TRAINING ON HIV / AIDS FOR NURSES AT PRIMARY HEALTH CENTERS
Item
- Title
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TRAINING ON HIV / AIDS
FOR
NURSES AT PRIMARY HEALTH
CENTERS
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TRAINING ON HIV / AIDS
FOR
NURSES AT PRIMARY HEALTH
CENTERS
FACILITATORS MODULE
2004
St. John’s College of Nursing,
St. John’s National Academy of Health Sciences
India Canada Collaborative HIV and AIDS project (ICHAP)
4/13-1, Cresent Road, High Grounds
Bangalore -1
Phone - 08002201237 /8/2201436/39
Entail:ksaps@Jbgl. vsnl. net. in
LIST OF CONTENTS
Topic
Page No
Introduction
Chapter I
Chapter II:
_____ Magnitude ofHIV/STI_____
The implications ofRTI/STI/STDs
10
14
20
Chapter III:
HIV and AIDS - the challenge weface
35
Chapter IV:
Prevention ofSTD / HIV/AIDS
52
Chapter V:
Universal precautions - in caringfor a person
with STD/HIV
77
Chapter VI:
Post exposure prophylaxis
90
Chapter VII:
Attitudes about STI/HIV/AIDS
98
Chapter VIII:
Communication and counseling in the context
ofSTI/STD/HIV
108
Chapter IX:
Community based carefor people living with
HIV/AIDS
126
Chapter X:
Role of nurse in caringfor a person with HIV
/AIDS
138
Chapter XI:
Referral, services and networking
156
Chapter XII:
Legal and ethical issues
170
Chapter
178
Appendices
Bibliography
205
List of resource
persons
210
2
DESIGN OF THE MODULE
This module includes 12 chapters:
: Magnitude of HIV / STI
Chapter I
: The implications of RTI / STI / STDs
Chapter II
: HTV and AIDS - the challenge we face
Chapter HI
: Prevention of STD / HIV / AIDS
Chapter IV
: Universal precautions - in caring for a person with STD / HTV
Chapter V
: Post exposure prophylaxis
Chapter VI
Chapter VII : Attitudes about STI / HTV / AIDS
Chapter VIII : Communication and counseling in the context of STI / STD / HTV
: Community based care for people living with HIV / AIDS
Chapter IX
: Role of nurse in caring for a person with HIV /AIDS
Chapter X
: Referral, services and networking
Chapter XI
Chapter XII : Legal and ethical issues
Each chapter contains a number of topics that explore related subject matters.
Purpose of the module
This module is designed to enable nurses working in the Primary Health Center as
facilitators to carry out discussions and provide information on STI, HTV and AIDS. The
training provided to nurses at this level through this module would equip them with
information on the diseases, their prevention, how to be active in the prevention of these
diseases and on available services for persons living with STI/HIV/AIDS. They could
become the information banks/ resources for the community at large.
Scheduling
This module has been designed for a 3-day training workshop and it is preferable that
trainees devote three continuous days to training, as this is a skill-based module.
The sessions are presented in sequential order of the chapters suggesting that session 1
should be covered before session 2. Likewise, the topics within the sessions should
follow the suggested sequential order. However, the facilitator can adapt any of the
training material depending on the level of training and expertise of the trainees and the
availability of time. For example the topic on hand washing would be very familiar and
hence this may be omitted or modified. A sample workshop schedule is included for your
convenience (See Annexure A).
How to facilitate
The workshop trainers / facilitators should be familiar with experiential and participatory
forms of learning. The trainers / facilitators should have the ability to ask exploratory
open-ended questions and should be sensitive towards involving all the trainees. The
3
facilitator should also be technically competent to answer questions related to the training
topics.
Some sessions can be sensitive and exploring the topics can be difficult and
embarrassing, for example, talking about and demonstrating condoms. Hence it is
suggested that this training be facilitated separately for women’s group and men’s group.
That would mean that even facilitators would have to be of the sex as that of the group.
However, for any HIV and AIDS work, becoming comfortable about talking about sex
and sexual activities is essential. Fortunately, these tasks become more comfortable with
practice.
The module also includes some ideas for energizers to provide a break during long
sessions (See Annexure B).
Suggested teaching methods
A variety of teaching methods have been suggested for each topic. These include the
following participatory techniques:
1. Group discussion
Discussion is a technique that is central to participatory education. It allows members
of a group to openly express their opinions on a subject, and listen to the opinions of
others thus learning occurs through interchange among members. Discussion can be
conducted with the whole group (large group), but reducing the number of
participants in a discussion creates a more informal atmosphere and promotes
participation by all. Small groups of 4 to 5 participants are ideal. It is preferable to
give the group a guideline so that discussion is focused.
2. Work pairs
Two participants can explore topics or issues that could be sensitive or of a very
personal nature in a secure setting. Pair work is also appropriate for problem solving
exercises that encourage intensive input, not consensus agreement. Remember to
change pairs often so that the same two people do not always work together.
3. Brainstorming
Brainstorming involves getting people to list all of the related ideas that they can
think while someone records the ideas on paper without editing them. This technique
helps participants to generate ideas quickly and fluidly while allowing them freedom
to express any /all ideas. The advantage of working in groups is that the thoughts of
one person may stimulate new directions of thought in another. When approaching a
difficult topic, such as sex, which usually makes people nervous and shy, you may
find brainstorming invaluable in loosening up a group. It can also be a lot of fun
4. Role play
A role - play is a simulation technique and involves a participant imitating or acting
out a situation with members of the group. These members assume other roles related
to learning objectives. Role-play allows participants to practice situations before they
4
come across them in real life. It helps in sensitizing the participants to what may
happen in a real situation.
5. Mini lecture
This is brief and well-paced lecture where definitions, facts or other information are
presented to participants. The lecture should be presented verbally and should be
visually supplemented by teaching aids such as information on flip charts, handouts,
chalkboards, power point, transparencies etc. It should hot last more than 10 minutes.
6. Demonstration
In a demonstration, facilitators use examples, experiments, models or actual materials
in order to illustrate a principle and show the participants how to carry out a certain
activity. Demonstration provides concrete experiences of life-like situations.
Demonstration improves practical skills and the ability to communicate with others.
For example, using demonstration as a technique can be vital in educating
participants how to use condoms.
7. Case studies
It is a method of simulation, aiming to give experience in the sort of decision-making
that the participants will have to do later. They are written based on real life events
from existing sources of information such as newspapers, journals etc. Hence it is
important to avoid over simplifying the case study since it would dilute the reality of
the case. It would help the participants in self analysis if at the end of a case study the
facilitator ends like this ‘we have considered the case presented to us and come to
certain conclusions; now let us consider the case ourselves. How do we solve the
problem ourselves r
Suggested teaching aids
Try to use many different teaching aids when presenting the topic information. Examples
include:
Brochures
Flip chart
Games
Photographs or pictures
Chalkboard
Films and/or videos
Handouts
Overhead projector/ LCD
Checklists
Graphs/diagrams
Participants module
Models
How to use the guide
The content in this module is comprehensive and it is preferable to have a minimum of
five to six facilitators for each training workshop, so that the facilitators can themselves
interchange content or complement each other.
Organization of the chapters
Each chapter is organized under the following headings
• Introduction
5
•
•
•
•
•
•
•
•
General objectives: What the facilitator hopes to achieve overall at the end of
teaching the session.
Specific objectives: What the facilitator hopes to achieve in behavioral terms at
the end of the session
Key concepts: It highlights what is expected to be achieved at the end of the
session
Suggested teaching methods: What teaching methodology and techniques will be
used for the session
Materials / preparation required: What material are required for the session viz.
handouts, marking pens, black board, OHP, chart paper, flip charts etc.
Topic outline: Lists the individual topics in the session
Total session time: Gives an overview of approximate time to cover the session
Background material: Gives the information to help the facilitator to have a
successful teaching experience in each chapter. Interspersed between the text
content appropriate exercises are placed to facilitate in the achievement of the
objectives
How to preparefor every topic
• Read the entire module thoroughly to see how each topic relates to the next topic
• Prepare the materials and resources identified. For e.g. if the module says to use
pictures, check whether the pictures are available or make them before the
workshop, or if it is recommended to use the black board, see that chalk, duster
etc is available, etc.
How to evaluate
It is important to see that the participants give a feed back of the workshop that is
conducted. This is needed to assess the strengths and weaknesses of the training sessions.
Hence there should be time set aside in the schedule of the workshop. Various aspects of
the workshop and of the module it self have been considered in the evaluation tool given
in Annexure - B.
How to close the workshop
Close the workshop with a wrap up debriefing, songs, tea, distribution of certificates, and
an oral feedback from a representative of the participants.
After the training workshop
Classroom training is the first step. Participants would need to be supported by providing
them information in the form a participant’s module, contact numbers or addresses of
facilitators or of one person who would be responsible for providing follow-up support of
the participants.
6
ACRONYMS
AFB
AIDS
ANM
ART
AZT
BMT
CRC
EC
ELISA
FHAC
HAART
HBV
HCV
HIV
ICHAP
IDV
IEC
IUD
IVDU
KSAPS
LGV
MEC
MTCT
NACO
NGO
NNRTI
NRTI
NVP
OI
OPIM
OT
PEP
PI
PID
PLHA
PPTCT
PMTCT
RTI
STD
STI
USAIDS
VCT
VCTC ,
Acid fast bacilli
Acquired Immuno Deficiency Syndrome
Auxiliary nurse midwife
Antiretroviral therapy
Zidovudine
Breast milk transmission
Convention of Rights of Children
Exposure code
Enzyme linked immunosorbent assay
Family health awareness campaign
Highly active antiretroviral therapy
Hepatitis B virus
Hepatitis C virus
Human Immuno Deficiency Virus
India Canada Collaborative HIV /AIDS Project
Indanivar
(
Education, information and communication
Intrauterine device
Intra venous drug users
Karnataka State AIDS Prevention Society
Lymphoma granuloma venerium
Medical education cell
Mother to child transmission
National AIDS Control Organization
Non government organization
Non Nucleoside Reverse Transcriptase Inhibitors
Nucleoside Reverse Transcriptase Inhibitors
Nevirapine
Opportunistic infections
Other potentially infectious material
Operation theater
Post exposure prophylaxis
Protease Inhibitors
Pelvic inflammatory diseases
People living with HIV /AIDS
Prevention of parent to child transmission
Prevention to mother to child transmission
Reproductive tract infections
Sexually transmitted disease
Sexually transmitted infection
United States Agency for International Development
Voluntary counseling and testing
Voluntary counseling and testing center
7
WHO
ZDV
: World Health Organization
: Zidovudine
This module is not entirely an original development. It has borrowed extensively from
existing documents and training modules / Manuals. A bibliography is provided. Faculty
of St. John’s College of Nursing, St. John’s National Academy of Health Sciences, has
compiled this module. We would like to thank
• Mrs. Vandana Gumani (IAS) KSAPS and all the KSAPS members who supported
us in this endeavor
• Dr. Reynold Washington (Project coordinator, ICHAP) for giving us the
opportunity to develop this module
• Management of St. John’s National Academy of Health Sciences (SJNAHS)
• Mrs. Madonna Britto (Principal, St. John’s College of Nursing, SJNAHS) for the
support and encouragement
• INSA (International Services Association, Benson Town) for resource materials
made available to us
• All the experts / external evaluators for their help in contributing towards this
module
• Dr. Sanjiv Lewin (Coordinator MEC, St. John’s Medical College and Hospital)
for the support and confidence he had in our abilities
• Mrs Naiseel D’Souza, Ms. Mary Rani, Mrs. Wilma D’Souza, Mrs. Pandichelvi
and Ms. Angel Mary for assisting the facilitators for Kannada translation during
the four training programs at Bagalkot and Hubli to test the module
• All the participants of all the training programs we conducted at Bagalkot and
Hubli to test the module for their interest in learning
For details contact, maryannvc @hotmail.com.
Views expressed in the module are those of the authors. Comments from readers or users
are encouraged and should be sent to ICHAP.
8
Authors: Faculty of St John’s College of Nursing, SJNAHS
• Mrs. Glory Lagali (M.Sc. Community Health Nursing) Lecturer
• Mrs. Dorothy Deena Theodore (M.Sc. Mental Health Nursing) Assistant
Professor
• Mrs. Vijayalakshmi (M.Sc. Community Health Nursing) Associate Professor
• Mrs. Preethy D’Souza (M.Sc. Child Health Nursing; M.Phil. Nursing) Associate
Professor
• Mrs. Jasmine Benny (M.Sc. Medical Surgical Nursing; M.Phil. Hospital and
Health Systems Management) Associate Professor
• Mrs. Maryann Washington (M. Sc. Child Health Nursing; M.Phil. Hospital and
Health Systems Management) Professor and Coordinator
Edited by Mrs. Maryann Washington, MSc, MPhil
Experts
• Mr. Albert Selvanagayam (Rtd. Professor, St. Joseph’s College of Arts &
Science, Dept, of Zoology, Bangalore)
• Mrs. Rosalin Selvanagayam (Counselor- individual and family; Resource person
for marriage preparation course- Family Welfare Center, Bangalore)
• Rev. Fr. Mathew Perambil (Director, Snehadan, Carmalaram, Bangalore)
• Dr. Ms. K. Lalitha (M.Sc. Mental Health Nursing; PhD. Nursing) Associate
Professor, NIMHANS, Bangalore
• Mrs. H. Lalitha (M.Sc. Community Health Nursing) Rtd. Principal, Govt.
College of Nursing, Bangalore; Part-time Professor, St. John’s College of
Nursing SJNAHS, Bangalore
• Mrs. Edwina Pereira (M.Sc. Community Health nursing) Program Director
training, INSA, Bangalore
• Dr. Sanjiv Lewin (MD Pediatrics) Associate Professor and Unit head. Dept, of
Pediatrics, St. John’s Medical College and Hospital, SJNAHS, Bangalore
• Dr. Reynold Washington (MD Community Health; DNB) Associate Professor,
Dept of Community Health, St. John’s Medical College (SJMC); and of
Mannitoba University, Canada; Project Coordinator, ICHAP
• Mrs. Madonna Britto (M.Sc. Medical Surgical Nursing) Principal, St. John’s
College of Nursing, SJNAHS, Bangalore
Artist
• Dr. Silvia Selvaraj (MD Community Health)
Translation
• Mr. Abdul Rehman Pasha (Dip in translation. Film director)
• Mrs. Naiseel D?Souza (B.Sc. Nursing)
I |fcrnaj evaluators
• dr. S-uresh Shastri (KSAPS)
• Dr. Srinath (ICHAP)
9
INTRODLfCTlON
An overview of the whole workshop is given to the participants. After this, to help the
participants get familiarized with each other, they can be introduced with the help of an
icebreaker (an enjoyable activity that will help persons to feel at ease with each other).
General ohjectivcs
At the end of the introductory session the participants will be able to get to know each
other, the objectives of the workshop, their commitments for the workshop and the
schedule and other details concerning the workshop.
Specific ohjectives
• To welcome the participants to the workshop
• To get to know each other so that they could feel comfortable with each other
• To clarify the objectives of the workshop so that the participants are aware of the
scope and purpose of the workshop
• To be aware of the norms to be followed during the three day workshop
Teacitnt^ methods,
• Ice breakers
• Group activity
• Brain storming
Material//preparaihm required
• Chits of paper with names of animals / birds
• Black board, chalk, duster
• Chart paper, colour pens
• Transparencies of objectives, OHP and pens
Topic mtifnte
• Welcome of the participants
• Introduction of facilitators and participants
• Clarifying the objectives
• Formulating norms to be observed
• Introducing the MET concept
Total session time
30 minutes
10
BACKGROUND MATERIAL
Welcome of the participants
• Begin the workshop with a welcome to all the participants
• Welcome any guest or important person who may be available
Introduction of facilitators and participants
Exercise 1,
The purpose of this exercise is to divide the participants into smaller groups so that
they can get to know each other
1. The facilitator distributes small chits of paper that have the name of an animal
or bird written in it (e.g. dog, cat, donkey, crow, hen, goat).
2. The participants are instructed not to reveal to the neighbor what is written in
the chit of paper they have received.
3. Once all the participants have received the chits, the facilitator instructs them
to find the group members by making the sound of the animal / bird
4. Once they have identified their group members, the participants are instructed
to find out the name of the person on their right and to also describe the
person with an adjective preferably starting with the first alphabet of the
person’s name (e.g. Bharathy - beautiful / beaming). This activity should not
take more than 3 minutes
5. Once the above activity is completed each group is called to come forward
and each participant is asked to introduce the person whose details they had
collected to the rest of the participants. This activity should not take more
than 20 minutes
Clarifying the objectives
• Deliver a short speech about the overall objectives of the workshop and the
relevance of the workshop to them
• Encourage participants to voice out tlieir expectations of the workshop and to
clarify any aspects about the objectives
Formulating norms to be observed
The facilitator needs totell the participants that in order to make the best of the workshop
everyone must agree on some groundnorm& or way&.of preventing any gioup tensions or
conflicts during the three days. Encourage the participants to brainstorm and finally agree
upon the norms they would like to observe as a group during the three-day workshop
11
Exercise 2.
1. The facilitator encourages the participants to remain in the same groups as
in Exercise 1
2. Place a chart in the middle of the floor / table of each group
3. Each group is asked to discuss within their groups about ideas that can be
formulated into a rule provided all the members in the group agree upon it
(e.g. punctuality, being nonjudgmental, making everybody to talk etc.).
This should be completed in 5 minutes. This rule is then written on the
chart paper, large enough for all the participants to see
4. Then the leader of each group is asked to present the norms that were
identified in the group and to fix the chart in the front of the class for all
the participants to see.
5. Any clarifications are encouraged by the facilitator, and if needed the rule
is reviewed again for clarity
6. One volunteer of the participants is asked to finalize the list of norms on a
chart. This is placed on the wall or at the entrance of the class where all the
participants can see it clearly. All other chart papers can be removed
7. The participants are then encouraged to follow these rules and are asked to
remind each other about the same if someone forgets
Note: This is an optional exercise if time permits. But if done it could help in
developing good team effort
Introducing the MET concept
Introduce the concept of MET (Monitoring Evaluation Team) by saying, this training
program is a participatory one and we want you to participate in coordinating it. So we
are entrusting the responsibility of the training to you. A team of three participants would
need to volunteer to be the Monitor, the Reporter and the Evaluator. This team will take
care of the training program and coordinate it.
The responsibilities
The monitor
Is the team leader and the overall coordinator of the program
• Fixes the starting time, tea break, lunch time and the ending time
• Discusses with the participants and facilitators on any extension or change in
timings during the training and informs the concerned people
• Ensures that the arrangement are done properly for food, stay, trips, training hall
arrangements and so on
• Ensures that the reporter and the evaluator are doing their works properly
This person has an over all control over the program and its proceedings, even the
facilitators function only based1 on his recommendations with regard to these areas.
12
The reporter
The reporter records the day’s proceedings and he/she prepares a summary of it and
presents it on the following day morning for the benefit of the participants and the
facilitators.
The evaluator
The evaluator gets the feedback from all the participants as to how the day went on.
He/she prepares a few heads or questions and discusses with 75% of the participants and
gets their feedback on how effective and useful the training was and ask them the positive
and negative aspects of the training. The Evaluator presents the report on the following
day morning.
Functions
Assembling all the participants and facilitators starts the day. The monitor starts the day
with a thought for the day or a song or a prayer, followed by a short presentation of the
previous day’s proceedings by asking the reporter and the evaluator to present their
reports. Then after a concluding note the monitor invites three new participants to take up
their positions and all the three previous participants handover their responsibilities to the
next team. The duration of the MET is a day.
The MET that takes responsibility on the last day will have to conduct a valedictory
function. If the participants feel that the MET has to continue for one more day then the
team’s duration can be extended for half day or a day with their consent.
13
Chapter-I
MAGNITUDE OF STI AND HIV/AIDS
Introduction
The greatest challenge today before us is the prevention of HIV / AIDS epidemic in the
world. AIDS is a real challenge for the health professionals as there is no effective cure
or vaccine against it. But however STI / HTV/AIDS is preventable and the epidemic
could be controlled. Consequently the prevalence figures during the last few years have
been increasing all over the world without any manifest sign of remission.
General objective
At the end of the session, the participants would be able to understand the significance of
STI / HIV / AIDS epidemic, appreciate its importance and apply this information in her /
his approach to individuals.
Specific Objectives
At the end of the chapter the participants would be able to:
• Recognize the gravity of HIV/AIDS situation
• Recognize the gravity of STI
Key concepts
• The prevalence of HIV in the country is growing at an alarming rate
• Karnataka state has a rate of around 1 % prevalence rate of HIV in the general
population
• Burden of STI / STD is higher than HIV
Teaching methods
• Lecture
• Group discussion
• Reflective exercise
Materials /preparation required
• Transparencies of maps of India, Karnataka, world indicating scenario of HIV
• Transparencies of relevant tables
• Black board, chalk, duster; overhead projector
Topic outline
• History and origin of HIV / AIDS
• Magnitude of HIV/AIDS
• Magnitude of STI
Total session time: 30 minutes
14
BACKGROUND MATERIAL
1. The facilitator starts the session with the statement which is projected
‘HIV/AIDS the biggest challenge ofthe 21st century?9
2. The facilitator asks the participants whether they could agree with the
statement and if so why. The activity should not take more than 3 minutes.
History and origin of HIV / AIDS
Scientists have different theories about the origin of HIV, but none have been proven.
The earliest known case of HIV was from a man’s blood sample collected in 1959
although it is not known how he became infected. He was from Kinshasha, Democratic
Republic of Congo. Genetic analysis of this blood sample suggests that HTV-1 may have
stemmed from a single virus in the late 1940s or early 1950s.
The virus has been said to exist in the United States since at least the mid-to late 1970s.
Between 1979-1981 rare types of pneumonia, cancer, and other illnesses were being
reported by doctors in Los Angeles and New York among a number of gay male patients.
These were conditions not usually found in people with healthy immune systems. In 1982
public health officials began to use the term ’’acquired immunodeficiency syndrome," or
AIDS, to describe the occurrences of opportunistic infections, Kaposi's sarcoma, and
Pneumocystis carinii pneumonia in previously healthy men. Formal tracking
(surveillance) of AIDS cases began that year in the United States.
The virus causing AIDS was identified by a team of French scientists lead by Dr. Luc
Montanier of Pasteur Institute and American Scientists lead by Dr. Robert C. Gallo of
National Cancer Institute in 1983-1984. The virus was at first called by an International
Scientific Committee as HTLV-III/LAV (human T-cell lymphotropic virus-type
III/lymphadenopathy- associated virus) and only later was named HIV (human
immunodeficiency virus) by the same committee. To date two types HIV-1 and HIV-2
are identified.
Historical perspectives
• The HIV may be a mutant or more virulent form of the already existing
organism
• Organism was circulating in an isolated group of population which developed
resistance
• Organism has been introduced to human from another source like
chimpanzees.
The first case of HIV infection in India was diagnosed in commercial sex workers in
Chennai, Tamilnadu in 1986. The first patient of full-blown AIDS was reported from
feombay in 1987 that had received blood transfusion in USA for coronary artery bypass
graft. The first case that was detected in Karnataka was in Belgaum in 1987.
15
Magnitude of HIV /AIDS
Global scenario
• World Health report (2004) estimated 34-46 million people living with HIV AIDS
• 3 million people died with HIV /AIDS in 2003 alone (WHO Report 2004)
• About l/3rd of people currently living with HIV / AIDS are aged 15-24. Over 50%
of new infections are occurring in age group 10-24 years.
• Ratio of male: female affected is 1:1 globally
• Of the 31-43 million adults with HIV infection - the global estimate in end-2003 25-28.2 million were in Sub-Saharan Africa and more than 9.5 million in Asia.
The South-East Asia region is said to be most likely to suffer the greatest from
this pandemic - it being the home of over half the world's population
• According to UNAIDS estimates, by December-2003, nearly 34-46 million
people including over 2.5 million children - had been infected with HIV since the
start of the epidemic.
• More than 95% of people infected during 2002 occurred in developing countries.
Among these about 12,000 are in persons aged between 15-49 years of whom
almost 50% are women and 50% are aged between 15-24 years
Table LI. Total summary of the HFV/AIDS epidemic - Dec. 2003
Particulars
Total___________
Adult__________
Women_________
Children < 15 yrs.
No. of Person
living
With HIV/AIDS
42.0 million_____
37.0 million_____
19.2 million_____
2.5 million
Persons newly
AIDS death during
2003
infected with HIV
during 2003
5.0million________
3.1 million
2.5
million
4.2 million_______
2.0 million_______
1.2 million
0.7 million
0.5million
Source: UNAIDS, 2003
Scenario of HIV/AIDS in India
Exercise 1.1
The purpose of this exercise is to help the participants become aware of the
scenario of HIV/ AIDS in India
1. The facilitator divides the participants into 5 small groups of 5-8 members
each
2. Each group is given the map of India
3. The participants have to discuss in the group and indicate (using asterix
signs as given below) in the map the risk status according to the
categorization given below of the States in 5 minutes
• Generalized high risk epidemic***
• Concentrated moderate epidemic risk * *
• Low risk epidemic*
4. After the exercise the facilitator presents the following information
16
HIV AIDS in India 2002
'■
■
■ - r a.’ tenatai -cfiers
i
1
Ri$». '.r.-ucs
<5% >n High nsk gtCwps
Group I
Generalized high
risk
epidemic:
HTV>=1% among
ANC____________
Group II
Concentrated
moderate epidemic
risk: HTV> 5%
among high risk
group < 1 % among
ANC____
Group HI
Low risk epidemic:
HIV<5%
among
high risk groups < 1
% among ANC
Maharashtra, Tamil
Nadu, Karnataka, Andhra
Pradesh, Manipur and
Nagaland.
Gujarat, Goa,
Pondicherry
All remaining states
Figurel-lScenario of HIV in India
The other information to be highlighted is
• There were 51. million Indians reported to be living with HIV / AIDS during
2003, of them 38.5 % were women
• The total AIDS cases in India during 2003 were 55,764, of whom 14,486 were
women
• 54% reported AIDS cases were between the age 30-44 years
• The UN population Division projects that India’s adult HIV prevalence will be
1.9% in 2019
• UN projects 12.3 million deaths due to AIDS during 2000-2015 and 49.5 million
deaths due to AIDS during 2015-2050
• Globally India is second to South Africa in terms of overall number of people
living with the disease
During the last 13 years, the HIV epidemic has spread rapidly in the country. It is also no
longer a problem restricted to the high-risk behavior groups such as sex workers and
intravenous drug users. In five states namely Tamilnadu, Maharastra, Andra Pradesh,
Karnataka and Manipur, the HIV prevalence is 1% of the general population and
threatens to further increase in women and children.
Some other important aspects of HIV / AIDS in India are:
• The heterosexual contact is still by far the most prevalent modes of transmission
• IV drug users in North Eastern states are having increasing sero - positivity rate
• Most of the AIDS cases are males (79%)
• Antenatal mothers are also found to be HIV positive (1%)
17
•
HIV is rapidly spreading to rural areas through migrant workers and truck drivers.
The scenario of HIV/AIDS in Karnataka
Prevalence of HIV at District ANC clinic
sentinel sites, Karnataka, 2003
.
I-
..
;
..
.■
a
■’
Figure 1
•
•
•
•
1
■
I—I <1% in both sites: Bidar, Gulbarga,
Uttara Karnataka, Haveri, Chikmangalur,
Chitradurga, Tumkur, Dakshina Kannada,
Hassan,
Kolar,
Bangalore,
Mysore,
Chamarajanagar.
>1 in one site: Dharwad, Gadag,
Shimoga, Udupi, Kodagu and Mandya.
1.0%: Bijapur,
HMN Both sites or mean
Bagalkot, Belgaum, Raichur, Koppal,
Bellary & Davangere.
Prevalence of HIV at district ANC clinical sentinel sites in Karnataka
(2003)
Although there is not enough data for accurate estimation, the HIV disease burden
in Karnataka is already high. Mean prevalence is 1.5%. Median prevalence is
1.25%
Based on the HIV sentinel surveillance data, the prevalence of HIV among those
attending STD clinics is approximately 14 % meaning that at least one in six
persons with an STD is perhaps already infected with HIV.
Assuming an adult prevalence of 1.7% and an adult population age 15-49 years of
over 30 million, there are more than 5,00,000 persons now living with HIV in
Karnataka. However, most of these persons have not yet been diagnosed
15,321 persons have tested positive for HIV since 1987. Officially 1.648 AIDS
cases and 183 deaths due to AIDS have been reported (Dec. 2002)
Magnitude of STI / STD
Global scenario
• fhe population at risk of acquiring STI / STD / HIV has increased as a result of
demographic sociologic and behavioral changes that have occurred over the past
20 years.
• Women and newborn children have the most significant complication of these
diseases. WHO estimates that 340 million new cases of Syphilis, Gonorrhea.
Clamydia and Trichomoniasis have occurred through out the world in men and
women aged between 15 to 49 years.
• Two thirds of infertility is due to STI / STDs.
18
Indian scenario
• STDs have been found to occur both in villages and in the cities. They affect both
males and females. Every year nearly 40 million new STI / STD cases are
reported through out India.
• At any given time, STDS affect 9.7% of people
• 1-5 % maternal deaths are due to ectopic pregnancies due to STI / STDs.
• 35% of postpartum morbidity is due to STI / STDs.
• 50-60% of women in India are known to have RTIs.
• During pregnancy 8 - 23 % of the women screened for VDRL are positive.
Summary
•
The prevalence of HIV in the country is growing at an alarming rate
•
Our State Karnataka has a rate of around 1% prevalence rate of HIV in
the general population
•
The prevalence rate in some districts in Karnataka is alarming
•
Prevalence of STI / STD is also increasing
•
There are no boundaries for STI / STD / HIV in terms of age, religion,
caste, sex, or geography
19
Chapter -II
THE IMPLICATIONS OF RTI /STI /STD
Introduction
A person already having STI / STD has the greater risk of acquiring HIV. The growing
evidence available from all over the world undoubtedly indicates that the incidence of
HIV infection is higher in conditions of presence of sexually transmitted diseases (STDs).
This calls for a discussion on RTI / STI / STD.
General objectives
On completion of this session the participants will understand the reasons why RTI, STI
and STD are gaining more importance today, appreciate the focus given to this topic and
apply knowledge gained in the daily work activities.
Specific objectives
On completion of this session the participants will:
• Be aware of common symptoms of RTI / STI / STD
• Demonstrate skill in history taking process in symptomatic individual
• Recognize the components of care of STI / STDs
• Participate in syndromic case management of STI / STDs
Key concepts
• All STI / STDs are preventable
• Persons with STI / STDs need to take complete treatment
• STI / STDs can be recognized by careful observation of changes in urethral or
vaginal discharge and presence or ulcers in the genitalia
Teaching methods
• Lecture
• Small group discussion
• Reflective exercises
Materials /preparation required
• Black board, chalk, duster
• Transparencies, pictures, flowcharts of syndromic management
• Handouts
Topic outline
• Rationale for knowing about RTI / STI / STD
• Basics of RTI/STI/STD
• Assessment for a person suspected to have RTI / STI / STD
• Components of care for STI / STDs
Total session time: 1 hour
20
BACKGROUND MATERIAL
Rationale for knowing about RTI / STI / STD
Link between STI/STD and HIV
• HIV infection leading to AIDS is also sexually transmitted in most instances
• It is estimated that a person with STI / STDs is 5-9 times more likely to acquire
HIV infection since ulcers and sores and genital discharges caused by STI / STDs
in men and women will make it easier for the HTV to enter into the persons body
• Many persons with the HIV infection say that they had episodes of STI / STD in
the past
• STI / STD may also be present in some of the HTV infected persons
• Effective treatment of STI / STDs will reduce the risk of HTV transmission
• Measures to reduce HIV transmission will include control of STI / STDs
• Most of the STI / STDs are curable and early detection and treatment of STI /
STDs will greatly reduce the sexual transmission of HIV
Hence knowledge of these diseases wouldfacilitate in recognizing them and thus help
you to
L Stress on the need for early treatment ofSTI/STDs since
• Its magnitude is high and it has a strong association with HIV transmission.
• If STI / STDs are left untreated they can be transmitted from one person to
another during sexual intercourse.
• If untreated, STI / STD can cause infertility in both men and women
• Some STI / STDs can be passed from a woman to her baby while it is still in the
womb or during birth.
• If untreated STI / STDs can spread into women’s reproductive organs and cause
pelvic inflammatory diseases (PID) or pain in the abdomen or ectopic
pregnancies.
• Some STI / STDs can cause miscarriage, abortion or stillbirths.
ii. Concentrate on the prevention and treatment ofSTIs / STDs
• People are more likely to change their behavior to prevent a problem, which
affects them now, than to prevent an illness, which they have never, seen and
which may not appear for another ten years.
• The actions, which prevent STD, will prevent HIV, so people at low risk of STI /
STDs are also at low risk of HIV.
• The reduction of STI / STDs will also reduce HIV transmission. This is because
HIV is more easily transmitted when a person has sores or discharges.
• The reduction of STI / STDs will prevent a lot of infertility.
21
Exercise 2.1
The purpose of this exercise is to make the participants aware of the present
situation faced by those infected with STI /STD especially women.
1. Ask the groups to listen to the stoiy of ‘Mayadevi’
Story of Mayadevi
UI am a village health worker and one day a friend, Mayadevi came to visit me
to my house. She looked worried. We had some tea and talked a while and
then she told me that she was having a lot of pain when she had sexual
intercourse. She also said she had a thick and bad smelling discharge from
the vagina. She felt shy and embarrassed to go to the health center regarding
this and it was difficult for her to even tell me. Mayadevi got this infection
from her husband Raman, who works as a driver and travels out of the district
almost every month. She loves her husband and they have one daughter also.
She & her husband are hoping to have another child after a year also".
Divide the participants into 2-4 groups depending on the number of
participants so that the total number of members in each group does not
exceed 8 members
3. Ask the groups to discuss the following questions. Take 5 minutes for
this
• What do you think is the problem? What are the possible factors
predisposing to high-risk behavior?
• What are the reasons for Mayadevi or any other person with a
similar problem not wanting to seek treatment?
2.
4. At the end one representative from each group can present the summary
of their discussions
5. The facilitator will then discuss points given in the Handout 2.1. Any
clarifications could be made in this period
22
Handout 2.1 (Optional could make out copies and give to the participants if needed)
Possiblefactors predisposing to high-risk behavior
• Travel to far off places where identity of the person may not be known.
• Girls and boys attain maturity and become sexually active at young age
• The trend of both parents being employed and thus away from home may
predispose to lack of time for them to counsel their children about sex.
• Lack of knowledge, the desire to experiment, peer pressure may compel
youth to experience sexual encounters before marriage
• The easy availability of money to the young
• The easy availability of pornographic films, books and Internet to the young
• Inadequate and improper medicines to treat STI / STDs by untrained
personnel
Reasons for persons with STI / STDs failing to seek treatment
• Stigma attached to the disease
• Preference for self medication, to go to unqualified medical practitioners
• Fear that they will be treated with discrimination
Possible factors predisposing to high risk behavior among youth
I /z
d
Watching phonographic pictures...
Peer pressure...
Both parents being busy / Easy money...
23
Basics of RTI/STI/STD
Just like STI / STDs, RTIs could also predispose a person to developing STI /STDs and
thus HIV /AIDS. Hence a brief review of RTI will be covered, before STI / STDs are
discussed.
1. Reproductive Tract Infections
Reproductive Tract Infections (RTI) is an infection of the genital tract. The infection can
affect vulva, vagina, cervix, uterus, tubes and ovaries in the women. Infection of the
uterus, and the tubes is known as pelvic inflammatory Disease (PID). This infection is
usually acquired due to poor personal hygiene; is usually not transmitted from one person
to another person unlike that of STI / STD, but could be due to STI, poor sterile
techniques during procedures on the reproductive tract by the health personnel.
2. Sexually Transmitted Infections (STI) /Sexually Transmitted Diseases (STD)
These are infections that are commonly acquired by sexual contact but this may not be
the only route of transmission in all cases (For example Scabies, and Herpes simplex
could be acquired through contact). They are also sometimes called venereal diseases
(VD).
RTI/STI is suspected in women whose husband / sexual partner has problem of urethral
discharge with burning or ulcers in genitals or with scrotal swelling.
Symptoms ofRTI/STI/STD
Exercise 2.2
1. Ask the participants to name any sign and symptom of RTI / STI / STDs for
men and for women that they know about (3 minutes)
2. Write these on a large paper for all to see with the heading women and men.
3. One participant could then be asked to read out Handout 2.1 from their module
(Facilitators module Handout 2.2).
Handout 2.2 Common symptoms of RTI / STI / STD in men and women are:_______
_____________ Men________________
___________ Women______________
• Ulcers, sores, warts near the penis
• Ulcers, sores, warts near the vagina
• Ulcers around the mouth or anus for
• Ulcers around the mouth or anus for
those who practice oral or anal sex
those who practice oral or anal sex
• Discharge from the urethra
• Discharge from the vagina or
• Burning sensation while passing
specifically cervical discharge in
urine
women
• Swellings in the groin
• May complain burning sensation
while passing urine
• Swelling of scrotum in males
• Swelling in the vagina or a feeling
• Tenderness in inguinal region
of fullness
• Chronic lower abdominal pain
• Back ache
24
List ofSTDs
Exercise 23
1. Ask the participants to name any list of STDs they have heard of before or know
2. Write these on a large paper or the black board for all to see
3. Then the facilitator can ask the participants to read the Handout 2.2 from their
module (see Handout 23 in Facilitators module)
Handout 23 List of common STDs
_________ Major STDs_______
• Chancroid
• Donovanosis (Granuloma
inguinale)
• Gonorrhea
• Lymphogranuloma Venereum
• Syphilis
_________ Other STDS___________
• Candidiasis
• Condyloma acciminate (warts)
• Hepatitis B
• Hepatitis C
• Herpes Simplex (Herpes Genitalia)
• HIV infection
• Pubic Louse
• Molluscum Contagiosum
• Mycoplasma infection
• Scabies
• Trichomoniasis
• Vaginitis
Who can ^et STI/STD?
The persons who are more predisposed to STD include those who indulge in unsafe
sexual behavior.
Sexual contact may include:
• Vaginal sex (contact between penis and vagina)
• Anal sex (contact between the penis and anus)
• Oral sex (contact between penis/vagina and the mouth or tongue)
Unsafe/ hi^h risk sexual behavior means having
• Sexual intercourse with multiple partners, without using condoms
• Sexual contact with single known infected partner without using condoms (the
spouse remains infected as long as he/she is not fully treated)
25
P J
Anyone and everyone can get STD
STI /STDs are not restricted only to those with so-called high-risk behavior. A person
with high-risk behavior may pick up the infection and he/she will spread the STDs to
his/her partner, who may not have the same behavior.
Remember that women are more prone to STDS than men. The important reasons
being...
• Due to the hidden nature of the reproductive organ of women, the symptoms
are revealed much later or not at all and consequently if at all they seek
treatment, have they done so at a late stage.
• STD lesions in women are asymptomatic in 50% of the cases
• White discharge is considered natural and women are ignorant that some of the
white discharges could be STDs
• Many women may not have the facility to use separate toilets or bathrooms to
examine themselves.
26
Assessment for a person suspected to have RTI / STI / STD/
L History taking
History taking is important for a number of reasons such as it:
• Helps to establish a rapport between the health care personnel and the concerned
person
• Gives early clues to the possible presence of an STD, traumatic lesions, previous
treatment and allergies
• Helps to assess the person’s risk factors for infection, and duration of infection if
present
• Helps to identify sexual partners who may have been exposed to the infection so
that measures can be taken to ensure that the partners are also treated
Exercise2.4
The purpose of this exercise is to make the participants aware of how to question a
woman presenting with the problem of foul smelling from the vagina
1. Give the following case to the participants
Ms X comes to you with a problem offoul smelling per vaginal discharge associated
with lower abdominal pain and back pain for the past 2 weeks.
2. Ask the participants ‘what questions will you ask her? Write the responses on
the black board
3. Facilitator supplements information and tells the participants to read the
Handout 2.3 from their module (Handout 2.4 of the Facilitators module)
Handout 2.4 Questions to be asked in the event of vaginal discharge
If a woman complains of vaginal discharge^ ask her the following question
• When did the discharge start?
• Whether the sexual partner has any sore on the genital organ or urethral
discharge?
• What is the nature of the discharge, is it
Watery /Sticky and clear / Purulent / Curd - like / Yellow / Greenish
and frothy / Blood stained or foul smelling / Whether it is scanty or
profuse
• Whether the woman is pregnant or has recently delivered?
• Whether the woman is using loop/IUD?
• Whether she has burning while passing urine or itching in the vulva?
• Does she have any pain in the lower abdomen?
• Does she have any ulcer in the genital region?
27
Vaginal discharge in women may be
• Physiological
• Due to infections that occur due to
- Unsafe sexual practices
- Invasive procedures in the reproductive tract
- Unsterile procedures during labor
- Unsafe methods followed for termination of pregnancy
Vaginal discharge is a common complaint in women:
• Physiological during ovulation or during pregnancy. The discharge is
o Mucoid
o Not blood strained or foul smelling
o Not associated with itching of the vulva
• Candidial infection (Thrush) Occurs commonly during pregnancy. A woman
would present with the following:
o Curd like white patches on the vaginal mucosa
o Thick, curd white discharge
o Itching at the vulva
• Trichomonal vaginitis (parasitic infestation) Is transmitted during sexual
intercourse or by contact with contaminated articles. It is characterized by
o Greenish yellow, frothy, foul smelling discharge
o Itching and redness of the genital area
• Gonorrhea: In women it is characterized
o By purulent discharge from the cervix
o Or may pass unnoticed
o If untreated, it may result in infertility in women.
• Puerperal sepsis: Is an infection of the genital tract, occurring after delivery or
after an abortion. It presents as
o High fever
o Headache
o Low abdominal pain
o Foul smelling, purulent vaginal discharge
• Following IUD insertion: This discharge
o Is profuse
o Is watery
o Usually subsides after the first menstrual period following insertion
• Cancer cervix: Occurs more commonly in older women.
o In the early stage it is characterized by watery discharge
o Later it becomes blood stained and fouls smelling
o They could present with irregular vaginal bleeding
28
Components of care for STI / STDs
L Early treatment through syndromic case management
Rationale for syndromic case management
• Facilitates early diagnosis and treatment of STI / STD
• Prevents complications
• Renders a person with STI / STD non-infective to his/her partner quickly
• Provides simple and easy flow charts (see at the end of the chapter)
• Enhances cost effectiveness
iL Treatment compliance
Non-compliance with treatment of STI / STD not only prevents cure but also leads to a
lot of complications like drug resistance. It may be more difficult to treat such drug
resistant cases. If there is no compliance to treatment incomplete treatment will only lead
to disappearance of symptoms but not ‘cure’, thus leading to severe complications.
HL Follow -up
• Follow-up of patients being treated for STI / STDs is essential to assess the extent
of cure, and to be on the look out for any possible treatment failure, or
complication of STI / STDs.
• Referral to centers with STI / STD specialists (see Annexure C for details of
centers) will be needed for treatment failure, suspected drug resistance and
complications of STI / STD.
iv. Partner treatment
Treating the partner is important because:
• The treated person may again get the disease from the partner not yet detected,
who may sometimes be symptomless.
• A person who takes treatment for STI / STD may not abstain from sex
Advice partners to get treated...
29
v. Condom promotion
• Persons suffering from STI / STDs should be educated about the usefulness of
condom in preventing further spread of these infections/diseases (See Chapter IV
for details).
FLOW CHARTS OF SYNDROMIC CASE MANAGEMENT
VAGINAL DISCHARGE
History vaginal discharge
(Vaginal itching)
,y,
Lower abdominal
tenderness or
f
•
,
“
j *«...«
________________
Partner symptomatic
r
?
i
»J
Yes
life . •
Treat for vaginal
infection
¥ Tr 1 No
2- - Educate
*,'4f
No
- Educate on safe sex
- Counsel if needed
—► - Promote/provide
condoms
- Refer to VCTC
J
r—
Specific risk factors
positive?
ir
Treat for cervical and vaginal
infections
Educate
Counsel if needed
Promote/provide condoms
Partner management
Ask for follow-up
■■■
?
‘
•’'4
5,
c
1
.
"K •
t
30
Treatment for Gonorrhoea and Chlamydia (Mucopus
from cervix- cervicitis)
- Azithromycin 2 G single dose OR
- Azithromycin 1 G + Cefixime 400 mg single dose. OR
- Azithromycin 1 G + Inj. Ceftriaxone 250 mg IM
single dose
. 5Mt-;' v
'K-
-;
:
Treatment for Trichomoniasis ( Profuse dischargeVaginitis)
- Tinidazole or Metronidazole 2G stat + Fluconazole
150 mg stat
Discharge from the vagina
Sterility, tubal pregnancy, pelvic
Complications:
inflammatory disease (PID) may result if prompt
treatment is not given.
GENITAL ULCERS I SORES
No ulcers or vesicles
History of / and examine for
genital ulcer / sore
Vesicles — intact /
broken
History of vesicles
I
Genital ulcer / sore
present
Swollen groin
(may)
Yes
Management of Herpes
- Educate
- Counsel if needed
- Promote/provide
condoms
- Treatment protocol
____
<\
Reevaluate
-________ - -
-J
■'js,
- Educate on safe sex
- Counsel if needed
- Promote/ provide condom
- Advise return after 7 days
- Refer to VCTC
- Partner treatment
Treat
for
and
Syphilis
Chancroid
Educate
Counsel if needed
Promote/provide condoms
Partner management
Advice to return in 7 days
31
Treatment for Herpes Genitalis
- Genital hygiene
- Acyclovir 400 mg orally 3 times daily for 5-10 days.
1
....
Treatment for Syphilis and Chancroid
- Inj. Benzathine Penicillin G 24 Lakhs IM in 2
equally divided doses + Inj. Ceftrioxone250 mg
single dose IM OR
Azitromycin 1 G single dose orally under
supervision OR
Ciprofloxacin 500 mg 2 times a day
For persons sensitive to penicillin Doxycyclin 100
mg orally 2 times daily for 15 days
During pregnancy: Erythromycin stearate 500 mg
orally 4 times daily 15 days.
Ulcer in the penis
Complications: Cardiovascular and nervous symptoms
may result if prompt treatment is not given.
Ulcer in the female genitalia
URETHRAL DISCHARGE
--
--
v’**'
1
History of urethral discharge
-yr:
-.
Examine: milk urethra if necessary
No
Discharge confirmed?
z...
J Yes
"1 -
-
■-va' >•<*,1jcSfiXiL--'
4
Ip
Educate
Counsel if
needed
Ulcer/s
<1
{ Follow chart of ulcers
*
Treat for gonorrhea’s
Educate
Counsel if needed
Promote/provide condoms
Partner management
Return if necessary
32
Treatment for Gonorrhoea and Chlamydial
Infections:
• Azithromicin 2 G single dose OR
- Azithromicin 1 G single dose + Cefaxime
400 mg single dose OR
- Azithromicin 1 G single dose + Inj
Ceftriaxone 250 mg IM single dose
Complication: Stricture of urethra may result
if prompt and complete treatment is not
given
Urethral discharge
LOWER ABDOMINAL PAIN
Take history and examine the abdomen
Abdominal rebound tenderness
and /or guarding
z* Yes
Refer to a surgeon
No
■’ t *.•.“■4'37;; ■
i.
• Last menstrual period
overdue?
• Recent abortion or delivery?
• Menorrhagia /metrorrashia?
Refer to a
gynecologist
Yes
<
■
No
Mucopus coming from cervix
Tenderness on cervical
movements
High temperature > 1010 F
?
■
IgpgJ* Yes
....
• Treat PFD
• Examine and treat
partners
• Educate
• Counsel
1 Review for improvement after 3 days
or earlier if pain persists
Refer to higher level
Yes
-------------rA’-
4.v.
!r
’
No
i 3-------
'
<fea Continue
&
33
-
NgSr ■>
-F . - .
- -
Treat Gonorrhoea and Chlamydia infection
(PID) as given for vaginal discharge
Treat anaerobic infection with metronidazole
400 mg. Twice daily for two weeks
Treatment for gonorrhoea: Cefixime 400 mg
orally single dose OR Ceftriaxone 250 mg IM
single dose
Treament for Chlamydia: Doxycycline 100 mg 2
times daily for 14 days
Woman must be well enough to take food and
lots of liquids
Refer if needed to VCTC
Remove IUD, if present
INGUINAL BUBO (SWELLING)
Take relevant history and examine
Genital ulcer -present?
Yes
» Use genital
ulcer - flow
chart
No
Treatment for Lymphogranuloma Venereum (LGV)
• Doxycyline 100 mg orally twice daily for 14 days
• Alternative regimen: Eiythromycin stearate 500mg orally
for 14 days
• Refer to the doctor for aspiration every 2nd or 3rd day if
fluctuant
•
•
•
•
•
Educate on safe sex
Counsel
Advise to complete treatment
Advise to return and refer to higher
facility if does not respond to
treatment
Provide condoms and promote
usage
•
•
Refer to VCTC
Treat partner
34
Chapter-III
fflV/ATOS-THE CHALLENGE WE FACE
Introduction
Persons infected with HTV may not show any signs of the disease immediately but could
present with features any time later, perhaps as late as when they reach the stage of AIDS
defining illness (or major opportunistic infection). A nurse thus would need to have a
thorough knowledge about the virus causing HTV, modes of transmission, clinical
manifestations and progression of the disease.
General objectives
At the end of this chapter, the participants will be able to understand the various aspects
of HTV / AIDS, appreciate this knowledge and apply the information in their daily
nursing practice
Specific objectives
At the end of this chapter the participants will
• Describe the meaning of HTV / AIDS
• List the modes of transmission of STI / STD / HIV
• Discuss the clinical spectrum of HTV/AIDS
• Be able to recognize the progression of HIV to AIDS in persons
• Describe the management of persons with HTV infection
Key concepts
• HIV is transmitted through the specific routes
• A person with HIV infection has a decreased capacity to fight organisms which
normally reside in the human body
• The rate at which HTV infection progresses to AIDS could be increased with anti retro
viral therapy and practice of safe behaviors
Teaching methods
• Lecture
• Group discussion
• Role play
• Reflective exercise
Materials/preparation required
• Chart paper and colour pens
• Black board, chalk, duster
• Transparencies of figures, tables, important content, OHP
• Plain A-4 size paper for group discussions
• Handouts copies
• Case study handouts for all participants
35
Topic outline
• Basics of HIV and AIDS
• Modes of transmission of STI / STD / HIV
• Clinical spectrum of HIV/AIDS
• Opportunistic infections
• Progression from HIV to AIDS
• Management of HIV
Total session time
1 hour
BACKGROUND MATERIAL
Basics of HIV and AIDS
Exercise 3.1
1. Ask the group to sit back and close their eyes, and then ask them to remember
all what they heard about AIDS.
2. Ask them what is their understanding about the HIV / AIDS. Record responses
on a larger paper/ black board for all to see (take only 2-3 minutes )
3. After which the facilitator explains the following content
Meaning ofHIV and AIDS
HIV stands for Human Immunodeficiency Virus. It is called so because
Human. Because HIV is found only in humans and can live only in human beings or
on human cells.
Immunodeficiency Means that the capacity of the immune systems to respond and
fight against infections is lost (see Figure I). The immune system is the system in our
body that helps us fight against common infections. The HIV slowly destroys the
body’s defense system. It kills an important kind of blood cell, the CD4 T
lymphocytes (T cells). Without these important defenses, person with AIDS cannot
fight off germs and cancers. The HIV infected person therefore gets a number of
common infections and disease.
Virus. Because it is a virus. HIV is a retrovirus. A retrovirus is a type of virus that is
able to convert RNA into DNA (see Figure II for the structure of HIV).
• Single stranded RNA Virus
• Envelope protein has affinity for CD4 molecule on host cell membrane
• Mutates rapidly
• Killed by heat
• Two types of virus: Type I and II
• Both types are prevalent in India. Type I is more frequently reported
• HIV Type I is more virulent than Type II
HIV Type II is generally milder, slower to progress and poorly transmitted vertically
(mother to child)
37
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38
HIV STRUCTURE
Envelope
___
[Matrix ProteinJ
p17
Core Proteins
p24
RNA
B
RT
A
Integrase
O Protease
Figure 3-lStructure of the human immunodeficiency virus*
HIV replication in the cell (see Figure 3-z)
■ HIV infects predominantly t helper (CD4) Lymphocytes
" Virus gets attached to the CD4 receptor of CD4 T lymphocyte
■ The reverse transcriptase uses viral RNA and synthesizes DNA (Double stranded
proviral DNA)
- Viral DNA gets attached to the cell DNA (viral DNA takes control and hijacks the
lymphocytes)
’ ProRNA (New virus) is formed with the help of protease enzyme
is the short form for Acquired Immune Deficiency Syndrome. It is called so
because
Acquired: This means that the disease is 'got' and not 'caughf. HIV cannot be
caught from the air like common old or cough. It spreads only by few specific routes.
Syndrome, means a collection of signs and symptoms. AIDS is a disease that
presents with different kinds of signs and symptoms. The diseases that arc caused
because of the immunodeficiency are referred to as opportunistic infections (01).
When people with HIV get these infections or when their CD4 T cell levels become
very low they have AIDS.
Incubation period
Following are some of the significant features regarding incubation period of HIV
infection:
• It ranges from few months to many years
• HIV positive person can develop AIDS within IO years usually. Median
incubation period 5-8 years in adults while in infants and children 2-5 years
39
INFECTING
VIRUS
HIV
RNA
[xtegrase]
REVERSE
TRANSCRIPTASE
y-
I
HIV*
h
k Immrtian
linHcnt? .
, Genome '
D.S. \
DIM
REVERSE
TRANSCRritON
• NW h
mRf* S
X
NEW
VIRUS
A
/ prearsor
/
< pratdns qoO i J .
I INTEGRATION
RJBOSONES
HIV
LIFE j
•?; * t
HIVLG. PROTEMS
Figure 3*2. Illustration depicting HIV life cycle
Modes of transmission of STI / STD / HIV
Exercise 3.2
The purpose of this exercise is to make the participants not only aware of modes of
transmission but to become comfortable to talk about the modes of transmission
1. Distribute one flash card to each participant. Ask them to look at the card and make
sure that they have understood the meaning of the picture. If in doubt tell them to look
behind the picture for the meaning of the picture
Flash card illustrations include
Anal sex/
Blood transfusion / Bathing in the same pond/lake / Breast-feeding /
Coughing / Giving birth / Drinking from the same cup or glass / Holding hands /
Hugging / Kissing / Mosquito biting a person / Oral Sex / Per vaginal examination /
Playing with others / Sharing clothes, combs etc. / Sharing needles or syringes
Swimming in the same pool / Using same toilets / Using condoms /
Vaginal
intercourse
2. Then ask them to decide whether or not STI /STD / HIV could be transmitted or not
transmitted through the route depicted in the picture.
3. Divide the black board equally and have the words written as: u STI/STD/HLVcould
spread through this" / “STI/STD / HIV could not spread". Place two chairs under
each heading
4. Call out for each participant with the card one by one and ask each of them to place
the given card in the chair under the proper heading after showing the card to all
participants and telling them aloud what she / he thinks the picture depicts. Ask them
to confirm with the rest of the participants whether or not their answer is right.
5. If there is a controversy among the participants about the answer ask the said
participant to place the card on the floor in between both chairs.
6. Then have the participants read the Handout 3.1 as well as see the pictures given in
the book and to correct mistakes that are written in the board
7. Clarify any picture that participants have doubts about (those pictures which are
placed on the floor)
STI / STD / HIV DO NOT SPREAD BY...
Playing together
Passing urine beside another
Sharing the same toilet
Holding hands
Coughing
Mosquito bite
Sharing the same glass
Using a condom
Traveling in the same vehicle
Hugging and kissing.
Bathing in the same pond
Talking to each other
41
STI / STD / HIV SPREAD BY.
Unprotected sex...
Infected blood
Multiple sex partners...
From an infected mother ...
Sharing shaving blades Sharing needles
Occupational exposure
Handout 3.1. Modes of transmission of STI / STD / HIV infection
1. Sexual route:
From infected person to his or her sexual partner (anal, oral or vaginal sex)
• man to woman
• woman to man
• man to man
• rarely woman to woman
2. Intravenous route:
• By sharing needles and syringes when injecting drugs
• By blood transfusion which may be from an infected donor
3. Occupational exposure
4. Traditional customs and practices
• Through scarification with unsterilised needles or blades as part of
traditional customs or circumcision
• Sharing blades for shaving
5. From parent to child transmission
• From infected mother to child during pregnancy, delivery or breast feeding
42
Exercise33
The purpose of this exercise is to help participants recall from experience what the signs
and symptoms of a person with HTV could be.
1. Divide the participants into smaller groups of 4-6members each.
2. The participants in each group would have to discuss about the clinical picture of
people infected with HTV either from the experience of taking care of the patient
or from prior knowledge for 5 minutes
3. They must be instructed to compile the information and present to the whole
group
4. The facilitator could then present the following information on how an adult and
a child present with HIV and then could ask the participants to read Handout 3.2
in their module.
Clinical spectrum of HIV/AIDS
An adult person infected with HIV could present with
• Positive test for HIV infection
• Any one of the following five criteria
Weight loss >10 per cent of body weight or cachexia (not known to be due to
a condition other than HIV infection) and/or chronic diarrheas for more than
one month (intermittent or constant) and/or prolonged fever for more than one
month (intermittent or constant)
Tuberculosis: disseminated, miliary or extra-pulmonary
Kaposi’s sarcomas
- Neurologic impairment preventing independent daily activities, not known to
be due to a condition unrelated to HIV infection (e.g. trauma).
Candidiasis of the esophagus (diagnosable with dysphagia and oral
candidiasis)
Clinical presentation of children with HIV
Pediatric AIDS is suspected in an infant or child presenting with at least two major signs
and two minor signs in the absence of known causes of immunosupression.
Major signs
Weight loss abnormally slow growth (failure to thrive)
Chronic diarrhea for more than one month
Prolonged fever for more than one month
Minor signs
Generalized lymphadenopathy
Orpharyngeal candidiasis
Repeated common infections (Otitis, pharyngitis, ARI and so on)
Persistent cough for more than one month
Generalized dermatitis
Confirmed maternal HIV infection
43
Handout 3.2 Systemic manifestations when a person has HIV infection
__________SYSTEMS
MANIFESTATIONS
Diarrhea
• GASTROINTESTINAL
Dysphagia
Perianal discomfort
Cough
• RESPIRATORY
Cyanosis
Dyspnoea
Pleural effusion
Tachypnea_______
Head ache
• NEUROLOGICAL
Personality changes
Lethargy
Dementia
Ataxia
Convulsions
Meningitis
Neuropathy
Visual impairment
Opportunistic infections
There are many microorganisms that commonly inhabit the body without causing any
illness, but when the immune system is depressed, they can cause serious problems like
oral candidiasis. These are called opportunistic infection. Pneumocystis Carinii found in
lungs can cause pneumonia in immunodeficiency. The tubercle bacilli are reactivated
when the immune system is depressed causing pulmonary tuberculosis in AIDS.
Exercise 3.4
The purpose of this exercise is to help participants gain confidence about their ability to
identify the problems a person with HIV could present with and their ability to do a
thorough assessment through histoiy collection
1. Make one copy of the case study to distribute to each group. Divide the
participants into 4 smaller groups. And give them some blank paper to write their
responses
2. Each group is given one case study and they are instructed to discuss in 5 minutes
the possible causes for the persons described in the case study to be presenting
with the specified features
The group must also present to the rest of the participants what additional histoiy
they would collect from the person in the concerned case study
4. After the groups present the facilitator could supplement any information that was
missed out. Following this the facilitator could present the symptoms of
opportunistic infections in persons with AIDS and the list of opportunistic
, infections
44
Case Studies for Exercise 3.4
Case study I
• A woman has had progressive weight loss for six months. She is weak and needs
rest when she walks to the PHC. She has a poor appetite and had diarrhea for the
past four months. She comes from a village where there is a history of frequent
episodes of gastroenteritis. She has had no fever, no enlargement of lymph
nodes, nor any history of cough but is seen to have white patches in her tongue.
Case study II
• A woman comes to the PHC with a history of cough for the past two months,
shortness of breath on walking, fever in the evenings for the last two months.
She has a good appetite but is always tired. She has a history of several sexual
partners for the past four years.
Case study III
• A man has a dry cough, is breathless on walking and feels tired by the afternoon.
He presents to the PHC with a history of weight loss of 4 kilograms in the last
month and notices that his memory has reduced considerably. You also notice
that his speech is also slow and when you ask him he tells you that he has
noticed a change in the way he speaks as well. He gave a history of having sex
with both men and women.
Case study IV
• A woman brings her two-year-old child to the PHC because he is lethargic and
weak. She also gives a history of poor appetite in the child, diarrhea and fever
for the past one month. She says that he has been treated several times for
hemophilia in a near by hospital and is worried that something else is wrong
with the child.
45
Possible answers to case studies in Exercise 3.4
Case study I
• The woman may be having a intestinal parasites
• Do a thorough physical examination to rule out other possible causes
• Collect relevant history including spouse / partners history in the light of
association of the symptoms to a HTV infection
• Treat for intestinal parasites and if her condition remains the same or worsens
suspicion of HIV infection becomes stronger
• Refer for counseling and blood test to a VCTC
Case study II
• The woman could have tuberculosis
• Ask for a chest X-ray and sputum for AFB to be done
• History is suggestive of her likelihood for HIV infection
• Refer for further investigations
Case study III
• All signs and symptoms of the man are more or less suggestive of HTV infection
• He may also have a tuberculosis, hence rule this out as well
• Refer for further investigations to confirm the diagnosis
Case study IV
• Get a detailed history from the mother to rule out the possibility of recurrent
enteritis
• Get a detailed history of possible risk factors in the child as well in the mother
which could point to the possibility of HIV infection
• Refer the child for further investigations if the history collected is suggestive of
a possible HIV infection
Symptoms of opportunistic infections common in persons with AIDS
■ Coughing and shortness of breath
■ Seizures and lack of coordination
■ Difficult or painful swallowing
■ Mental symptoms such as confusion and forgetfulness
■ Severe and persistent diarrhea
■ Fever
■ Vision loss
■ Nausea, abdominal cramps and vomiting
■ ' Weight loss and extreme fatigue
■ Coma
46
•
•
•
•
•
•
•
•
•
•
•
•
•
Opportunistic Infections related to HIV Infections
Pneumonia caused by
- Mycobacterium tuberculosis
- Pneumocystis carinii
Cytomegalovirus
- Atypical Mycobacterium
- Lymphoid interstitial pneumonitis
Oral and /or esophageal candidiasis
Kaposis sarcoma
Recurrent bacterial and viral infections
Herpes zoster infections
Generalized lymphadenopathy
Herpes simplex infections
Neurological impairment
Wasting disease
Gastro intestinal infections
Neurological infections
Lymphoma
Cytomegalo virus infection
NB: The above is only a selected list of opportunistic conditions
Progression of HIV to AIDS
Factors influencing progression ofAIDS include
■ Type and subtype of HIV
■ General health
■ Access to good nutrition
■ Access to medicines to treat opportunistic infections
■ Access to medicines which help to control the spread of HIV in the body
Frequently asked question by people affected with HIV.......
Does this mean that I have AIDS even though I feel quite healthy?
The most appropriate response would be
No, it does not mean that you have AIDS right now. The Human Immuno
Deficiency Virus (HIV) kills cell that defend our body against diseases. Gradually
the body finds it difficult to fight germs, which do not normally affect people with
good immune systems. Only then a person develops AIDS.
Then ask the participants a question to determine if they know the difference between
HIV and AIDS
'What is the difference between HIV and AIDS?
47
Stage I: Acute primary infection (seroconversion)
• Usually asymptomatic
• Incubation period (2-6 weeks up to 36 weeks)
• Acute viral syndrome experienced by 50 % of persons
• Symptoms may be mild and disappear. This self limiting condition is called
seroconversion illness
• Within 6-12 weeks after infection it is possible to detect HIV antibodies I the blood
• Common signs and symptoms include
- Fever / rash / joint pain / swollen lymph node enlargement / diarrhea / sore
throat
• Few may develop (10-20%)
- Headache / Meningo-encephalitis / Peripheral neuropathies / Myelopathy /
Bells palsy / Guillain Barre syndrome / Oropharyngeal candidiasis
Stage II: Early asymptomatic disease (CD4 count > 500/mm3)
• Longest period (5-7 years) when the person is asymptomatic
• Virus continues to replicate leading to progressive damage to the immune and
nervous system
• Common signs and symptoms
- seborrhoeic dermatitis / pruritis / cellulites / Herpes zoster infection /
Persistent generalized lymphadenopathy (PGL) / Lab reports show
leucopoenia and thrombocytopenia
Stage HI: Intermediate HIV infection (CD4 count 200- 500/mm3)
• Early symptoms of the illness
• Signs and symptoms (called AIDS related complex -ARC)
- Oral thrush / diarrhea / weight loss / low grade intermittent fever, night sweats
/ skin rashes / loss of energy / fungal infection (Tinea infection) / herpes zoster
infection / orophaiyngeal or vaginal candidiasis / mycobacterium tuberculosis
Stage IV: Late stage HIV disease (CD4 count 50- 200/mm3)
• Signs and symptoms are related to aids defining opportunistic infection or
malignancy
• Common opportunistic infections include
- Pneumocystis Carinii pnuemonia / cerebral toxoplasmosis / diarrheal disorders
/ pulmonary or disseminated tuberculosis / severe oropharyngeal candidiasis /
cryptococcal meningitis
• Opportunistic cancers include
- Kaposis sarcoma / undifferentiated B-cell lymphomas
Stage V: Advanced HIV disease (CD4 count < 50/mm3)
• Even with therapy the persons in this stage have a likelihood of dying in 2 years
• Other manifestations in this period include
48
Neurological effects that present as motor abnormalities, cognitive
impairment, and behavior changes / significant weight loss / wasting of
muscles / various types of malabsorption / HIV wasting syndrome
Management of HIV infection
L History
it Physical assessment
HL Laboratory investigations
• HIV test (See chapter IX)
• Immune functions: CD4, CD8 cell counts, CD4/CD8 ratio
• Plasma viral loads (where-ever possible)
• Full blood counts, liver and renal functions tests
• Mantoux test
• X-ray chest
• Co-infections: Tests for Syphilis, Gonorrhea, Hepatitis A, B & C, Toxoplasma, E-B
virus. Pap smear for women
Various hematological, renal, cardiac, endocrinal, reproductive and other manifestations
have also been reported and must be kept in mind.
iv. Medical management
The nurse dealing with HIV/AIDS affected individuals need to be aware of the medical
management of HIV/AIDS. Antiretroviral drugs suppress the viral replication by
inhibiting either reverse transcriptase or protease. The other aspect of therapy includes
prompt treatment of opportunistic infections.
Aims oftherapy
• Prolonging life and improved quality of life.
• Reduction of viral replication as much as possible for as long as possible to halt
disease progression and to prevent and reduce resistant variants
• To achieve immune reconstitution and thus to prevent opportunistic infections and
malignancies
• To achieve reduction in HIV transmission
^4/y/z retro viral drugs All the currently licensed anti-retroviral drugs, namely AZT, ZDV,
Stavudine, etc.
• Have effects that last only for a limited duration
• Are very expensive
• Have severe adverse reactions
In addition the virus tends to develop resistance rather quickly if the person is not
compliant with medication or takes single-drug therapy. The emphasis is now on giving a
combination of drugs including newer drugs called protease inhibitors; but this makes
treatment even more expensive. These drugs if however are taken optimally could result
49
in undetectable viral loads, increase in CD4 counts, clinical improvement and decrease in
mortality. No one regimen has shown superiority over others. Therefore the choice of the
initial regimen is based on tolerability, potential for adverse drug reactions, drug
interactions and cost.
WHO's present policy does not recommend antiviral drugs but instead advocates
strengthening of clinical management for HIV- associated opportunistic infections such
as tuberculosis and diarrhea. Better care programs have been shown to prolong survival
and improve the quality of life of people living with HIV/AIDS.
When to start?
Guidelines for when to start anti-retroviral treatment may vary with country to country
and depend on a lot of factors. In India presently according to NACO the guidelines that
are followed are as shown below:
• Positive HIV test
• CD 4 count < 200
• Total lymphocyte cell count < 1200
• History of chronic diarrhea > 1 month
• Any other major sign
Regimens
The most commonly recommended treatment regimen in India as per NACO includes:
• Start Nevirapine 200 mg. twice a day for 14 days. It is important that the person is
hospitalized during this period in order to monitor and manage effectively any side
effects of the drug. The person must have been counseled adequately on the need for
adherence to the regimen for life since this could reduce resistance
• Then if the person tolerates the medication on the 15th day onwards this regimen is
followed (2 NRTI + 1 NNRTI):
Combination drug
(Trade name- Virolans)
Single drug given twice in a
__________ day__________
• Nevirapine (NNRTI)
• Lamivudine (NRTI)
• Stavudine (NRTI)
Dosage according to body weight
< 60 Kilograms
> 60 Kilograms
200 mg.
150 mg.
30 mg.
200 mg.
150 mg.
40 mg.
Other important points if this regimen is followed includes
- Counseling the person on the need for adherence to the drug
- On the 15l day PLHA will be given tablets for 30 days, but will be asked to
return on the 28th day. He / She should show the drug strip indicating the
number of tablets taken plus additional two drugs remaining for the next two
days.
- Following which the person is again given drugs for the next 30 days.
50
CD-4 count should be checked after 3 months of starting therapy. Good
response is indicated by an increase in CD-4 count.
All PLHAs must be necessarily treated with Tab. Albendazole
•
Zidovudine is also available as a combination drug (see below) twice a day after
administration of nevirapine alone for 14 days. But it is not given to persons with a
hemoglobin level of less than 6 Gms, since it causes severe anemia. Hence if the
PLHA has anemia this is usually contraindicated
- Nevirapine 200 mg.
Lamivudine 150 mg.
- Zidovudine 300 mg.
Caution
• Avoid mono therapy or dual therapy (EXCEPT for PMTCT AND PEP)
• Adherence to therapy for life is important and needs to be emphasized to the PLHA
• Watch for resistance for drugs
• Treat side effects of the drugs promptly. Common side effects include: nausea,
vomiting, skin rashes, myalgia, diarrhea and headache. Persons may normally
succumb to the side effects
• Keep in mind ART is expensive and needs to be given life long. It is not the cure but
only prolongs life
• Hence sometimes better to treat OIs than to recommend ARTs since this is a good
means to prolong the life of the person
51
Chapter -IV
PREVENTION OF STD / MV / AIDS
Introduction
Emphasis is placed on the ABC approach to AIDS prevention. A -Abstinence translates
to efforts to delay sexual initiation among young people; B - Be faithful focuses on
remaining faithful after marriage; and C - Condom use promotes safer sex practices and
condom use among people who are sexually active. The ABC approach is widely
accepted as a model to approach adolescents and young adults where HIV infection has
been spreading most rapidly, as the approach is not only flexible but also comprehensive.
In this module the approach used is referred to as the SCAAB-P way to mean
• Safe sex
• Condom promotion
• Avoid substance abuse
• Adapt traditional customs safely
• Blood management and handling of body fluids done safely
• Prevention of mother to child transmission
Brief descriptions of these methods are given in this chapter to help the nurse become
more competent in educating the public on these issues.
General objective
At the end of this session the participants will be able to understand the prevention of
HIV transmission and will use this knowledge in educating persons and the community
on preventive aspects.
Specific objectives
• Be sensitized to the methods of preventing of HIV transmission
• Identify areas of health education for the public on prevention of HIV transmission
• Participate in awareness programs on safe sex, substance use, blood transfusion and
traditional customs to sensitize the public on prevention of HIV transmission
Key concepts
• HFV could be prevented by adopting safe sex
• There is a link between substance use and HIV transmission
• Safe blood transfusion is needed
• I raditional practices could be made more safer
•fi
Teaching methods
• Lecture
• Small and large group discussion
• Reflective exercises
• Role play
• Case study
52
Material/preparation required
• Black board, chalk, duster
• Chart paper, colour pens
• Transparencies of figures or pictures and OHP
• Handout copies
Topic outline
• Safe sex
• Condom promotion
• Avoid substance abuse
• Adapt traditional customs safely
• Blood management and handling of body fluids done safely
• Prevent transmission of infection from parent to child
Total session time: 3 hours
r
53
BACKGROUND INFORMATION
Prevention of STI / STD/ HIV - SCAAB-P
Exercise 4J
The purpose of this exercise is to help the facilitator gain an insight as to what the
participants already know about prevention of HIV. The facilitator, when covering the
contents of this chapter could also use it subsequently.
1. The facilitator divides the participants into two groups
2. Asks the participants of group I and group II to enact the respective situations
Group I
• The nurse visiting the communityfoundpeople are afraid of drinking waterfrom a
well situated near the house of a person who died ofAIDS. She plansfor a health
education to the people in that locality regarding the ways of transmission and
prevention ofAIDS.
Group II
• As a nurse you have to talk to a group of college going youths regarding how to
prevent HIV infection
3. One of the participants from the first group could enact the role of a nurse and 4
other participants would enact as the local people in the first situation while for
the second situation one of the participants from the second group could enact the
role of a nurse and 4 other participants would enact as youths
4. Each group is given 5 minutes to prepare themselves and 5 minutes to perform.
Any five participants could volunteer from each of the group to enact the two
situations
5. The rest of participants are instructed to observe carefully the interaction between
the nurse and the local people or the nurse and the youth and also to make note of
the points they learnt from the exercise.
6. Following the role play the facilitator discusses on prevention of HIV infection
under these headings:
• Safe sex
• Condom promotion
• Avoiding substance abuse
• Adapting traditional customs Safely
• Blood management and handling of body fluids done safely
• Prevention of mother to child transmission
54
1. Safe sex
• Avoid premarital sex
• Practice monogamy (having only one partner or being faithful to your partner)
• Practice abstinence if possible
• Use condoms during sex with partners
• If you know that you are uninfected and are already sexually active, have sex only
with a mutually faithful partner who is also known to be uninfected
• Engage in non - penetrating sex if infected (such as hugging, kissing, petting etc.
In simple terms not having sexual intercourse)
• Avoid sex when intoxicated or under the influence of drugs
Figure 4.1. Practicing safe sex.... monogamy
Remember that...
• The most common way people get HTV is by having sex with an infected
person. In India, more than 85% of reported HTV cases have got the infection
through the sexual route
• Safe sex means that no vaginal fluid, semen, or blood enters the partner’s
body
2. Condom promotion
Condom promotion is perhaps the most significant preventive measure for STI / STD /
HIV/AIDS. Behavioral change in a person who is at a high risk of acquiring
STI/H1V/AIDS towards practice of safer sex is the basic prevention strategy, the other
strategies being abstaining from sex and sex between mutually faithful partners.
Role ofnurse in condom promotion
• To motivate persons to accept and adopt preventive behavior
• To promote the use of condoms as a part of treatment
• Demonstrating condom use to the patient
r
55
What is a condom?
Condom is a rubber sheath (latex) and is used on an erect penis. The semen after
ejaculation is collected at the tip of the condom and prevents the exchange of semen and
vaginal fluids during a vaginal/oral/anal intercourse.
Use ofcondoms
• Prevent unwanted pregnancies and
• Protect from diseases such as STI /STD and thus HIV infection
Remember.^
• Condoms must be used consistently and correctly to provide maximum protection
• Condom users have product options (can choose from a variety of condoms)
• Education about condom efficacy does not promote sexual activity
• Prevention is cost-effective
Efficiency ofcondoms
Numerous studies among sexually active people have demonstrated that a properly used
latex condom provides a high degree of protection against a variety of STI /STD,
including HIV infection. The degree of protection that proper use of latex condoms
provides against HIV transmission is most evident from studies of couples in which one
member is infected with HIV and the other is not.
Nirodh is of good quality even though the packet does not look attractive
When should one use condoms?
• When spouse is pregnant
• When partners feel that one of them would have an RTI / STI / STD infection
• When one partner has other sexual partners
• When having casual sexual intercourse
• When partner is hired
Exercise 4.2
1. The facilitator calls for one or two volunteers to demonstrate correct condom usage
on the model of the penis
2. After that the facilitator will demonstrate the steps of correct condom usage as given
below
Following this the participants can be divided into small groups of 5-6 members
and each member is asked to demonstrate the correct usage of condom or if there are
sufficient models available the participants could be divided into pairs and then
asked to demonstrate the same. They must be supervised by facilitators
4. The activity must not take more than 20 minutes.
5. Highlight to participants about how could one ascertain the expiry date if the person
' is illiterate or when in the dark. Participants could be asked to practice the same
when they are free during the training program
56
Correct condom usage (see Figure II)
• Check the expiry date for condoms
- Emphasize that if sex is taking place in the dark or if the person is illiterate
then it is important to check for the movement of the condom within the
packet. If it moves freely it indicates that it is within the expiry date and safe
to use. Condoms that appear to be stiff within the pack or not moving
freely may be beyond the expiry date.
• Open the pack carefully without damaging the condom
- Emphasize that if sex is taking place in the dark or if the person is illiterate
then it is important to push the condom to one side and tear the packet from
the side that is empty to avoid damage of the condom
• Wear the condom only after penis becomes fully erect
• Press the tip of the condom (to expel any air, since if air is trapped at the tip it
would be most likely that the condom could tear during ejaculation) and fix it on
the erect penis
• Hold the tip of the condom and slowly unroll it to full length so that the penis is
completely covered
• Ensure that the condom is in position before commencement of sexual intercourse
• After ejaculation hold the bottom of the condom while withdrawing the penis
after the act.
• Slip out the condom carefully without spilling the semen and tie a knot at the
open end to avoid spilling of the semen
• Dispose the condom into a garbage bin.
Figure 4.2: Proper usage of the condom (diagram)
57
Female condoms
The Department of Family Welfare had launched the country’s first women controlled
contraceptive that also offers protection against sexually transmitted infections and HIV /
AIDS. Presently the cost of the condom is Rs. 45/- but it is likely to come down with
subsequent increase in use. Hindusthan Latex will distribute it. The brand name of the
female condom is Femidome.
Other characteristics of the condom
are
• It is made of polyurethane
• It is soft, thin, odorless and strong
• It is 17 cms. Long with flexible
rings
• It can be worn up to 8 hours
before sex and need not be
removed immediately after sexual
act
• It must be used only once and
then discarded
Using a female condom (See Figure III)
1. Open end (Outer Ring): The open end covers the area around the opening of the
vagina. The inner ring is used for insertion, and to help hold the sheath in place.
2. How to hold the sheath: a. Hold inner ring between thumb and middle finger. Put
index finger on pouch between other two fingers, (or) b. Just squeeze.
3. How to insert the condom: Squeeze the inner ring. Insert the sheath as far as it will
go. It’s in the right place when you can't feel it. Don't worry-it can't go too far, and IT
WON'T HURT!
4. Make sure placement is correct: Make sure the sheath is not twisted. The outer ring
should be outside the vagina.
5. Removal: Remove before standing up. Squeeze and twist the outer ring. Pull out
gently. Dispose in the dustbin, not in toilet.
Remove and insert a new female condom if:
• The female condom rips or tears during insertion or use
• The outer ring is pushed inside
• The penis enters outside the pouch
• The female condom bunches inside the vagina
• You have sex again
58
Step 1
Step 2
Step 3
R RINl >
uPIMMj
Step 4
/
Step 5
Figure 4.3: Steps to be kept in mind when using the female condom
Use more lubricant if:
• The penis does not move freely in and out
• The outer ring is pushed inside
• You feel thefemale condom when it is in place
• The female condom comes out of the vagina when in use
• There is noise during sex
Why don "t people use condom?
Exercise 4.3
1. The facilitator conducts a brain storming session by asking the participants to
respond to the question 'Why don’t people use condoms?'
2. One volunteer from the participants is asked to write the responses on one half
of the black board
3. Then the participants are asked to give ways by which they feel these problems
can be overcome
4. Another volunteer is asked to write these responses on the black board
5. The facilitator first mentions any points that have not been mentioned and then
draws the attention of the participants to Handout 4.1
People may not use condoms because
• Sometimes they may not be available or accessible
• They may have fear of being looked upon as persons indulging in high risk
behavior
59
•
•
Lack of knowledge on correct use of condoms
Myths and misconceptions
Handout 4.1 Myths / misconceptions about use of condoms
Myths/
Misconceptions
Using condom
during sex is
irritating
Condom will tear
during intercourse
Condom is sticky
and oily
Condom reduces
sexual pleasure
Reason
How to overcome
Inadequate foreplay
leads to lack of
lubrication in the
vaginal passage
This could also happen
with an old condom
Condom may burst if
the air is not expelled
from the tip of the
condom
This may also happen
when the condom in use
is an old one after its
expiry date.__________
Sexual intercourse also
is sticky due to the
semen and vaginal
fluids.
Presence of lubricant
Lack of practice of
using condom
It has to be used at a
veiy sensitive moment
Adequate foreplay before
penetration
To use a quality condom within its
expiry date
Women do not
like condom
It is an excuse by men
Erection goes
before using
condom
Ignorance in using
condom
Hold the tip of the condom before
rolling it over the erect penis to
expel the air in it.
Ask the patient to check the expiry
date, packing condition. Address the
wrong belief and demonstrate
condom use.
Educate how lubrication helps to
avoid genital trauma and also makes
it pleasurable.
Educate and demonstrate (it is
simple and easy to use)
Educate to introduce condom at the
right time.
Sexual pleasure is not just limited to
penetrative pleasure and therefore
condom use cannot reduce other
types of sexual pleasure.__________
Women would like it because it
would make them feel that the man
cares enough to protect them from
diseases and also because it enhances
duration of penetrative sex________
Educate with practical tips
Demonstrate how to use these tips
effectively
60
Frequently asked questions about condoms
Are Indian condoms inferior?
India is one among the leading condom manufacturing countries. Indian manufactured
condoms are at par with International quality. Indian condoms are exported to nearly 150
countries including USA.
Who are the condom manufacturers in India? Which are the popular brands?
The major Indian condom manufacturers are Hindustan Latex Limited, TTK LIG, JK
Ansell, etc. Hindustan Latex manufactures Moods, Moods Supreme and Ustad, while
TTK-LIG’s famous brands are Kohinoor, Durex and Fiesta. JK Ansell manufactures
Kama Sutra, Midnight Cowboy and Sajan.
Do Indian condoms go through quality tests?
Condom passes vigorous testing for burst volume, lubrication quantity & packaging to
ensure quality. Condoms manufactured by different companies are procured by
Government and distributed free of cost under the brand name Nirodh. These free
distributed condoms are on par in quality with other commercially sold condoms.
How many condoms are there in a pack?
Condom is available as packs ranging from 3-6, 10-15 and even as many 20 pieces; now
single piece condom packets are also available.
Where are commercial condoms are available?
Condoms are available in all medical shops, grocery shops, provision shops and even
petty shops as well as petrol bunks. They are also available in every PHC, dispensaries,
government hospitals, and NGO working for the control of STI / STD / HIV.
Where are free condoms are available?
Condoms are freely distributed by all Government hospitals. Primary Health Centers
(PHCs), dispensaries and NGOs working for STI/ STD / HIV control.
What is the price of the condom?
Varieties of priced condoms are available in the market & their prices vary accordingly.
It ranges from approximately Rs.0.40 to Rs.6/- per piece.
61
3. Avoiding substance abuse
The patterns of substance use in any society can have an influence on HIV transmission
because of
• Practices connected with the administration of the substance
• Effect the substance can have on perception, judgment and behavior of the person
• The risk of the person indulging in unsafe sexual behavior due to the altered
perception and judgment
Exercise 4.4 (Optional)
The purpose of this exercise is to help participants recognize what routes of substance
administration could be most risky for STD / HTV transmission
1. The facilitator will write down the following methods of substance
administration on six large pieces of paper
• Ingestion / Sucking or chewing / Inhalation / Sniffing / Intravenous
injection / Other modes of ingestion
2. The facilitator will stick the six sheets of paper on the wall, some distance
apart.
3. Then a substance name is called out (E.g. tobacco) from the list of substances
given below and one of the participants will be asked to write the name of the
substance under any of the headings to indicate the way in which the substance
could be taken by people. Alternatively the following substances could be
written, one on each chit of paper. Participants could be randomly given one
chit and then asked to come forward and write the name of the substance under
the appropriate route/s of administration
• Tobacco / Ganja / Marijuana / Opium / Pethidine / Morphine /
Phenobarbital / Cannabis / Brown sugar / Caffeine / Cocaine / Heroin
4. The facilitator must be able to draw the attention of the participants to the
methods of substance abuse that is most risky for HTV transmission. (See note
given below)
Note:
•
•
•
Intravenous drug abuse is highly associated with HIV transmission
All other routes viz. intramuscular, intradermal and subcutaneous
could also aid in transmission of HIV infection
All other routes viz. ingestion, sucking, chewing, sniffing, inhalation
could be safe with regard to HIV transmission but remember it could
alter the perception, judgment and behavior of the person which may
predispose to unsafe sexual practices
62
4. Adapt traditional customs safely
Some traditional customs are now risky because of HIV, for example customs, which
involve having non - regular sexual partners. Any custom, which involves sharing
cutting instruments, is also risky.
Risky customs include
• Wife- sharing and wife inheritance that has a become dangerous for the spread of
HIV
• Circumcision with unsterilised knives or blades
• Scarification with unsterilised knives or blades or needles
• Devadasi
• Skin piercing practices when many people share an instrument, without
sterilization between uses.
Remember that....
You cannot know who has HIV. HIV is found both in villages and town. So it is much
safer to modify dangerous practices in order to make customs safe
Exercise 4.5 (Optional)
The purpose of this exercise is to sensitize the participants that it may be difficult to tell
people to give up traditional practices but that traditional practices could be done safely so
as to avoid transmission of STD/ HIV
1. The facilitator asks the participants for volunteers to role-play considering the
following points.
You have to approach a traditional practitioner who is known in the community to use
skin piercing methods that are not safe
•
•
•
•
How would you let the person know that you respect him /her?
How would you present the problem to the practitioner?
How would you describe the harmful effects of the practices?
How would you arrive at solutions for the above problem?
2. Summarize the role play at the end with the following points
•
•
•
When you cannot avoid skin-piercing instruments such as blades, needles and
syringes insist on having sterilized instruments
Do not share razor blades, because they might come into contact with blood
from an infected person from cuts on the skin
Do not share needles that have been used for intravenous injection, either for
therapeutic purposes or as part of drug abuse
63
L Blood transfusion
■ Avoid the need for blood transfusion (seek proper medical treatment for
malabsorption, hookworm, and during pregnancy to prevent anemia)
■ When blood transfusion cannot be avoided, insist on having blood, which has been
tested for HIV. It is safer when relatives donate blood than professional donors.
Ensure the safety of blood and blood product
• A well organized blood transfusion service (BTS) is a necessary part of any safe
and effective use of blood and blood products
• Safety considerations must be built into every stage of the blood collection
process: testing, storing, distribution and transfusion
• Emphasize volunteer non remunerated blood donors
• Defer donors who report risk behaviors until screened
• Effective blood testing strategies
• Appropriate use of blood and blood components. Use only when necessary.
• Training of staff handling blood and blood products
Contact with potentially infective bodyfluids
• Universal precautions (See Chapter V) to be followed while taking care of any
person in the community / patient in the hospital setting
6. Prevention of mother to child transmission (MTCT)
More than 70% of pediatric HIV occurs due to parent to child transmission of HIV. When
a mother is infected transmission to the child could occur mainly through the placental
route in the antenatal period or, during the process of labor or during the delivery of the
baby and in the postnatal period through breastfeeding. However this risk of transmission
can be significantly reduced by antiretroviral (ARV) chemoprophylaxis. This section is
dealt with in detail in order to enable the nurse to provide appropriate health education to
potential mothers.
Table 4.1. Risk ofMTCT
Antenatal period
Percentage of perinatal
____ transmission____
30-40%
Intrapartum period
60-80%
- Between 1 -5 years
Post partum period
12-14%
- Between 1 -5 years
Time of transmission
Manifests
- Early fetal loss
- In early infancy
64
This section will be dealing with methods of prevention of MTCT through primary
prevention, and secondary prevention strategies. Secondary prevention strategies target
women who have been diagnosed to have HIV infection while primary prevention
strategies target women who have not yet acquired the infection.
On whom should a nurse focus to prevent HIV infection among the childbearing age
in women?
Exercise 4.6
1. The facilitator conducts a brainstorming session with the participants for 3
minutes
2. The participants are asked a question
On whom should a nurse focus to prevent HTV infection among the childbearing
age in women?
3. One participant is asked to come forward and write down all the responses given
to the question on the black board
4. Then the participants are also asked to give reasons why they had given the
previous responses. This is also written in the black board for all to see
5. The Handout 4.2 is then given to the participants to read and comment on
Handout 4.2: Which women must a nurse focus on to prevent STD /HIV infection in
them?
A nurse must focus on all women because
• Women are more susceptible to STDs since they are
- Biologically more susceptible to infection if exposed to HTV and others STDs
- Often socially, economically as well as sexually subordinate to men. Hence the
chance of their exposure to practices, which are risky such as, forced sex,
unprotected sex could raise their risk for acquiring the infection
• Women under 20 years are increasingly presenting with HTV infection in our State
despite the fact that most of them are house wives
This means that our programs should be targeted towards:
• Commercial sex workers'. However to focus only on them would be useful in
controlling the infection in the early phases of the epidemic
• Teenagers: since high rates of teenage pregnancy and STDs indicate the extent of
unprotected sexual activity among them
• Women in stable relationships but who are exposed to the infection due to their
partners' behavior or changing patterns of sexual relationships
• Pregnant and lactating women: The risk of the infant acquiring HIV from the
mother is said to be higher especially when she acquired the infection either
during pregnancy or lactation
65
Strategiesfor prevention ofHIVInfection from mother to child
Exercise 4,7
The whole session of PMTCT is dealt in such a manner the participants learn from
experience and then information is reinforced in them when they read the handouts
1. The fecilitator divides the participants into 6 smaller groups. Each group is given one
situation. Make sure that participants are asked not to refer their modules. Distribute
to each group only their topic for discussion written on an A4 size paper. Do not write
the Handout number in this paper.
Group I:
Group II:
Group III:
Group IV:
Group V:
Group VI:
How to reduce the risk for women to get infected with HIV (Handout 4.3/
Handout 4.4)
Steps to reduce the risk of MTCT of HTV during pregnancy and delivery
(Handout 4.5)
Steps to reduce breast milk transmission of HTV (Handout 4.6)
Helping a HTV positive mother on how to feed her infant (Handout 4.7)
Helping a HTV positive mother reduce infant’s vulnerability to infection
(Handout 4.8)
Helping a mother whose status is not known on how to protect her baby
from acquiring the infection (Handout 4.9)
2. Each group will have a leader. The group must discuss what the role of the nurse must
be and how could he / she fulfills the said role.
3. Each group will be given 5 minutes to discuss and one member of the group must
volunteer to write down points discussed
4. Then any one member of Group I must be called up after 5 minutes to read out to all
participants what they discussed in their respective groups. The corresponding
Handout for that particular group must then be read aloud to all the participants
following this. Any clarification could be made by the resource person
5. The facilitator must be able to give any other pertinent information before the next
group comes forward to present their points of discussion
6. Similarly all other groups must come forward and present their discussion after which
the respective handout is read aloud to all participants.
66
Strategies for primary prevention ofHIV Infection from mother to child
This means reducing the risk of a woman from acquiring STD / HIV infection even
before she becomes pregnant
Handout 43 Primary prevention — ways in which the infection can be avoided and
cannot be spread
Aspects of prevention
1.
Information, Education and Communication (IEC)
Give sex education in the school to pre-adolescent girls (10-12 years)
Give information on STD / HIV and the ways of preventing these diseases to all
adolescent girls
• Inform girls about risk behaviors
• Teach problem solving skills to girls
• Help adolescent girls to develop skills in decision making, resisting negative influence,
protecting themselves from eve teasing, rape, and sexual harassment, building and
maintaining healthy and satisfying relationships
• Help adolescents girls need to learn about sexual and reproductive health, safe sex.
different forms of sexual behavior and the consequences of sexual behavior
• Teach teachers of preadolescent girls about how to give sex education
• Encourage the use of posters with important messages so that the adolescent and
preadolescent girls can learn
•
•
2.
Increasing access of family planning for women at risk to prevent unintended
pregnancy
•
•
•
•
Deliver family planning services more extensively in AIDS affected areas
Discuss family planning and sexual health issues with women
Emphasize on barrier methods
Address the dual protection (i.e. to use one or more contraceptives to protect from the HIV
infection and to prevent pregnancy simultaneously) appropriately (see Handout 4.3).
Expanding access to HIV counseling and testing
•
•
•
•
Develop link with VCTCs, PMTCTs
Identify infected women in the antenatal period and refer
Reduce the risk in seronegative women by education and motivation so that they could
modify their behavior
Provide sero positive women with the services of a VCTC
67
Handout 4.4. Contraceptives and their role in prevention of infection
Contraceptive
methods
Condoms
Bacterial RTI /STI/STD
Viral RTI/STI/STD
Protective
Protective
Spermicidal
Moderately protective against
cervical gonorrhea
No evidence of protection in
vivo
Diaphragms
Protection against cervical
infection. Associated with vaginal
anaerobic overgrowth
Protective against
cervical neoplasia
Hormonal
Associated with increased cervical
chlamydia.
Protective against symptomatic
PID, but not unrecognized
endometritis
Not protective
IUD
Associated with PID in the first
month after insertion
Not protective
Fertility
awareness
Not protective
Not protective
The dual method is not recommended for all women. The following steps are
recommended as a guideline for you to help women:
• Be aware of the STD/HIV prevalence rates for a geographical area. This will help
you know what is risk women are likely to face
• Consider those women who think of themselves or their partners in the high risk
category as good candidate for dual method
• Know that the male condom alone, if used in the correct manner will be sufficient
enough to protect against infection and unintended pregnancy
• Encourage the women whose husband or partner refuse to use the condom, to use
the female condom or diaphragm along with a spermicidal
Inform women regardless of her status that if the contraceptive she is using presently
does not protect her against STD /HIV, and she is concerned about her partners9
behavior and thus her risk status, she should immediately start using additional
protection.
68
Strategies for secondary prevention ofHIVlnfection from mother to child
This means reducing the risk of HIV transmission from a HTV positive mother to the
child. For this it is important to first know what factors increase the risk for MTCT.
Risk factors for MTCT of HIV during pregnancy and delivery
The risk of MTCT is multifactorial, and is influenced by maternal, obstetrical, child, and
viral factors:
Table 4.2. Risk factors during pregnancy and delivery for MTCT
Maternal factors
• Stage of maternal HIV disease
• Maternal nutritional status
• Disruption of placental barrier integrity by chorioamnionitis
• STD during pregnancy
• Substance abuse
• Vitamin deficiency
Obstetrical factors
•
•
•
•
•
Vaginal delivery over cesarean section
Preterm delivery
Breast feeding
Rupture of membranes
First bom among twin pregnancy
Factors related to the child
•
Genetic characteristics of the fetus has been suspected to increase risk for
transmission
Viral factors
•
MTCT rates of HIV-1 is higher than that of HIV-2
Handout 4.5
1. Reducing risk of MTCT of HIV during pregnancy and delivery
This section attempts to give a brief overview of various preventive options available to
reduce the risk of MTCT.
Reducing risk of MTCT of HIV during pregnancy
a. Vitamin supplementation
• Administration of multivitamin supplementation has shown a significant
reduction in the risk for low birth weight babies, severe prematurity, or small for
date babies. These babies have higher risks of mortality especially if they acquire
HIV infection perinatally
• Administration of Vitamin A during pregnancy may be helpful in reducing the
risk of MTCT
69
b. Avoid invasive procedures on the uterus such as amnioscopy, fetal scalp
electrodes, amniocentesis etc*
c.Antiretroviral therapy:
Anti retroviral therapy is recommended to reduce the maternal viral load and to inhibit
the replication of the virus in the newborn. Various regimens have been recommended
based on the cost and logistical obstacles. What we follow in our country is:
• Avoid ART in the first trimester of pregnancy due to know teratogenic effects
• Advise monotherpy such as Zidovudine 300 mg. twice a day for the full course
of pregnancy from the second trimester
Reducing risk ofMTCT ofHIV during delivery
a. Antiretroviral therapy:
What we follow in our country includes
• Nevirapine (NVP) 200 mg administered as a single dose to the mother at the onset
of labor.
It is said to reduce the risk of transmission from 35 % to 12 %.
b. Prevention of premature rupture of membranes
c Mode of delivery
• Elective cesarean section protects more than vaginal delivery
• With constraints of resources (equipment, experienced personnel to perform a
cesarean section as well as the cost), then hospital / home vaginal deliveries must
be conducted by the health personnel with extreme caution to avoid the spread of
infection to the baby. Avoid episiotomy for such mothers as far as possible
• The episiotomy needs to be sutured as fast as possible to reduce the chance of
bleeding and thus the risk of occupational exposure
d. Vaginal disinfections
• Vaginal disinfection with chlorhexidine solution (0.25%) is a low cost method
and also helps to reduce neonatal morbidity
e. Care of the baby soon after birth
• Suction any secretions from the oral cavity first and then from the nose to
prevent the baby from swallowing any secretions
• Do not milk the umbilical cord
• Cut the cord as soon as pulsations are not felt
• Wipe the baby’s body thoroughly with a warm clean towel to remove any blood
stained secretions
• Administer single dose (2mg /kg) of Syrup Nevirapine to the child within 72
hours after birth
Follow-up care of the mother and the infant
Any intervention to reduce MTCT should include good postpartum and infant care.
Continued counseling about
70
•
•
•
•
•
•
The infant and young child feeding
Prevention of HIV transmission to sexual partners
Access to and provision of family planning
Emotional support for the mother and the family
Follow-up of the baby to check for HIV infection
If HIV positive the woman needs to be warned about early medical management.
They need to be motivated to seek help as early as possible since they are more
prone for infections in the post partum period.
2. Reducing the risk ofMTCT through breastfeeding
I. Handout 4.6: Helping a HIV positive mother to reduce chance of breast milk
transmission (BMT)
a. Ensure good nutrition during pregnancy and the postnatal period
All women need to be counseled and educated to
• Take a nutritious and well balanced diet during this period
• Supplement diet with iron, folic acid, zinc and other nutrients
• Use high doses of vitamin A following delivery
b. Instruct on good breast-feeding technique
i. Preparation ofbreasts in the antenatal period
The women should be advised to
• Examine her breasts for any defects such as bifid nipple, flat nipple etc.
• Prepare the nipples for suckling by massaging them well with oil everyday and
then drawing them out gently.
ii. Adopting proper methods while breast feeding
Mothers must be advised on
• Proper positioning of the herself and baby (See Table 3; see relationship of poor
position, latching on BMT in Figure IV)
• To use a mild soap
• Poor position
• Baby not latching well on
breast
• Use of strong soaps or
creams
Cracked nipples
>
Difficult to feed
Breast engorgement
Mastitis
Increased
risk for
BMT
Abscess
Figure 4.4: Relationship of improper methods of breast-feeding technique with
BMT
71
Table 43. Correct positioning and attachment
_________ If the baby is:________ _____________ Show mother___________
Correct positioning
Not positioned correctly:
•
Baby is facing mother and is close to her.
• Baby’s tummy is not flat against
• Baby’s tummy is flat against mother’s
mother’s
tummy.
Not properly attached to the
breast:
>
• Baby looks like sucking a straw
• Baby’s mouth does not cover
areola
Correct Attachment
• Baby’s chin is touching the breast.
• Baby’s mouth covers all the areola (dark
skin around the nipple).
• Baby’s lower lip is curled outward
IL Handout 4.7: Helping a HIV positive mother decide how to feed her infant
• Explain the benefits of breastfeeding
• Confirm by asking mother if she knows her HIV status
• Explain the risks of breastfeeding for HIV positive women
• Explain the options HIV positive mother have for infant feeding (see Table 4)
• Explain about the concept of a wet nurse (someone known to the family who is
not HIV positive, who is willing to breast-feed the baby. Remember breast milk
is the best milk for a baby)
72
Table 4.4 Options for breast feeding in HIV positive mother
Rationale
Counsel her to:
If an HIV
positive
mother
• Protects the baby
WANTS to
• Feed colostrum
• Aids in successful breast
breastfeed
• Put the baby on the breast
feeding
within 30 minutes of birth
AND
• Protects the baby
• Breastfeed exclusively for 3
months or less
IS ABLE AND • Practice abstinence or
• Protect herself from sexually
WILLING to
transmitted diseases
consistent use of condoms
use animal
• It increases the risk of passing
during sex
milk or
HIV to the infant
• Avoid giving water or other
commercial
• Reduces the number of times
foods with breast milk
infant formula
the baby would suckle on the
• Avoid the use of pacifiers
breast and therefore decrease
the amount of milk production
• Increases milk production by
suckling
• Longer the duration of breast
• Breastfeed regularly
feeding greater is the risk for
transmission
• Stop breast milk abruptly at 3
• Mixed feeding (breast milk and
months or earlier if possible
artificial feeding increases risv
of
transmission
• Feed only animal milk or
commercial infant formula from • Builds the nutritional status of
3 months (or earlier) to 6
the baby
months
• Reduces risk of transmission
• Feed animal milk or
commercial infant formula and
give complementary foods (ragi
/ rice etc.) from 6 to 24 months.
CHOOSES
• Use commercial infant formula • Safest for a baby not to be
breast fed
NOT to
or animal milk from birth to 6
breastfeed
months
AND
• Meets the basic caloric
• Use infant formula or animal
IS ABLE AND
requirements of the baby
milk and give complementary
WILLING to
foods from 6 to 24 months
use
• Take all precautions to maintain • Protects the baby from
commercial
gastrointestinal infection
hygiene during feeding
infant formula
or animal milk
73
WANTS to
breastfeed
AND
IS NOT ABLE
OR WILLING
to use animal
milk or
commercial
infant formula
• Breastfeed exclusively for only
6 months or less (no other food
or drink, except prescribed
medications)
• Stop breastfeeding abruptly at 6
months
• Avoid feeds such as fruit juices,
acidic milk like curds, sugar
water, skimmed milk or even
sweetened condensed milk
before six months of age
• Give only complementary foods
from 6 to 24 months
• Practice abstinence or
consistent use of condoms
during sex
• Mixed feeding increases risk of
transmission
• Longer the duration of breast
feeding greater is the risk for
transmission
• Since the infants gut is not yet
ready to digest these foods
readily and they are likely to
cause allergies
• Meets the basic caloric
requirements of the baby
• Protect herself from sexually
transmitted diseases
Inform HIV positive woman and those who are unaware of their HIV status to avoid
feeding if they have cracked nipples, mastitis or breast abscess.
Cracked nipples / Breast engorgement / Mastitis
One breast affected
Both breasts are affected
f-----Don’t feed
Express breast milk
Feed from other breast
Pasteurize/ boil
Figure 4.5. Algorithm to follow for cracked nipples, breast engorgement, mastitis
Handout 4.8. Helping a HIV positive mother reduce infant’s vulnerability to
infection
i. Help mother to learn when to stop breast milk: (See Table 4.5)
Table 4.5 Options for breast-feeding in a HIV Positive mother
If an HIV positive mother is: __________________ Tell her to:_______________
Willing and able to use animal Stop breast milk abruptly when infant is 3 months or
milk or commercial infant
less.
formula__________________
Not willing or able to use
Stop breast milk abruptly when infant is 6 months or
animal milk or commercial
less.
infant formula
74
ii Explain how stop breast milk abruptly (See Table 4.6)
Table 4.6. Steps to be taken by the HIV positive mother to stop breast feeding
abruptly
When the mother decides to stop breast milk as in Table 4.5, tell her to express breast milk
(EBM) and give to baby using cup / paladai / spoon especially during the day___________
Encourage the mother to continue to breastfeed during the night_____________________
Increase the number of breast milk feeds from the cup, while decreasing the number of
breastfeeding gradually over a period of 2 weeks._________________________________
Ensure the mother knows how to prepare animal milk or commercial milk_____________
Stop breast-feeding abruptly. Tell the mother to ensure that there is a reliable supply of
replacement feeding (animal milk or commercial infant formula) before stopping breast
milk___________________________ __________________________________________
Explain how much milk to feed the baby (See Table 4.7)
Table 4.7. Guidelines for the amount of milk to be given to the baby______________
If baby’s weight is:
Or the baby is: ________ Then tell the mother to:_____
3Kg
1 month old
• Use 450 ml of milk per day
• Give about 60 ml of milk per feed
• Feed the baby at least 8 times per day
4 Kg
2 months old
• Use 600 ml of milk per day
• Give about 90 ml of milk per feed
• __ Feed the baby at least 7 times per day
5Kgs
3-4 months
• Use 750 ml of milk per day
• Give about 120 ml of milk per feed
• Feed the baby at least 6 times per day
6 Kg
5-6 months
• Use 900 ml of milk per day
• Give about 150 ml of milk per feed
• Feed the baby at least 6 times per day
Note:
1. The amounts above are only a guide as some babies are betterfeeders than others.
2. An adequately fed baby will gain weight and pass urine 7 to 8 times in a 24- hour
period.
75
IV. Handout 4.9: Helping a mother with unknown HTV status decide how to protect
her baby from acquiring the infection
1.
2.
3.
4.
r
r
f
Ask her what she knows about mother to child transmission of HTV
Ask her if she wants to know her HTV status
If she says yes, refer her to the nearest voluntary counseling and testing (VCT) center.
Explain that HTV can be transmitted to a child of an HTV positive mother through
breastfeeding.
5. Reinforce the benefits of breastfeeding. If the mother is HTV negative or her status
unknown, counsel her to
• Breastfeed exclusively for 6 months.
• Continue breastfeeding and give complementary foods from 6-24 months.
• Protect herself from getting HTV during the time she is breastfeeding through:
-Abstinence or
-Consistent use of condoms during sex.
• Explain the risks of artificial feeding
6. Explain the risks of breastfeeding for HTV positive women but also
• Explain that exclusive breastfeeding means giving the baby breast milk only without
any other foods, drinks or water (except prescribed medications).
• Explain that mixed feeding (giving breast milk plus other foods or drinks) for infants
bom to HIV positive women increases the risk of transmission of HTV.
• Encourage her to eat more food while breastfeeding.
Watch out for...THE SPILL-OVER EFFECT
The effect ofgiving information about the risk ofHIV transmission through breast milk on
infant feeding practices of HIV negative mothers or on those who do not know their HTV
status. Advise them on the benefits ofbreast- feeding.
r
!
Summary of PMTCT
i Primary prevention strategies
This includes reducing the risk for women to get infected with HTV by
• Information, Education and Communication (DEC)
• Increasing access of family planning for women at risk to prevent unintended
pregnancy
• Expanding access to HIV counseling and testing
iLSecondary prevention strategies
This includes
• Reducing risk of MTCT of HIV during pregnancy and delivery
• Reducing the risk of MTCT through breast feeding
Helping a HIV positive mother to reduce chance of breast milk transmission
(BMT)
Helping a HIV positive mother decide how to feed her infant
Helping a HIV positive mother reduce infant’s vulnerability to infection
Helping a mother with unknown HIV status decide how to protect her baby
from acquiring the infection
76
Chapter — V
UNIVERSAL PRECAUTIONS - IN CARING FOR A PERSON WITH STD/ MV
Introduction
HIV may be transmitted in the health care setting from either patient to patient, from
patient to health care worker or from health care worker to a patient. Infection control
measures are those standards recommended by the health authority and are adopted by
the health personnel, which help to prevent or minimize occurrence of infection among
themselves or their patients. Adequate infection control measures like universal
precautions, waste management and post exposure prophylaxis need to be practiced at all
times to ensure safety of both patients and staff.
General Objective' On completion of this section, the participants will understand the
general safety practices and precautions to be taken while caring for clients, apply this
knowledge while at work, for the prevention of blood borne pathogens.
Specific Objectives
By the end of the training program the participants will:
• Recall the principles of universal precautions.
• Use universal precautions within the available facilities while caring for patients or
while handling potentially infections materials
• Demonstrate how to disinfect materials used for caring for patients or persons
• Segregate infected materials appropriately in the health care setting
Key concepts
• Universal precautions is necessary to prevent transmission of infection through
potentially infected body fluids
• Contact with body fluids make one at risk for acquiring blood borne infections
• All persons in the health care scenario i.e. both health care personnel and patients are
at risk of acquiring infection
• Universal precautions can be easily put into practice if one is sensitized to its
importance
Teaching methods
• Lecture
• Discussion both small and large
• Reflective exercises
• Demonstration
77
Materials/preparation required
• Transparencies with figures, OHP
• Black board, chalk, duster
• Copies of handouts
• Charts for writing and colour pens
Topic outline
• What are Universal Precautions?
• Body fluids and universal precautions
• Principles of universal precautions
o Using protective devices
o Protecting oneself
o Preventing accidents
• Precautions in the event of handling potentially infective material
Total session time
1 hour
78
BACKGROUND MATERIAL
The risk of transmission of blood home viruses is as follows:
• HIV
- percutaneous exposure
: 0.05 - 0.4%
• HIV
- mucocutaneous exposure
: 0.006 - 0.05%
• Hepatitis B virus (HBV) - percutaneous exposure
:9-30%
• Hepatitis C virus (HCV) - percutaneous exposure
: 3 -10%
Hence in order to prevent this risk we need to follow universal precautiions
What are universal precautions?
Universal precautions are a set of guidelines designed to protect the health care worker
from exposure to blood borne pathogens like HIV or Hepatitis B and C.
• They are based on the assumption that body fluids are potentially infectious
regardless of whether it is from any patient or a health care worker
• They are procedure based and not person based.
The practice of universal precautions including proper sharp disposal (needles/ampoules
etc) has reduced the risk of transmission from 50% to 20%.
Cardinal rules of universal precautions
• All patients / persons as potentially infectious
• Never consider the diagnosis or presumed infection status
• All blood, body fluids and tissue are contaminated
• All unsterile needles and sharps are considered contaminated
• Identify a risk before starting any procedure
• The type of barrier protection used should be appropriate
Body fluids and universal precautions
Exercise 5.1
The purpose of this exercise is to help participants become aware of what they presently
know about when they must or must not apply universal precautions
1. Write on the various body fluids as given below on small chits of paper (one on
each chit of paper)
Blood / Semen / Vaginal secretions / Any visible bloody body fluid / Amniotic
fluid / Breast milk / / CSF / Pericardial fluid / Peritoneal fluid / Pleural fluid /
Pus / Synovialfluid / Feces / Nasal secretions/Saliva/Sputum/Sweat / Tears /
Urine / Vomitus
2. Distribute one chit of paper to each participant. Ask the participant to identify
whether they would apply universal precautions or not apply universal
precautions to the said body fluid in 1 minute.
3. Call out one participant at a time and ask them to state whether they would apply
universal precautions or not apply universal precautions to the said body
fluid and the facilitator could list these on the board or a big chart paper
4. Following this the attention of the participants is drawn towards Handout 5.1
Table 5.1 Body fluids to which you would need to or need not apply universal
precautions
Universal Precautions needed
Infectious body fluids or secretions
• Blood
• Semen
• Vaginal secretions
• Any visible bloody body fluid
Any potentially infectious body fluid
or secretion
• Amniotic fluid
• Breast milk
• CSF
• Pericardial fluid
• Peritoneal fluid
• Pleural fluid
• Pus
• Synovial fluid
Universal Precautions not needed
Non infectious body
secretion
• Feces
• Nasal secretions
• Saliva
• Sputum
• Sweat
• Tears
• Urine
• Vomitus
fluid
or
(Unless they contain visible
blood)
Components of universal precautions
1. Using protective devices
The protective devices used include
i. Gloves: Nurses need to be judicious while using gloves. Since Gloves are not 100%
safe double gloving that affords greater protection is recommended where exposure risk
is very high.
Remember.,.
There are two types of gloves available in the hospital:
* Examination gloves: These are clean but not sterile - to be used for all
procedures not requiring sterile technique e.g. used for sponge bath
* Sterile gloves: These are used for all procedures where sterile
technique is mandators
80
Do’s while using gloves
• Thick rubber gloves to be worn while cleaning instruments and handling soiled
linen
• Remove gloves before leaving the patients bedside
• Change gloves between patients and procedures
Don’is while using gloves
• Don’t use gloves with holes or tears
• Do not wash hands with gloves on
• Do not reuse disposable gloves
w
a a
■ !-W
■
Figure 5.1: Procedure for putting on and removing gloves
iL Masks
• Use complete face mask for all procedures that are likely to contaminate eyes, nose or
mouth by droplets of blood and body fluids
• Cover the mouth and nose
• Change masks for every procedure or immediately if they become contaminated
Hi. Eyewear
• Choose the type that helps to cover the eyes both in front and on the sides
• See that they do not restrict your vision and you are comfortable
• See that it fits well on the face and is directly in contact with the skin
• Il eyewear is not available you could improvise one by making use of the face shield
that is attached to a helmet. The advantage of this is it could be easily cleansed.
/v. Protective clothing
It is important to remember that all protective clothing and equipment must be properly
discarded / stored before leaving the work area.
81
v. Gowns:
•
•
Wear a plastic apron under the gown.
Use impervious (does not allow liquid to soak through) full - sleeved gowns for
procedures where hands are thrust deep into the viscera, and much blood loss is
anticipated
Shoes:
Use impervious shoes covering the dorsum (top surface) of the feet completely in
the operation theatre (OR) and in the labor room.
• If this is not available then you could use plastic packets or bags and put a rubber
band to hold it in place
•
Use of the protective devices depends on the type of risk of transmission associated with
each procedure
Exercise 5L2
The purpose of this exercise is to help participants become aware of what they presently
know about when they must use the appropriate protective device. It could be a period
when any misconceptions could be clarified by the facilitator
1. Write the various procedures as given below done by a nurse, one procedure
each on a card
Bed making / Endotracheal intubation / Conduct of delivery / Uncontrolled
bleeding /Back care /Insertion and removal ofIV needles /During surgery /Pervaginal examinations / Sponge bath / Dressing of large open wounds / Minor
wound dressing /Handling blood spills/Mouth care /Handling lab specimens/
Suctioning / Catheter care/Perineal care /Injections/Expressing breast milk /
Handling dead bodies /Lumbar puncture
2. Mark on three separate tables 4low risk*, ‘‘medium risk’ and L high risk’ (this
could be done on the black board or a flannel graph or even by using three boxes
which are labeled in this manner)
3. Ask the participants to come up one by one, give them a card and ask them to
place a given card under the categories of low, medium or high risk after having
identified the risk of the procedure
4. Following this the attention of the participants is drawn towards Handout 52
82
Handout 5.1. Tyne of risk associated with procedure
Type of
Examples
exposure
Low Risk
Bed making, back care, sponge bath, mouth
care, minor wound dressing, catheter care,
perineal care, injections, expressing breast milk,
handling dead bodies, lumbar puncture (LP),
Medium
Insertion and removal of IV needles, perRisk
vaginal examinations, dressing of large open
wounds, handling blood spills, handling lab
specimens, suctioning, endotracheal intubation
(ET)___________________________________
High Risk
Conduct of delivery, uncontrolled bleeding,
during surgery
Protection Required
Gloves helpful, but not essential.
In the case of LP, use gloves and |
mask.
j
Use of gloves and waterproof |
aprons may be necessary.
Gloves, apron, goggles, mask are
needed for ET.
Gloves,
waterproof aprons
masks and protective eyewear is
necessary
________________________________________________
2. Protecting oneself
When in risk of exposure to potentially infectious or infectious body fluids
• Apply good basic hygienic practices with regular handwashing
• Wear gloves
• Avoid direct patient care till you cover breaks in your skin with a waterproof dressing
and sterilized gloves
• Take care when you handle instruments
LHand washing
■ It is the single most important method
■ Use running water and soap
■ Remember to wash hands before as well as after any procedure
■ Wash for 20 seconds
■ Never scrub your hands with a brush when there is a break or cut in the skin
The steps of the procedure are given in Figure 5.2.
fell1
w
r- - ; W
•
5*
-■.Ik
1
<»•
Figure 5.2. Steps of hand washing procedure
3. Preventing accidents
Accidents can be prevented by the following measures
• Always use puncture resistant containers
• Disinfect used syringes
83
• Segregate wastes at the source itself
• Use appropriate technique of disinfecting for each item before disposal
• Incinerate disposable items wherever and whenever possible
• Avoid overfilling of containers
• Avoid putting hands into the waste containers
• Protect fingers from injury by using forceps and needle holders when suturing is
being done
• Keep disposal containers with disposable items close to the work spot
Care ofused needles and syringes
• Never bend / break disposable needle
• Do not recap needles. If so do it in the manner given below by using the single
hand technique
- Place the needle cap on the table
- Hold the hub of the needle with the right hand and push it into the cap
Then lift the needle with the cap above the table
Fix the needle to the cap with the left hand
• Keep needles/ sharps in puncture resistant disposal containers like a tin with a lid,
a thick plastic bottle or box.
• Use all needles and syringes only once followed by proper disinfection and
sterilization techniques
• Use disposable syringe and needle only once and then discard as mentioned
previously
4. Proper use of disinfecting techniques and sterilization
HIV is a weak virus that is easily destroyed by heat and drying. Disinfectants should not
be used for cleaning needles and syringes because they are not reliable enough. They can
be used for cleaning surface such as table tops & spill blood
How to prepare a bleach solution (ifnot already available)
Bleach: water =1:9
• Prepare just before use
• Soak for at least 30 min.
• Soak heavily contaminated objects overnight
• Do not soak metal objects e.g. needles scissors, forceps, scalpels
• Cover the container
Points to keep in mind for disinfection
• Clean instruments thoroughly before disinfecting
• Rinse bleach or chloramine off metal instruments with H2O as soon as sterilization is
complete or they will corrode
• Sterilize soiled or blood stained laundry, plastic sheets or gloves by boiling or soaking
in disinfectant.
84
Labor boards, examination table, OT tables, floor and work surfaces
should be cleaned with 10% sodium hypochlorite solution. Table spreads
should be changed at the end of each procedure.
There are four ways to sterilize instruments and kill HIV and other viruses and bacteria.
These methods are listed below
1. Boil in water for 20 minutes after through cleaning of instruments
2. Sterilize with steam under pressure for least 20 minutes:! atmosphere (101 kpa, 15
lb/m2) above atmospheric pressure, 121 °C (250° F) in an autoclave, pressure cooker
or steam sterilizer.
3. Sterilize with dry heat in an electric oven for 2 hours at 17OoC(34OoF)
4. Soak in one of the following disinfectants for 30 minutes.
a) Chlorine releasing compounds (e.g. bleach 0.5% to 1% which is freshly
prepared)
b) 2% Glutaraldehyde / gluteral
c) 70% ethyl & isopropyl alcohol / spirit
d) Others
• Polyvidone Iodine (2.5%)
• Formaldehyde / Formalin (4%)
• H2O2 (6%)
Low level disinfectants e.g. Dettol and Lysol do not kill HIV
5. Disposal of wastes
All of us as health personnel are at risk of contact with potentially infected body fluids
during our day-to-day routines. Hence we must be doubly cautious of the way we dispose
wastes either in the hospital setting or even in the home setting.
85
Exercise S3
The purpose of this exercise is to help participants become aware of what they presently
know about and how they must use the appropriate colour code in segregating wastes.
1. Write the various waste materials that one may come across in the hospital
setting as given below, one each on a card
Blood / used IV needles / soaked sponges during surgery / gloves used for pervaginal examinations / soaked dressing of large open wounds / Minor wound
dressing / suction catheter / indwelling urinary catheter / used disposable needles
/ Expressed breast milk / urine /stool / tissue biopsy specimens /sanitary napkins
/scalpel blade /food/vomitus /sputum /paper/glass syringe which is broken /
disposable syringe
2. Place on the table five separate boxes colored ‘black’, ‘ ‘red’, ‘yellow’, ‘blue’,
and ‘steel /metal /grey color’ (this could be done on the black board or a flannel
graph by writing the color as given above)
3. Ask the participants to come up one by one, give them a card and ask them to
place a given card in the respective colored boxes namely boxes colored ‘black’,
‘ ‘red’, ‘yellow’, ‘blue’, and ‘steel /metal /grey color’ after having identified the
categorization of the particular waste
4. Following this the attention of the participants is drawn towards Handout 53 /
5.4
In the hospital setting definite color codes are given depending under what category the
waste material would come under as given in Handout 5.3. Handout 5.4 gives details of
ways wastes can be disposed in the hospital or in the home setting.
Handout 5JL Colour coding for segregation of wastes
_____Colour
Black
■
Type of waste
General waste
_____ Examples - type of waste_____
Office waste / Dry non infectious waste
Red
Infectious plastic
Syringe / Cannula / Catheter
Infectious waste
Pathological specimens / Anatomical
waste
Blue
Glass waste
Whole and broken glass
Steel / metal
Sharps
Needles / Blades / Scalpels
Yellow
[
]
86
Handout S3. Method of disposal of specific wastes
Wastes
Liquid
Examples
• Blood
• Urine
• Stool
Method of disposal______ ________
• Flush into the sanitary sewer or pit
latrine
Solid
•
•
Soaked dressing
Sanitary pads /
napkins
Placenta
Tissue biopsy
specimens
• Bum or carefully bury
• Incinerate if possible
• Avoid placing these materials in open
dumps to which animals and children
have access
• Avoid burying where there is a
possibility of it being dug up or where
it might contaminate water sources
Needles
Scalpel
Blades
•
•
•
•
Sharp
instruments
•
•
•
Dispose into puncture proof containers
Disinfected with chemicals or autoclave
or incinerate before disposal
Precautions in the event ofhandling potentially infective material
Exercise 5.4
The purpose of this exercise is to help participants become aware of what they presently
know about how they must dispose wastes in the hospital or in the home setting.
1. Divide the participants into 4 groups. Each group is asked to select a leader
2. Give each group one topic to discuss for 15 minutes
Group I: As you were starting an IV line for a patient, blood spilled on the floor
Group II: You have a patient coming to you for dressing
Group III: A patient with pneumonia needs IV antibiotics. You start an IV line for
the patient. In the process, a bloodstain is found on the bed sheet after the
procedure
Group IV: A 45 year old person who was in the health center had died
3. Have the group decide what action is to be taken
4. After the discussion the leader of each group is asked to come forward and report
the summary of the discussion to the entire class
5. Following this the attention of the participants is drawn towards the respective part
of Handout 5.5. Any clarifications could be done by the facilitator at this point
6. The next three groups would also be asked to present their discussion in a similar
manner
7. 'The facilitator could also discuss respective sections of the Handout 5.5 that have
not been presented
67
Handout 5.4:
L Steps to be taken ifthere is a blood /body fluid spill
You must be aware that blood or body spill can occur both in the hospital as well as in
the home setting of a person who is HIV positive. There are definite protocols that you
have to follow in order to protect yourself.
_____________ In Hospital_____________ ______________ At Home______________
• Wear gloves
• Cover your hand with a plastic bag /
wear rubber (latex) gloves — available
• Place cloth / cotton over the spill
in medical stores.
• Flood with freshly prepared sodium
•
Pour
some freshly prepared bleaching
hypochlorite solution (0.5-1%)
powder solution on the blood.
• Wipe thoroughly
• Discard cloth in to appropriate waste • Mop up the blood
container
• Bum or bury the cloth used or wash it
as described above
• Wipe surface with disinfectant solution
•
Wash hands with soap solution and
• Incinerate wastes
water.
• Remove gloves and wash hands
iL Steps to be taken in handling of vomitus^ suction fluids other secretions and
excretions
• Pour down drain connected to sewer
• Disinfect bedpans, urinals, suction jars etc., with 1% household bleach for 30 minutes
or by any other methods of disinfections.
• Wash the articles with soap and water
• Re-use articles after proper disinfection and cleaning
HL Steps to be taken in dressing an open wound
_______________ In Hospital______________ ____________ At Home____________
• Cover hands with rubber or latex gloves
• Make sure you do not touch the
• Clean the cut or wound with antiseptic
blood directly.
solution
• Cover hands with a thick plastic
• Apply medicines
bag or a towel or wear rubber
(latex) gloves, before touching the
• Cover it with a pad and apply plaster
bleeding part. Clean the cut or
• Bum or bury the blood soaked bandages,
wound
with solution and water
cotton, gauge, and plastic bag/gloves
• Soak reusable gloves in freshly prepared • Apply medicine and cover with
plaster
bleaching powder solution for 30 minutes.
• Bum or bury the blood soaked
• Wash hands with soap and water
bandage, cotton, gauze and plastic
bag/ gloves
• Reusable gloves are handled in the
same manner as in the hospital
• Wash hands with soap and water
88
iv. Steps to be taken in hmdlin^ laundry and linen
_________ In Hospital_____________
• Handle with gloved hands
• Prepare bleach solution a bucket
• Place all the contaminated into the
solution
• Soak for 30 minutes and then send
to laundry
___________At Home______________
• Handle with gloved hands
• Put clothes in the bucket of water
with bleaching powder
• Cover the bucket with a lid
• Soak the clothes for 30 minutes
• Bum clothes that are grossly soaked
with blood
v. Steps to be taken ifthe person infeded with HIV dies
• Treat the body with respect
• Remove all ornaments if needed and place in a separate package. Then hand over to
the relatives. Instruct them to disinfect the ornaments or if possible disinfect before
handing them over
• Place the body in the position preferred by the family members. In order to keep the
normal features, close the eyes immediately as in sleep, straighten the body and keep
the arms straight by the sides, close the mouth, replace any dentures if needed
• Use gloves while giving the ceremonial bath
• Pack all orifices (nasal, ears, mouth, anus) with non absorbent cotton wool
• Advise cremation
• Advise those who want to bury the body to wrap it in a large heavy-duty plastic bag.
And to sprinkle bleaching powder below and above it.
89
Chapter-VI
POST EXPOSURE PROPHYLAXIS
Introduction
Nurses / ANMs while caring for patients / persons who are HIV positive, are at risk of
developing the infection.
All health care workers by nature of their work put themselves at risk for acquiring the
infection. Though the risk of acquiring HIV infection while taking care of a person
infected with HIV or a patient (called occupational exposure) is low, in the health care
setting, improvement of hospital infection control practices and adoption of standard
safety precautions can further reduce the risk. If occupational exposure has occurred post
exposure prophylaxis (PEP) can make a difference through appropriate treatment and
immediate care, leading to reduced risk of acquiring infection.
General objective
On completion of this session, the participants will be able to understand the general
precautions to be taken against accidental exposure to infective and potentially infective
body fluids in the health care setting
Specific objectives
By the end of the session the participants will:
• Be sensitized to the meaning of Post Exposure Prophylaxis.
• Be aware of steps to be taxen during an accidental exposure.
• Identify the situations where PEP should be used
Key concepts
• Post exposure prophylaxis is only relevant for accidental exposure of health personnel
in the health care setting
• Post exposure prophylaxis will reduce the risk of acquiring infection after an
accidental exposure
• The only way of preventing accidental exposure is by adopting safe work practices or
universal precautions
Teaching methods
• Case discussion
• Lecture
• Reflective Exercise
Materials / preparation required
• Transparencies with important points or figures, OHP
• Black board, chalk, duster
•
•
Chart paper and colour pens
Handouts
90
Topic outline
• Meaning of occupational exposure and PEP
• Indications for PEP
• Components of PEP
o Crisis management
o Immediate care
o Recording
o Risk assessment
o Testing and counseling
o PEP medication
o Follow up care
• Frequently asked questions with regard to PEP
Total seston time
1 hour
91
BACKGROUND MATERIAL
Meaning of occupational exposure and PEP
Occupational exposure: is an exposure that may place any health care personnel at risk
for infection.
Post Exposure Prophylaxis'. PEP means taking precautionary measures and antiviral
medications as soon as possible after exposure to HIV, so that the exposure will not result
in HIV infection.
How can occupational exposure to infections such as HIV and HBVprevented!
Following safety guidelines known as Universal Precautions may prevent occupational
exposure.
Indications for PEP
PEP reduces the rate of HIV infection from workplace exposures by 79%. This does
not mean that it provides 100% protection against the infection. PEP is to be practiced in
the following situations, which are considered as a serious exposure:
• Exposure to a large amount of blood
• Blood coming in contact with cuts or open sores on the skin
• All Needle stick injuries
• Exposure to blood from someone who has a high viral load (a large amount of virus
in the blood)
Components of PEP
Exercise 6.1
The purpose of this exercise is to help participants become aware of what they presently
know about how they must act in the event of an accidental occupational exposure to
HIV infection ___________________________________________________________
Case Study 6.1
A needle pricks Ms. Kavitha (28 years old) who is working as a staff nurse in the
medical 1CU accidentally while collecting blood from a patient diagnosed to have
tuberculosis.
The facilitator must be able to draw the attention of the participants to these questions as
and when the content is to be covered
•
•
•
•
•
•
•
Would Ms Kavitha have cause to be worried?
What should Ms. Kavitha do immediately after the accidental exposure?
To whom and when should Ms Kavitha report about the incident?
How high is the risk for infection in Ms. Kavitha?
Since the patient’s HIV status is not known, should we wait for ELISA HIV result
of the patient before beginning PEP?
HOw soon after exposure should PEP be initiated?
For how long should Ms. Kavitha take the treatment?
92
AS.
1. Crisis Management
• It can be a frightening experience for any person and in this situation for Mrs.
Kavitha, the staff nurse
• Persons are likely to be anxious especially when there is a high degree of suspicion
that the index person is HIV positive or has been diagnosed so.
• Some may present with extreme anxiety, which needs direct confrontation.
Reassurance without dismissing the feelings of the concerned person is vital.
• The person may underestimate their risk status and hence the person in charge of such
situations should also take measures to inform people of the need for reporting and
need for appropriate measures.
.dF-
2. Immediate care
L For Needle pricks^ cuts:
• Encourage bleeding by squeezing
• Wash for 10 minutes with soap and water or antiseptic.
• Cover with waterproof dressing e.g. Band-Aid. Don’t attend to patients until the
wound is covered
• Pricked finger should not be put into mouth reflexively
ii. For splash to nose/mouth
• Flush with water
r
Hi. For splash to eyes
• Rinse thoroughly with plenty of running water or irrigate copiously by running a pint
of normal saline over 10 minutes, with the eye being held open by another person.
3. Recording and reporting
• It is important that Mrs. Kavitha goes by herself to the person in charge of such
situations in the hospital (medical officer/ authorities / infection control officer)
regardless of the patient HIV status
• If she does not go she is reminded to seek the help of the person in charge of such
situations.
• Complete the “Needle stick or occupational exposure register.”
The register would provide information regarding the type of injury, the category of the
staff, the time, the place and the circumstances of the injury. Information from the
register could be used to assess risks and trends. This database should help reduce the
possibility of injury in the future. An example of how such a register is to be maintained
is given.
93
Sharps /needle stick injury report __________________
DETAILS
PATIENT
HEALTH PERSONNEL
NAME___________________
Hospital No._______________
Designation_______________
Age______________________
Sex________________ __
HIV Status (Known/Unknown)
HBV Status_______________
Other
INCIDENT DETAILS
Time:
Describe the mode of injury:
.Location:
Sharp / Needle—with visible blood on the instrument:
Reported to:
.Time of the report:
ACTION TAKEN (for administration purpose only):
YES / NO
FOLLOW UP (including serological investigations):
4. Risk Assessment
A person is considered to be at a greater risk if any of the following factors are present
• Large bore Needle - No. 22 gauge and above was instrumental for the prick
• Peripheral blood was collected
• Visible blood was found on the tip of the needle
• Deep muscle injury occurred with the needle stick injury
• Patient or person is HIV positive or HIV status is not yet clear
Table 6.1. Categorization of occupational exposure and type of PEP regimen
Small
volume
Less severe
Large
volume
More severe
• Few drops of blood / body fluids / other potentially
infectious materials (OPIM)
• Short duration__________________
• Solid needle (no bore in it)
• Superficial scratch________________
• Several drops of blood / body fluids / OPIM
• Long duration (several minutes or more)_________
• Large bore hollow needle
• Deep puncture
• Visible blood or needle used in persons artery /vein
Basic
Regimen
Advanced
Regimen
94
5. Testing and counseling
i. Test the patient / person (on whom the procedure was being done) for HIV
antibodies: It is advised that the nurse / ANM who sustains the injury collects 2-5 ml
of blood from the index patient (for HTV, HbsAg and HCV testing) and takes it to the
Medical officer / infection control officer, while going for risk assessment.
ii. Test the nurse / ANM for HIV antibodies after obtaining informed consent. The
blood samples are sent to Virology lab for screening for HTV antibodies. The duty
doctor would need to check the results within 45 minutes. The confirmatory test must
be done later. If the Nurse / ANM refuses HTV testing, this must be recorded in her
medical record.
iii. Pre-test and posttest counseling: AH health care personnel must be counseled by a
trained professional or in the case if such a person is not available then by the chief
medical officer / concerned authorities responsible to manage such situations / or the
infection control officer. Counseling must be performed irrespective of the status of
the index case and as appropriate. HIV testing must be carried out on three ERS test
kits or antigen preparations (Elisa / Rapid / simple) as a base line assessment for legal
purposes to rule out positive HIV status at the time of injury. Advice must be given to
refrain from donating - blood, semen or organs/ tissue and to practice safe sex.
Further counseling would be required in the case of a pregnant nurse.
6. PEP medication
When should PEP be initiated?
Do not delay PEP while awaiting index person or source patient’s laboratory results. The
PEP decision is based on the clinical risk assessment. And no time should be lost since
the best result occurs if PEP is started immediately. Moreover, the concerned health care
personnel in this case Mrs. Kavitha can stop PEP if the result is negative.
Mrs. Kavitha knows that prevention is possible if PEP is initiated. PEP must be started as
soon as possible preferably within 1-24 hours and is best if started within 1-2 hours.
Initiating treatment after 72 hrs of exposure is not recommended.
What are the investigations that have to be done before starting PEP?
The other investigations that have to be done before starting chemoprophylaxis testing
includes
• Hemoglobin / Platelet count / Reticulocyte count / WBC - Total and differential
counts / Renal function tests / Liver function tests / Random blood sugar
Do not delay starting chemoprophylaxis for the sake of these investigations. This should
be done to obtain baseline values and at follow-up every two weeks.
95
Frequently asked questions with regard to PEP
1. Should the only concern of the health care personnel after stick injury be only HIV
or is she at risk to infectionsfrom other organisms?
Yes, one is at a risk to Hepatitis B (HBV) and Hepatitis C(HCV) . The risk to HBV and
HCV is greater when compared to HIV.
2. If the nurse begins the drug regimen and develops fever and feels sick. Does she
have the acute symptoms ofHIV infection or is it related to her drugs?
Symptoms of acute HIV or hepatitis resemble those of an adverse drug reaction (fever,
rash, abnormal liver function tests) so the nurse / ANM needs to consult the doctor
immediately.
3. If the Nurse / ANM
discontinue the regimen?
begins PEP what are the possible reasons why she may
One may discontinue the regimen for reasons such as
• Source is HIV negative
• Side effects are not manageable
• One’s own choice
• Lab results are negative
4. You want to do a blood test to determine the index person 9s HIV status. He /she may
refuse. What will you do?
• Counsel the index person on the need for being tested
5. Is there a PEP program in the Government?
Yes! PEP is now available in all district hospitals in Karnataka. Any accidental exposure
needs to be reported to the medical officer. Though the risk for Nurse / ANM acquiring
HIV is very low, the absence of a vaccine or effective curative treatment makes the Nurse
/ ANM apprehensive. So it is very necessary to have a comprehensive program in place
to deal with anticipated accidental exposure.
6. What is the protocolfollowed in private hospitals?
When a staff gets accidentally injured it is immediately reported to the ward in charge
and the infection control officer and the treatment is started. This is also been informed to
the nursing superintendent and the needle stick register is entered. The same procedure of
PEP is followed even in private hospitals. The hospital administrator has to sanction the
prescription for issue of these drugs from the pharmacy, especially in situations when the
exposure is found to be genuinely accidental. But this is subject to institutional policy.
Chapter-VH
ATTITUDES REGARDING STI /HIV/AIDS
Introduction
Nurses are members of the society and are influenced by prevailing cultural, social and
religious attitudes. This can affect their attitudes towards those they care for and lead to
conflicts. Becoming aware of our own values and beliefs may help us to see how these
could affect our work with the community.
Exercise 7.1
A list of statements is given below. Ask the members to go through each statement
and put a tick (V) mark in the column provided and write briefly why they think so in the
reason column. Give them 3 minutes to do so.
Agree
Disagree Reason
1. The purpose of having sex is to show love for
some one_________________________________
2. If a person gets a sexually transmitted disease
it is his / her own fault______________________
3. People with AIDS should be isolated from the
rest of the community.______________________
4. Women who talk about sexuality are of low
moral character____________________________
5. Any sexual behavior between two consenting
individuals is O JC_________________________
6. Laws should be passed against the practice of
commercial sex
After the participants complete the exercise pick up one or two statements and ask any one
participant what they feel about it. Check if there are any contradictions and allow the
contradictions.
Then point out that nearly everyone has strongfeelings and opinions about certain issues.
But sometimes beliefs can change after listening to different perspectives.
Nurses must have open minds and not judge what others believe.
General Objectives
On completion of this topic, the participants should be able to identify the psychosocial
factor that affect people with HIV infection and be aware of the nurses role in relation to
social attitudes, values and beliefs and their effect on the individual.
98
Specific Objectives:
On completion of this session the participants will
• Be sensitized to attitude towards sexuality.
• Discuss the social and cultural attitudes and beliefs that affect individuals infected
with HIV/ AIDS & STD and their care.
• Describe the socio cultural constraints that a nurse and counters while educating or
communicating to people regarding STD / HIV/ AIDS.
Key concepts
• Sexual feelings are normal and real and no one should be embarrassed for having
them
• Persons with HTV are stigmatized and discriminated
• The human rights of all individuals including persons with HIV should be respected
• Nurses and persons with HTV face sociocultural constraints which have to be
identified and dealt with
Teaching methods
• Large and small group discussion
• Case presentation
• Reflective exercises
Material/preparation required
• Transparencies of important points, OHP
• Black board
• Handouts of exercises, other handouts
Topic outline
• Attitudes towards sexuality
• Illustrate ways in which some diseases are stigmatized
• Discuss the social and cultural attitudes and beliefs that affect individuals infected
with HIV/ AIDS & STD and their care
• Sensitive controversial issues
Total session time
45 minutes
99
BACKGROUND MATERIAL
Meanings
Values: Those aspects of culture that are held within high regard by the group and are
felt to be desirable and worthy of acceptance and practice.
Belief: Principles having a shared meaning among members of the group and held
by the group to be true. E.g. Belief in the existence of evil spirit.
Attitude: A pattern of mental views established on the basis of all one’s prior
experiences
Sexuality: Is how one describes him /herself as a person, how one feels about being a
man or a woman or the third sex (intersex / transgender / hijra) and how one
relates to members of either sex
Attitudes towards sexuality
Exercise 7.2
1. The facilitator gives the participants a handout on talking about sex’ that has 17
items.
2. The participants are read the following instructions.
Tor each of the topics below please mark how you would feel about discussing
the topic in general or with a particular group or person. You can choose to
mark that you are “uncomfortable”, “comfortable”, or “undecided”. You have 5
minutes for the activity’.
3. The facilitator must reinforce to the participants that there are no right or wrong
answers, and that everyone has a right to their own opinions.
4. After the participants have completed the handout the following questions may be
discussed under the guidance of the facilitator
•
•
•
•
Which topics were you most uncomfortable discussing?
Which group ofpeople were you most uncomfortable talking to?
Did you find any items offensive?
What concerns do you have with respect to talking / teaching about sex?
Then tell the participants this exercise is to sensitize you about your own
attitudes. But when we talk to people we must go with an open mind only then we
communicate with them successfully.
100
______ How would I feel talking_____
1. About homosexuality with adults?
2. About homosexuality with
adolescents?
3. About incest (act of sexual
intercourse between close relatives
E.g. Between sister and brother)?
4. With unmarried pregnant girls?
5. About sex in the workplace?
6. With someone who has AIDS?
7. About specific sexual behavior?
8. With my daughter about sex?
9. With my son about sex?
10. How to properly use a condom with
adults?
11. How to properly use a condom with
adolescents?
12. With your partner about sexual
matters?
13. About masturbation?
14. About sex and religion?
15. About specific male and female
anatomy?
16. About sex in a mixed company (both
men and women)?
17. With doctors about sexually related
issues (STDS and contraceptives)?
uncomfortable
comfortable
undecided
Negative attitudes towards sexuality
• It is dirty to discuss about sex.
• Too much knowledge is dangerous - can lead to sexual experimentation.
• Too embarrassing a subject to talk about.
Positive attitudes towards sexuality
• Sexuality is a natural and healthy part of living.
• All persons are sexual.
• Sexuality includes - physical, ethical, social, spiritual, psychological and emotional
aspects.
• Individuals express their sexuality in various ways.
• It is the families that provide children the first education about sexuality.
• Sexual relationship should never be coercive / exploitative.
• All sexual decisions have effects and consequences.
• All persons have the right and obligations to make responsible sexual choices.
• Young people develop their values about sexuality as a part of becoming adults.
•
Prerpature involvement in sexual behavior poses risks.
z•
1
•
Young people who are involved in sexual relationship need access to information
about health care.
Illustrate ways in which some diseases are stigmatized
Exercise 73
Pinpose of this exercise is to sensitize the group with regards to the effects of
misconceptions and attitudes of the community on the infected person.
h Get a person who has bear diagnosed as HIV/AIDS positive and has come to
terms with it to discuss his/ her experience in relation to tbe societies response to
his diagnosis, treatment, management (attitudes and beliefs)
2. This could also be done in the form ofa video or audio recording.
Discuss the social and cultural attitudes and beliefs that affect individuals infected
with HIV/ AIDS & STD and their care
Stigma: It is a mark of shame or disgrace
Discrimination: It is to treat a person, an idea or a thing as different (worse or
better)
The most common reasons for the prevailing beliefs and attitudes regarding HIV/AIDS or
STI/RTI are
• Lack of knowledge
• Fear of contacting the disease
• Fear of society (fear to show affection and acceptance of an infected person)
Education and awareness building among the general public about the causes, signs and
symptoms, spread, treatment and prevention of RTI/STD and HIV/AIDS could help in
removing these misconceptions. These misconceptions are major determinants in
decisions made by persons who are affected with the infection.
102
Exercise 7,4
The purpose of this exercise is to sensitize participant about possibility of STIGMA
because of RT1/STD/HTV/AIDS.
L Have two charts ready. On one chart write rejected and on the other accepted.
Stick these charts on two opposite comers ofthe room.
2. Make chits of paper; write one each of the following examples on each chit
Ask for 13 volunteers and then pin one chit on the front ofa participant
• Woman who is faithful to her husband but has developed HIV
• Woman who has multiple partners presenting with STD
• Woman who comes from a poor background presenting with HIV
• Woman coming from a rich background presenting with HIV
• A devadasi presenting with STD
• Woman who is forced to have sex with many in the same family (wife sharing)
presenting with STD
• Man who has several partners presenting with STD
• Man who has only one partner and is an influential person in the community
presenting with STD
• Man who has several partners and who comes from a rich family that is well
known in the community presenting with HIV
• A young girl (13-18 years) who presents with features of STD
• A young boy who presents with features of HTV
• A young boy who present with features of HTV, known to be of good character,
but having a history of taking blood transfusions
• A man (20 years) known to have behaviors such as drug abuse presenting with
STD
3. Then ask all the participants to stand up and mix with each other
4. The facilitator asks the participants
UTro in your mind are most likely to be rejected (thrown out) by their community
or looked down upon or are treated as outcasts?
5. As when the rest of the participants see a volunteer participant with a chit of
paper pinned in front of them ask them to decide whether or not the person will
be accepted or rejected by the community. That means those that feel the person
will be rejected or accepted must ask the respective volunteer towards the chart,
which is either written, rejected or accepted
103
Certain prevailing beliefs and attitudes (Misconceptions)
Reflective exercise 73 (optional)
1. The facilitator divides the participants into 4 smaller groups of 5-8 members
2. The participants are asked to discuss in 5 minutes the various misconceptions
they feel are prevailing in their community regarding HIV/ AIDS and STI/ RTI
3. The group leaders could then come forward and present the points discussed in
their respective groups
4. The facilitator then tells the participants various beliefsAnisconcepticms relating
to RTI/STD/HIV/AIDS are given in Hand out 7.1 which they could read later
and discuss when time permits during tea/hmch break or after the days session
Handout 7.1 Certain prevailing beliefs and attitudes (Misconceptions)
Beliefs / Misconceptions
Facts
Causes of RTI /STD
• Dirt, contaminated water and air
• Eating hot and cold food together
• Evil eye
• Heredity
• Mixture of many men’s sperms in one
woman’s vagina
• Needles and unsterile syringes
• Single contact will not cause STD
• Tubectomy & contraceptive devises
• Consumption of tea, chilies & hot
food
Causes of RTI / STD
• Specific causative organisms
• Indulgence in unsafe sex behavior i.e.
multiple partners
• Young ones bom to STD infected
mother
• Infected blood transfusions
Causes of HIV / AIDS
• Casual contact
• Multiple sexual encounters
• Punishment from god
• People with low morals get infected
• Western disease that you get only if
you sleep with a foreigner.
• Homosexuals and drug users
Causes of HIV /AIDS
• Causative organisms - virus (HIV)
• Unprotected sexual intercourse with an
infected person
• Sharing needles, blades, syringes of an
HIV infected person
• Blood of an HIV infected individual
transfused to another
• Infected women may pass it on to their
child during birth.
104
««►
rv.
ft.
a
r
Signs & symptoms of RTT/STD
&mV/AIDS
SSgnsA symptoms ofRTl/STD
AMV/AIDS
• Look weak and thin
• Feeling hot
• Black or dark face
• Wants to stay in a lonely place
• Pimples on the face and tongue
• Healthy looking person cannot harbor
HIV
• All white discharges in females are
normal.
STD/RTI
• May be asymptomatic in females
• Excessive discharge
• Ulcer in the genitalia
• Chronic pain in lower abdomen
• Child bom with eye infection
leading to permanent blindness.
my/AIDS.
Major - Greater than 10% weight loss
- Fever longer than one month
- Chronic diarrhea
Minor: - Persistent cough (> one month)
- General itchy dermatitis /Herpes
- Oropharyngeal candidiasis
- Generalized lymph- adenopathy
A*.
Spread of RTI / STD
• Blood transfusion
• Bodily warmth of an infected person
• Clothing / underwear/dirty linen
• Evil eye
• Kissing
• Needles and unsterile syringes
• One passes urine immediately in the
same place where an infected person
just passed urine
• Shaking hands / sharing food
• Warm seat
Spread of MV/AIDS
• Bathing in dirty water
• Mosquito bites / insect bites
• Sharing the same cup, plate and spoon
• Sharing food of an infected person
• Shaking hands and hugging an infected
person
• Sitting next to an infected person
• Using the public swimming pool/pond
• Using the same toilet seat
Wearing the infected persons clothes
Spread of RTIZ STD
• Through sexual intercourse
• From infected mother to child
Spread of HIV/ AIDS
• Spread through infected persons,
blood, semen, vaginal secretions,
and any secretions mixed with
blood
•
It is also spread through breast milk
CSF, synovial, pleural, peritoneal
and amniotic fluid and pass
105
Treatment of RTI /STD//HIV/AIDS
• Apply lemon to genitals after sex
• Cured with out treatment
• Having sex with virgin
• Drinking lime juice
• Being treated for STD is enough
• Taking antibiotics before sex
• Washing private parts with dettol
• Treatment can be stopped as soon as
symptoms subside
• Sex with a pig / virgins
• Take bath 4-5 times per day
With exorcism______________________
Attitude toward HIV / AIDS positive
person
• Extent of sympathy depends on how the
person gets the infection.
• People who die of AIDS deserve it.
• It is dangerous to have people with HIV/
AIDS in the community.
• A child who is HIV positive should not
be given admission into a school in order
to protect other children.
• A person who is HIV positive should be
removed from the workplace to protect
other workers.
Treatment of RTI/STD
• Medical management
Treatment of HIV / AIDS
• No cure but care and prevention is
possible
•
Accept the individual as he /she is
•
They are eligible for basic human
rights (Refer the annexure)
Exercise 7.6
The purpose of this exercise is to sensitize participants about constraints they might face
in dealing with PLHAs
1. The participants remain in the same group as in exercise 7.5
2. The facilitator distributes two colour cards viz. yellow and blue to each group.
All groups are asked to use the cards in the following order in 5 minutes
a. List down the constraints that nurse’s face while working with persons
with HIV/AIDS in yellow colour cards
b. List down the constraints that person with HIV /AIDS may face in blue
colour cards
3. The group leaders could then come forward and present the points discussed in
their respective groups
4. The facilitator then supplements any information, which did not come out from
the group presentation following which the facilitator gives information on some
sensitive controversial issues
106
Sensitive controversial issues
In the Indian context we have the following psychosocial constraints:
LTraditional customs and practices
i. Wife sharing practices
In some of the parts of India it is normal for the brother - in - law of the widow
(brother of the husband) to marry her in order to retain the property within the family.
T
li. Skin piercing rituals
It is a normal Indian practice to pierce the ears and noses of women and occasionally
men. The instruments used are usually not sterile and the same needle may be used for
many. Tattoos are another form of skin piercing practices that is a cultural practice,
which again involves the use of needles shared by many.
iii. Traditional healers and remedies: This may give people false hope of healing and
thus hinder adequate health seeking behavior, which to some extent can prolong life.
iv. Devadasies: They are girls who are groomed from the time they attain menarche to
live in temples. They are temple dancers and are used as sex professionals.
2.False information
A typical example is in relation to adolescents. Wet dreams are a normal occurrence as
a part of growing up leading to masturbation. But the elders often tell the adolescents
that this makes them weak. In order to overcome this problem they are encouraged to
indulge in sexual activity that may not be safe or typically due to their developmental
age they may indulge in unsafe sex practices.
5. Decision makers of thefamily
In a joint family, which is a norm in the Indian scenario, the decision maker in the
family happens to be the father or mother-in-law. In such situations it is typically seen
that the younger members of the family are encouraged to keep their problems within
the family. This prevailing practice may prevent persons especially women, from
discussing the issues related to STD/RTI with the health personnel and seeking help.
107
Chapter-VIII
COMMUNICATION AND COUNSELING IN CONTEXT OF STI/STD/HIV
Introduction
HIV has no territorial boundaries. It is found in urban and rural areas. By and large it may
not be feasible to know who is infected and who is not. It is therefore safer to modify
dangerous practices and prevent the spread of HIV.
Nurses can play on important role in informing and counseling the people with whom
they come in contact including their patients about HIV, and its prevention. This being a
sensitive issue calls for tremendous skills in communication.
Exercise 8.1
1. Ask for 4 -5 volunteers to go out of the room. They must not be able to hear what the
facilitator will teli rest of the participants.
The message that is read out is~
Mrs. Yamuna, wife of Mr. Yellappa came to the PHC at Maddur and met Dr. Dasappa.
She complained offeeling of weakness, fever, loss of appetite and sleep for the past 8
days. Says her husband is a lorry driver and comes home only once a week Over the past
few months she finds him withdrawn and dull. She asks the doctor if she can bring him
along during the next visit. The doctor gives her two tablets to be taken in the mornings
forfive days and asks her to take an injection dailyfrom Mrs. Dayammafor the same five
days.
2. One volunteer is called back into the classroom and the same above message is read to
him / her in front of the rest, only once.
3. The first volunteer must listen carefully and repeat the message to the second volunteer
4. The second volunteer then should repeat the message to the third volunteer who is
called in to the class room, the third to the fourth and the fourth to the last volunteer.
5. The 5 volunteer is then asked to repeat the message to the group.
There will be a change in the meaning of the message. Once this happens the
facilitator must make the group aware of how communication if not properly done
can lead to distorted and untrue messages.
General objectives
On completion of this session the participants will be able to understand the basic
theories and practice of communication as it is related to people with STD / RTI and
HIV/ AIDS and feel confident to use the skills with adequate guidelines and support.
108
Specific objectives
On completion of this session the participants will:
• Identify their personal strengths and weaknesses in communication
• Be sensitized to the points for effective communication and phases of communication
• Be aware of barriers to effective communication
• Identify various aspects of behavior change communication
• Develop appropriate communication and counseling skills for individuals in need of
HTV testing services
Key concepts
• The nurse needs to have self awareness regarding her / his communication skills
• Communication follows a series of well organized steps in order to be effective
• Effective communication techniques enhance communication
• Barriers of communication need to be identified and overcome
• Counseling is part of the caring process of persons at risk for HIV or with HTV
• Nurses could help in the counseling of persons at risk for HIV or with HIV in settings
where trained counselors are not available
• Nurses can leam the various aspects of counseling of persons at risk for HTV or with
HIV through practice
Teaching methods
• Small and large group discussion
• Reflective exercise
• Role play
• Lecture
Materials/preparation required
• Black board, chalk, duster
• OHP, transparencies of important points
• Copies of handouts, checklists
Topic outline
• How do I rate as a communicator?
• Points to remember about communication
• Tips on communicating sensitive issues
• Barriers to communication
• Skills in counseling
• Characteristics of a good counselor
• Pretest counseling
• Post test counseling
Total session time
3 hours t
109
BACKGROUND MATERIAL
How do I rate as a communicator?
Exercise
1. Ask the participants to give their meaning of the word communication
2. Write the reqxaises on the board
3. Supplement this with the following definition
^Communiotion is a process by which information ideas and feelings are
exchanged between individuals^
It is important that each one of us is able to introspect and discover what are our own
personal strengths and weaknesses in relation to communication. This is necessary since
we have to build our skills in communication, as it is one of the strongest ways to
facilitate behavior change. The next exercise will provide you with a means to discover
your own strengths and weaknesses in relation to communication.
Exercise 83
This exercise would help participants evaluate themselves in relation to how well
they could communicate
1. Ask the participants to read the rating scale given soon after Exercise 83
of the module
2. Read the instructions to the group to rate themselves against each item by
placing a check (>/) in the column that best suits them.
3. Instruct them to fill in the columns as soon as they read the statement
/item and not to delve for too long on the item since then they are likely to
rate themselves differently. Also affirm to them there are no right and
wrong answers.
4. Ask each participant to complete the Performa in 2 minutes
5. Give them a feed back after they complete the exercise
Evaluation — The more the number of u can do very well” the better the
communication
no
Performa-How do I rate as a commoniaitor?
4k
Instructions:
A list of statements is given. Please read each statement and then rate yourself according
to the following criteria ‘can do very well’, ‘can do ’ and ‘unable to do’. Place a check
(^) against the respective column for the item. Complete all the 20 items.
Please remember there is no ‘right ‘ or ‘wrong’ response. This is only an exercise which
would help you understand your self better and would help you identify the areas in
communication which you would have to improve on. Try and be as honest as possible
with your response.
Do not take too much time with each item. Just check (*7) the item as soon as you have
rated yourself for the item. We will not be asking you how you have scored in this
exercise. It is just an exercise for self-awareness.
<■
Can do
very well
XT
-
Can do
Unable
to do
I can recognize my own feeling____________________
I can recognize another feelings___________________
I can express my own feeling_____________________
I can accept my own worth and feel happy with myself
I can accept my own limitations / weakness with myself
I can recognize and express my negative feelings_____
I can accept positive feedback without feeling shy_____
I can accept negative feedback without feeling bad
I can read others non-verbal communication well______
I can show sympathy or identify with other feelings
I can express my goals and intensions clearly_________
I can deal effectively with misused messages (words say
one thing and actions another)_____________________
I remain calm in high stress situations______________
I can give positive feedback to others so they feel good
and reassured__________________________________
I can give negative feedback in a helpful way_________
I can express my feelings nonverbally_______________
I can accept others as they are_____________________
1 can describe another’s behavior without passing
judgments ___________________________________
I can accept other peoples opinion even though they are
not my own_
I am op^n to new values, attitudes and experience
111
Tips on communicating sensitive issues
1. Create an environment that is supportive. This includes:
• Considering the timing of the discussion
• Selecting a place that provides privacy and less distraction
• Acknowledging the feelings of the person and reminding them that they are not
the only ones who face such problems.
• Beginning with less intimidating / less sensitive issues
2. Keep in mind the message: (Refer back to Exercise 8,1)
Distorted message occurs if
Solution for avoiding it
It is too long
Keep sentences short
Too many names / unfamiliar
words
Use simple understandable words / language
It is not repeated
Repeat important points
It is not important to the
listener
Make it appropriate for the listener
If the listener is nervous
Make the listener comfortable
3. Use audio visual aids since it makes communication clearer
Remember - “ What I hear, I forget.
What I see, I remember.
What I do, I know.”
4,Remain non judgmental and relaxed
5.Do not be afraid to ask but be aware of how to ask for information
6.Keep the following points (see Handout 8.2) in mindfor effective communication /
counseling
1 12
Handout 8.1. Points to keep in mind for effective communication / counseling
Message
• Keep sentences short and simple
• Make the listener comfortable
• Use a language known to the listener
• Do not use too many names and unfamiliar words
• Discuss one point at a time
• Focus on the listeners needs and interests.
• Talk slowly
• Ask for a feedback
• Repeat important points
• Summarize main points
Listening / Non verbal communication
• Respect the person/s.
• Maintain eye to eye contact
• Smile when necessary
• Lean toward the person
• Nod head occasionally
• Say “yes” “hmm” and “OK”
• Do not hesitate to touch the person when needed
Tone
• Use a tone of voice that encourages communication
• Utilize praise and encouragement more
Questioning technique
• Use open ended questions
• State questions clearly
• Use the language understood by the person
• Start with ‘how’, ‘when’, ‘why’ or ‘what’
• Ask only one question at a time
• Waits for answers rather than speaking immediately
• Repeats questions when not understood
Brainstorm (5 minutes)
What do you think are the barriers to communication?
1. List the points on the black board?
2. Ask one participant to read Handout 82 and clarity any doubts if any?
1 13
Handout
Barriers to communication
Personal Barriers
Remedies
Attitudes
Differences in attitudes
- Allow differences in attitudes and respect their
viewpoints even if you do not agree
Belief
Differences in beliefs between
individuals
- Encourage helpful beliefs
- Accept neutral beliefs
- Discourage through education / awareness those
beliefs that are harmful. E.g. People with AIDS
should be isolated
Misunderstanding
- Identify and clear doubts
Language
- Speak / communicate in the language familiar to
the listener
Not listening
- Be a keen listener (see checklist -2)
- Draw the individual back to the topic of
discussion
Cultural differences
E.g., wearing of footwear inside the
house
- Be aware and respect the culture of the target
group
Lack of identification of the need of
the community
E.g. There is a prevalence of cholera
in the village but the nurse addresses
the issue of TB
- Always communicate with consideration of the
felt need of the person to whom you are talking
Interruptions
- Redirect the communication back to the topic
Personal values and morals
E.g. The nurse may strongly oppose
idea that commercial sex workers are
also considered as professionals.
- Although all values and morals of the person
may not be acceptable respect his / her right to
their values / morals
Prejudice (pre judgment)
E.g. That all professional sex
workers are anti social elements.
- Show acceptance of the individual but not the
value / moral
- Always communicate writh an open mind
- Avoid being judgmental
114
Personal barriers to communication
Being embarassed...
Having no solution...
Being in a hurry...
Community Barriers
Being unsure of self...
Being unable to establish a rapport...
Remedies
Denial — of the existence of the problem
E.g. “AIDS is not a problem in our
village.”
- IEC activities
- Networking with influential people
Fear and stigma
E.g. “The more we talk about AIDS the
more frightened we get therefore it is
better not to talk about it”.
- Prevent it by showing positive attitude
- Educate the public about HIV/AIDS
Illiteracy
- Make them aware of the problem
Embarrassment / discomfort
To talk about the issue evidenced by
trying to change the topic
- Build rapport and help them feel
comfortable
Helplessness
E.g. “I can’t do anything about it.”
- Make them aware of their role in
controlling and preventing the spread of the
disease.
E.g. Through behavior control and
education
115
We need to learn to communicate effectively, as nurses we are responsible for
- Educating individuals, family and community.
Facilitating change in high-risk behavior.
Hence a brief discussion of behavior change communication will follow.
Behavior change communication
Meaning
Behavior. Is any or all of a persons total activity, e^ecially that which is externally
observable.
Behavior change communication'. Is communication by which information, ideas and
feelings are exchanged between individuals for the purpose of bringing about a change in
some of the concerned persons activities.
Goals of behavioral change communication
• Facilitate a positive attitude
• Aid in motivating the concerned person
• Identify obstacles in behavior change
• Recognize resources required for behavior change
• Assist and support individuals during the process of behavior change
Area in which behavior change would be required
• Self-care behaviors such meetings one’s personal hygiene needs
• Personal habits such as intake of alcohol, drug abuse, late night parties etc. that
may predispose the person to taking part in risky sexual behaviors
• Sexual behaviors
• Family life especially in terms of making plans for the future
Obstacles to behavior change
• Personal attitude such as denial and feeling of powerlessness (meaning that the
person feels that she / he cannot make the change)
• Socio-cultural factors like financers, peer group pressure, attitudes and beliefs
• Lack of knowledge and experience in the field
• Lack of resources
116
Factors influencing behavior chaages
Informations If persons are given correct
and appropriate information they may
become sensitized to the need for change in
their life styles or behaviors. Becoming
aware of the need to change by receiving
information is one of the strongest
motivations for a person to want to change.
&
Motivation'. Several factors could aid in
motivating individuals to want to change
their behaviors. It is however important to
remember that change and motivation is
strongest when it comes from within the
person. This usually happens when an
individual is faced with a personal crisis or
is in the cross roads of his or her life,
during which time the person is internally
driven to try a difficult change.
Methods to overcome obstacles
KnowM^e: Increase the knowledge,
through IEC activities
• Regarding spread of STD / RTI and HIV
/AIDS
• Its presentation
• Signs and symptoms
• Available resources for the treatment of
any of these infections
• Appropriate use of resources
• Risk reduction practices
Attitudes md belief^ Promote amcmg the
listeners the following attitudes and beliefs:
• I am in control of my life and health and
can change behavior.
• I deserve good health
• The sacrifices required to change is
worth it
• What the health personnel is telling me
is true
• Anyone can get STD / HIV
• There is no cure for HIV
• Condoms are for everyone to use
Skills: Enhance the following skills
• Increased ability to communicate with
their partner
• Improve their ability to discuss and try
new sexual practices with one partner
• Acquiring and using condoms properly
• Planning in advance for sexual activity
Support! Support can be available from
any number of sources (self, peers, family,
community and significant others viz.
religious, teachers, etc). It is important that
focus of all support persons must be in risk
reduction strategies. Other sources of
emotional support when change becomes
difficult must be tapped so that the person
at risk for infection is motivated enough to
practice safe behaviors.
Support to promote
Risk reduction practices includes the
following:
• The partner’s willingness to change
• Use of readily available and affordable
condoms
• Encourage practice of safe sexual
activities
117
Components of counseling in the context of STI / STD / HTV
Role plav gaidefines
1. The facilitator along with one or two otha-co-facilitators role plays a
situation
Mrs. Srimathi is presenting with a history ofexcessive vaginal discharge. She
approaches the nurse in the PHCfor help
2. The participants are taken through a scene of assessment, pretest
counseling and if time permits, post test counseling, follow -up and
support
3. The participants are then asked to review the Handouts 8.1,82 and 83.
4. The facilitator then reviews components of pretest co
ding. All the
participants are also asked to review Handouts 8.4 - 8.5
DON’T’S DURING COUNSELING
Be judgmental
Be embarrassed
Advise
DO’S DURING A COUNSELING SESSION
Show concern with your posture / same sex preferable
Be supportive
118
Handout 83 Phases of communication/counseling
Pre-orientation phase
• Obtaining available information of the person
• Self examination (comes to terms with own feelings about HTV/AIDS)
Orientation phase
• Develops a rapport
• Builds trust
• Assures confidentiality (keep in secret the information received)
• Gathers assessment information
(High risk behavior, time of the last risk behavior or contact, specific life
situations such as marriage, pregnancy and migration)
• Identifies strengths and weaknesses of the person (e.g. coping skills, family
support etc.)
• Assesses the knowledge of the person regarding HIV
Working phase (in relation to the case given)
• Gives information
- The test details
- Purposes
Window period
Interpretation of the test
Implications of the test
Who should know the t^st result
• Clarifies any misconceptions and doubts
• Orients regarding facilities available for testing and management
• Obtains consent for HIV testing
• Assesses the person’s capacity to cope with the results
• Educates regarding HIV
• Identifies problems and helps to find solutions
• Helps the person in making decisions
• Makes attempts to overcome resistant behavior if present
Termination phase
• Summarizes / reinforces the information given
• Assures the person of the availability of any staff to meet her needs (letting go)
119
Proper testing and counseling for HIV infection involves several activities and skills
that you would have to develop.
1. Pretest Counseling
Aims ofpretest counseling
• Preventing transmission
• Providing the opportunity to prepare the person emotionally for accepting a positive
result.
• Helping to become aware of the strengths and weaknesses of the person.
Steps in pretest counseling
i. Identify need for being tested
It is important that you are able to identify who should be tested. Highlights of persons
who must be encouraged to take the test are listed in Handout 8.4.
Many experts today feel that ALL individuals should be encouraged to be tested,
irrespective of their risk status. Figure I can be used as a simple guide to know who
should be counseled to seek HIV testing.
Handout 8.4. Persons who need to be tested
•
•
•
•
•
•
•
•
•
•
•
•
•
Homosexual or bisexual men
Intra venous drug users (IVDUs)
Transfusion of blood
Donors - blood, sperm or organ
Infants bom to HIV infected or high risk mothers
Sexually transmitted diseases (STDs)
Concerned - Any person worried about the possibility of having HIV disease
Hepatitis B, Hepatitis C (non A / B Hepatitis)
AIDS -like illness or illness consistent with AIDS
Multiple sexual partners -sex for money, pleasure or drugs
Partners of homosexuals, bisexuals, IVDUs or of any HIV positive individual
Organ recipients
Tuberculosis infected persons
ii. Appraise the persons risk status
In order to identify the risk status, you must be able to obtain reliable, personal history of
person’s concerned.
120
You do not need to go in to details but it is necessary for you to ascertain whether or not a
risk behavior was present or not in the individual. A list of some questions that you can
ask to the person is given in Handout 8.5.
4t
Handoat 83: List of questions that may be asked to a person to assess their risk
status
; • Do you have sex with more than one person?
I • Do you have sex with men or women or both?
i • Do you have oral, anal or vaginal sex without using a condom?
• Do you have sex with someone with known or suspected history of
■ Multiple sex partners?
■ Bisexuality?
■ Intravenous drug use?
■ Taking other drugs?
■ Receiving blood transfusion?
• Have you ever had
■ Genital ulcers?
■
Warts?
STDs such as syphilis, gonorrhea, crabs, scabies, herpes,
hepatitis B?
Have you ever injected any drugs intravenously and if so, do you share
needles?
■
•
iii. Provide needed information during pretest counseling
Information that has to be provided during pretest counseling includes
• The purpose of HIV testing
• The limitation of HIV testing
• Consequences of testing result
• Methods of prevention
• Importance of early medical intervention, since it is likely to decrease the sense of
hopelessness that goes hand in hand with the diagnosis of HIV
• Causes, spread, treatment and prognosis of HIV and AIDS with the main aim to
correct any misconception the person may have
• Anonymous testing in the event of persons who may refuse to consent for HIV
testing.
iv. Inform about the required tests and interpret the results
•
•
•
In VCTs cost of testing is only Rs. 10/A rapid test for detecting antibody to HIV is a screening test that produces very quick
results, usually in 5 to 30 minutes. In comparison, results from the commonly used
HIV antibody-screening test, the EIA (enzyme immunoassay), are not available for 12 weeks.
The availability of rapid HIV tests may differ from one place to another. The rapid
HIV test is considered to be just as accurate as the EIA.
121
•
Both the rapid test and the EIA look for the presence of antibodies to HTV. As is true
for all screening tests (including the EIA), a reactive rapid HTV test result must be
confirmed before a diagnosis of infection can be given.
Do not to tell the person the result until three tests are positive or reactive on the same
blood sample.
Remember
L Confirmed dia
is: Three positive tests on the same sample of blood is
needed to confirm tbe diagnosis of HIV
2. For known exposure: Advice them to repeat tests within 3-6 months if the
first test is non-reactive since they may be in the window period
3. Symptoms related HTV: Advice the need for retesting serially on the same
sample of blood till three consecutive positive test is obtained
2. Post test counseling: Posttest counseling could be done following HIV testing and
once the results are known definitely.
Aim ofpost-test counseling is to:
• Support the HIV positive person
• Prevent HIV transmission to a HTV negative person
Posttest counseling should be considered separately for two categories of people
• Persons who are HFV negative or have indeterminate tests
• Persons who are HIV positive
Exercise 8.4
The purpose of this exercise is to give participants the chance to role play different
situations of pre test counseling.
1. Divide the participants into 6 groups
2. Ask participants to role play the following situations while the rest of the
participant observes
Counsel a person
• Whose test is negative with high risk behavior (see HandoutS.6)
• Whose test is positive (see Handout &7)
• Whose spouse needs to be informed about the partners HIV status (see
Handout & 7)
• Regardingfollow-up (see Handout 8.9 in Facilitators module and
Handout 8.8 in Participants module)
• Regarding reducing risk for oneself( see Handout 8.10 in Facilitators
module and Handout 8.9 in Participants module)
• Regarding preparation for death (see Handout 8.11 in Facilitators
module and Handout 8.10 in Participants module)
3. It is preferable that all participants and each group be given the opportunity to role
play all situations and then given the chance to read out handouts 8.6-8.11
‘ provided time permits. Alternatively if time does not permit, ask each group to
come forward and present a role-play on the given topic. After the role play the
rest
122
Handout &6: Persons who are HIV negative (no clinical signs bnt has risk
factors) and those with indeterminate resnhs (no clinical signs bnt have risk
factors)
HIV negative
a. Counsel face to face as soon as the results are obtained
b. Check whether the person is ready to hear the result, if not suggest a later date
and ask them to bring a support person if needed
c. Emphasize on the need for change in life styles in relation to sexual
relationships, habits such as drinking, smoking etc. since this could increase
their risk for participating in unsafe sex
Indeterminate results
a. Counsel face to fece as soon as the results are obtained
b. Check whether the person is ready to hear the result, if not suggest a later date
and ask them to bring a support person if needed
c. Counsel on need for additional testing, clinical follow-up, and change in
subsequent high-risk behaviors if they have repeated indeterminate result but
have a history of exposure
d. Confirm the need for subsequent testing to those persons who have a nonreactive result but have been recently exposed to any of the risk factors
e. Do not tell the person with the indeterminate test that they have the infection
f. Advice them on the need to avoid donating blood, semen, breast milk or organs.
Handout 8.7. Person who is positive - Points to be kept in mind when revealing
HIV status to the person or to the infected person’s sponse/partner
a. Counsel face to face as soon as the results are obtained
b. Check whether the person is ready to hear the result, if not suggest a later date
and ask them to bring a support person if needed
c. Reveal the HIV status sensitively.
■ Keep in mind that there are no standard instructions for this
■ Follow the person's lead. For example even before revealing the diagnosis
you may start by asking c Have you been thinking a lot about your tests
results? Would you like to know it? The person's response to these
questions would reveal how prepared for the diagnosis
■ Give result simply, clearly and humanely
■ Allow time for result to sink
■ Be positive in approach. Reinforce that presently the person is healthy but
is likely to develop problems in the future
■ Give information according to the needs of the person.
d. Deal with immediate reactions (see Handout 8.8)
e. Remind them on the need for more counseling sessions.
f. It is encouraging to tell the person ^you may have HIV infection but there are a
number of ways in which you can live healthily' or 1 have suggestions for you
r which you can use to live healthily despite knowing that you have HIV'
123
Handowt RUxImnediate reactions of persons when they are revealed the
diagnosis of HIV
★Deniai/Shock - Phrases that they are likely to come out with fcME?’ or they might
just be silent having a blank expression.
Mwger — it may be directed to themselves for their previous behavior or it would be
directed towards the people who most likely infected the person, or even to God for
not sparing the person. Typical phrases are* why me? Otfiers do it all the time and
yet I have got the disease!
★Revenge or spite - due to excess anger the person likely says 41 got the disease
because of one acf now why I should only suffer, let the others also get the disease
from me!’
★Bargaining- sometimes they bargain with God for a better deal. Common phrases
being mentioned during this period are 4 if I am given a chance I will live a better
life’ etc.
★Lonetmess, despair and depression- manifested in the later stages of reactions to
any bad news and are aggravated by the way significant others are likely to react to
the affected person. Depression could lead to suicide.
★Fear — Common reasons of fear are of pain, losing a job, others getting to kne w
that the person is HIV is positive, leaving children, death, or even of spreading the
disease. Fears are worsened because of media and literature, which refer to the
disease as a fatal disease or a bad disease.
★Acceptance and hope — If the person is given continued support and reassurance
they are likely to accept their HIV status and learn to live with the infection
Handout 8.9
Speak the truth gently in discussing follow-up care and support
need for ongoing counseling
counseling the partner and the family
personal, family, social implications
social support
legal advice
referral for screening and treatment of STDs
family planning counseling
special services to pregnant women
medical reference
'
treatment plan and future plans
124
Handout 8,10: Develop personalized risk redaction plan
Discnss issues sndt as
• Practicing safe sex
• Enhancing selfesteem
• Avoiding alcohol, drugs and smoking
r:TiV«nl
• Changing lifestyles to avoid transmission
• Those related to transmission such as to
□ Avoid donating Hood, semen, breast milk, organs
□ Avoid sharing needles
□ Always use sterile needles and syringes for drug use
□ Take care of blood stained clothes especially those after
□ Use separate tooth brushes razors, blades etc.
/**•
Ideni^y optiotts mdnsourcesforfuturt
Issues that may need to be discussed depend on the individual person’s need. It is also
necessary to communicate to the individuals the availability of counseling whenever
needed. Points that need to be discussed include
• Initiation of appropriate early treatment
• Reinforcement of the concept of hope
• Need for health information
• HIV disease process- cause,, spread, treatment options, prognosis
• Associated opportunistic infection
• Prevention oftransmission through sexual contact, breast milk, placental,
during delivery, intravenous route
• A vaiiability ofmethods to prevent transmission to others and in the case of
HIVpositive mother methods cfprevention to thefetus or the baby
• Needfor complete health or medical evaluation
• Availability ofsupport services and community based organizations
• Referrals to rehabilitation and community agenciesfor additional support
Handout 8>11: Preparing a person for death
• Assess the persons knowledge of what he/she has been told about the condition
• Assess the person’s support systems (Family, friends, any other form of support)
• Find out what resources the person has to cope with the situation of impending
death
• Encourage the person to express his /her feelings or fears or needs or concerns
• Support the person while he / she reacts
• Enquire whether the person requires any specific help or person to be with him /
her
• Check whether the person wants to make plans for the family
• Check whether the person wants to see any religious person
• r Enquire about what the person wishes for his / her last rites
• Make appropriate measures to see that the person is comfortable
• Above all be with the person
TZ3
Chapter ~ IX
COMMUNITY BASED CARE FOR PEOPLE LIVING WITH HIV/AIDS (PLHA)
Introduction
Persons with HIV infection/AIDS do not require isolation but the virus needs to be
isolated. Hence focus is shifting on care for people with HTV in the community itself with
the hospital being reserved only for acute episodic illnesses.
Comprehensive care concept encompasses medical treatment, nursing care, counseling
and other social as well as psychological support for persons with HTV/AIDS, their
families and dependents. Community based care requires effective linkages between
hospitals, health centers, communities and home which can be initiated by nurses. By
involving communities, the quality of life for people living with HTV/AIDS can be
substantially improved.
(jeneral objectives
The participants will be able to understand the meaning of community based care and
develop skill in providing need based care in the community for people living with HIV
and AIDS.
Specific obiecmes
On completion of this session, the participants will:
• Demonstrate an awareness of care and support
• Recognize the types of care and its benefits
• Implement the components of community-based care
• Participate as link for providing community based care
Key concepts
• Community based care is necessary for PLHA
• Nurses could play a vital role as links for providing community based care
• Hospitals could be best used to meet the acute needs of PLHAs
• Community based organizations, support groups, NGOs and homes could be used to
meet the day to day needs of PLHAs
Learning methods
• Lecture
• Discussion both small and large group
• Case study
• Exercises
126
A
SES*
Materials/preparation required
• Transparencies with figures and important points, OHP
• Black board, chalk, duster
• Chart paper, pens
• Handouts
98*-
HA
rr.
Topic outline
• Meaning of key terms
• The present scenario of care and support
• The purpose of care and support for PLHAs
• Components of community based care
• Types of care
• Frequently asked questions while caring for PLHAs
Total session time
45 minutes
127
BACKGROUND MATERIAL
Meaning of key terms
Exercise 9J
L The facilitator conducts a brainstorming session on the meaning of &care7
and ^support*
2. Participants are requested to express anything that comes in their mind
about the two words
3. The facilitator then summarizes the points that come forth
Caring
Caring means ‘concern for the well being of another. It means helping persons to recover
from illness so that they can live as normal a life as possible
Caring process
• Knowing
• Being with
• Doing for
• Enabling
• Maintaining belief
Caring may mean...
• Being there to help them get a meal together
• Feeding them
• Helping them get dressed
• Sitting with them, being quiet/talking
• Helping them get to the bathroom
Continuum of care
• Entry
• Counseling and information
• Management
• Home based care and family counseling
• Palliative care in the hospital or home
• Care and support of the family after death
Support
Support means the assistance given to the person by another in all ways. Support is
important to maintain a positive attitude and includes support from family, friends, lovers
and partners.
128
The present scenario of care and support
_______ Present situation_______
• Many states in India do not have
adequate care center
• Majority of money is spent on
prevention rather than care
• Essential life saving drugs is not
available.
• Death rate increasing
• Rejection from the community
•
•
•
•
Our dire need and vision______
Education of the community to
facilitate in community based care
Home and community care
Medicines for all OI including ART
Support groups to help PLHAs lead
a normal life
The purpose of care and support for PLHAs
• Improving the quality of life
• Developing cost effective, sustainable approaches
• Increasing life expectancy
• Reducing the stigma
• Providing diagnosis and treatment for common diseases
• Preventing the spread of the infection
• Improving counseling care and support services
• Providing palliative treatment and supportive rehabilitation
• Enhancing awareness on legal and human rights
• Initiating livelihood program
• Developing support agencies and other financiers of AIDS program as a powerful
tool for expanding the response to the epidemic
• The final goal of all care and support intervention is to help PLHAs live positively
Exercise 9>2
1. The facilitator divides the participants in to four small groups
2. Each group is asked to discuss what they mean by living positively in 5 minutes
3. A representative of each of these small groups would then come and present this
to the rest of the participants
4. The facilitator then could then request
volunteer from among the participants
to read aloud Handout 9.1
129
Handout 9.1: Livmg posithrely with illV /AIDS
Livmgpmitmfy witk HIV/AIDS means^
• Spending time with family and friends
• Planning for the future of loved ones
• Maintaining spiritual health
• Having hope
• Managing self care
• Eating a balanced diet
• Keeping busy
• Remaining productive
• Maintaining a balance between activity and rest
• Avoiding the use of alcohol and tobacco
• Seeking medical help whenever an illness arises
• Going for individual and for group counseling
• Learning about transmission and management of HIV infection.
Components of community based care
The components within the continuum of care can be summarized as follows
Medical services
For details refer to Chapter-II
Nursing care'. Nursing care can be given at the
• Hospital
• Day care centers
• The homes of persons with HIV/AIDS preferably by family members after
appropriate training and with supervision by nursing staff
• Outreach programs
• Community based health
• Social welfare programs
Focus of nursing care must be towards
• Modifying behaviors to reduce risk of HIV transmission (see Chapter VIII)
• Educating persons with HIV/AIDS and their family members about prevention (see
Chapter IV)
• Counseling (see Chapter VIII)
130
Focus of nursing care.
counseling
Social support
• Starts in the hospital by health care personnel at all levels and/or social workers
• Needs to be followed up through the community based care program in collaboration
with social welfare institutions and NGOs.
Social support of PLHAs couM help.
Types of care
Types of care for PLHAs may include care in the hospital, clinic, home based care, day
care centers, and respite care.
Exercise 93.
This learning activity gives the participants the opportunities to consider the relative
advantages and disadvantages of people being cared for in a variety of settings (E.g.) in
hospital, in out person clinics and in the home.
1. The facilitator divides the participants into 3 groups of 5-6 members each
2. Ask them to discuss the advantages as well as disadvantages of care given in
different settings 10 minutes
3. One representative from the group will come forward and present points
, discussed to all the participants
131
i. Home based care
Objectives
To visit people with HIV infection in their homes in order to
• Assess their physical, psychological, social and spiritual needs
• Provide for these needs where possible
• Carry out contact testing
• Carry out counseling and education with the families and communities
• Provide personal support, and promote sustained behavior change through community
support
• Counseling of the concerned person regarding treatment and prevention of
transmission
• Assess the educational input of AIDS management on people with HIV/AIDS and
their families
Who provides kaa^e based care?
The health team members can be a clinical officer, 2-3 nurses, social workers, health
educators and project manager. There must be strong links between medical
professionals, paramedics, social workers, volunteers, families and communities. The
home care teams use a medical kit that contains a range of basic treatment to improve the
clinical status and personal comfort of the PLHA
Steps involved in hone based care
Exercise 9.4: Role Ptav
1. The facilitator requests for volunteers to enact a scene where a nurse is
providing home based care for a person with HTV infection.
2. Review with the participants once the role play is over what are the Do’s
and Don’ts to be kept in mind during home visits
______ Do*s during home visits______
• Customary greeting
• Respect confidentiality of the person
• Review of how the illness has
developed since the last visit
• Physical examination
• Enquire about any new probelms,
care and supplies of medicine
• Provide hygiene advice to the PLHA
and their families.
• Spiritual support (if needed or
requested)
• Demonstrate any procedure to other
members in the family
• Involve other members in active care
• Give date for next visit
Donfts daring home visits____
Go without prior notice to the
person
Dress inappropriately
Show facial ex press ions such as
disgust, surprise, non-approval
etc.
Give blind referrals
Be in a hurry
Go without a plan of care
132
H—d<Nrt9X Advantages and disadvantages of some settings of care for PLHAs
Ei,
■r
Advantages
Dtsadvantagps
Hospital
• Ideal for investigation
• Costly or sometimes not affordable
• Ideal for treatment of acute conditions • May increase chance of stigmatization
(e.g.) acute respiratory infections, severe
especially if isolation of persons is a
diarrhea, encephalitis etc
policy
• May not be appropriate
• May not be available
• May be rejected by the person
• May be too far away______
Ontpatient clinic
r
■ • More person friendly than hospitals
• May not be able to treat acute conditions
! • Cheaper for hospital and person
i • Can continue one’s social and personal
activities
• More acceptable to persons because their
needs are assessed
• More possible to preserve confidentiality
Home-based
• Holistic care possible and more personal
• May cause emotional drain in persons
• Person may feel more accepted
i • Person affected must feel confident of
• Less expensive
the possibility of care at home
• Facilitates availability of hospital beds • Availability of a support system to
for care of other persons
provide care e.g. Family, partner,
• Reduces stigma
friends, community people
• Helps in tracing contacts
• Shortage of care providers
• Enables the ill to be as active and • Lack of home nursing resources
productive as the disease allows
• Person may not have a home
• Preferred option if they know they cannot • Places continuous demand on other
be cured in hospital
family members
• Reduced pressure on hospital
• Other members of the family may also
• Family support is strengthened for the
be sick or fall sick
person and his /her dependents after • Break in confidentiality
death
• Preventive education takes place within
the immediate and extended family and
outwards into the wider community
• Avoids dependability on hospitals
• Is more sustainable
• Relatives may be able to carry out their
duties more easily
133
Contd'nt.s. ofH&m/e' Care kit
Medications
• Bicarbonate of soda. 500 mg.
• Ferrous sulphate
• Loperamide
rm r tablets
• Muhivitamin
•
Oral rehydration salts
•
•
Nystatin sn^ension 25 ml
.fe'iiKi; tablets 500 mg.
Paracetamol
External metticaticuts
• Benzyl benzoate — 30 ml.
• Calamine lotion 500 ml.
• Gentian violet 15 ml. Vials
• Hydrogen peroxide - 30 ml. Vials
• Household bleach
• Iodine solutions 10% 30 ml. Vials
• Menthol balm
• Potassium permanganate 10 mg. Sachets
Miscellaneous
• Bandages. Cloth pieces. Cocoout oil. Condoms. Cotton wool.
Gloves^ Matches^ Micro pore tape. Piasters. Plastic bags. Soap
powder. Safety pins. Talcum powder. Scissors. Elastic bands
Community care
Community based groups; NGO and associations of people living with HIV have become
key partners in the fight against the epidemic. Women’s club, youth, religious groups as
well as local political and social organizations can also be mobilized to assist.
Community organization should organize
• Educational sessions on how HIV infection is spread
• How HIV is not spread
• How to help support individuals/families affected with HIV
infections/AIDS by
arranging for:
o Financial assistance
o Food
o Spiritual care
o Medical care
o Ambulance/transport for medical care
o Care and support of children affected with HIV infection/AIDS as well as
healthy children and orphans.
134
Hospice care
Hospices
■ Cater to the needs of the terminally and acutely ill
■ Are very good environment for pain management and palliative care
• Are good respite options for PLHAs and their carers
• Provides for convalescent care with the aim to return the person to their home
Hospices may vary with their policies as well as their health and support services.
Hospices may be public health services, which will be free, or private, for which you will
have to pay. Even public hospices may have to charge for some services, which are not
provided directly by them.
Respite care
Respite care means someone else cares for the people that are cared for. It could be for a
few hours, a few days or longer. It could be regular or something that just happens when
needed.
There are 3 main ways respite care is usually provided.
• In-home respite care
• Day centers
• Residential respite care. Most people end up using a combination of all 3.
In-home respite care:
• Someone (family, friends, or a volunteering caring service) comes into the home of
the person and looks after the person
• The person who requires care goes and stays with relatives or friends for a while
It’s often the easiest to organize. It can be the least threatening and the least disruptive.
It can feel intrusive, at least at the start, but most people get used to it.
Day centers
Day centres are places that someone who is mostly at home can go to on a daily basis for
socializing, recreating, and to give their carer some respite.
Most day centres offer a mix of passive and active recreation, books and television on the
one hand or games and may be some less energetic sports. Many will also offer a meal at
mid-day on some of the days they are open. They may offer art and craft classes, outings,
or fitness and relaxation programs. Some have services like hairdressing. Day centers are
generally free, but may charge a small amount of money for some of the activities or
meals.
135
Frequently asked questions while caring for PLHAs
What can I do to safeguard othersfrom HIV?
• Adopt safer sex practices
• Do not donate blood or organs, such as eyes, kidneys
• Do not share needles and syringes
Can I get married and have children?
Most appropriate response: Yes, you can get married. The choice is yours. It is better to
tell your partner that you have HIV before the marriage. You will need your partner’s
support and care if you get sick. If your partner has been deceived, he or she will be hurt
and resentful, especially if he or she has also become infected. There are other ways like
adoption.
To have children you will have to practice unprotected sex, i.e. not use a condom. You
may want to discuss this with your partner as he or she may become infected. The
chances that your baby will be HTV infected is high. To protect your partner and prevent
pregnancy you will have to adopt safer sex practices, especially use condoms regularly
and correctly.
Pregnancy in a HIV positive woman can hasten the onset of AIDS, as her body’s
resistance to disease is lowered. Even if her baby does not have HIV when it is bom,
there is some chance that it may get infected with HIV through breast milk. So, even if
both partners have HIV, use condoms to prevent
• Pregnancy
• STDs
• Infection with another strain of HIV
Can 1 live with myfamily and take up responsibilities?
Home is the best place for a person with HIV because:
• You are not exposed to infections
• You have the support, love and comfort of your family
• You can carry out your daily activities
• You can relax in a loving, stress free atmosphere.
There is no danger to other members as HIV is only transmitted through direct contact
with blood, semen and vaginal secretions; you will not expose others to infection by:
• Playing with children
• Cooking food for family members
• Sharing food, plates and other utensils
• Sharing the toilet
• Touching and kissing others
• Working with others
136
Caution them by saying ‘You should not share your...9:
• Toothbrush
• Razors/shaving blade
• Menstrual pads/clothes that are reused after washing
5J*
What can myfamily do to help me?
Like everybody, you also need your family’s love, understanding, support and help. You
may feel that the society has turned against you. Your family can give support and bring
you out of your lonely feelings. Your family can help you by:
• Including you in family activities
• Showing affection, touching, hugging, kissing
• Encouraging you to eat well and maintain good health
• Recognizing that you may have poor memory, concentration or little interest as a
result of HIV infection.
• Tolerating changes in behavior and mood
• Seeking yourdoctor’s advice and assistance
• Keeping you in good humor
• Discussing their fears and anxieties.
Is it safeforfamily andfriends to look after someone with HIV?
Yes, it is safe if you follow precautions like wearing gloves/plastic bags and disinfecting
with bleach solution.
The need for broad educational programs is equally urgent. The AIDS crisis has shown
the difficu’ty of modifying attitudes towards sex. Even more difficult to change is actual
sexual behavior. Religious teachings and social norms with regard to sex provides one
picture or reality, while the AIDS crisis has revealed quite another.
Hidden
homosexuality, marital unfaithfulness, and premarital sex have surfaced as causes of HIV
infection. Because of the association of AIDS with such behavior, people infected with
the disease are understandably reluctant to admit to being ill. Those infected through
contaminated blood transfusions and blood products may also be afraid to admit their
illness, for fear of how they will be viewed by others secrecy and dishonesty act to
increase the burden of the illness.
137
Chapter X
ROUE OF NURSE IN CARING FOR A PERSON WITH HIV AAIDS
Introduction
Persons with HIV /AIDS have similar health problems as any other sick person. The
nursing care becomes different only when the nurse considers the precautions she / he
would have to take while caring for PLHAs.
This chapter gives a brief overview of the care needs of PLHAs in a simplified manner
that could help nurses in their functions.
General objectives
At the end of this chapter, the participants will be able to understand the various aspects
of care of PLHAs, appreciate this knowledge and apply the information in their daily
nursing practice
Specific objectives
At the end of this chapter the participants will
• Recognize the common problems in PLHAs
• Plan appropriate care for person with HIV /AIDS both in the home setting and
hospital setting
• Be aware of the treatment protocols of various problems related to HIV /AIDS
• Be aware of teaching topics for PLHAs
Key concepts
• PLHAs have specific health problems
• Nurses can take care of these persons both in the hospital and home setting
• Nurses need to be aware of teaching needs of PLHAs
Teaching methods
• Small and large group discussion
• Reflective exercises
• Brainstorming
Materials /preparation required
• Black board, chalk, duster
• Handouts
• Transparencies of important points, OHP
Topic outline
• Common health care problems of persons with PLHAs
• Nurses role in the management of various health care problems in PLHAs
• Treatment protocols for home based care of PLHAs
138
• Teaching needs of PLHAs
• Nursing care of persons with HIV and AIDS with focus on community based care
Total session time
45 minutes
139
BACKGROUND MATERIAL
Common health care problems in PLHAs
Exercise 10L1
This activity is intended to familiarize participants with the broad range of potential
health care problems commonly seen in symptomatic HIV infection so that they
could develop increased skills in appropriate nursing interventions.
The format of a large group discussion is used so that students can contribute and
discuss possible interventions. This will enable the facilitator to draw upon the
considerable expertise which already exists within the group, and to reinforce the
point that the participants current competencies, practice skills and knowledge are
sufficient to enable them to assess, plan, implement
1HTC
and evaluate meaningful nursing
care for people with symptomatic HIV infection.
L The facilitator asks the participants to come forward and write on a board in
front of the class the list the health care problems of a person with HIV
/AIDS
2. As each problem is listed, ask the participants to describe:
• The assessment and observations relevant to that specific
health care problem
• Appropriate interventions that might be planned for a person
with that particular health care problem
3. The participants responses should be written on the board as they are made
4. The facilitator could then supply and list additional relevant information if it
is not forthcoming from the group as given in Table 1.
A nurse must be able to identify the health problems of PLHAs
140
Table 10.1. Common health care problems in symptomatic HIV infection
Problem
Anorexia
_________________________ Possible cause______________________
Commonly seen in end-stage disease, sometimes complicated by nausea
and vomiting may be a side-effect of some drugs used in medical treatment
Dependence
May be caused by chronic disease progression, weakness and neurological
impairment (physical / cognitive)
Diarrhea
Often chronic and severe, it can make the person house-bound or confined
to bed. It may cause significant weight loss and may be life threatening
because of dehydration and electrolyte imbalance
Dysphagia
Frequently caused by oesophageal candidiasis
Dyspnea
Chest infections, anemia
Malnutrition
May be due to dysphagia, anorexia, or malabsorption or inadequate intake
of nutrients (esp. protein). Severe weight loss often seen in end-stage
disease
*
Neurological
Impairment
This may have physical and cognitive aspects. Physical: Lack of fine motor
coordination, peripheral neuropathy, ataxia, dysphasia, visual impairment
and blindness, loss of hearing, paralysis
ST
Edema
May be due to lymph node enlargement as a result of Kaposis sarcoma
Pyrexia
Continuous or intermittent, often low grade, rising during periods of acute
infection and sometimes associated with night sweats
Skin lesions
May be caused by a variety of skin problems (e.g.) candidiasis, Kaposis
sarcoma. Herpes simplex/zoster, etc. lesions often involve mucous
membranes
Visual
problems
Frequently seen in retinitis caused by cytomegalovirus (CMV) or may be
neurological in origin
141
Nurses’ role in the management of various health care problems of PLHAs
NURSES’ ROLE IN MANAGEMENT OF
ANOREXIA /MALNUTRITION /DYSPHAGIA
Anorexia
Cause
•
•
Malnutrition
Dysphagia
Cause
Side effect of
medical treatment
Emotional
problems
•
•
•
Ancwexia
Diarrhea
Vomiting /'
Look for
• Weight loss
• Wasting of muscles
• Weakness and fatigue
• Decreased intake of food and fluids
• Presence of any of the causative factors
<
Cause
• Esophageal /
oral
candidiasis
Lookfor
• Presence of white
patches in the oral
cavity
• Difficulty in
swallowing
Pain
What should the nurse do?
• Give fluids orally 1500-2000 mL per day
• Plan a diet according to the preferences of the person
• Encourage the person to take food preferred according to taste
• Provide dietary supplements like Folic acid. Vitamins, and Iron etc.
• Encourage or assist the person to maintain good oral hygiene
• Administer anti-emetics, analgesics as per doctors orders
• Avoid painful procedure just before meals
• Administer IV fluids and electrolytes if prescribed
• Provide soft bland diet in small and frequent amounts in the case of dysphagia
• Take measures to treat the cause as prescribed (Oral candid /nystatin for
candidiasis)
• Advice not to take alcohol or other irritants
• Advice the use of a soft tooth brush, pain relieving topical agents (xylocane gel)
. and good oral hygiene if there are ulcers in the mouth (brush teeth twice a day)
and to rinse mouth well with water.
142
NURSES’ ROLE IN MANAGEMENT OF DIARRHEA
Diarrhea
Oricse
•
•
Disease itself
Opportunistic infections
Lookfor
• Prolonged or intermittent (on and oft)
• Acute (< 2 weeks) or chronic (>2 weeks)
• Changes in colour (bloody; greenish, etc.), consistency, odour of
stool
• Signs of dehydration
Alert / lethargic / disoriented /unconscious
- Sunken eyes
- Loss or decrease of skin turgor (pinch the skin over the
dorsum of the hand / abdomen) and see if it retracts
- Changes in pulse rate /respiratory rate/blood pressure
Decrease in urine output
4
What should the nurse do?
• Monitor the person to avoid complications
• Provide a home made fluid diet that is bland, low in fiber and
milk products (soup, conjee etc)
• Encourage the person continue to take food
• Encourage extra fluid intake more than normal requirements
• Administer ORS with every loose stool
• Administer IV fluids as per order
• Find out the number of times the person has passed urine
• Check whether the person is taking enough fluids
• Administer anti-diarrheals / antibiotics if ordered
• Take measures to maintain the skin integrity around the anus
• Refer if the person's condition worsens
• Follow precautions to protect the nurse and others
143
NURSES’ ROLE IN MANAGEMENT OF DYSPNEA
Dyspnea
7T
•
•
Chest infections
Severe anemia
I
Ask for
• Number of days the person is presenting with breathing difficulty
• Associated features such
- Prolonged cough with fever
- Fatigue
Presence of sputum
Pallor
What should the nurse do?
• Position the person in an upright sitting position
• Give oxygen if available and if needed
• Help the person to get enough rest and sleep periods
• Encourage the person to take extra fluids
• Encourage the person to put on light and loose clothing
• Administer bronchodilators / antibiotics as per order
• Give chest physiotherapy and steam inhalation
• Refer if the person's condition worsens
144
NURSES’ ROLE IN MANAGEMENT OF NEUROLOGICAL IMPAIRMENT /
PHYSICAL DEPENDENCE
Neurological impairment
•
Central and nervous system
involvement
•
Opportunistic infections;
I
Lookfor
^4H <
• Lack of fine motor coordination
(e^*. holding a cup/pen etc.)
115
• Abnormalities
in walking, standing, and maintaining balance
• Loss of vision, hearing, and memory
• Changes in behavior of the person, depression or suicidal
symptoms
• Progression of mental confusion
• Paralysis (inability to move limbs H whole body etc.)
What should the nune do?
• Prevent the person from falling from bed
• Assist while the person walks
• Encourage the person to do as much as he / she can do (eating,
drinking, meeting hygienic needs etc.)
• Help the person to get enough rest and sleep periods
• If paralyzed, take measures to meet the needs of the person
(feeding, hygiene, elimination)
• Take measures (physiotherapy/exercise) to prevent
complications such as bed sores, urinary stasis, contractures,
foot drop, chest infections
• Teach stress reduction techniques such as doing something that
the persons likes to do. breathing exercises, watching TV. etc
• Speak in simple short sentences
• Provide written instruction
• Instruct the family members to use memory cues such as the
clock, calender etc.
• Refer if the person's condition worsens or if the person requires
care in a hospice
145
NURSES’ ROLE IN MANAGEMENT OF OEDEMA
Oedema
I
Cause
• Lymph node enlargement
Lookfor
• Weight changes
• Changes in urine output
• Extent of swelling (localized or generalized?)
• Type of swelling (pitting or not?)
What should the nurse do?
• Encourage fluid intake according to the prescription of the
doctor
• Encourage the person to reduce salt intake
• Administer diuretics if ordered
• Refer if the person's condition worsens
• Check whether the person is taking enough fluids
• Check whether the person is passing sufficient urine
146
NURSES’ ROLE IN MANAGEMENT OF PYREXIA
Pyrexia
Orme
• Acute infection
• Opportunistic
infections;
Askfor
• Number of days the person is presenting with fever
• Associated features such as sweats, chills, etc.
• Type of fever (when fever is high?)
• Any other complaints which may help in the diagnosis of fever
- Cough with sputum
- Burning micturition, etc.
Lookfor
• Changes in blood counts, culture reports etc
• Pattern of fever
i
Hkat should the nurse do?
• Encourage or give plenty of fluids
• Provide adequate ventillation
• Apply cold applications (cold compress, tepid sponge etc.)
• Encourage the person to put on light clothing
• Administer anti-pyretics /antibiotics
• Encourage the person continue to take food preferably a diet
that is bland and easily digestible
• Refer if the person's condition worsens
147
NURSES’ ROLE IN MANAGEMENT OF SKIN LESIONS
Skin lesions
Cause
• Opportunistic infections
Lookfor
• Lesions filled with fluid or pus such as vesicles^ pustules, or
abrasions or ulcers
• Peeling of skin
• Redness or changes in the colour of the skin
• Location of skin lesions
• Extent of skin lesions (localized or generalized)
What should the nurse do?
• Encourage good skin care
• Apply lotions or ointments as indicated
• Encourage the person to avoid scratching
• Handle the person with care to avoid skin damage
• Encourage the person to put on light and loose clothing
• Give antibiotics, antihistamines as per orders
• Refer if the person's condition worsens
• Wash clothes in water and sun dry after proper disinfection.
148
NURSES’ ROLE IN MANAGEMENT OF VISUAL PROBLEMS
Visual problems
I
•
•
Retinitis (eye infection)
Neurologieal impairment
I
Lookfor
• Changes in vision by a^dng the person about it (cannot see
clearly, frequently bumping on furniture, history of fails)
• Discharge from the eye
• Redness of the eye
What should the uurse do?
• Keep all articles in reach of the person
• Encourage the person to have someone by their side to assist
them
• Assist the person in walking
• Give antibiotics as prescribed (Locally to the eye or orally)
• Refer if the person's condition worsens
• Do not change position of furniture.
149
Treatment protocols for home based care
Respiratory system
The most common respiratory symptoms are cough, chest pain, weight loss and
hemoptysis. The most frequently used antibiotics in both hospital and home-based care
are:
• Cotrimoxazole
• Penicillin V
• Erythromycin
• Tetracycline
1.
2.
3.
4.
Treated as pneumonia with antibiotics
Pain relief with acetyl salicylic acid/paracetamol if indicated.
Severe cases/suspicion of PTB are brought back to hospital for further investigations.
Persons who are coughing are encouraged to cough up sputum into a cup/cloth, which
can be emptied or washed regularly and allowed to dry in the sun.
Gastro-intestinal system
Diarrhea and weight loss are the most common symptoms seen in both hospital and home
based setting. Diarrhea responds most commonly to cotrimoxazole or metronidazole
• Rehydration with ORS or home made electrolyte solution
• Antiemetic if excessive vomiting
• Antacid for enteritis.
• Antiobiotic or amoebicide
• Mycostatin suspension or tablets for oral candidiasis
• Pain relief with analgesics if indicated.
• Milk powder or soyabean - based powder ‘HEPS’ (High Energy Protein
Supplement), which can be cooked into a nutritious porridge.
• Persons are brought back to the hospital if this will not benefit them
Central nervous system
• Pain relief with analgesic
• Diazepam given to restless persons.
• Treatment of bacterial meningitis is usually with Chloramphenicol,
persons are seen to respond to diazepam or chlorpromazine.
Restless
Genitourinary system
• Assessment of progress of STD treatment response
• Specific STDs treated with appropriate antibiotics
• Analgesics if necessary
• If persons condition warrants hospital treatment, person is admitted
• Contact tracing is mostly done in the OPD
150
Skin
1. Rash/dermatitis
• Skin scraping to rule out fungal infection
• Anti histamine if itchy
• Analgesics if indicated
• Antibiotics if indicated
2. Herpes Zoster
• Unburst pustules - calamine lotion
• Burst pustules - gentian violet paint
• Paracetamol/acetyl salicyclic acid or pethidine depending on severity of pain
• Antibiotics if secondary infection of ulceration
3. Abscess
• If small, incised under local anaesthesia, and treat with antibiotics.
• If large, send to hospital for incision and drainage under general anesthesia
4. Kaposis sarcoma
• Encourage to continue treatment (if available)
5. Discharging anal sinus
• Zinc oxide and analgesics
• Surgery for discharging anal sinus is not successful. Healing tends to be poor and
prognosis for these persons is poor
Teaching needs of PLHAs and of their families
All family members and PLHAs must be taught to recognize signs and symptoms that
are to reported to the health facility immediately
Exercise 10>2
1 ~ The facilitator conducts a brain storming session for 5 minutes
2. The facilitator asks one volunteer anw the participants to come forward to
write what responses the participants give to the question
What are- the signs and symptoms thatfamily or affected person needs to report
immediately?
3. The facilitator then tells the participants to read Handout 10.2 on the same
topic
151
Handout lOLL Signs and symptoms that have to be reported mmediateiy by PLBAs
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Bleeding from the rectum
Burnings itching or discharge from eyes
Change in the level of consciousness
Dehydration
Flank pain
Fever which is very high
Headache with nausea and vomiting
Onset of weakness
Oral lesions
Productive cough.
Rash
Seizures
Severe depression
Shortness of breath, chest pain
Yellow discoloration of the skin
Vision changes
Vaginal discharge, pain or itching
Watery diarrhea
Other aspects that have to be taught to PLHAs / family members include
• Good skin care (position changing, emollients, special pads and beds, hydration
and nutrition)
• Maintain cleanliness of the environment
• Avoid exposure to persons with infection
• Breathing and coughing exercises especially when confined to bed
• Avoid repeated exposure to HIV by practicing safe sex (use of condoms,
abstinence)
• Instruct visitors about hygiene
• Avoid eating raw or under cooked food
• Do not take care of pets
• Handling potentially infected body fluids and waste materials (see details in
Chapter V)
• In the event if any family member is exposed to potentially infective body fluids
or materials report the matter immediately to health personnel
• Maintain strict aseptic technique when performing invasive procedures e.g. giving
an injection
• Avoidance of smoking, alcohol and drugs
152
Nursing care of people living with HIV and AIDS with focus on community based
care
Exarcfee 1CL3: Case stwdy rf symptamatic HIV iafeciioa
L The participants are provided with a case presentation that raises the ma^or
issues that might need to he dealt with when carir^ for a person with
symptomatic HIV infection.
2. The participants are divided into four small groups and each group should be
given a copy of the case study.
3. Each group is asked to read only one part of the case study, then to asse^ and
identify nursing care needs of the person according to the said situation. They
then must answer the questions given in the case study, which follow each
section. This should take 5 minutes.
4. Group leaders should report back in a plenary class discussion.
Case study - Part A
Mrs. Gayathri is a 28-year-old woman who lives with her husband and three children in a
village in the out skirts of a large city. Her husband is a truck driver who is absent 3-4
days a week. Her mother lives nearby. Mrs. Gayathri has not felt well for the past year
and her mother has frequently taken care of the two younger children during the day and
the older child after school. Mrs. Gayathri has no appetite, has had diarrhea and has
gradually lost weight bylO kg. She thought she had intestinal parasites, a common
problem in her village, so six months ago she went to the health clinic where she was
treated for parasites. However, since then the diarrhea has become more frequent and the
lymph nodes in her neck are swollen and tender, she has fever nearly every evening and
wakes up during the night soaked with sweat This week she has white patches in her
mouth and a sore throat. When she swallows, she has a burning feeling in her chest just
beneath her ribs. She is dehydrated. You are seeing her at the primaiy health centre.
Identify the nursing care needs ofMrs. Gayathri
• What additional information do you think you need to ask Mrs. Gayathri in order
to decide what action to take?
• What do you suspect is the underlying medical reason for Mrs. Gayathri may
different problems?
• What immediate nursing care needs and interventions would you implement for
her?
• What nursing support would Mrs. Gayathri required in relation to any potential
emotional/social issues she may have to cope with?
• What referrals or further investigations might be appropriate and available?
Case study - Part B
Mrs. Gayathri is admitted to the hospital and rehydrated. A scraping of her tongue
reveals oral candidiasis. The doctor thinks that she also has oesophageal candidiasis
because of the burning feeling in her chest and her difficulty in swallowing. Nystatin
tablets'are prescribed and she is also given nystatin suspension for the oral candiasis.
153
Stool specimens are taken and are negative for parasites, but positive for AFB. Blood
studies reveal anemia and the presence of AFB. The doctor asks Mrs. Gayathri for
consent to have a blood test for HIV antibodies and explains the reasons why he feels this
test is necessary. He also veiy carefully explains to Mrs. Gayathri what a positive and a
negative result might mean. After careful thought, Mrs. Gayathri agrees to have the HIV
antibody test. This test is positive for HIV antibodies.
A chest X-ray does not demonstrate pulmonaiy tuberculosis and the doctor explains that
the positive AFB in the stool and blood specimens are probably the result of atypical
mycobacterial infection (Mycobacterium avium-intercellular MAI) i.e. MAI and not
tuberculosis. He prescribed Ethambutol and streptomycin that may control MAI. The
doctor writes this in the chart and asks you to accompany him when he tells Mrs.
Gayathri that her diagnosis is AIDS. Mrs. Gayathri is extremely upset and wants her
mother contacted immediately.
Identify the nursing care needs ofMrs, Gayathri
• What specific information indicates to the doctor that Mrs. Gayathri has AIDS?
• What should the nurse know about the administration and possible side effects of
the medications prescribed by the doctor?
• What aspects would you cover while counseling Mrs. Gayathri with her
diagnosis?
• What are her educational needs in relation to her anemia and weight loss and how
will you plan to help meet these needs?
Case study - Part C
Mrs. Gayathri has received the medications for two weeks. The Candida is no longer a
problem and the diarrhea is much better with only one loose stool per day. She has
gained 5 kilograms and is feeling much stronger. The doctor is ready to discharge her to
her home. She has to continue taking ethambutal and streptomycin and to continue to use
the nystatin suspension to keep her oral candidiasis under control. Mrs. Gayathri says she
is worried that she will infect her children or that her neighbors will tell her to leave the
village.
Identify the nursing care needs of Mrs. Gayathri
• What are the educational needs of Mrs. Gayathri prior to her safe discharge from
PHC and how will the nurse meet these needs?
• Mrs. Gayathri is particularly worried about infecting her children and husband
and asks the nurse if it is safe to cook for her family and can she still have sexual
relations with her husband; how does the nurse respond?
• Is there anything the nurse can do to help Mrs. Gayathri in relation to her fears
that her neighbors will reject her and force her to leave the village?
154
R
Case study - Part D
Mrs. Gayathri returns home and her condition is stable for two months, although she has
started to lose weight again. Then she begins to weaken and to have more severe
symptoms. You make a home visit from the clinic. Mrs. Gayathri does not want to
return to the hospital because traveling to and from the clinic has been very hard on her
husband (who is now also unwell) and her mother. She thinks she will probably die and
cries when she thinks about leaving her children and her husband. She wonders what will
happen to her children if her husband (who she thinks also has AIDS) dies, as her mother
is very old now.
b.
»
Identify the nursing care needs ofMrs. Gayathri
• What can you teach Mrs. Gayathri’s mother and husband to enable them to care
for her at home?
• What are you able to do to provide emotional support for Mrs.Gayathri?
• What will you tell her when she asks you to help explain to her husband that she
knows she is going to die and wants to die at home?
• What support is available locally to Mrs. Gayathri to die at home?
• How will you help Mrs. Gayathri to cope with her anxiety regarding her children
if her husband becomes ill and also dies and Mrs.Gayathri’s mother is no longer
able to cope?
F
*
Different health care needs ofPLHA
• Health needsi providing competent health workers; medicines, services, home
care and medical supplies.
• Emotional needsz Encouraging a safe and supportive environment in the home
and community; decreasing stigma; giving counseling; family support groups.
• Spmtual needsz Encouraging a supportive environment in religious communities^
organizing prayer groups, promoting home visits by religious leaders.
• Nutritional needs: teaching about nutritional food and preparation, encouraging
lid hi
safe drinking water, and providing food.
• Capacity needs: Helping PLHAs (People living with HTV/AIDS) and their
families and caregivers make their own decisions regarding daily activities
• Day to day needs: Helping with childcare, feeding and tending livestock, going to
the market and other household chores.
• Financial needs: Helping families of PLHAs by providing school uniforms or
fees, seeds and fertilizers, house rent etc.
155
Chapter -XI
REFERRAL, SERVICES AND NETWORKING
Introduction
The role of the nurse while dealing with persons infected with RTI / STI / HIV also
includes referring the person and his / her partner to a qualified medical practitioner, and
stressing on the importance of complete treatment as well as documenting the cases seen
and referred.
This section provides information about how the nurse could make a referral, document
and network in the context of RTI / STI / HIV.
General objectives
At the end of this chapter the participants will be able to understand the concept of
referral, documentation and networking, appreciate this information and be able to apply
this in their daily practice in the health care setting
/specific objectives
At the end of this session the participants will
• Be aware of the need for active referrals and networking in the context of HIV/AIDS
• Demonstrate skills in reporting and making referrals
• Be aware of the various VCTCs, PPTCTs, Support centers etc. in Karnataka
Key concepts
• Referral is a good means of supporting persons who require to be treated and
followed up
• Nurses could be important links in the care and follow up of persons infected with
STI / RTI/ HIV
• Appropriate networking could reduce the load placed on hospitals to care for nersons
with STI/ RTI/ HIV
Teaching methods
• Discussion
• Group exercises
• Role Play
• Introspection / reflective exercises
Materials /preparation required
• Handouts
• Transparencies, OHP
• Black board, chalk, duster
• Chart paper, pens
156
Topic oatfme
• Referral
• VCT
• PPTCT
• Support and care centers
• Reporting and documentation
• Developing effective networks
• Follow-up
• FHAC
ToM sessiMt tmte
1 hour
157
BACKGROUND INFORMATION
Referral
Meaning of referral
It means that if a person approaches you with symptoms of STI / RTI /HIV, you would
counsel the person and encourage him / her to go to a qualified doctor for management of
his / her problems. This would also mean that you would follow up the person
subsequently.
Exercise 11J
L The facilitator asks the participaiits to mention what type ofpersons have they referred,
to whom and why
2l These responses are noted on the black board by one volunteer from the participants
3 . The participants are asked to read Handout 11J that is projected for them or one
volunteer is asked to read aloud to the rest of the participants the contents ofthe
handout
4. The facilitator would ask the participants if they require any further clarification
5. The facilitator could then highlight the precautions to be taken while making a referral
158
Handout 11.1 Whe, towawd why MBst referrals bedoae
WHO?
__________ l__
>
• Any person coming with signs and
symptoms of Sn/ RTI/ HIV (Refer Chapter
-II and Chapter—HI)
• Partner/s of such persons
Qualified medical doctor |—
Vohmtary Counseling
and Testing Centers
* (VCTCJ
• Any person with suspected high risk
behavior (Refer Chapter—X)
• Partners of such persons
• All pregnant women (Refer section on
Chapter XI)
• Children bom to infected mothers
Persons with HTY /AIDS (Refer
Chapter II)
TO WHOM?
Prevention of Mother to
CMdTn n IkS? Xi
*■ Centers (PMTCTC)
I
u
Hospitals /' Hospice /
Day care center / Clinics
Support centers / groups
WHY?
•
•
•
•
•
•
•
•
•
Over come problems that a person with STI/RTI/HIV may face
Overcome problems of bringing a partner for treatment
Persons prefer to go to an unknown person for treatment of such infections to
maintain anonymity
Give a sense of importance for the person
Avoid delay in seeking treatment / treatment of opportunistic infections
Make the person aware of the need for treatment compliance / complete treatment
Avoid inadequate medication in the case of STI /STDs that will only suppress the
signs and symptoms of the infection
Prevent the spread of the infection
Control the epidemic of HIV
PRECAUTIONS & POINTS WHILE MAKING REFERRAL
Maintain confidentiality, knowledge of referral service, refer to the right person, check
absolute need before making the referral, explain to the person about the need for
referral, brief the person about distance, cost and how to find the place of referral
159
Most hospices will take a referral when a person has an AIDS defining illness. People
can self-refer or their friends can refer them, but you will usually need to get a doctor to
fill in some medical information. Doctors, nurses, social workers and some hospital staff
can refer. Some hospices will take referrals from pastoral care workers.
Voluntaiy counseling and testing (VCT):
Voluntary counseling and testing is the entry point for HIV prevention and care. HIV
counseling is defined as ‘the confidential dialogue between the person and the care
providers and is aimed at enabling the person to cope with the stress of being
diagnosed as HIVpositive as well as to make personal decisions related to HIV/AIDS9.
The benefits of VCT are depicted in Figure I.
Acceptance of sero status
Facilitates behavioral
change
\
Plan for future- orphans,
wills
ReducesMTCT
Voluntary
Counseling
Normalize HTV/AIDS
Early management of
opportunistic infection
&
Testing
Reference to social
support
Preventive therapy
(TB)/contraceptive
Figure ll.l.Benefits of VCT
Services possible through VCT
General HIV education in the community could help increase their awareness of the
benefits of VCT
- Pretest counseling (See for details in Chapter VIII)
HIV testing (See for details in Chapter VIII)
- Posttest counseling (See for details in Chapter VIII)
Future and follow-up counseling and psychological support (See Chapter VIII)
Voluntary counseling testing centers (VCTCs) have been established in 142 microbiology
departments of medical colleges and tertiary care hospitals. One VCTC has been
established in each district hospital of States with a high prevalence rate of HIV. A list of
160
ife
&
the centers operating in Karnataka is given in the Appendix D (Handout -2). National
Institute of Mental Health and Neurological Sciences (NIMHANS) in Bangalore is the
external quality assessment center for HIV testing.
Barriers to VCT
- Stigmaz Many people may hesitate to go o a VCTC for fear that society or the
community, as having HTV or AIDs will shun them. It is important that VCTCs are
organized in such a manner so that confidentiality is attained and the community is
educated on its benefits.
- Gender b9etiualitiesz Women tend to fed more traumatized than men in our setting
simply because of male dominance
- Lnck ofperceived benefitz Many peof^e are unaware of the benefits of approaching a
VCTC. It may be that someone just requires information on HIV prevention and that
he or she does not have any risk behavior or any exposure. It is again necessary that
the public is informed about the benefits so that they can utilize the services of
VCTCs.
Sapport could help overcome barriers to VCT
PPTCTs.
Prevention of Parent To Child Transmission Centers (PPTCTs) are usually situated in
antenatal clinics of hospitals. All pregnant women need to be counseled about HIV/
AIDS and MTCT. They also need to be told about the advantages of knowing one’s own
serostatus. (See Appendix E for handout of PPTCT centers in Karnataka) Chapter -XI
Services (see details in Chapter IV)
• Counseling of all mothers
• Voluntary testing for HIV
• Care during prenatal period to prevent transmission to fetus
• Care during intranatal period to prevent spread to the newborn
• Counseling services for follow up care while feeding the baby
161
Support and care centers
These are centers, which are run by voluntary agencies and provide services such as care;
counseling; treatment for opportunistic infections; and palliative care. See Appendix F for
Support and care centers in Karnataka
PLHAs wiD require support
One of the ways of controlling the disease from further spread is to carry out direct
intervention programs among targeted groups through a comprehensive and integrated
approach, which comprises behavior change communication, counseling, providing
health care support treatment for STDs
Targeted interventions for behaviour change in Karnataka
Targeted intervention is an important component of the National AIDS Control Program.
The basic purpose of the Targeted Intervention program is to reduce the rate of
transmission among the most vulnerable and marginalized populations such as sex
workers, intravenous drug users, men having sex with men, truckers, migrant laborers
and street children. The ultimate aim of targeted intervention programs must be to create
an enabling environment that will facilitate behavior change.
All over the world, it has been commonly found that particular groups of people are more
vulnerable than others to the HIV/AIDS epidemic. These groups, because of their
behavioral attributes, are prone to get the infection more quickly and are likely to cause
the spread of the disease in a very short period.
Why is it called target intervention programs?
It is called so because it focuses on specific groups of people. Theses are mostly socially
and economically backward, and are easily accessible. Hence conventional government
services may not be appropriate for them. NGOs, Community Based /Organizations and
other appropriate agencies are recommended since they are able to reach out to these
populations more effectively. These groups need information and services in a focused and
non-judgmental manner. It is, therefore, important to develop a peer-based approach, which
enables and sustains behavior change. An environment that is conducive to empowering
them for behavior change must support these interventions.
162
Karnataka State Aids Prevention Society (KSAPS) has 32- targeted interventions. See
Appendix for the details of agencies providing such interventions.
Reporting and documentation
Benefit ofmaintaining records
• Helps to determine trends in type of people getting the infections
• Helps to determine the whether there is an increase or decrease in the number of
people getting infected
• Helps to find the differences in the incidence among areas
• Helps to determine in which area the work has to be more intensive
• Helps to monitor persons
• Helps in follow-up of persons
Exercise 11-X
The purpose of this exercise is make the participants aware ofaspects that have to be
docuqjented for a person with STI /STD/HIV
k The facilitator divides the participants into four small groups
2. The groups are then asked to discuss what information they would document about
a person presenting with signs or symptoms of STI / RTI / HTV^ why they want to
record this information^ and how they will maintain confidentiality ofthe person.
3. The groups should come out with a sample format for documentation in 15
minutes
4. At the end of this the representative of each of the groupswill come and present
their information
163
Haadowt 11 >2, Sample format for ■mmtammg mformatimi
STI / HIV
perscms. with RT1 U
1. Case number:
2. Date ofregistration
3. Age
4. Sex
5. Place of residence
6. Marital status
7. Education
Occt
9. Does oect
involve frequent travel
IG. Religion
IL Caste
12. Reported complaints: Ulcer / discharge /! inguinal swelling /scrotal swelling /
abdominal pain
13. Any treatment taken for current symptoms
Yes/ no
14. If yes, particulars
15. Name of the doctor the person is being referred
16. Lifestyle
* Smoking cigarettes/beedi/alcohol : Never
: Never
* Consumption of alcohol
: Never
* Gambling, cards etc.
: Never
* Paid sex
: Never
* Sex with casual partner
: Never
* Use of condoms with spouse
: Never
* Use of condoms with casual partner: Never
* Use of condoms with paid sex
: Never
17.
Sometimes
Sometimes
Sometimes
Sometimes
Sometimes
Sometimes
Sometimes
Sometimes
Sometimes
Regularly
Regularly
Regularly
Regularly
Regularly
Regularly
Regularly
Regularly
Regularly
HIV status: Not tested/Positive/Negative
164
Handout 11A. Sainlefimaaf far FcBaw-wp (to be maintained in (xmtinuation of
B^andout 11 J* on doaimentarion)__________
Yes/No
L Did you meet the doctor after referral
2. Ifno*why
3. Did you take full treatment prescribed
< If no* why
Yes/ No
5. Are your symptoms better
6. Did your partner take
7. Ifyes^did the partner take full treatment
S. Ifno^why
Yes /No
Yes/No
Yes /No
9. Are your partner's symptoms belter?
Yes /No
10. Did you use condoms during the period of infection Yes / No
Once a person who has been detected to be HIV positive has been confirmed to have
AIDS, then this should be reported to the State health departments. Specific formats
(Report of infectious diseases) are available which have to be filled completely before
being notified to the respective departments.
Developing effective networks
Exercise 113
I i i 0 into small groups
L The facilitator divides the participants
2. Each group will have to discuss in 5 minutes instances when they have
networked (or can network) with persons* NGOs in order to help people
they served / or would serve
3 . Then also the groups are asked to discuss the difficulties and challenges they
would face in networking
4. The representative of each group is then asked to present their discussion to
all the participants
5. One volunteer could then read out Handout 11.4 to the rest of the
participants participants
PHC staff need to develop good networks...
165
Handowt 11A Networkrng - Purposes, role of Borse, with whom and shffis requral
Pvrp&ses of
•
Avoid duplication of services
•
Enhance optimum utility of services
Role ofa nurse' in networking
Be aware of all services and centers providing services in the community near
by localities and in the state
• Develop good rapport with these centers
• Gain skill in making referrals
• Inform the people and the community of these services and centers
• Help persons who require such services to get these services
With whom am a nurse network?
• Individual personsz Anganwadi workers, Counsetors, Community workers.
Doctors, Influential persons // political persons. Physiotherapists, Religious
persons. School teachers. Social workers
•
Groupsz NGOs, Community based organizations. Support groups /'
organizations (See appendix F). Village panchayats
•
Institutions: Hospitals- government, private; VCTCs; PMTCTs
What skills must a nurse have to network?
• Be able to recognize the needs of others
• Be able to get along with any one
• Be able to convince
• Commitment to help people in need
• Interpersonal communication
• Speak for the rights of PLHAs (see Annexure)
• Time to take persons to these centers
Effective network means going out of one’s way...
166
Exercise 11,4
L The * <<>■
are given a case
Thepmtm
adsxt expressesd^ffiadtks behrgfixxdl beantse ofAe Bhress. Ymtfeei Ae
person cm be helped niAongb Ae PHC wherepm me working does mt
hove AefocSity A meet M Ae needs ofAeperson
2. I>vide the participants into the same groups as in exercise 2
3. Ask the group to develop a plan ofaction so that all the needs ofthe person
are met (see for needs ofa person with HIV in Chapter XIII
4. Give a chart paper along with pens to each group and ask them to draw the
network you would develop for the above case in lOminutes
5. All the representatives would come and exhibit their charts for all to see
6. The facilitator then explains that there are no standard ways ofnetworking
but that it is important for the nurse to be aware it is possible to get the best
for the persons requiring help
Follow-up
The nurse must take an active role in following up persons who have approached her
/him for care. Follow up is essential to ensure quality care for persons with STI/ STD
/HIV. It would also ensure complete treatment, partner treatment, and condom use. (See
sample format 11.2)
Advantages offollow-up
• Can identify the effect of treatment
• Can ensure compliance to treatment
• To identify the partner/s of the person infected so that treatment of the partner could
be initiated
• Can diagnose complications
• Can identify reasons for non compliance
• For ongoing support and counseling
• To facilitate in behavior modification
• To assess cure of the person
Follow-up procedures
• Personal contact with the person during visit to the home of the person
• Contact by mail
• Contact through phone
• Sending messages through community health workers. Community health assistants
etc. to the concerned person
Remember at all times to maintain the confidentiality of
the person
167
Family Health Awareness Campaign
As part of the functions of a nurse in prevention of HTV / AIDS a small session on Family
Health Awareness Campaign (FHAC) will be taken. This would help you gain insight as
to your role in FHAC.
Exercise 11^: Brant sternuBg session
1. The facilitator invites group responses to the following questions:
(Brainstorm for 5 minutes)
• What is FHAC / When & Where is FHAC condncted / Who cendnets
FHAC / Why FHAC/Role of Health Workers in FHAC
X While the participants are making their comments^ the trainer has to make notes of
what is being mentioned
3. Feedback of the correct information to the participants must be given according to the
questions.
The Family Health Awareness Campaign, which was started in 1999 on a trial basis. It
was introduced all over the country by National AIDS Control Organization (NACO) in
2000 in an effort to bring under control the rapidly growing epidemic of HIV, especially
in the rural areas and other marginalized populations. It is usually conducted during the
months of March and April in Karnataka.
Objectives of FHAC
The overall objective of the campaign is to contain the spread of Reproductive Tract
infections including sexually transmitted diseases and HTV/AIDS.
The specific objectives are • To raise awareness on RTI/STD and HIV/AIDS in rural areas and other
vulnerable groups of the population
• To encourage health seeking behavior in the general population for RTI/STD.
• To make people aware about the services available in the public health system for
the management of RTI/STD.
• To facilitate early detection and prompt treatment of RTI/STD by mainstreaming
the program.
• To implement a focused IEC strategy for the male population.
Strategy
The strategy includes L Effective intersectoral co-ordination
Steering and mass media co-ordination committees have been established at Central.
State and District levels under the Union Health Minister, Chief Secretary and District
magistrates respectively with the objective to forge co-ordination amongst public, private
and voluntary sector.
168
g. Mass mmmntea and socM naob^ption
Two rounds of house-to-house contact by health workers are to done prior to the
observance of FHAC to inform target group in age range of 15-49 years about
reproductive health problems, facilities available for treatment and ways and means to
prevent sexually transmitted infections. Sensitization workshops for community opinion
leaders, NGOs and representative of panchayats at district and block levels are done to
seek their active participation in this campaign. During the week when FAAC is to be
conducted camps are conducted in a different subcenters each day. At the camps the
various activities includes
• Providing awareness of STI/STD/HTV.
• Doing physical examination and diagnosing of STI/STD.
• Treating those diagnosed with STI/STD.
St Capacity bu3ding in naanageuaent ofSTD
A massive training program is undertaken in all the identified districts. For the training of
MOs at each level, booklets on Syndromic management of STD have been supplied. Flip
charts are being used for the training of paramedical workers.
in Procurement of
drugs
STD drugs have been supplied to each PHC to treat patients with STD and partners.
v. Holding camps, in each village during cantpaign
Through the campaign separate camps are held for male and female target groups in each
village by male and female health workers separately and assisted by community
volunteers. The health workers discuss the problems of RTI/STI with the target group in
reference to cases, symptoms and complications. They also make persons aware about
HIV/AIDS, about the facilities available for treatment of RTI/ STD and referral slips are
issued to those who need treatment. Health care workers also keep a record for those who
are referred for treatment to permit follow-up visits. A sample record of details required
by the health worker is given below.
Name
Address
Age
Sex
Symptoms
Referral
Follow-up
vi Monitoring and evaluation
• Supervisory visits by central and state level observers- a standardized checklist
has been devised for the purpose.
• Concurrent evaluation- state will identify agency for conducting concurrent
evaluation.
169
Chapter XII
LEGAL A1NB ETHICAL ISSUES RELATED MV /AIDS
Introduction
Every person has the right to live with dignity, so also a person affected with HIV /
AIDS. But there have been instances where PLHAs and or their children were denied
schooling, medical care and treatment, employment etc.
This chapter deals with the legal and ethical issues that relate to PLHAs. Awareness of
the nurse on these issues could help her take care of such persons more effectively.
General objectives.
At the end of this session the participants will be able to understand the legal and ethical
issues related to PLHAs, appreciate and apply these concepts in the care of such persons.
Specific objectives
At the end of this session the participants will
• Be sensitized to the legal and ethical issues that relate to person with PHLAs
• Handle situations that may cause dilemma appropriately
• Discuss these issues openly with their colleagues or with other persons in their day to
day practice
Key concepts
• HIV positive persons have a right to live with the same dignity as others
• Nurses could play a vital role in handling networking with other groups to meet the
legal and ethical issues that relate to persons with HIV /AIDS
Teaching methods
• Case discussions
• Reflective exercises
Materials /preparation required
• Handouts of case studies
• Transparencies of important points
Topic outline
• Issues of overall management of HIV / AIDS
o Ethical issues
o Legal issues
Total session time
1 hour
170
BACKGROUND INFORMATION
All persons have certain rights such as the right to a name; a nationality; a religion; an
education; basic amenities such food, water, shelter, clothing; health; to freedom etc. This
means that persons with any illness would be entitled to these rights. Appendix H gives
some of the rights of persons and rights pertinent to a child who is HIV positive.
Legal issues
• Denial of property rights
• Denial of social security insurance
Exercise 12>1
L The participants are asked by the fadlrtator to re^ond top the question
What ture Ae iaws reAintg A m pmott watft HIV/AIDS msthtg m our contry mA m
oAer comtries?
2. The facilitator asks fora volunteer to write all the responses on the Wack board
. X The facilitatorcan ask a volunteer from among the participants to read aloud
Handout 12J and invite for an open discussion oo the same from the participants
4. This activity must take only 5 minutes
Handout 12,1
• Mandatory testing of blood and Wood products for transfusion (drags and cosmetic
rules -1993 Blood safety)
• Artificial insemination human act 1995
• Right to privacy of a person - article 21 of the constitution of India stress on
fundamental right for treatment
• Testing only
- For high risk groups with consent
- For people who volunteer to be tested after pretest counseling
For surveillance done anonymously
- For research purpose it must be unlinked or anonymous but with consent
• Professional misconduct and negligence could lead to legal liability
• A doctor must consider his/ her duty to ensure that any sexual partner of a known
HIV positive person is informed of the risk, regardless of the person’s own wishes Supreme court judgment
• Disclosure of the details of treatment must be done only with the permission of the
concerned person except to the doctor to whom the concerned person may be
referred to
171
Ethical issues
o
Ethical principles
• Beneficence (do good)
• Nonmaleficence (Above all do no harm)
• Justice (treat everyone fairly, without discrimination, without taking undue advantage
of the person)
• Veracity (to be truthful)
• Self determination (to be fully informed so that a rational decision can be made by the
person)
• Respect for human dignity
- Maintain the confidentiality (not to disclose the information received from
person to another person)
Maintain anonymity (not to be able to link information about one person
to the same person)
Exercise 12-2
L The participants are divided into 5 groups
X Each group is given one case to discuss the related ethical issues and to determine the
actions a nurse would have to take to keep theses ethical issues in mind when taking
caring for patients / persons. This should take at least 5 minutes
3. After the discussion one person is asked to come and present the discussion from each
group
4. The facilitator must moderate the session using the respective Handouts
Case study 12.1
Mr. X is a clerk working in private institution. He has been presenting with chronic
cough, shortness of breath upon walking and fever in the afternoons for the past four
weeks. He was diagnosed to have tuberculosis. Detailed history taking revealed that Mr.
X had the habit of taking Injection Pethidine every now and then. He had the habit of
going to a friend’s house where he along with his friend used to share the same needles
and syringes for injecting the drug. His friend and he had a close physical relationship.
The doctor in the PHC was busy one day and he called the nurse and told the nurse to
counsel Mr. X to have the test for HIV. Mr. X refused and informed the nurse that he felt
that HIV test was not necessary.
Activity
Discuss the issues involved in the above case
172
Haxknrt 12-2- Legal »d ethical aspects coacenmtg HIV testing (for case study 12.1)
Information to be given to Mr. X
• Testing of HIV infection involves a simple test but the results have a lot of
______ importance for the person concerned and the community_______________
__________ Ethical aspects__________
______________ Solution_________________
•
Mandatory testing should not be
done
•
Vohmtaiy testing can be done
after informed consent is taken
from the person to be tested
•
Pre and post test counseimg
must be done to ensure that the
person being tested has the
knowledge of the significance
ofthe test results and options
available in case ofpositive
status
• Counsel the person on the benefits of
testing
• Counsel the person on the benefits of
knowing one’s status early initiation
of therapy
• Counsel the person on the available
options for treatment________________
• Counsel the person on all aspects of
VCT as discussed in Chapter X
• Remember that more than one session of
counseling may be required___________
• See Chapter X for details on both pre
and post test counseling
• See Chapter II for details on Therapy
• See Chapter XII for options on care
Case study 12.2
Ms. Seetha and Mr. Raghu were engaged for the past three months and had plans to be
married in the next six months. Mr. Raghu’s parents had recently read in the papers about
a couple that were married for just a month. Apparently the girl was found to be HIV
positive during her antenatal visit in the first month of her pregnancy, which happened to
be just a month after marriage. Mr. Raghu’s parents were convinced that this girl might
have been positive for HIV even before her marriage. Hence they were determined that
Seetha undergoes the HIV test before marriage. They did not want the same situation as
they had read in the papers. Finally both families that were in conflict about the issue
approached the community health nurse for options.
Activity
Discuss the issues of the above case
173
Hagdowt 1Z3L Legal and ethical tssnes related to screening (for case study 122)
Screening is aBowcd for
•
Safe blood supply
•
Antenatal mothers can be counseled and then tested after informed consent is
obtained. This is needed to reduce MTCT
•
Sero prevalence study: This is unlinked anonymous screening that helps to collect
quantitative data to understand whether the epidemic is worsening or under control
Screening for safety purposes is not allowed
• Hence no one can be forced to undergo a HIV test But individuals who consent to
voluntary testing, can be encouraged
Refer laws in relation to HIV testing given earlier in the Chapter
Case study 12.3
A nurse while doing a routine family visit came across a couple that was diagnosed to be
HIV positive. The couple was open and discussed their concerns with the nurse. They
expressed their wish to have a child of their own.
Activity
What would be the advice the nurse could give in the above issue?
174
Haudout 124. Passible advice a uursie could gjve a couple that« HlV iMKative (for
case study 123)
If the husband and wife are both positive
• All couples by duty of health care personnel must be counseled in order to reduce
<<?■>!
transmission.
Parents can claim damage of wrongful birth if not counseled
It is ideal that they avoid getting children since the chance that the child also be
positive does exist
•
The optioni of adoption should be made known to them. However the ultimate
decision must be that ofthe couple
•
Adoption foe the couple is legal and will be allowed only ifthe couple are able to
show enough resources as well as st^port systems in place for the care ofthe child
in the event ofthem becoming terminally ill
•
The couple needs to be explained about the consequences of having their own child
•
They must be explained about the need to practice safe sex i.e. the use of condoms
in order to prevent re-infection with HIV
Case study 12.4
Ms. Rani working in a multinational company was diagnosed to be HIV positive. Ms
Rani insists that the treating doctors and nurses keep the results confidentially. She did
not want even her parents or the company people to know the result. All the members of
the company liked Ms Rani and she did not want her image to be spoilt.
Activity
What ethical issues are involved?
Handout 123. Ethical issues in case study 12.4
Privacy and confidentiality
• Unwanted disclosure prohibited
• Counsel the concerned person on the need for disclosure
• Inform about the need to disclose HIV status to partner
• Allow disclosure to sexual or needle sharing partner only after the person
concerned has given consent for the same
• Identification of HIV status must be prevented on the persons medical record
• Reporting to health authority is allowed
• Reporting to referred doctor is allowed
• , Inform to the concerned person the people who could be revealed the HIV
status
175
Case study 12.5
A tertiary hospital doctor refuses admission of a full-blown AIDS case. The concerned
person’s relatives insist on the admission to the hospitals. The doctor gave various
reasons for not admitting the person. The furious relatives filed a case against the
hospital.
Activity
What are the legal and ethical aspects involved
Handout IXtk Legal and ethical issues in the event of refusal of treatment by health
personnel (for case study 12.5)
Medical practitioners have the duty to diagnose, treat counsel
Litigation in the case of negligence could lead to accountability ofthe
practitioners
• No health personnel can decline to treat or take care ofa person because of
HIV status
• Health care personnel need to be trained and educated on universal
precautions
• Health care personnel need to follow with utmost care universal
precautions
• Duty to counsel is important for reducing transmission
•
•
Other ethical issues in relation to HIV /AIDS
Exercise 123
1. The facilitator conducts a brainstorming session
2. The participants are asked c Do you think there are any other issues that have
ethical concerns when dealing with persons with HTV / AIDS’
3. A volunteer is asked to write the responses on the black board
4. The facilitator finally summarizes the points given and then mentions the
points not listed on the black board
The other issues are
• Confidentiality about revealing the test results to spouses, partners, employers etc.
• Exclusion of HIV positive persons from occupations involving high risk practices
like health care personnel
• Conducting behavior and intervention research into revealing the identity of the
effected person
• Limits and significance of confidentiality
• Obligation to seek informed consent
• To care for those in need
• Testing new drugs
176
Exercise 1X4
1. The facilitator presents; a case study to the participants
Mr. YeshwanA^ a construction worker goes to differentplacesfor carrying out
job contracts^ committed suicide along whh his wtfe by consuming rat poison.
They Uved m a village. Subsequent enquiries revealed Ae Mr.
had been
diagnosed to be HIVpositive and his wffe had also got Ae infection. Unable to
They had two chddren one bay^ aged 12 years and a girl aged byears* boA of
whom were studying A school situated m Ae vdlage itself After Ae death of
theirparents both Ae chddren were asked not to attend school
Evex ctose natives wko imdm Aesmte village xbrndouedthe two children.
Finally a social worker from a near by village who was working in a NGO
took interest in Aefntnre ofthe children and helped them to get admission in
an orphanage in the near by town.
When Ae relatives were approached by Ae social worker^ they revealed that
theyfeared Aatthey would also get the HIV infection
2. The facilitator asks the participants to
• Identify the issues that are coming out from the case
• How would you deal with the situation if you come across such a
case in your daily practice?
3. The facilitator writes the responses on the black board and supplements
information needed
177
Appendix -A
SAMPLE SCE TmTTJLE FOR WORKSHOP
__________________ Particulars
Magnitude of HIV / STI
Chapter
Chapter I
Time
30 minutes
The implications of STI /RTI/STDs
Chapter II
1 hour
HIV and AIDS - the challenge we face
Chapter HI
1 hour
Prevention of STI / STD / HIV
Chapter IV
3 hour
Universal precautions - in prevention of STI and HIV
Chapter V
1 hour
Post exposure prophylaxis
Chapter VI
1 hour
Attitudes about STI / HIV / AIDS
Chapter VII
45 minutes
Communication and counseling services in the context
of STI / STD/HIV
Chapter VIII
3 hours
Community based care and support
Chapter IX
45 minutes
Role of nurse in caring for a person with HIV /AIDS
Chapter X
45 minutes
Referral, networking and services
Chapter XI
1 hour
Legal and ethical issues
Chapter XII
1 hour
_______________________
178
Appendix - B
Energizer 1. In the pond — out of the pond
Description
All the participants are asked to stand in a circle and one volunteer is asked to give
instructions to the participants
Process
1. Ask the participants to form a circle
2. Draw a circle in the center and tell the participants that this is a ‘pond of water’.
3. The volunteer will call out ‘in the pond’ or ‘out of the pond’. When the volunteer
calls out ‘in the pond’ the participants must be able to get into the circle, which was
drawn. Instruct the participants that they can hold each other so that the maximum
number of persons could fit in the pond
4. If ‘out of the pond’ is called out then participants must move out of the circle.
5. Those who do not respond correctly to what is called out and those who cannot fit
into the circle have to stand out of the game
Change
the order of the calling out the two commands so that participants cannot
6.
guess what will be called out. You could also keep decreasing the size of the circle by
saying the pond is drying up.
7. Continue the process till only one person is left out
Time
5 minutes
Note
This exercise illustrates to people that as a person resources get smaller, the number of
persons who can fit in to his / her social life will decrease. It also shows that the
maximum number could fit into the pond only if there is cooperation between everyone.
If anyone pushes, or if anyone rushes in they are likely not to give others a chance. This
could also teach participants the need to support each other, in their activities. The
concept of networking could be reinforced here
Energizer 2. Building a tower
Description
The participants are given a set of cards. They have to make a tower in 3 minutes. Then
they work in groups to make a tower in the same time limit but before planning
Process
1. Ask for five volunteers who will be observers of the small group activity
2. Then divide the participants in to five smaller groups of five members each
3. Each person is given ten cards that are cut in a particular way (rectangular pieces of
cards are cut such that they have three limbs)
179
4. They are asked to build a tower with their ten cards and before this they must plan in
their minds how tall they will make their tower and write it in a piece of paper. They
should not discuss with each other and try to avoid looking at what the other person is
doing. They should not bend the cards in any way
5. At the end of 3 minutes ask them to stop. And see whether they have achieved their
goal
6. Then the five members of each group is asked to discuss in 1 minute how tall a tower
they will make with all their cards (25 cards). They will be given 3 minutes to
complete the task
7. The observers must see the interaction between the members in the group.
Time 10-15 minutes
Note
This exercise is preferably done after the participants get to know each other, probably,
on the second day. It helps to see how when we work as a team we will be able to achieve
more than if you work as an individual. The sharing of cards indicates that everyone
would have to pool their resources to be able to get the best out come. It is also an
exercise that teaches you planning. Do we plan more than we can achieve? Or do we plan
less than what we can achieve. It is important that we are realistic in our plans. It is
ENERGIZER 3. DRAW A CAT
Description
The participants are given an activity to perform
Process
1. Ask for ten volunteers from the group. Tell them to step aside.
2. Keep a dupatta or big handkerchief available.
3. Then tell the volunteers to listen to your instructions clearly before proceeding with
the activity. Each volunteer would be asked to do the activity separately
4. Narrate a story. ‘There once lived a lovely furry black cat in a certain town that
everyone loved. One day when it was busy chasing a rat it did not bother to look
either side of the road and it ran across the road blindly. At that instant, a car came on
the way of the cat. Luckily the cat survived but the tail of the cat got cut.
5. While narrating the story draw a cat on the black board, and then draw its tail fallen
off
6. Call for the first volunteer. Tell her / him this ‘ Take this dupatta, blind fold your self
and draw the tail of the cat in 10 seconds’
7. See that you instruct the rest of the participants to remain silent, not to make any
comments, but to observe carefully what was happening
8. Call the next volunteer and tell her / him this ‘ Draw the tail of the cat in 10 seconds’
9. Call the next volunteer and repeat the same command as given to volunteer number 2.
Repeat the same till you complete all ten volunteers
10. Then ask the rest of the participants what they observed
180
Time: 3-5 minutes
Note: This is used to get participants realize how well they listen as well as how
preconceived notions could make them do things they were not asked to do. It has been
seen that invariably most of the volunteers will do exactly what the first volunteer was
told to do although they were not asked to blindfold themselves. It could be used as an
energizer for Chapter VIII.
ENERGISER4.
Description
The participants are given an activity to perform
Process
1. Ask for two volunteers from the group. Tell them to step aside.
2. Tell the rest of the participants to form a circle
3. Ask one of the volunteer to act as a wolf and another as a hen. The wolf is hungry and
wants to catch the hen
4. The circle that the rest of the participants form is the boundary and prevents the wolf
from entering the safe place of the hen
5. Narrate a story. ‘There once lived a lovely black fat hen in a certain town (the circle
formed by the participants is the boundary of the town) that everyone loved. One day
when it was busy catching a worm it did not bother to look around and went near the
boundary. It suddenly was face to face with the prowling hungry wolf that was
watching from close by. It immediately ran away but the wolf then started trying to
catch it.
6. While narrating the story ask the volunteer who would act like the hen to come inside
the circle and the other volunteer to be outside the circle
11. Instruct that the rest of the participants could be asked to try as far as possible to
protect the hen from snare of the wolf.
12. Allow the activity to go till 3 minutes elapse. Then ask for another volunteer to act
like a wolf. Hence there are two wolves now and only one hen. Both the wolves are
hungry. With each minute keep increasing the number of wolves till the hen is caught
13. Then ask the rest of the participants what they learnt from the exercise in relation to
the topic HIV /AIDS
Time: 3-5 minutes
Note: This is used to get participants realize about the process of stigma, how the disease
HIV could spread despite being careful, how even despite good knowledge and safe
practices the infection could be acquired. It could be used as an energizer for Chapter III
or VIII.
ENERGISER5.
Description
The participants are given an activity to perform. It is preferable that this is done as an
outdoor activity. Depending on the number of the participants, there could be just one big
181
group (15 participants) or two groups (if there are 30 participants). If there were two
groups then it would be ideal that there are two facilitators to take care of the two groups.
It is ideal that the number of participants for this energizer is in multiples of three (9, 12,
15 18, 21 etc). Articles that are required for the activity includes some cloth to blind fold
one member of the team, chairs according the number of teams and a ball.
Process
1. Ask the participants to number themselves as 1, 2, 3, 4, and 5. This continues till all
the participants are given of a number. If there are 30 participants then see that you
ask them to number of till 10. This is because you must have teams of three members
each.
2. Tell the participants to form groups according to the numbers they have been given.
See how many teams of participants are there. If there are more than five teams then
split the number of teams so that there are two groups
3. Suppose there are 10 teams then split the group into two groups, each with five teams
4. Each team must be asked to carry a chair out side.
5. Give the following instructions to the participants once they are taken out
- This is a race where you would use verbal and nonverbal communication
- Ask the teams to number themselves as 1, 2, and 3
One person (no. 1) in each team will be blind folded by a person from
another team. All the blinded folded persons will then stand in a straight
line as in a race
The chairs will be placed behind each of the blind folded persons in a
straight line
- Another member of each team (no. 2) must sit on the chair
The third person (no. 3) in the team must stand facing the person who is
sitting on the chair
The facilitator will place the ball in a particular place this can be seen only
by the person who is standing in front of the chair (no.3). It is either on the
ground or held by the hand of the facilitator. This need not be told to the
participants but you could change it with the second race
- Number 3’s should then only show actions, to the number 2 of their team
to indicate how the person who is blind folded (No. 1) must move to reach
the ball. The moment No. 2 sees the action then he /she should shout out
to Number 1. of their team how to move, i.e must give them directions
- Rules of the game: No. 1 must be properly blond folded / No. 2 must not
turn back but only face No.3 / No. 3 cannot talk but must only show
actions to No. 2/ No. 3 and No. 1 can talk to each other but both cannot
see each other since one is blind folded and the other is turning in the
opposite direction
Ask the teams to plan how they are going to try and win the race
Set each member of the team in their respective places
6. The whistle will blow and the race can start
7. The winner is the person who gets the ball
8. Then ask the rest of the participants what they learnt from the exercise in relation to
the topic HIV/AIDS
182
Time: 5-10 minutes
Note: This is used to get participants realize about the process of communication. It could
be a powerful exercise and an energizer for Chapter III or VIIL
ENERGISER
1. The MET team could decide any other culturally appropriate energizer as and when
they feel it is necessary during the training program
2. However the facilitator must try and draw lessons from each energizer used
ENERGISER 6. PLAYING GOD
Description
The participants are given a situation to reflect on. The situation is narrated and the
participants are asked to give a response to the questions put forth by the facilitator.
Process
1. Narrate the situation
‘ A wonder drug has been discovered for AIDS. You are the person
who has this wonder drug. There are three people who come to you
for the drug:
A child
iii.
A sex worker
iv.
A business man
Who would you give the drug to?’
2. Tell the participants to respond to the question. As they choose ask them why they
chose a particular person. Allow this to go on. Tell participants they could feel free to
defend their choice of person
3. As they are more or less sure whom they would give the drug to (it is important since
you may see that most of them will choose the child). Then tell them ‘I have not
completed the story’
'The child has been diagnosed to have cancer and is said to have only
two months to live. Now whom would you choose?
4. Again as they are more or less sure of their choice then tell them ‘ there is still
another part of the story’,
‘ The business man is involved in a lot of charity and got HIV as a
child through a blood transfusion9
5. The participants will ultimately make their choice
6. Then ask the rest of the participants what they learnt from the exercise
Time: 5-10 minutes
Note: This is used to get participants realize about the likely attitudes one has towards
people with HIV/AIDS. It could be a powerful exercise for Chapter VII. Conclude then
by telling the participants we do have preconceived notions of people and we easily
discriminate among people. It is important that we go with an open mind.
183
Appendix-C
HANDOUTi LIST Of TAttfiKTED fNTFUVFNTtONs
| SEN
0.
I
2
Name and address of the NGO
~BhorukaOiari table Trust, BPCL, Lorry parking lot, Devanagundhi, Hoskote
- -------------------------
e-mail:bctbng@bgl.vsnl.net.in
Targeted
Place of
Intervention
intervention
Truckers
Devanagundhi,
Bangalore
I
—
Ph: 6608428.
e-mail:bctbng@bgl.vsnl.net.in
__£ontact Person: Dr. Krishna Murthy (Project coordinator); Dr. Surya Prakash (Program Manager)
Ph^3289272aJ amith1’ No-B’318’ shetty layout, Ullalu upanagara^angalore - 560056.
I
4
—Cgntact Person: Smt. Sudha.S (Programme Coordinator)
Healthy
Highway
Project
NH 4,
Bangalore
Migrant
Labourers
Ullalu
Upanagara,
Bangalore
Mangalore
Migrant
Labourers
r
r6
I e-mail:citizensalliance@yahoo.com
| Ph: 08242-431215/431947
__Contact Person: Mr, Satyendra Prakash(Project coordinator)
Truckers
Tumkur
Commercial
Sex Workers
Bangalore
Healthy
Bangalore
.-Contact Person: Mr. Ravindra, M. Hegde (Project coordinator)
JSrXx:
tspADi F'a'Noj-13’
Ph:5471680
e-mail:spadorg@satyam.net.in
Contact Person: Mr. B. Vijay Kumar (Project coordinator)
L^g£l£SLfoLPggple^sActjon_forpeyelopment, [SPAD], FlatNo.1-13, Orient Manor, 15, Highstreet, Cooke
184
T
9
10
11
12
13
i
b
Town. Frazer Town Post Bangalore-560005.
Ph: 5471680
e-mail: spadorg@satyam.net. in
Contact Person: Mr. Augustine. C. Kaunds (Project coordinator/ President)
Bangalore Oniyavara Seva Coota, [BOSCO], # 91, ’B’ Street, 6th Cross, Gandhinagar, Bangalore-560009
Ph: 080-2253392/2208471
e-mail:bosco@bgl.vsnl.net.in
Contact Person: Fr. Francis (Project coordinator)
Samuha-Samraksha, Flat. No.4, Sadhashivanagar, Gadag Road, Koppal
Ph: 080-3546973/3546965/3546961
Contact Person: V.M.Devi (Project coordinator); Smt. Sangamitra Iyengar (Director)
Samuha-Samraksha, # 17/1, Harris Road, Benson Town, Behind ISI, Bangalore-560046
Ph: 080-3546973/3546965/3546961
e-mail:samraksha@vsnl.in
Contact Person: Ms. Nagaveni (Project coordinator); Smt. Sangamitra Iyengar (Director)
Jagruthi. Jyothi Complex, C3, II Floor, # 134/1, Infantry Road, Bangalore-560001
Ph: 91-80-2860346/5266132
e-mail: jagru@vsnl.net
Contact Person: Smt. Renu Appachu (Project coordinator/Director)
Suraksha, # 76, 2nd Stage, Kamalanagar, Bangalore-560079.
“
e-mail: suraksha-harini@yahoo.com
Ph:3223669
Contact Person: Smt. Harini Kakkeri (Project coordinator)
Karnataka Integrated Development Services [KIDS], Kalmath Building, Tikare Road, Dharward-580001
Ph: 0836-74087/744196
e-mail:kids_dharward @ hot mail. Com
Contact Person: Smt, Pankaja Kalmath (Project coordinator)____________
Karnataka Network for PLWH/A, No.l 13, lsl Floor, 15"' Cross, 8'h Main, Wilson Garden,
Bangalore-560 030.
Ph:2120409 ; Fax:2120410
Contact Person : Mr. Elango (Project coordinator)_________________________
Asha Foundation, No. 58, SBM Colony, 3rd Main, Anandnagar, Bangalore-560024
'
Ph: 3543333/91-80-3332921
Highway
Project
Street
Children
Bangalore
Truckers
Raichur and
Koppal
Commercial
Sex Workers
Bangalore
MSM&
Transsexuals
Bangalore
Migrant
Labourers
Bangalore
Truckers
Dharwad
PLWHA
Bangalore
Telephone
Counselling
Bangalore
185
>
He
rr?
i________
I 18
e-mai 1 :asliaf@satyam.net.in
"
----------------------------------- ----------- ---—fontact Person: Dr- dory Alexander (Project coordinator/ Chair person)
nr M35 ™R)5'5 (Xr'"
[URDSSl J"d" Ga"'-
N-^ BiJ.p«-SS6104-------
_ _Contact Person : Smt.Sunanda.V.Tolabandi (Project coordinator)
Bangalore-SSOOni6^3''
«2.1“ Cross, Chlekkann, O.Hen, Sh.„k.„pm„, ~
Commercial
Sex Workers
Bijapur
Truckers
Bangalore
Truckers
Gulbarga
Truckers
Belgaum
Truckers
Gulbarga
Truckers
Bidar
Ph: 6612126/6678526
"Rh”13?
Sath'Sh J°Shy (Pr0-'eCt co-coordinator); Mr.B.Channa reddy(ManaEinP trustee)
e-mail: bhoruka_charities@yahoo.com
_ Contact Person: Mr.Devendra Kattimani (Projector co-coordinator); Mr.Krishna Madhav (Director)
i 19
larnaS^DeveloPme"‘ Society, [BIRDS], Naganur, Gokak Taluk, Belgaum District,------i
)
p°
Ph: 08332-384678/08334-388622; 08332-324435
Contact Person: F.M.Jiralimat
(Project co-coordinator)____________
- 585 ia06.iVid°ddeSha S 8ha’ Veerendra patil colon>'’ Flat No.259, G.D.A. Layout, Sedam Road, Gulbarga
Ph:08472-465933, Mobile: 94483-33514
I Contact Person: Sanganna Ijery (Project coordinator)
1
r 22
I_
I 23
: 24
pI“8.?2^
Seethe, Aurad, KourtafB). Bidar.-----------------
- S01113.? Pe?on: Mr-Shiva Kumar (Project co-coordinator)
Rural Welfare Trust, Gramadeep, Santibastwad, Belgaum - 590014
Ph:0831 -413220/413378/402121; Fax:0831430714
jContact Person: Mr. Sanjeev, R, Kulkarni (Project co-coordinator)
9448410708
~
-------------------
Migrants
l^T4- MCC’ 'B'8'“k’ Telephone
Belgaum
-------------Davangere
| Contact person: B.M.Satish (Project co-coordinator/President)
counselling
LaSnea^arya-,^ithi’ K°tgyal post Nittur (B)’ Bhalki taluk’ Bidar District----------------------------------------| Ph: 08482-225679/224903; Mb: 9448466567
Migrants
Bidar
186
.J
25
r
27
28
29
30
31
32
J
I
Contact person: Mr.Basavaraj PatilJProject co^oordlnator)
Mandya Jilla AIDS Prevention Mahila Sangha, Rudrappa building, 4th Cross, R.P.Road, Subhash Nagar,
Commercial
Opp. Guru Bhavan, Mandya - 571402.
Sex Workers
Ph: 08232-236083(R)/ 08232-221839(PP)
Contact Person: Shanthamma (Project co-ordinator)
Sanjeevini AIDS Jagruthi Mahila Sangha, C/O. B.S. Lokesh, No.52/D, Vinayaka Nagar, 1st cross, Tumkur - Commercial
Sex Workers
Ph: (PP)0816- 2090224/ 08133-266895 (Sharadha (Papamma)
Contact Person: Sharadha (Project co-ordinator)
____
Vimukthi AIDS Prevention Mahila Sangha, C/O.S.Indirabai, No.16, Ward No.3, Station Road, Bellarv - Commercial
583101.
y
Sex Workers
Ph: 08392-232395( Girijamma)
Contact Person: Girijamma (Project co-ordinator)
Shakthi AIDS Prevention Mahila Sangha,Ms. Nulli building, behind ADB Bank(SBI), Gokak Commercial
Taluk,Belgaum - 591307
Sex Workers
Ph: 08332-24435(0), 08332-29178(R)
Contact Person: Kasturi Kollur (Project co-ordinator)________________
AIDS Jagruthi Mahila Sangha, Flat No.31, Hirendagi building, Opp. Anikethana Hospital,
Commercial
Near ING Vysya Bank, K.K.Colony, Jalnagar, Bijapur - 586101
Sex Workers
Contact Person:Yashodha Melinkeri (Project co-orinator)
___
Darbari AIDS Prevention Mahila Sangha, C/o. Siddamma Arjun, Railway Employ Calony, H.No.72, Gate Commercial
No. 83, Afazalapur Road, Gulbarga
Sex Workers
Contact Person: Mrs.Shamala Kerartigi (Project co-ordinator)
Samuha-Samraksha (Raichur/Koppal), #17/1, Harris Road, Benson Town, Behind ISI, Bangalore-560046
Commercial
Ph: 080-3546973/3546965/3546961
Sex Workers
e-mail :samraksha@vsnl.in
Contact Person: V.M. Devi (Project co-ordinator- incharge); Smt, Sangamitra Iyengar Director)
Sadhana, Guru Garden, Vasavi nagar, PWD Camp, P.B. No. 19, Sindhanur, Raichur - 584128
’ Migrants
Ph: 08535-523699/ 520053; Mb: 9448302953
Contact Person : Sharanappa Barasi (Project co-ordinator/ Secretary)
I
Mandya
Tumkur
Bellary
Belgaum
Bijapur
Gulbarga
Raichur and
Koppal
Raichur
187
I
Appendix-D
1
2
3
4
5
6
7
8
_9_
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
VCTCs
Department of Microbiology, Victoria Hospital, Bangalore
Department of Neurovirology, NIMHANS, Bangalore
Department of Microbiology, KIMS, Hubli.
Department of Microbiology, VIMS, Bellary. __________________
Department of Microbiology, K.M.C. Hospital, Manipal, Udupi Dist,
Department of Microbiology, K.M.C. Hospital, Attavar, Mangalore.
Department of Microbiology, Mysore Medical College, Mysore
District Hospital, Bagalkot_________________________________
District Hospital, Mandhya _____________________________
District Hospital, Bidar ___________________________________
District Hospital, Bijapur__________________ _____ __________
District Hospital, Belgaum________________ _______________
District Hospital, Chamarajnagar____________________________
District Hospital, Chitradurga
District Hospital, Chikmagalur
~
District Hospital, Davangere_______________
District Hospital, Dharwad
_______________________ ~
District Hospital, Gadag_______________
_______
District Hospital, Gulbarga__________________________
District Hospital, Hassan
______________________
District Hospital, Haveri
District Hospital, Karwar (U.K)
~
~~~
District Hospital, Kodagu (Coorg)
District Hospital, Kolar______________________
District Hospital, Koppal
_______________ ______
District Hospital, Raichur
District Hospital, Shimoga
PPTCTCs
STI/STD
<✓
✓
188
28 District Hospital Tumkur
_______
29 District Hospital, Udupi
30 Taluka Hospital, Jamkhandi, Bagalkot District
31 Taluka Hospital, Mudhol, Bagalkot District
32 JSS Hospital, Mysore
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
Vivekananda Memorial Hospital, Saragur, H D Kote Tq, Mysore
Dist.
______________
Sadhan Clinic, Surathkal, Mangalore
______
K..C. General Hospital, Bangalore
District hospital, Madikeri
Vani Vilas Hospital, Bangalore____________
Kempegowda Institute of Medical Sciences, Bangalore
M .S. Ramaiah Medical College, Bangalore
Dr. B. R, Ambedkar Medical College,Bangalore
Sri Devraj Urs Medical College, Kolar
Sri Siddartha Medical College, Tumkur
Jaya Jagadguru Murugarajendra, Davangere
Karnataka Institute of Medical Science, Hubli___________
Jawaharalal Nehru Medical College, Belgaum
__
Mahadevappa Rampuri Medical College, Gulfagrga
Vijay Nagar Institute of Medical Sciences (VIMS), Bellary
Al-Ameen Medical College, Bijapur
______
Sri B M Patil Medical College , Bijapur
_____
Kasturba Medical College (KMC), Mangalore
__________
Father Muller Medical College,Mangalore
KMC (Kasturba Hospital), Manipal______________________
Government Medical College (K.R.Hpt), Mysore____________
Jagadguru Sri Shivarathreswara, Mysore
SNR Hospital, Kolar__________
General Hospital, Ankola
*
✓
V
«✓
189
57
58
59
General Hospital, Kollegala
’
Bowring & Lady Curzon Hospital, Bangalore
District Hospital, Bellary
----------------60 General Hospital, Saudatti, Belgaum District
61 _STD Clinic, General Hospital, Hospet, Bellary District
62 General Hospital, Haveri
63 General Hospital, Jayanagar, Bangalore,
64 General Hospital, Shahpur, Dist. GulbargT
v<
>/
>/
>/
190
Appendix-F
LIST OF CARE AND SUPPORT CENTRES
1
2
3
4
5
Snehasadan,
St. Camillus Rotary Rehabilitation Centre,
P.O. Kinnikambla, Gurupur,
Mangalore-574151.
Ph: 0824-2258118/2258119
Contact Person: Fr. Joshy (Project coordinator/Director)_________________________
Snehadaan,
St. Camillus Home of Charity,
Sagapura Road, Ambedkar Nagar,
Carmelaram Post, Bangalore-560035.
Ph: 080-8439516-102/080-8439631
Contact Person: Fr. Methew perumpil
(Project co-ordinator)_______________________
Freedom Foundation,
# 180, Hennur Cross, Bangalore-560043.
e-mail: ffeedom@bgl.vsnl.net.in
Ph: 91-805440134/91-80-5449766
Contact Person: Dr. Nirmala (Project co-ordinator)
Mr.Ashok.K.Rau (Executive Trustee)__________
Freedom Foundation,
No.30B, Infantry Road, Opp. T.B.Hospital,
Bellary Cantonment, Bellary- 5831102
Ph: 08392-240888/244985
Contact Person: Mrs. Rathi Kapadia
(Project co-ordinator)
Mr.Ashok.K.Rau (Executive Trustee)__________
Freedom Foundation,
No.3/3A, Survey No. 14/1,
C-2, Moolur Village, NH 17,
Post Uchila- 574117, Udupi District
Care & Support
Mangalore
94481-18119
Care and Support
Bangalore
Care and Support
Bangalore
Care and Support
Bellary
Care and Support
Udupi
Ph: 0820-2552312
6
Contact Person: Dr. Krupa (Project co-ordinator)
Mr.Ashok.K.Rau (Executive Trustee)___________
ACCEPT-Aids Care, Counselling, Education and
Prevention Training,
Rehoboth., Agape Street, Horamavu^
Agara post. Bangalore — 43.
Ph No. 080-8465418/56990452
Contact Person: Mr. A.S.Muralidharan
(Project Co-ordinator)
Sri. Raju.K.Mathew (chairman)
Care and Support
Bangalore
191
7
8
Moolika Samvrudhi Arogyabhivrudhi Prathishtana®
Hariyappa hospital, R.P Road, Sagar Taluk-577401,
Shimoga District.
Ph.No.08183-326618/321870/328141 (R)
Contact Person: Dr. K.H. Chandra shekar Rao
(Project co-ordinator/Vice President)
Asha Jyothi, Samraksha,
No. 10, Gundi Road,
NH 13, Kustagi - 584121
e-mail:samraksha@vsnl.in
Ph: 08536-668214
Contact Person: Ms. Sulekha (Project co-ordinator)
Care and Support
Sagara, Shimoga
Care and Support
Kustagi
192
Appendix-H
Rights
HIV/AIDS iadhridwal
Basic human rights having direct relevance to people living with HIV / AIDS adapted
from Kirby 1996 modified in 1992.
• Right to confidentiality and privacy
• Right to employment without discrimination
• Right to gender equity
• Right to development
• Right to highest attainable level of care
• Right to protection against oppressive laws and state policies
• Right to marry and start a family
• Right to receive basic information necessary for their protection, health and life
PM
Rights of a HIV positive child (source: Convention of the Rights of Children)
General priaciples
- Principles of non discrimination (Article 2)
- The best interest of the child (Article 3)
The rights to live, survival and development (Article 6)
- Respect the views of the child (Article 12)
Rights
-
Right not to be separated from the parents (Article 9)
Right to privacy (Article 16)
Right to be protected from violence (Article 19)
Right to special protection and assistance by the state (Article 20)
Right to children who are differently abled (Article 23)
Right to health (Article 24)
Right to social security (Article 26)
Right to education and leisure (Article 28 & 31)
Right to be protected against economic exploitation, narcotic and sexual
exploitation (Article 32, 33. 34 and 36)
Right to be protected from abduction, sale, trafficking, torture, degrading
treatment and punishment (Article 35 and 37)
Right to physical and psychological recovery and social reintegration (Article 39)
193
Appendix -I
EVALUATION
Aim: To evaluate the overall workshop
Description: The participants are given a chance
• to give a feedback on the overall training workshop
• to give recommendations for improving the workshop
Materials
• Small pieces of paper or index cards
• Three boxes that are clearly labeled ‘good points’, negative points’ and
‘suggestions’
Duration
• 20 minutes
Process
• Distribute three index cards to each participant
•
Ask the participants not to write their names on the cards, and that it is preferred
to have the feedback anonymously
•
Ask the participants to write ‘ three good points’ of the workshop on one card;
three ‘negative points’ on another card ; and three ‘suggestions’ for the workshop
to improve in future
•
Display the three boxes labeled ‘good points’, negative points’ and ‘suggestions’
•
Ask the participants to put their cards in the respective boxes
•
Tell the participants you will be compiling their feedback and the results will be
documented in the workshop report (written within 2 weeks and given to all
facilitators and organizers)
194
Sample format: HIV/AIDS training programme - feedback
Instruction:
Please put tick mark ( ^ ) in the appropriate column. Fill it after each session.
Session I
Information
gained
Excellent
Good
Average
Poor
Presentation
interesting
Method of
teaching used
Any comments
The same format could be used for all sessions
195
Pre and post test sample questions
could *
“,he
8ained by
Instructions: Please select the single best option for each item,
Write your choice in
the box provided.
1. The following are the modes of HIV transmission except:
a) From infected person to his or her sexual partner
b) By sharing needles and syringes when injecting drugs
c) By sharing bath towels and soaps with an infected person
d) From infected mother to child during pregnancy, delivery or breast feeding [
2. The prevalence rate of HIV infections in Karnataka is-
a) 0.1%-0.3%
b) 1-1.7%
c) 5-8%
d) 10-12%
3
TWhich
'
one of the statements does not indicate the link between STI /STD’s and HIV
a)
b)
c)
d)
4.
r
Effective treatment of STI/STD’s will reduce the risk of HIV transmission
Measures to reduce HIV transmission will include control of STI/STD’s
Both are sexually transmitted in most instances
There is no way to prevent STI’s & HIV.
T”
Which of the following is a major manifestation of HIV:
a)
Weight loss > 10 percent of body weight
b)
Generalized rashes
c)
Upper respiratory infections for more than 2 weeks
d)
Indigestion for more than one month
5. Which isof the following is not an opportunistic infection related to HIV infections
a)
Mycobacterium tuberculosis
b)
Kaposis sarcoma
c)
Ulcerative colitis
d)
Acquired immuno deficiency syndrome
6.
Fhe advanced stage of HIV disease is called:
a)
Opportunistic infections
b)
Symptomatic stage
c)
Seroconversion stage
d)
Acquired immune deficiency syndrome
1%
]
7. The antiretroviral drug used in HIV infection:
a) Ranitidine
b) Zidovudine
c) Ctmetidine
d) Famotidine
8) The following arc sexually transmitted disease except
a) Gonorrhea
b) Syphilis
c) Chancroid
d) Cervical polyps
*
9) The probable cause ofdysphagia in a person having HIV infection is:
a) Esophageal dysmotility
b) Esc^hagitis
c) Esophageal candidiasis
d) Esophageal stricture
I
10) Nurses need to consider all the points while planning diet for HIV persons except
a) Provide soft Hand diet in small and frequent amounts
1 FFiiiTT
b) Administer
anti-emetics as needed
c) Provide dietary supplements
d) Restrict protein in tiie diet
11) The body fluid to which universal precautions apply include
a) Pus
b) Saliva
c) Urine
d) Stool
12) The type of risk involved which handling blood spills is:
a) Low risk
b) Medium risk
c) High risk
d) No risk
13) Needles and syringes before the next use should be:
a) Disinfected
b) Sterilized
c) Cleaned with bleach solution
d) Boiled
197
14) To prepare a bleach solution, the ratio of bleach: water is:
a) 1:3
b) 1:5
c) 1:9
d) 1:12
15) The disinfectants effective against HIV
a) Spirit
b) Dettol
c) Lysol
d) Phenol
16) While segregating wastes the color coding for collecting infection waste is
a) Red
b) Blue
c) Yellow
d) Green
17) After an accidental needle prick one should immediately:
a) Report to the concerned person
b) Pour Hypochlorite solution on to the wound
c) Put the finger into mouth.
d) Wash area with soap and water
18) Risk assessment to start PEP is based on:
a) Location of the injury
b) Sex of the person
c) Volume of blood contacted
d) Age of the person
19) PEP medication should be started:
a) After obtaining the lab results of the index person
b) As early as possible
c) Only when the person wants to start the medication
d) Within one week after the incident
20) All the following investigations that have to be done before starting PEP except
Serum electrolytes
b)
WBC - Total and differential counts
c)
Renal function tests
d)
Liver function tests
e)
198
21) The follow up of the person after accidental exposure should be done for:
a) 2 months
b) 4 months
c) 6 months
d) 8 months
22) The drugs used in PEP for the basic regimen include:
a) Lamivudine
b) Indinavir
c) Nelfinavir
d) None of the above
23) A common reason for stigma towards HIV +ve persons is
a) Lack of openness
b) Lack of knowledge
c) Poor interpersonal communication
d) None of the above
24) One favorable attitude towards sexuality is
a) Too much knowledge about sexuality is dangerous
b) It is dirty to talk about sexuality
c) All humans are sexual beings
d) It is embarrassing to discuss about sexuality
25) One misconception about the cause of HIV is
a) Sharing infected needles and blades
b) Transmission from the mother to the infant
c) Unprotected sexual intercourse with an infected person
d) Due to casual contact such as holding hands, hugging etc
26) Nurses need to have the following behavior towards HIV +ve persons
a) Sympathy towards the person especially considering the way the person got the
infection
b) Acceptance of the person as he or she is
c) Avoiding contact and interaction with the person
------d) Warning the community against interaction with the person
------27) HIV can be treated by
a) Encouraging exorcism
b) Having sex with a virgin
c) Bathing four to five times a day
d) None of the above
199
28) The task involved in the orientation phase of communication includes
a) Self examination
b) Addressing the issue at hand
c) Building trust
d) Summarizing information
29) The last phase of interpersonal communication includes
a) Termination phase
b) Working phase
c) Orientation phase
d) Pre-orientation phase
30) All the below are reasons for distorted messages except
a) Short sentences
b) Impartial listener
c) Too many details
d) Nervous listener
31) Method of handling prejudice include
a) Showing acceptance
b) Communicating with an open mind
c) Not being j udgmental
d) All of the above
32) When beliefs interfere with communication, the principle to avoid it is
a) Encourage useful beliefs
b) Accept neutral beliefs
c) Discourage harmful beliefs
d) Aggressively confront the belief
33) Areas requiring behavior change in HIV +ve person who is working in an office as a
clerk (i) family life (ii) sexual behavior (iii) occupation (iv) personal habits
a) All of the above
b) None of the above
c) Only (i), (ii), (iv)
------d) Only (i), (ii), (iii)
------34) The attitude to be promoted for behavior change is
a) I deserve the illness I got
b) Sacrifices required of me are not worth it
c) I am in control of my life
d) I can not help my self
200
►
ft.
35) Skills to be promoted for behavior change are
a) Knowledge of HTV
b) Ability to communicate with the partner
c) Knowledge of sexual behavior
d) Knowledge of resources
36) Aspects to be supported for behavior change include (i) Partners willingness to
change (ii) Use of condoms (iii) Building awareness in the community
(iv) Developing support groups in the community
a) All of the above
b) (i), (ii), (iii)
c) (i), (iii), (iv)
------d) (ii), (iii), (iv)
------ i
ft
37) Pretest counseling is aimed at:
a) preventing spread of HTV/AIDS
b) treating persons with HTV/AIDS.
c) Identifying persons with HTV/AIDS
d) Managing persons with HTV/AIDS
38) To confirm the diagnosis of HIV ELIZA test must be done:
a) Three times on the same sample of blood.
b) Twice on the same sample of blood
c) Once on different samples of blood
d) Twice on different samples of blood
39) A person who has been exposed to high risk behavior may not show a positive test
because:
a) Hie person is still safe from infection
b) It is the window period
c) The test is giving a false result
------d) None of the above
-------
40) Post test counseling is needed to (i) reveal test result (ii) support the person (iii)
counsel the person on modifying behavior (iv) refer the person
a) All (i),(ii),(iii) & (iv)
b) None of the above
c) Only (i) & (ii)
d) Only (iii) & (iv)
41) Persons al risk of developing HIV include all except:
(a) Those involved in unsafe sex
(b) Those who are mutually faithful to partner
(c) Those involved in drug abuse
(d) Those who receive frequent blood transfusions
201
42) A nurse must refer persons with high risk for HIV to all except:
a) VCTC
b) PMTCTC
c) Radiographic centre
d) Hospitals
43) A nurse must be able to maintain effective networks with (i) health professionals
(ii) support centres, VCTC, PMTCTC (iii) influential person.
a) (i)&(ii)
b) (ii) & (ii )
c) (i) & (iii)
------d) (i), (ii) &(iii)
-----44) Documentation of referrals is necessary since it aids in:
a) Tracing contacts
b) Identifying compliance to treatment
c) Tracing persons with high risk behavior
d) Checking how good referrals were
45) Follow up is needed since it helps in:
a) Checking quality of services to persons referred
b) Identifying persons with high risk behavior
c) Assessing progress of person referred
d) Developing good net works.
46) MTCTCs are centers for HIV testing for:
a) All women who are pregnant
b) All adolescents girls
c) All women at risk for HIV person
d) All married women
47) Women who must be advised to have a HIV test in order to prevent its transmission
to the child include those: (i) Who have children >15 years (ii) Who have history of
exposure (iii) Want to have children (iv) Who are pregnant
a) (i) (iii) (iv)
b) (ii) (iii) (iv)
____
c) (iii) (ii) (i)
|
e) (iv) (ii) (i)
48) Primary prevention of MTCT include:
(a) Educating all adolescents about HIV causes, spread, prevention
(b) Treating women who have been diagnosed to have HIV.
(c) Treating pregnant women who has been tested positive for HIV
(d) Testing all women with history of exposure for HIV.
[
202
49)The best advise to give a woman from a low socio economic background who is HTV
positive to prevent MTCT is:
a) Not to breast feed
b) To exclusively breast feed for 6 months
c) To breast feed and give top feeds.
|
d) To breast feed for 3 months and then switch to tin milk
50) Women who is pregnant in her 6th month of gestation and is diagnosed to HIV
positive.
a) Can be given ARTs safely
b) Cannot be given ARTs
c) Must be advised to have hospital delivery
i
d) None of the above
5 l)If a HIV positive woman opts to breast feed her infant, she must be told: (i) To
exclusively breast feed for baby for 3 months (ii) To abruptly stop breast feeding by 3
months (iii) To start feeding expressed breast feed by 2 months using cup/paladai (iv) To
mix feeds i.e. (breast milk and other feeds)
a) (i) (ii) (ni)
b) (ii) (iii) (iv)
c) (iii) (iv) (i)
____
d) (i) (ii) (iv)
i
52) For PLHAs hospital is an ideal place for:
a) Care
b) Treatment of acute conditions
c) Counseling
d) Health education
53) The content of Home Care kit will include
a) Diazepam
b) Inj. Adrenaline
c) Calcium gluconate
d) Nystatin suspension
54) Hospice care:
a) Provides financial assistance
b) Provides contact testing
c) Caters to the needs of the terminally and acutely ill.
d) Means someone else cares for the people that are cared for
203
55) HTV infection can be transmitted to other family members through.
a) Sharing the toilet
b) Touching and kissing others
c) Cooking food for family members
d) Sharing razors/shaving blade
56) A HIV infected person:
a) Can get married
b) Cannot get married
c) Can get married provided partner is told about HIV status
d) Can get married, without telling the partner about the HTV status before marriage
KEY
1. c
2. b
3. d
4. a
5. c
6. d
7. d
8. c
9. c
10. d
11. a
12. b
13. b
14. c
15. d
16. c
17. d
18. c
19. a
20. c
21. c
22. a
23. b
24. c
25. d
26. b
27. d
28. c
29. a
30. a
31. d
32. a
33. c
34. c
35. b
36. c
37. a
38. a
39. b
40. a
41. b
42. c
46. a
47. b
48. a
49. b
50. a
51. a
52. b
53. d
54. c
55. d
56. c
43. d
44. b
45. c
204
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r
LISIOIUEXPERTS AND AUTHORS
______ Name - Experts
l .Mr. Albert Selvanayagam
> 2. Mrs Rosalind Selvanayagam
___________ _______________ _
3. Rev Fr. Mathew Perambil
___________ Address_______
31, Loyalo Layout
Victoria Road
Bangalore 560047___________
31, Loyalo Layout
Victoria Road
Bangalore 560047___________
______ Email address
rosal@vsnl.com
_____ Telephone number
Residence: 9180-25362564
rosal@vsnl.com
Residence: 9180-25362564
Director
Nil
Office: 9180-28439516
-28439631
Mobile: 9844005191
Snehedan St. Carmillus home of
charity
Carmelaram post
Sarjapur road, Bangalore 35
4. Dr. Ms. K. Lalitha
27, Mental Hospital Quarters,
Near Krishna guest house
NIMHANS, Bangalore
Krishna@nimhans.kar.nic.in
Office: 9180
Residence: 9180-26567884
5. Mrs. H. Lalitha
# 160, 7,hAmain
“
16lh Cross
J.P Nagar 4tl1 Phase, Bangalore 78
Nil
Office: 9180-22065121
Residence: 9180- 26581095
210
14. Mrs. Edwina Pereira
Program Director, training
INSA- India (International services
Association),
5/1 Benson cross road
Benson Town
Bangalore 560046
|7. Dr. Sanjiv Lewin
Assoc Professor and Unit Head
Dept of Pediatrics
St. John’s Medical college Hospital
Bangalore 560034
____________________
I 8. Dr. Reynold Washington
Program officer, India Canada
Collaborative HIV/ AIDS Project
Pisces Building # 4/137
Crescent Road, High Grounds
Bangalore 560001
insaind@blr.vsnl.net.in
Office: 9180-23536633,
-23526299
Residence: 9180-25461261
Mobile:9448011208
lewin@vsnl.com
Office: 9180- 22065284
Mobile: 9886085076
reynold@ichap.org
Office: 9180-22208354
Mobile: 9341948345
Nil
Office: 9180-22065120/1
Residence: 9180-25566849/
-25300208
___________________
9. Ms. Madonna Britto
Principal, St. Johns College of Nursing
105 Victoria Layout
1st Cross,
Bangalore 560047
L.
211
Resource persons / authors
I 1. Ms. Glory Lagali
(Chapter IX & X)
Lecturer, St. John’s College of Nursing
glorydinkar@yahoo.co.in
Office: 9180- 22065129
Residence: 9180- 25531860
Mobile: 9845992728
Nil
Residence: 9180-25307650
Mobile: 9880417807
Nil
Office: 9180- 22065129
Residence: 9180- 25631575
Mobile: 9886472981
F-l 1, St. John’s Staff Quarters
Hosur Road
Bangalore 560034
2. Ms. Dorothy Theodore
(Chapter VII & VIII)
Asst. Professor, St. John’s College of
Nursing
No 122, Austin Town
1st Square
Bangalore 560047
3. Ms. Vijayalakshmi Satheesh
(Chapter II)
Associate Professor, St. John’s College
ofNursing
E-42, St. John’s Staff Quarters
Hosur Road
Bangalore 560034
212
4. Ms. Preethy D’Souza
(Chapter 1, IIIJV & X)
Associate Professor, St. John’s College
of Nursing
rovand@hotmai 1 .com
Old 67, New 29
III Cross, Gospel Street
St. Thomas Town PO
Lingarajapuram
Bangalore 560084
5. Ms. Jasmine Benny
(Chapter V & VI)
Associate Professor, St. John’s College j asm inebenny©hotmai 1 .com
of Nursing
#2129, 15th Cross, 22nd Main
HSR 1st Sector
Bangalore 560034
6. Ms. Maryann Charles
(Coordinator of the project Editor,
Chapter IV, VIII, XI, & XII)
Professor, , St. John’s College of
Nursing
752, Victress Villa
5th Cross Gokul Extension
Bangalore 560054
maryannvc@hotmail.com
Office: 9180-22065129
Residence: 9180- 25479253
Mobile: 9845359439
Office: 9180-22065129
Residence: 9180Mobile: 9845359439
Residence: 9180- 25506375/
- 23377377
Mobile: 9845803423
213
- Media
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