8,500-11,500 persons infected with HIV as of September 1997. Of the state's 83 counties, only 5 (rural) counties reported no cases of HIV infection. The Detroit area had the highest infection rate, with 3,929 reported cases of HIV infection.

Although AIDS was originally associated primarily with gay men and intravenous drug users, we now know that the disease can infect an individual regardless of race, sex, income, age, or sexual orientation. Currently in the United States, AIDS is increasing more rapidly among females than males. In fact, AIDS is the fourth leading cause of death among women ages 25-44. Not surprisingly, this shift in epidemiology has also impacted children. By the year 2000 it is estimated that there will be over 80,000 AIDS orphans in the U.S. On any given day there are an estimated 7,200 children in the U.S. under the age of 12 with AIDS and 10,000 who test positive for HIV. The number of children infected and affected by this disease continues to grow.

Knowing the facts about HIV and AIDS is important for workers in the child welfare system. Being informed and supportive about the condition is essential when working with families who are either infected or affected by HIV. Direct-service workers should keep in mind that in most cases, infected families have been shunned and avoided by extended family members who may not understand the disease. Children, especially, are looking for hugs and genuine affection, and can sense when a worker is not comfortable with them. Workers need to build trust in order to help fortify these families. Take time to explain terms and concepts, and emphasize the importance of cleanliness, hygiene, and nutrition. Workers should re-schedule visits when sick so that family members with weakened immune systems are not needlessly exposed to germs. Making sure that families are connected with other support services is also essential when trying to keep families together. Children infected with HIV are eligible for SSI.

Planning for the future care of a child is essential in cases where one or both parents are infected with HIV. There are planning guides available for families, as well as various resource programs that can assist with this effort. Whether it be adoption or permanent guardianship, early planning is important since the physical and emotional factors associated with later stages of AIDS may make it more difficult for parents to plan at that time.

When an HIV infected child enters the child welfare system, it is imperative to place the child with a family who is trained to provide care for that child's special needs. In response to the rising HIV infection rate in the Detroit area, the Wayne County Family Independence Agency has developed a special unit specifically for these medically fragile children. The Medically Fragile Unit is designed to respond to the complex needs of children and families who are infected or affected by HIV. It also specifically recruits families who are willing to foster children who are HIV infected/affected, as well as children who require specialized medical attention.

Because a child's HIV status is a highly sensitive issue, workers often struggle with the question of who specifically needs to know the child's HIV status when that child is placed in out-of-home care. One obvious party that must know the status of the child's health is the foster family. As temporary providers for the child, the foster family must be knowledgeable about the child's needs in order to provide proper care. Agency policies regarding confidentiality do permit the foster family to be informed of the child's HIV status. If the child subsequently becomes available for adoption and the foster family wishes to adopt, that family will already be aware of the child's special medical conditions.

But what about when an agency must recruit an adoptive family for a HIV positive adoption-eligible child? MCI Superintendent Bill Johnson emphasized the importance of the adoption evaluation as a useful, even crucial tool that can document what is in the child's best interest, and the specific medical needs of that child. Because the evaluation may be shared with families who may not be directly involved in caring for the child (i.e. a recruited family who may be interested in adopting the child), Johnson stressed that the child's HIV status should be "eluded to, but not specifically stated." Using terms in the evaluation such as "serious communicable disease" or "severe medical needs that will require lifelong support" would be common and appropriate indicators of a positive HIV status, yet still protect the confidentiality of the child. These terms should also be used when exposing children to potential families through recruitment efforts such as the MARE photolisting book or waiting child columns in newspapers.

Johnson acknowledged that the child's HIV status needs to be held in strict confidence and should not be disclosed to individuals other than the family where the child is to be placed for care. He also recognizes that the child's HIV status may be shared between child care agencies in cases where a potential family has been identified from outside of the child's foster care agency. When an agency is recruiting families for an HIV positive child and another agency (or agencies) has a family who is interested in that child, the foster care agency may share the adoption evaluation and disclose the child's condition to the other agency. It is then up to the family's worker to determine if they feel the family can meet the child's medical needs. If the child's worker has more than one approved family to select from, that worker should make an initial assessment as to which family can best meet the needs of the waiting child. Once a family has been selected and the family determines they would like to proceed with adoption, disclosure of the child's HIV status can be shared at that time. If a family who has not yet been studied inquires about the child, no further information should be released until that family has been studied and assessed as to their ability to care for the child's special condition.

Balancing confidentiality and the need to identify an appropriate permanent family for HIV infected children can be challenging. By being knowledgeable about HIV/AIDS, confidentiality issues, and available resources to support families and children affected by the disease, we can do a better job of serving children and families.

Resources for children and families infected/affected by HIV:

• Children's Immune Disorder (CID) (313) 837-7800
• Simon House (313) 863-1400
• Detroit Community AIDS Library (313) 577-8947
• Michigan AIDS Hotline 1-800-872-AIDS
• Wayne County FIA - Medically Fragile Unit (313) 396-0361
• Children's Hospital - Immunology Clinic (313) 745-4450

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Child Protection Bills Signed into Law

reprinted from FIA Icon Newsletter and Michigan Federation of Private Child & Family Agencies Law Changes Seminar handbook

Parental rights will be terminated sooner in extreme abuse and neglect cases, and both courts and the Family Independence Agency will publish annual report cards evaluating their performance in foster care.

These are among the changes necessitated by a series of bills which passed the state Legislature late last year. The new laws provide greater protection for children and implement certain recommendations from the Binsfeld children's commission report of 1996. Governor John Engler signed the bills December 29, 1997 at the St. Vincent Home for Children in Lansing.

"The work we are signing today will save lives," said Engler. "There's more to be done, but this package goes a very long way." Engler praised the work of Lieutenant Governor Connie Binsfeld, who chaired the task force that developed the child protection proposals.

"I applaud Connie Binsfeld's leadership and the legislature's action," said Engler. "Michigan has long been a leader in protecting children, and these changes will help assure we continue to lead."

The package is the first of a series of bills based on the recommendations of Ms. Binsfeld's commission. Other legislation adding to the package is anticipated to be worked on in the next several months. The governor signed these bills:

• Public Act (P.A.) 163: defines permanent foster family agreement, Specifies certain time-lines for court action, authorizes court to order certain persons to leave the home of a child, requires FIA conduct a homestudy of a relative's home, requires release of certain information by a child placing agency to a foster parent upon written request, authorizes foster parents to object to a change in foster placement in certain circumstances, and restricts movement of a child from one foster home to another until review by a foster care review board and court in certain situations.
• Public Act (P.A.) 164: requires substance abuse licensees to give waiting list priority to parent of a child who has been or is at risk of being removed from the home.
• Public Act (P.A.) 165: allows Dept. of Consumer & Industry Services to grant a variance to licensing statute to allow siblings to remain or be placed together in foster home.
• Public Act (P.A.) 166: requires a standard child abuse and neglect investigation and interview protocol in each county.
• Public Act (P.A.) 167: establishes requirements for county child fatality review team and composition and duties of a state advisory committee on child fatalities.
• Public Act (P.A.) 168: mandates maintenance of a statewide, electronic central registry and specifies who has access to the records. Also sets out require ments for reviewing investigations of substantiated cases where harm came to the child, prohibits interviewing a child in the presence of suspected perpetrator, and requires FIA to file an abuse/neglect petition and request for immediate termination of parental rights in certain circumstances.
• Public Act (P.A.) 169: stipulates limitations on court granting continuances or adjournments, discharging of attorney for good cause; requires timely issuance of opinion on petition for termination of parental rights, child's attorney must be present at all court proceedings, CSAO must publish an annual report evaluating the court's duty related to obtaining permanency for children.
• Public Act (P.A.) 170: requires formation of local county foster care review boards, allows for up to 15 boards in one county, permits appointment of alternate members, permits boards to hear appeals of changes in foster care placements, and authorizes boards to recommend a licensing variance to permit siblings being placed together. * This act also authorizes local foster care review boards to review cases of permanent wards who have been registered on "hold" status with MARE for more than 12 months. (Effective July 1, 1998)
• Public Act (P.A.) 171: authorizes the superintendent of the Michigan's Children's Institute and attorneys representing a child to communicate regarding matters pertaining to commitment, placement and permanency planning, and directs the attorney to consult with the superintendent if said attorney has any objections or concerns regarding these issues.
• Public Act (P.A.) 172: defines "supervising agency," requires additional actions of supervising agencies, and requires FIA to publish an annual report cared for each supervising agency. * This act requires a child to be registered with MARE (photolisted) if an adoptive family has not been identified within 90 days of the order terminating the parent's rights.

Most bills become effective in April 1998.