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ABOUTTHEHANDBOOK
This handbook has been developed for the Link Worker
Scheme, under NCAP-III. The Link Workers are the target
audience for this handbook though it is equally relevant and
useful for the volunteers and other community based health
workers.
This handbook summarizes the key discussion points from
the Training Manual which will be used during two weeks
training programme for Link Workers at the time of
induction.
This handbook is meant to be used as ready reference
material by the Link Workers while working in the
community. At the same time, the handbook provides an
outline of 'on the job' training to be provided to the
volunteers under the Link Worker Scheme.
The use of the handbook by the Volunteers and Link Workers
will depend on their level of literacy and ability to read it in
the language in which this document is available. It is
expected that the Handbook will be translated into the
local languages by respective State AIDS Control Societies.
The translated version will facilitate the use of the
handbook by a larger number of Link Workers and
Volunteers.
*
PART-1: LINK WORKER
•z
IxJ
1.1 Role of Link Worker
1-2
1.2 Ethics and Values
3-4
1.3 Directory of Services and Important Contacts
5-10
1.4 Acronyms
11-12
1.5 Glossary
13-16
Z
PART-2: HIV & AIDS
o
2.1 HIV Epidemic in India
19-20
2.2 National AIDS Control Programme III
21-22
2.3 HIV & AIDS: Understanding the terms
23-26
2.4 Modes of HIV Transmission
27-30
O
PART-3: UNDERSTANDING THE CONTEXT
3.1 Women and HIV & AIDS
33-34
3.2 Youth and HIV a AIDS
35-36
*
3.3 Sex and Sexuality
37-39
PART-4: PREVENTION AND CONTROL OF HIV a AIDS
4.1 High Risk Behaviours and Reducing Risk
43-47
4.2 Sexually Transmitted Infections and STI Management
48-49
4.3 Condom Promotion and Demonstration
50-54
4.4 Getting tested for HIV
55-57
4.5 Parent to Child Transmission of HIV
58-60
4.6 Anti Retroviral Therapy ( ARTs)
61-62
4.7 Continuum of Care (Prevention , Care, Support and
63-64
Treatment Services)
PART-5: UNDERSTANDING RISK AND VULNERABILITY
UJ
5.1 Populations with High Risk Behaviour
67
5.2 Sex Worker: HIV Risk and Vulnerability
68-69
5.3 Men who have sex with men or MSM: HIV Risk and
Vulnerability
70-71
5.4 Injecting Drug Users: HIV Risk and Vulnerability
72-73
5.5 Migrants and Mobile Populations: HIV Risk and
Z
o
Vulnerability
5.6 Truckers: HIV Risk and Vulnerability
74-76
77-78
PART-6: WORKING WITH THE COMMUNITY
6.1 Creating an Enabling Environment
81
6.2 Interpersonal Communication
82
6.3 Behaviour Change Communication
83-85
6.4 Stigma and Discrimination
86-89 v
6.5 HIV and AIDS and Human Rights
90-91
PART-7: WORKING WITH THE VOLUNTEERS
7.1 About the Volunteers
95-96
7.2 Training Programme for Volunteers
97-104
PART-8: MAPS OF POPULATION AND SERVICES
8.1 Village-1
107
8.2 Village-2
108
8.3 Village-3
109
8.4 Village-4
110
8.5 Village-5
111
8.6 Availability of Services
112
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PART -1
Link Worker
1.1 ROLE OF LINK WORKER
Link Worker is the key personnel under the Link Worker Scheme under
National AIDS Control Programme Phase-Ill. Their main responsibilities will be
to enhance the access to HIV related information and services among the high
risk groups and vulnerable young people and women in the rural community
(for example, partners/spouses of migrants, mobile populations, IDUs, young
girls/women in women headed households etc.).
It is expected that the Link Worker will
spend at least two third of the time for
reaching out to individuals with high risk
behaviours who are part of the general
population. The rest of one third time
will be spent working with vulnerable
young people and women in the
community. While reaching out to high
risk groups is the prime target, the Link
Some of the key roles identified
for the Link Workers are: '
•
Conduct the village level mapping
(vulnerability mapping, community
resource mapping, health
services/facility mapping, household
mapping)
•
Understand the migration patterns
(both in and out migration) in the
local community
•
Work with the communities to create
an enabling environment by
establishing linkages with positive
networks/CBOs and NGOs that have
ongoing interventions for prevention,
care and support
Worker will establish rapport with the
communities and understand the specific
conditions in that particular location
that makes certain people vulnerable.
This approach will also help them
identify these individuals as they are
likely to be 'hidden*.
Handbook| for Link Worker
1
Work towards reducing stigma and
discrimination in the community by
facilitating involvement of positive
people, and addressing its gender
dimensions
•
Advocate with identified stakeholders
(key persons in the community) for
creating an enabling environment
(see section on stigma and
discrimination)
Create awareness regarding the
Rights of positive people and High
Risk Individuals (HRIs)
*
Facilitate formation of Red Ribbon
clubs (RRC)
utilization of VCTC/ICTC, PPTCT
services) by HRGs and other highly
vulnerable population
•
Identify and train volunteers
Facilitate formation of condom
depots. Ensure timely supply of
condom in intervention areas
•
Supervise volunteers, Red Ribbon
Clubs (RRC) and condom depots
•
Collection of monthly data from RRC
and condom depot holders
•
Making monthly reports for the
intervention area
Work towards reducing barriers to
accessing services (STI management,
•
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1.2 ETHICS AND VALUES
The Link Worker is expected to be o role model for volunteers and society at
large to catalyse the changes in individual and thus society for effective
prevention and control of HIV & AIDS. It is also understood and respected that
the Link Worker is a part of the community s/he is working for and also
brings along certain family and societal values.
and volunteers, especially regarding
vulnerable and high risk groups.
The Link Worker however needs to
follow some values and ethics, while
dealing with the members of the
•
Do not blame or ridicule the person's
practices, especially related to
sexual matters. Rather, encourage
them to talk about it and provide
appropriate advises.
•
When you are not sure of certain
information or do not have
knowledge on the subject under
discussion, mention that you will
return with more information on the
subject. Discuss the matter with the
supervisor if you don't find much
about it in the handbook.
•
Do not offer incomplete information
or the information that you are not
sure of.
•
Always seek consent of the affected
person before discussing his/her
sexual identity/problems with
others, even with the family
member(s) of the concerned person.
•
Collect all possible information
about the services to which you
refer to a person.
community, especially those are
members of high risk/vulnerable groups
and/or people living with HIV & AIDS.
This is essential in order to enable the
members of the high risk/vulnerable
groups and/or people living with HIV &
AIDS to access and utilise the available
information and services to reduce their
vulnerability and improve the quality of
life for themselves.
The ethics and values that need to be
followed by the Link Worker and
Volunteers are:
Maintain the confidentiality of the
person in all circumstances. Ensure
that no words or phrases are used in
any situation that may lead to the
identification of any member of high
risk or vulnerable group or any
PLWHA.
Discuss the findings of the mapping
exercise only with the supervisor
Handbook| for Link Worker
3
•
•
Be gender sensitive and weigh
possible implications while offering
your suggestions/advises especially
to women in different age groups
and member of transgender
community.
•
Behave in a manner that is
unfriendly.
•
Appear embarrassed.
Respect people’s choices and their
circumstances, while offering any
suggestions/advises with regard to
the control and prevention of HIV &
AIDS.
• Act witty.
• Appear not to care.
•
•
difficult to talk about. So try to
find out your comfort level for
facilitating and guiding the
discussions in the community.
Nobody is perfect the first time. You
•
Give information and instructions
that are confusing.
•
Discuss issues, events inappropriate
in the given situation.
• Make feel participants selfconscious.
•
Not allow opportunity for
participants to share their own
knowledge and experiences.
•
Usage of terms and language that
are difficult to understand or may
be confused for different meaning.
need to practice and minimise the
mistakes. There is always scope for
improvement. Never hesitate to
accept your mistake and correct
yourself.
While in the community and
participating/facilitating any
discussion or counselling anyone,
you SHOULD NOT DO the following:
4
Handbook| for Link Worker
Speak too fast.
• Tell people they are wrong.
There could be many issues and
concerns that can be sensitive and
Be inflexible.
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Community Health Centre
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i.4 ACRONYMS
AIDS
Acquired Immuno Deficiency Syndrome
HRG
High Risk Group
ANC
Ante Natal Clinic
HRI
High Risk Individual
ANM
Auxiliary Nurse Midwife
ICDS
Integrated Child Development Services
APAC
AIDS Prevention Control Project
ICHAP
India Canada HIV/AIDS Prevention
ART
Antiretroviral Therapy
ICMR
Indian Council of Medical Research
ARV
Anti Retro Viral
ICT
Integrated Counseling St Testing
ASHA
Accredited Social Health Activities
ICTC
Integrated Counseling & Testing Centre
AWW
Aanganwadi Worker
IDSP
Integrated Disease Surveillance Programme
BCC
Behaviour Change Communication
IDU
Intravenous Drug User
BSS
Behavioural Surveillance Survey
INP+
Indian Network of Positive People
CAU
Communication and Advocacy Unit
I EC
Information, Education and Communication
CBO
Community Based Organisation
IPC
Inter Personal Communication
CIDA
Canadian International Development Agency
ITPA
Immoral Trafficking Prevention Act
CCC
Community Care Centres
KP
Key Population
CGHS
Central Government Health Services
LHV
Lady Health Visitor
CHC
Community Health Centres
LWS
Link Worker Scheme
CMIS
Computerized Management Information System
MCI
Medical Council of India
CSM
Condom Social Marketing
MDGs
Millennium Development Goals
CST
Care, Support and Treatment
M&E
Monitoring & Evaluation
CSW
Commercial Sex Worker
MEA
Ministry of External Affairs
MHRD
Ministry of Human Resource Development
DAPCU District AIDS Prevention and Control Unit
DMU
District Management Unit
MOYA
Ministry of Youth Affairs
DOTS
Directly observed Treatment
MPW
Multi Purpose Worker
DSA
District Strategic Assessment
MSJE
Ministry of Social Justice & Empowerment
FSW
Female Sex Worker
MSM
Men having Sex with Men
GFATM
Global Fund for AIDS, TB & Malaria
MSW
Male Sex Worker
GIPA
Greater Involvement of People living with AIDS
MTP
Medium Term Plan
NAC
National AIDS Committee
NACB
National AIDS Control Board
HLFPPT Hindustan Latex Family Planning Promotion Trust
NACO
National AIDS Control Organisation
HRD
NACP
National AIDS Control Programme
HAART Highly Active Anti Retroviral Therapy
HIV
Human Immuno-deficiency Virus
Human Resources Development
Handbook| for Link Worker
11
NARI
National AIDS Research Institute
SACS
State AIDS Control Society
NCA
National Council on AIDS
SHG
Self Help Group
NE
North East
SIMS
Strategic Information Management Systems
NFHS
National Family Health Survey
SIMU
Strategic Information Management Unit
NGO
Non-Governmental Organisation
SM
Social Marketing
NHA
National Highway Authority of India
SMO
Social Marketing Organisation
NHP
National Health Policy
SRH
Sexual and Reproductive Health
NRHM
National Rural Health Mission
STD
Sexually Transmitted Disease
NYKS
Nehru Yuva Kendra Sangathan
STI
Sexually Transmitted Infection
01
Opportunistic Infection
SW
Sex Worker
OVC
Orphans and Vulnerable Children
TAC
Technical Advisory Committee
PD
Project Director
TBA
Traditional Birth Attendant
PHC
Primary Health Centre
TG
Trans-Gender
PIP
Programme Implementation Plan
Tl
Targeted Intervention
PIU
Project Implementation Units
TOR
Terms of Reference
PLWHA People Living with HIV/AIDS
TRC
Tuberculosis Research Centre
PMU
Project Management Unit
TRG
Technical Resource Group
PNC
Post Natal Care
TSG
Technical Support Group
PPTCT
Prevention of Parent to Child Transmission
TSU
Technical Support Unit
PRA
Participatory Rural Appraisal
USAID
United States Agency for
PRI
Panchayati Raj Institutions
PSV
Participatory Site Visits
UT
Union Territories
PWN
Positive Women's Network
VCT
Voluntary Counseling & Testing
RACU
Regional AIDS Control Unit
VCTC
Voluntary Counseling & Testing Centre
RBA
Right-Based Approach
WB
World Bank
RCH
Reproductive & Child Health
WBC
White Blood Cells
RCSHA
Resource Centre for Sexual Health and HIV & AIDS
W&CD
Women & Child Development
RIMP
Rural Indigenous Medical Practitioner
WHR
World Health Report
RMP
Registered Medical Practitioner
YFIC
Youth Friendly Information Centre
RNTCP
Revised National TB Control Programme
RRC
Red Ribbon Club
RTI
Reproductive Tract Infection
12
Handbook| for Link Worker
International Development
1.5 GLOSSARY
Abstinence
Not engaging in any sexual behaviour with another person. Some individuals define
abstinence in terms of refraining from penile-vaginal intercourse; others define the
word to exclude a wider range of sexual activities.
AIDS (Acquired
Immuno Deficiency
Syndrome)
Anal intercourse
A disease caused by a retrovirus, HIV (human immuno deficiency virus), and characterized
by failure of the immune system to protect against infections and certain cancers.
A sexual act involving the insertion of a penis in, or external stimulation of, another
person's anus.
Anaemia
A deficiency of functional red blood cells or a low haemoglobin level,
which reduces the bloods ability to carry oxygen. Symptoms may include fatigue,
weakness, shortness of breath, and heart rhythm abnormalities.
Antenatal
Antibody
Before birth.
A substance in the blood formed in response to invading disease agents such as viruses,
fungi, bacteria, and parasites. Usually antibodies defend the body against invading
disease agents, however, the HIV antibody does not give such protection.
Antiretroviral
A treatment that may prevent HIV from damaging the immune system.
ART
Antiretroviral therapy is the course of medications or drugs you take to fight HIV.
Other terms that mean the same thing are HAART (Highly Active Antiretroviral Therapy),
antiretroviral drugs', 'HIV treatment', 'medications’, 'drug regimen' and 'HIV drugs'.
ARV
Antiretroviral - Antiretroviral therapy is the course of medications or drugs you take to
fight HIV. Other terms that mean the same thing are HAART (Highly Active Antiretroviral
Therapy), 'anti-retroviral drugs', 'HIV treatment', 'medications', 'drug regimen' and 'HIV
drugs'.
Asymptomatic
Having no signs or symptoms of a disease, yet able to transmit the causative agent.
Behaviour Change
There are a number of theories and models of human behaviour that guide health
promotion and education efforts to encourage behaviour change, i.e, the adoption
and maintenance of healthy behaviours.
Blood transfusion
The infusion of donated blood or blood components for the treatment of a medical
condition (e.g., anaemia, loss of blood due to injury or surgery).
Commercial Sex Work
The work which involves the exchange or selling of sex (anal/or/vaginal) for money.
Commercial Sex Worker
The person who engages in commercial sex work. A person could engage in commercial
sex work by force and/or by choice.
condom
A sheath made of latex or polyurethane that is worn over the penis to prevent pregnancy
and/or the spread of HIV and other sexually transmitted infections; the female condom
is an internal pouch worn inside the vagina or anus.
Handbook| for Link Worker
13
Contraception
The use of mechanical devices, foams, medication and/or creams to prevent pregnancy.
Cunnilingus
Oral sex on a woman; sexual contact between one person’s tongue or mouth and a
woman's vulva, clitoris, or vagina.
Deficiency
Not up to normal levels or not working as well as it should be
ELISA (Enzyme-Linked
Immunosorbent)
A blood test used to detect the presence of antibodies to HIV; results that show the
presence of HIV antibodies must be confirmed by the Western Blot test before a person
is considered to be HIV-infected. Has high degree of sensitivity (accurate for detecting
true positive samples).
Fellatio
Oral sex on a man; sexual contact between one person's tongue or mouth and a man's
penis or scrotum.
Gender
Gender refers to the economic, social and cultural attributes and opportunities
associated with being male or female in a particular point in time. (World Health
Organization definition).
Genital
Refers to the reproductive or sexual organs.
HIV Positive
The presence of antibodies against HIV in the blood. If antibodies are present
(indicating exposure to or infection with HIV), an individual is HIV positive;
if not, the individual is HIV negative.
Human Immuno Deficiency HIV is the virus that causes the Acquired Immuno Deficiency Syndrome (AIDS). HIV
Virus (HIV)
attacks and slowly destroys the immune system by entering and destroying the
cells that control and support the immune response system. After a long period of
infection, usually 3-7 years,enough of the immune system cells have been
»
destroyed to lead to immune deficiency. The virus can therefore be present in the
body for several years before symptoms appear. When a person is immuno
deficient, the body has difficulty defending itself against many
infections and certain cancers, known as “opportunistic infections”.
Immune Deficiency
(immuno deficiency)
Inability of the immune system td function properly, resulting in increased susceptibility
to opportunistic illnesses and cancers; immunodeficiency may be either congenital
(present from birth) or acquired, as with HIV & AIDS.
Immune System
A system of the body that recognizes germs that cause infection and tries to eliminate
or fight against them.
Immunity
Resistance to disease; the body’s ability to recognize and defend against pathogenic
organisms and cancerous cells.
Immune Deficiency
Infection
A deficiency or weakness of the immune system's response that prevents it from working,
doing its job well.
Acondition in which the body is invaded by an infectious microorganism (e.g., bacteria,
virus, fungus).
Informed consent
14
A mechanism designed to protect subjects in clinical trials. Before entering a trial,
participants must sign a form stating that they have been given and understand
important information about the trial and voluntarily agree to take part.
Handbook| for Link Worker
IUD
Intra-uterine device-A long-term, reversible method of contraception, involving the
insertion into the uterus of a small flexible device of metal/plastic/hormonal
materials. IUDs are effective for at least four years, and many for much longer.
Monitoring
The continuous follow-up of activities to ensure that they are proceeding according
to plan and are on schedule and/or to signal the need for adjustment.
Monogamy
The practice of having one mate (sexual partner in the context of HIV and STD
transmission) at a time.
MSM
Men who have sex with men.
Opportunistic
illnesses/infections
People with HIV infection have a high risk for a wide range of illnesses
due to HIV risk factors and HIV itself. Among the most severe illnesses
are the 26 AIDS-defining opportunistic illnesses (Ols) that occur as a
result of HIV disease progression, and generally occur only after
substantial damage to the immune system.
Oral
Refers to the mouth; taken by mouth.
Policy
A set of decisions to pursue courses of action for achieving goals.
Postpartum
The period following childbirth.
Primary Health Care
Package of basic health services provided at the lowest level of a health system.
Safer sex
Sexual activities that reduce or eliminate the exchange of body fluids that can
transmit HIV by means of barriers such as latex condoms, gloves, and dental dams.
Sexual Intercourse
Penetrative sexual behaviours, including oral sex, anal sex and penile-vaginal sex.
Sexuality
The sexual knowledge, beliefs, attitudes, values, and behaviours of individuals. Its
dimensions include the anatomy, physiology, and biochemistry of the sexual response
system; identity, orientation, roles and personality; and thoughts, feelings, and
relationships. The expression of sexuality is influenced by ethical, spiritual, cultural,
and moral concerns.
Sexually Transmitted
Disease/Sexually
Transmitted
Infection
Disease resulting from bacteria or viruses and often acquired through sexual
contact. Some STIs can also be acquired in other ways (i.e. blood transfusions,
intravenous drug use, mother-to-child transmission). The term ’STI’ is slowly
replacing 'STD' (sexually transmitted disease) in order to include HIV infection. Most
STIs, like HIV, are not acquired from partners who are obviously ill, but rather
through exposure to infections that are asymptomatic or unnoticeable at the time of
transmission.
Symptom (adjective
symptomatic)
A subjectively perceptible sensation or change that signals the presence of a
disease or condition.
Handbook| for Link Worker
15
Syndrome
A set of symptoms or disease manifestations that occur together and characterise a
specific condition.
Traditional Birth
Attendant
This comprises women who provide delivery services in the community. This includes
traditional birth attendants who initially acquired their skills by delivering babies
themselves or through apprenticeship. (WHO does not include them in the category of
'skilled attendants' who are allowed to provide/manage deliveries).
\
One of a group of minute organisms that cannot grow or reproduce outside a host cell;
Virus
various families of viruses infect humans, animals, plants, and bacteria. During
replication, a virus integrates its genetic material (DMA or RNA) into a host cell and
takes over the cell's biological machinery to reproduce new virus particles.
Voluntary
Counselling and
Testing
VCT is the process by which an individual undergoes counselling enabling him or her
to make an informed choice about being tested for HIV. This decision must be
entirely the choice of the individual and he or she must be assured that the process
will be confidential.
Western Blot
A confirmation test for the presence of specific antibodies that is more
accurate than the ELISA test for detecting true negatives.
White Blood Cells
In human body WBC are the basis of immune defences against infections and cancer.
Withdrawal
One of the oldest known methods of contraception in which the man withdraws his
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penis from the vagina before ejaculation. Also known as coitus interruptus.
Not an effective method of preventing pregnancy and HIV Transmission.
16
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PART -2
HIV a AIDS
2.1 HIV EPIDEMIC IN INDIA
The first cose of HIV infection in India was reported in 1986 in Chennai,
Tamilnadu.
Today the number of people living with HIV & AIDS in India is estimated to be
between 2 and 3.1 million1. This accounts for 0.24% to 0.29% of the total
population. Over 99% of the population is still HIV negative and this
emphasizes the need for HIV prevention. By August 2006, 124,995 cases of HIV
& AIDS were reported. Of these, over 88% cases are in the age group of 15-49
years2. Women constitute close to 30% of the reported cases.
Over the years the HIV has moved from
The lower status on women in the
urban to rural and from high risk to
general population. 57% of the total HIV
society and less access to resources
prevents them from protecting
positive persons are at present in rural
themselves. Many women are getting the
areas. Also increased number of women
HIV infection from their husbands or
are now contracting the infection.
partners who have high risk behaviours
(for example they may be having sex
In India, HIV transmission is mainly
taking place through sexual route (86%).
in North Eastern part of the country,
especially in Nagaland and Manipur, the
with other men or women or sharing
injections and syringes with others)
Certain populations are categorized as
transmission is mainly through injecting
key or high-risk population since they
drugs use. This route is however
have high risk behaviours. Their high risk
becoming more common in other parts of
behaviour is characterized by
the country as well. The third most
common way of transmission is from HIV
unprotected multi-partner (often paid)
’positive’ mothers to their babies - 4% of
the total cases have contracted the
infection through peri-natal route3.
sex - vaginal and/or anal sex; and/or
injecting drug use with shared injecting
equipment. Thus commercial sex workers
(male, female and transgender); their
partners and clients; the injecting drug
1 http: I i www.avert.0r5/indjaaids.htm accessed on September 25, 2007
2
http://www.nac00nline.0r3/ accessed on September 25, 2007
http://www.nacoonline.org/ accessed on September 25, 2007
Handbook| for Link Worker
19
users (IDUs) and their partners; and Men
Prevalence among anatehatal women and
having sex with Men (MSM), including
transgender are at the highest risk.
more than 5% among high risk groups.
These states are Tamil Nadu, Karnataka,
Truckers and migrants are also at risk
subseaquent to the high risk groups
described above. Many of the truckers
and migrants have unprotected sexual
contact with sex workers (male, female
Andhra Pradesh, Maharashtra and two
North Eastern states - Nagaland and
Manipur. Three states have moderate
prevalence, namely, Gujarat, Goa and
Pondicherry.
and transgender) as well as with
Other states are also highly vulnerable.
partners from the general population
This means that if we do not take steps
(wives or regular partners) and so have a
to prevent HIV in these States, they may
potential to spread HIV infection from
also have a huge number of HIV positive
the high risk groups to general
persons in near future.
population.
Six states in India have high prevalence
of HIV. This means that more than 1% of
I
20
Handbook| for Link. Worker
2.2 NATIONAL AIDS CONTROL PROGRAMME - III
The primary goal of NACP-III is to halt and reverse the epidemic in India over
the next 5 years(2007-2012) by integrating programmes for prevention, care,
support and treatment. This will be achieved through four pronged strategy
namely:
1. Saturation of coverage of high risk
almost 40% of the country’s population,
groups with targeted interventions
with prevention messages.
(TIs), Scaled up interventions in the
To create a non stigmatizing
environment and enhance access of key
general population
2. Providing greater care, support and
populations and people living with HIV &
treatment to a larger number of
AIDS to services, a well coordinated
communication strategy is being put in
place. NACP-III will also seek
people living with HIV & AIDS.
3. Strengthening the infrastructure
systems and human resources in
prevention, care, support and
treatment programmes at the
district, state and national levels.
convergence with the Reproductive and
Child Health (RCH)and NRHM Programme
4. Strengthening a nation-wide Strategic
transmitted diseases, ante-natal care for
Information Management System.
Priorities and thrust areas of NACP-III
include the following:
particularly in the areas of access to
safe blood, treatment for sexually
all pregnant women living with HIV &
AIDS and screening of all pregnant
women attending ANC clinic.
*
Care, support and treatment
Prevention
The mainstay of the programme will
Under NACP-III, prevention will go hand
continue to be prevention since more
in hand with access to prophylaxis,
management of opportunistic infections
than 99% of the people are HIV negative.
The programme will focus on saturating
and ART. Focus will also be on assuring
the estimated 4 million people in the
high risk groups (commercial sex
workers, IDUs and MSM); an estimated 12
million highly vulnerable populations,
namely migrants and truckers; and the
large number of young women and men
in the general community who constitute
universal access to first line ARV drugs.
To ensure drug adherence, the
Community Care Centres will be planned
as a bridge between the patient and the
ART centres and provide psycho-social
support, counselling through strong
outreach services, referrals and
Handbook| for Link Worker
21
palliative care. Home based care will be
Decentralization of
an integral part of this strategy.
implementation
Care, support and treatment services
will include management of
Given the spread of HIV infection into
rural areas, NACP-III will further
opportunistic infections including
control of TB in PLWHA, anti-retroviral
decentralize its organizational structure
treatment (ART), safety measures,
positive prevention and impact
mitigation.
Impact mitigation
to implement programmes at the district
level. The basic unit of implementation
will now be the district. The
categorization of districts based on
vulnerability will be useful in preparing
NACP-III will make efforts to address the
plans that are need based. Accordingly,
differential packages of services have
needs of persons living with and
been developed for each category of
affected by HIV, especially children.
This will be done through the sectors
and agencies involved in child protection
districts. Institutional arrangements and
capacities of the SACS as well as the
and welfare. Impact of HIV on others
will be mitigated through other welfare
proposed District AIDS Prevention and
Control Units (DAPCUs) will be
agencies providing nutritional support,
opportunities for income generation and
strengthened. To address special
vulnerabilities of the North-Eastern
States, a Regional AIDS Control Unit
other welfare services.
(RACU) will be established as a sub
NACP-III will promote Greater
office of NACO.
Involvement of People living with HIV &
AIDS (GIPA) and facilitate establishment
Monitoring & evaluation
of PLWHA networks and civil society
A Strategic Information Management
forums in each district by 2010. Attempt
Systems (SIMS) unit will be set up at
national and state levels to address
to bring in non-stigmatizing legislation
will be made and capacity developed at
all levels for effective advocacy against
discrimination and a rights based
approach to the HIV mitigation
programme.
issues relating to planning, monitoring,
evaluation, surveillance and research.
The proposed surveillance system will
focus on tracking the epidemic,
identifying pockets of infection and
estimating the burden of infection.
22
Handbook| for Link Worker
2.3 HIV a AIDS: UNDERSTANDING THETERMS
HIV:
HIV (Human Immuno Deficiency Virus) is a virus that causes AIDS.
AIDS (Acquired Immuno-Deficiency Syndrome) is a health condition in which
the person develops infections and diseases because of poor immunity.
A person who has HIV virus present in the body is called HIV 'Positive'.
AIDS:
person develops illness not because of
the HIV but because of many other
When a person gets infected with HIV,
the virus enters the white blood cells
infections that a person catches because
the defence system is not functioning.
(WBCs) and begins to multiply there. In
the process white cells are destroyed.
"A"-Acquired means that the disease is
The virus is released into the blood
not hereditary (cannot be passed on in
stream and attacks more WBCs and the
the genes) but develops after birth from
contact with a disease causing agent (in
process continues. The number of WBCs
in the body starts to fall. The WBCs can
no longer do their job of protecting the
this case HIV).
body from various germs. The immune
body that protects us from infections-
system (defence system) gradually
the immune system.
T'-lmmune - It affects the system of the
breaks down.
"□"-Deficiency - The immune system is
Depending on the person's behaviour and
not functioning adequately or is
nutritional status the period for
complete break down of immune system
weakened.
may vary. When the immune system is
severely compromised and WBCs are
"S"-Syndrome - A set or a group of
present in very low numbers, the person
is said to have developed AIDS.
In the absence of an adequate defence
system the body is attacked by different
kinds of germs which would not have
affected a normal person. Thus the
symptoms that characterize a disease.
•
Summing up, HIV is a virus and AIDS
is a disease condition in which the
person becomes susceptible to many
infections and diseases because of
less number of wKIte blood cells In
the body.
Handbook| for Link Worker
23
Immune system
(WBCs), which make up the immune
system. The immune system is the
A healthy person's body is protected
normal defence of the body against
from infections by White Blood Cells
harmful germs.
\
WBCs
Your immune system is your guard against diseases. The immune system mainly
consists of the white blood cells and can be considered as body’s first line of defence.
24
Handbook| for Link Worker
Immune System
HIV attacks the white blood cells and
destroys them. Thus the immune system is
compromised and is no longer capable of
HIV destroys the white blood cells of your body
Handbook| for Link Worker
25
hl'ni
II.'
Once HIV has weakened your immune system,germs can easily
invade the body and make you sick.
26
Handbook| for Link Worker
2.4 MODES OF HIV TRANSMISSION
HIV spreads from one person to another through specific body fluids, which
include blood, semen, vaginal fluids, and mother's milk.
There are 4 modes of transmission of
HIV:
e
anal sex. Around 86 % of people in India
are infected by sexual route.
Unprotected sexual contact (sex
without condom)
Transfusion of infected blood
•
Use of infected/unsterilised
needles and syringe
•
From HIV ’positive’ parents to
newborn
I
1. Unprotected sexual contact
(sex without condom)
Unprotected sexual contact with a
person, who has HIV, is the most
common way of transmission of HIV
infection from one person to another.
HIV can be passed on by vaginal, oral or
A woman has a greater chance of being
infected by HIV as compared to a man.
This is because the contact period
between the semen and the female body
(vagina) is longer than the contact
period between the vaginal secretions
and the male organ (penis). Also the
surface area of a woman's genital
(vagina) is more as compared to those of
males (penis).
2. Transfusion of infected blood
Transfusion of infected blood (that has
HIV) can directly transmit HIV infection
into the blood stream of the person. This
can happen when the blood for
transfusion is not tested for HIV. The
Handbook| for Link Worker
27
chances of passing on the HIV infection
4. From HIV ’positive’ parents to
through this route are around 90%.
newborn
It is now mandatory for all blood banks
in India to screen all donated blood for
There are 30% chances of HIV being
HIV before the blood bag is cleared for
to the child. HIV can be passed on during
transfusion to a patient.
pregnancy, childbirth or breastfeeding.
3. Use of infected/unsterilised
needles and syringes
transmitted from a HIV positive mother
The transmission during birth is the most
common way. It happens through HIV
present in vaginal secretions and blood
(in the birth canal) at the time of
delivery. After birth, it can transmit
through breast milk.
—Bb
Using needles and syringes, which have
already been used by another person will
have small amounts of left over blood in
- V
the needle which can have HIV virus
present in it. This infected blood will
directly transfer HIV into the blood
stream, if the needle and syringe is
reused without being properly sterilized.
More information about this mode of
transmission is provided in subsequent
sections of this handbook.
28
Handbook| for Link Worker
HIV does not spread by:
Casual contacts such as touching,
holding hands, shaking hands,
embracing, socializing or living with
people with HIV & AIDS.
•
Caring and looking after people with
HIV & AIDS
•
Use of public toilets, swimming
pools, community showers
•
Contact with objects in phone
booths, public transport, doorknobs,
money etc.
Mosquito bites
e
Working or playing together
•
Sharing telephone or computers
•
Sharing food, utensils, or clothes
•
Sneezing and coughing
Body contact in public places
Hugging, touching or masturbation
Jwl
/y \ A.'j
%
Eating together from the same plate.
Sharing utenesils, clothes, money etc.
I
-i
Mosquito bite
V
A -—A
Shaking hands, hugging, kissing or masturbating
Handbook| for Link Worker
29
Using the same toilet
ff
ia I?
Sharing phones and computers
x\
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ft' \
/| 16
\ 7W
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Working together in the same work place
Caring and looking after people with HIV
30
Handbook| for Link. Worker
A
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PART -3
Understanding the context
3.1 WOMEN AND HIV & AIDS
Women are much more vulnerable to HIV than men and also face greater risk
of HIV transmission because of various other reasons
Physiologically, the differences in the
particularly vulnerable to HIV infection
genital tract directly contribute to
adolescent and young women running a
caused not by their own behaviour, but
higher risk of acquiring HIV infections.
include:
These differences include immature cells
in the genital tract and inadequate local
•
by that of their partner. These factors
Cultural norms often deny women the
immunity, which makes the genital tract
knowledge of sexual health; or when
more susceptible to infections. Besides
women possess such knowledge
the vaginal lining is thin and is more
likely to be injured or damaged during
regarding sexual health, it is often
considered inappropriate for them to
the sexual act.
reveal this, making partner
communication
Biologically, the risk for transmission
about risk and
from male to female is greater than
safety
impossible.
from female to male for several reasons.
•
There is a greater exposed surface
area in the female genital tract than
in the male genital tract.
There is a higher concentration of
HIV in semen than in vaginal fluids.
Coercive or forced sex might lead to
micro-lesions in the genital tract that
facilitate entry of the virus.
•
Women often have asymptomatic STIs
that are left untreated, which
increases vulnerability to HIV.
Socially, factors stemming from gender
inequalities also make women
Women are
often expected
to remain
monogamous;
yet being
married often
places them at
high risk for
infection
(because men
i
fI alI
are not often
expected to be
monogamous,
Handbook| for Link Worker
33
•
and women may not be able to refuse
sex with their husbands in a marital
relationship).
•
The threat of physical violence, the
Economically, lack of control over
fear of abandonment, or the loss of
economic support can act as
resources can also lead to vulnerability
for several reasons:
Young women are at greater risk than
men for rape, sexual coercion, or
being forced into sex work.
significant barriers for women to
negotiate condom use, discuss
fidelity with their partners, or leave
•
Young women are often forced to
enter into sex work and/or multiple
or temporary partnerships in the
relationships they perceive to be
risky.
hope of bartering sex for economic
gain or survival, including food,
shelter, and safety.
Women often have little control over
their bodies and little decision
making power; men make most
•
Many young women are at risk simply
because they are economically
dependent on their husbands for
decisions about when, where, and
how to have sex.
survival and support, which limits
their decision-making and
negotiating power.
Social pressure to bear children may
•
also affect women's choice
'
concerning the relative importance of
pregnancy versus protection from
infections.
•
Sex workers in general are at an
extremely high risk for infection,
particularly when they do not have
the ability to negotiate with clients
who refuse to wear a condom or
when they are working in settings
where commercial sex work is not
tolerated by society and law.
34
Handbook| for Link Worker
3.2YOUTH AND HIV&AIDS
Of the over 1 billion youth (ages 15-24) worldwide, some 10 million are living
with HIV. Every day, an estimated 6,000 youth are infected with the virus.
More than 70 percent of India's population is under the age of 35. Out of this
33.8 percent come under 15-34 age group. The number of adolescents alone
(10-19) has crossed 230 million. Thus, now every second Indian is a young
Indian. Yet young women and men are steadily emerging as the epicentre of
the HIV & AIDS epidemic.
A substantial segment of this critical sub
and STI transmission continues to be low
population is out of school, sexually
particularly in rural areas. The median
active, marry early, migrate for work in
age at first sex in the country is about
vulnerable situations and are exposed to
21 years for males and 18 years for
negative peer pressure and risk
females although there are wide inter
environment. The curiosity, risk-taking
state variations. It ranges from as low as
behaviour and peer pressure to prove
oneself are major factors that force an
adolescent and youth to take on drugs
16 years in Andhra Pradesh, Bihar,
Madhya Pradesh, Rajasthan and Uttar
Pradesh to as high as 20 years in Kerala
and sexual experimentation. This is
and Goa (rural female) and a low of 18
further fuelled by exposure to media and
years in Madhya Pradesh to a high of 25
confusing information sources. With
years in Kerala (rural males).
little or no information and knowledge
on implications of their behaviour many
of the youth contract STIs and HIV
infection. Lack of youth friendly
services and fear of social exposure of
their behavioural practices significantly
reduces their access to information and
services.
India about 86% HIV infection is
through heterosexual mode. Yet young
people’s knowledge of reproductive
health, sexual hygiene and modes of HIV
*
Thus, the risk perception and behaviour
of the young people (13 - 35) are going
to determine the future direction of HIV
& AIDS in the country. Nearly 33 percent
of reported AIDS cases in India are in the
age group of 15-29 years. Many of them
are also IDUs who started substance
abuse between 16 & 20 years.
Young women are another highly
vulnerable category. Currently women
account for 37 percent of HIV infected
adults in India. Nationally only 48
Handbook| for Link Worker
35
percent of women are aware of the HIV
Abstinence before marriage may not be a
protective value of a condom (NACO,
successful prevention strategy for girls
BSS, 2001). Because of stigma and
who marry early if their older husbands
discrimination a majority of young
already carry the virus. Marriage can
women are not able to access STI and
actually increase the risk of HIV for
HIV & AIDS service facilities. In view of
young girls. In various instances, married
this reducing growth of infection among
girls between the ages of 15 and 19 have
women and girls has emerged as a
higher HIV infection levels than non
challenging task. Thus, in many ways HIV
married sexually active females of the
& AIDS is primarily a youth issue.
same age. The big age difference
between girls (15 to 19) and their sexual
Young women face the highest
partners also limit their ability and
risks
power to resist unsafe sexual practices.
The higher biological vulnerability of
The Link Worker can facilitate the
females to infection accounts, in part,
formation of the group of youth and
for the growing number of young women
adolescents in the villages. The groups
infected with HIV. Socio-cultural norms
should be encouraged to learn and
that reinforce gender inequalities, such
discuss matters related to sex, sexuality,
as patterns of sexual networking and
STIs, HIV & AIDS, prevention methods
age-mixing, are also important factors
and access to services. The Link Worker
that leave girls and young women more
can also invite the ANM, ASHA, AWW and
vulnerable to HIV than their male peers.
NGO working in the area to share
One-third of all women living with HIV
are between the ages of 15 and 24.
Worldwide, young women (15-24 years)
are 1.6 times as likely as young men to
be HIV positive. Many young women are
reported to have experienced coerced
and unprotected sex from an early age.
Forced sex and consequent abrasions
facilitate entry of the virus.
36
Handbook| for Link Worker
information and knowledge about the
health issues and access to the services.
3.3 SEX AND SEXUALITY
The terms of 'sex' and 'sexuality' are often confused. One use of the term
sex is to refer to the state of being male or female based on the biological
characteristics. At other times, people refer to this term while implying
physical activity involving sex organs for the purpose of pleasure or
reproduction. Others use the word 'Sex' to refer to erotic feelings or desires
such as sexual fantasies and thoughts or sexual urges.
by whom one has sex with, in what ways,
Sex is the biological differences
between women and men that refer to
visible difference in genitals and the
why, under what circumstances, and
with what outcomes. It is more than
related difference in anatomy and
procreative function. The sex difference
sexual behaviour; it is a
multidimensional and dynamic concept.
between men and women are universal,
Explicit and implicit rules imposed by
obvious, and generally permanent. Sex
describes the biological, physical, and
society, as defined by one's gender, age,
economic status, ethnicity and other
genetic composition with which we are
factors, influence an individual’s
born.
sexuality
Female sex organ
&
!
V V
F alloplan
hmqm • or uicrv« a
bladder
w
bM_
karatKral
po*l»rlor lip
opanlng
1“ "
cp«>r»ln<g ,
pf ur»lh/a
Female Sex Organ (Anatomy)
Sexuality is a broader concept than
sex. Sexuality is distinct from sex and
gender yet intimately linked to it. It is
the social construction of a biological
drive. An individual’s sexuality is defined
Female Sex Organ (Outside)
Sexuality is the expression of who we
are as human beings. It involves a
person's thoughts, feelings, and sexual
expression and relationships, as well as
the biology of the sexual response
Handbook| for Link Worker
37
Male sex organ
I.
■
■iii
i
IM
to'
RW:
p»rlton*um
■iproktrata Qland
va»tela
• crotum 1
T
Male Sex Organ (Anatomy)
Male Sex Organ (Outside)
system. Sexuality is a total sensory
marriage between a man and a woman
experience, involving the mind and
but not between two men or two women
body- not just the genitals.
as partners.
Sexual health is the ability to express
All societies have values that guide
one’s sexuality free from the risk of
private and public behaviour. However,
an individual's values those reflecting a
sexually transmitted infections (STIs),
unwanted pregnancy, coercion, violence,
person’s day-to-day behaviour may not
and discrimination. It means being able
be consistent with the culture’s formal
to have an informed, enjoyable, and
values. For example, the expectation
safe sex life, based on a positive
from a young unmarried girl in India is
approach to sexual expression and
that she should be a virgin, however
mutual respect in sexual relations.
many young girls may not personally
endorse the same value.
Sexual norms and values
Every culture has norms related to sex
and sexuality. These norms are reflected
in gender roles, relationships, marriage,
Understanding the influence of
norms and values on sexual
behaviour
friendships, and family. Societal norms
often determine sexual practices,
marriage customs and what unapproved
sexual behaviours are. For example, the
Our society encompasses a wide range of
sexual norms and values. People’s sexual
attitudes, experiences and behaviours
are shaped to a large extent by their
norms in most cultures recognize
cultural traditions and beliefs. For
38
Handbook| for Link Worker
example, in many cultures, women are
Links between gender and
perceived to be the passive and
submissive sexual partner. Right from
birth, a girl is taught to suppress her
sexuality
sexual instincts. Among females, pre
marital and extramarital sex is a taboo
cultural contexts help define male
and female sexual and reproductive
and virginity among unmarried girls is
highly valued. On the other hand, sexual
activity among boys and young men is
health (SRH) behaviour. They
determine the power dynamics that
condoned.
experience intimacy, sexuality, and
Gender norms within different
influence the way girls and boys
reproduction. As adolescents come of
Most cultures also have social norms
regarding sexuality. For example, many
cultures define normal sexuality to
consist only of heterosexual sex acts
between married couples. Other cultures
aSef gender norms give them clues
about what they should know or not
know about sexuality, how they
should interact with the opposite sex
and groups go further, to regard only
sexual acts that have a reproductive
or same sex partners, and whether
or not they should have access to
sexual and reproductive health
purpose as acceptable.
information and services.
But at the same time studies have shown
that human sexual behaviour does not
Gender-related expectations compromise
generally fit neatly within structures
imposed by societies or religions, with
masturbation and pre-marital sex,
girls' knowledge and ability to protect
themselves. Their communication and
negotiation skills are restricted by the
lead role taken by males in decision
adultery and homosexual and bisexual
making. Their health risks are increased
behaviour being far more common that
by norms that teach them to take a
most societies are willing to
subservient role in decision-making; not
to question the fidelity of their partners
and to tolerate violent sexual behaviour.
acknowledge.
On the other hand, masculine ideals of
the strong, silent male can promote
violent behaviour and limit boys'
receptiveness to information, ability to
communicate, and openness in intimate
and sexual relationships.
Handbook| for Link Worker
39
1
PART -4
Prevent ion and Control of HIV & AIDS
4.1 HIGH RISK BEHAVIOURSAND REDUCING RISK
Any act of unprotected sex (sex without a condom) with a person who has HIV
could result in the partner becoming infected. This is because HIV is present
in high concentration in semen and in cervical and vaginal fluids. All forms of
unprotected penetrative sexual intercourse (anal, vaginal, and oral) with a
HIV 'positive' person carry a risk of transmission.
7. Unprotected sexual contact
High Risk Behaviour
Infection with HIV through sexual
intercourse is possible by the following
direct contacts:
1. Contact between the penis and
vagina in heterosexual intercourse.
in
ffl'i
2. Contact between penis and the
rectum in anal intercourse between
man and woman or man and man
and the female's body is longer than the
contact between the vaginal secretions
and the male organ. Vaginal surface area
3. Contact between seminal fluid
of women exposed to secretions is also
(possibly also vaginal secretions
larger compared to the males.
including menstrual blood) and the
mucous membranes of the mouth
HIV is more likely to be transmitted
during oral sex (mouth to genital
during anal sex than during vaginal
organs)
sex. This is because anus is more likely
to develop small tears and injuries
If one engages in unprotected sex with
during sex act. The anus is not naturally
several partners, the risk of becoming
lubricated and is also difficult to
infected with HIV increases with each
penetrate. The tears and injuries in the
sexual partner.
rectum during sex act allow HIV to pass
easily into the body. Since semen has
high concentration of HIV, the receptive
A woman has a greater chance of being
infected by a HIV positive male than a
man being infected by an HIV positive
female. This is because the contact
period between the seminal secretions
o
partner (or the one who is penetrated
during anal sex) is at higher risk as
semen stays in the anus.
Handbook| for Link Worker
43
fit
The risk involved in oral sex is much less
than that in vaginal or anal sex.
sores on the other partner’s skin) and
kissing that does not involve heavy
"No risk" behaviours
exchange of saliva and possibly
blood.
•
The safest option is abstinence.
•
Sex with one uninfected partner or
Abstinence means avoiding intimate
sexual behaviour - (oral, mouth-
mutual monogamy (even when
penis/anus contact/sex), vaginal
two conditions must be met - One,
intercourse and anal intercourse.
that both persons in the relationship
partners are male). In this situation
must have intercourse with each
•
One can engage in sexual practice
that involve no penetration such as
other only (mutual); and TwOj that
both persons must be uninfected.
caressing or massaging any part of
the body, hugging, masturbation
It is important to remember that by
(provided that sexual secretions do
not come in contact with cuts or
look it is impossible to find out if
1 a
- 4
B I
i fl j
Can you tell who has HIV^
44
Handbook| for Link Worker
'Low' risk behaviours
Low risk/no risk behaviour
Using condoms correctly and consistently
•
All injecting and intra-venous drugs
should be avoided.
•
If an injection is needed, one can
ensure that the syringe and needle
are disposable or properly sterilized.
•
The drugs should never be injected
especially with shared needles and
syringes.
during every act of penetrative sex
(oral, vaginal or anal sex) with every
partner greatly reduces the risk of HIV
transmission.
2. Sharing of needles and
syringes
High risk behaviour
Injecting drug use is one of the fastest
growing routes of HIV transmission. This
is primarily because needles, syringes
and drug preparation equipments are
frequently shared, enabling rapid spread
of virus.
-A
n
iii
Handbook| for Link Worker
45
Follow below given chart to explore the comparative risk of transmission of
STIs and HIV during various behavioural practices.
PRACTICE
RISK
NOTES
Abstinence
No Risk
Masturbation
No Risk
Sex with a monogamous
uninfected partner
No risk
It is difficult to know if partner is
monogamous and uninfected
Sexual stimulation of
another person's genitals
using hands
Low risk/No risk
Risk is very low if there are no cuts
or broken skin on hands especially if
there is no contact with secretions,
semen, or menstrual blood
Deep (tongue) kissing
Low risk/No risk
Risk is higher if bleeding gums,
sores, or cuts in mouth
Oral sex on a woman
(cunnilingus) with a barrier
Low risk/No risk
Risk is very low. Barrier must be used
correctly. Some STIs (e.g., herpes)
can be transmitted though contact
with skin not covered by barrier
Oral sex on a man
(fellatio) with a condom
Low risk/No risk
Risk is very low. Barrier must be used
correctly. Some STIs (e.g., herpes) can
be transmitted though contact with skin
not covered by barrier
Vaginal sex with a condom
Low risk
Small risk of condom slippage or
breakage - reduced with correct use.
Some STIs (e.g., herpes) can be
transmitted though contact with skin
not covered by condom
V
Vaginal sex with multiple
partners; condom use
every time
Anal sex with a condom
46
Handbook| for Link Worker
Having Multiple partners increases risk;
however, correct and consistent condom
use lowers risk
Medium risk
Risk of condom breakage greater than
for vaginal sex. Some STIs (e.g., herpes)
can be transmitted though contact
with skin not covered by-barrier
RISK
NOTES
Oral sex on a man
(fellatio) without a
condom
Medium risk
HIV and STIs can be transmitted through
oral sex; however, risk is lower than
that of anal or vaginal sex. Safer if
no ejaculation in mouth
Oral sex on a woman
(cunnilingus) without a
barrier
Medium risk
HIV and STIs can be transmitted
through oral sex; however, risk'is
Vaginal sex using
spermicides or diaphragm
and no condoms
High risk/
Reduced risk
Spermicides may reduce transmission
of HIV and STIs compared to unprotected
vaginal sex. Very frequent use of
spermicides (multiple times in single day)
can damage tissues, increasing risk.
Diaphragms can also reduce risk
of some STIs
Withdrawal
High risk/
Reduced risk
HIV can be present in pre-ejaculate and,
therefore, risk of transmission is
high; however, withdrawal may reduce
risk of HIV transmission somewhat.
Unlikely to reduce risk of other STIs
PRACTICE
lower than for anal or vaginal sex
Vaginal sex without a
condom
High risk
One of the highest-risk activities.
Receptive partner is at greater risk
Anal sex without a
condom
High risk
One of the highest-risk activities.
Receptive partner is at greater risk
Vaginal sex using hormonal
High risk
Hormonal contraceptives and IUDs do
not protect against STIs or HIV
High risk
HIV and hepatitis viruses can readily be
transmitted from infected person
through sharing of injection drug work
contraceptives or IUD and
no condom
Sharing needles, syringes
drugs, or other drug
paraphernalia
Handbook| for Link Worker
47
4.2 SEXUALLY TRANSMITTED INFECTIONS
AND STI MANAGEMENT
A person can get sexually transmitted infection by having unprotected sex
with another person who already has the infection. These infections can be
passed on during vaginal, anal or oral sex. Some STIs such as HIV (Human
Immunodeficiency Virus) can be passed on to the baby during pregnancy,
childbirth or breastfeeding as well. It can also be transmitted by using
unclean injecting or surgical instruments or untested blood transfusion. Some
of the common STIs are Syphilis, Gonorrhoea, HIV, and Hepatitis-B.
It is possible for a person to contract
STIs are serious health problem among
more than one infection and have
young people, especially women. This is
multiple STIs at the same time. Some
STIs show symptoms while some do not.
Many STIs are asymptomatic. One may
because their vaginal lining is delicate
look healthy but still can be infected
with STI and can transmit it as well to
his/her sexual partner(s).
Common symptoms of STIs are
•
Abnormal discharge from the vagina
and penis.
•
Continuous pain or burning with
urination.
•
Continuous itching or irritation of the
genitals.
•
•
Sores, blisters or lumps on the
genitals.
Pain in the lower abdomen.
Most STIs can be cured if treated in
time and with appropriate
medicines/drugs. Some like HIV do not
and has more surface area. Also their
vaginal immunity is very low at young
age. If STIs are not treated adequately
they can cause serious reproductive
health problems. Some can lead to
infertility in women, sterility in man and
complications during pregnancy.
A person who has an STI carries much
higher risk of contracting the HIV
infection. If the person has HIV as well
as STI then he/she has a greater chance
of passing on the infection to an
uninfected sexual partner.
Management of STIs
The treatment of STIs is primarily based
on changing the sexual behaviour that
put people at risk and on promoting the
use of condoms.
have any cure at present. They can only
Following are the main components in
be prevented.
STI control and management:
48
Handbook| for Link Worker
Creating awareness among individuals
how to get the regular supply of
at risk (female and male sex workers,
condoms. Providing free condoms
when they are available,
truck drivers, migrant and mobile
people, young people, etc.) on modes
ft
demonstrating correct condom use
of STI transmission and ways to
and advising about consistent use of
reduce risk of STI transmission.
condoms.
Explaining the association between
•
Promoting health care seeking
STIs and HIV; and, that the same risk
behaviour, discussion about'the
behaviours are responsible for
treatment of STIs and where these
services can be accessed (health
acquisition of both the infections.
services for STI prevention and
»
Promoting safe sexual behaviours,
management are available at primary
education on methods of risk
health centre, and as part of general
reduction including abstinence,
health services under RCH-II).
reducing multi-partner sex, and
consistent and correct use of
•
•
Encouraging such person for bringing
condoms, as is feasible in the context
his/her partner for STI related
of the individual.
counselling, screening and treatment.
Promoting condoms for safe sex and
encouraging discussions on where and
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Handbook| for Link Worker
49
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4.3 CONDOM PROMOTION AND DEMONSTRATION
Condoms ore the only contraceptives that protect against STIs, HIV and
unwanted pregnancies. However they should be used correctly, consistently
and every time a person has sex (vaginal, oral and anal). Latex condoms
protect against HIV by covering the penis and providing a barrier against
exposure to genital secretions, such as semen and vaginal fluids.
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For oral sex, it is best to use a condom
over the penis and or a plastic wrap or a
3. Condoms have a reservoir tip at the
end to collect the semen. Pinch the
tip of the condom to remove the air
cut-open condom to cover the vagina or
anus.
and unroll the condom till the base of
the penis. Make sure there is no air
trapped inside.
While some condoms come pre
lubricated, others are not, and some
people may need to use additional
4. Make sure that there is space at the
lubrication to increase comfort and
prevent breakage, which is particularly
tip of the condom and that the
important for anal sex. Only water-based
condom on, insert the penis for
intercourse.
condom is not broken. With the
lubricants, such as K-Y jelly should be
used. Oil-based lubricants, such as
5. After the intercourse the condom
must be removed while the penis is
vaseline, petroleum jelly, creams,
lotions, or cooking oil damage the
condom and make it significantly less
still erect. Do not let the semen spill
out of the condom while removing.
effective and more likely to break during
use.
6. Tie a knot of the condom before
throwing it. Wrap in a paper and
Use of male condom
throw it in the garbage.
1. While buying condoms, the expiry
Important Tips for Male Condom Use
date should be properly checked.
should be stored in a cool, dry place
A condom should be put on an
erect penis only and should be
.
.
, .
..
..
. .
kept on during the entire period
away from sunlight and not in hot
of intercourse.
moist places.
The condom should never be
•
Condoms are good for 2-3 years from
the date of manufacturing. They
used twice.
2. If the person is not circumcised, pull
back the foreskin. Put the condom on
the tip of the hard penis. If the
condom is placed on the penis back
wards it will not unroll. Do not turn
it around and use it again but throw
.
■
•
.
•
-
".W
•
Do not use grease, oils, lotions
or petroleum jelly as lubricants.
Only use water based lubricants
as KY Jelly.
-
’'i-*' r A
it and start with a new one.
Handbook| for Link Worker
51
I
Before intercourse
!
Carefully open the package so the
I condom does not tear. (Do not use
1 teeth or a sharp object to open the
package.) Do not unroll the condom before
putting it on.
I
I
If you are not circumcised, pull back
J the foreskin. Put the condom on the
4®™ end of the hard penis. Note: If the
condom is initially placed on the penis
backwards, do not turn it around. Throw it
away and start with a new one.
I
Pinching the tip of the condom to
■C squeeze out air, roll on the condom
until it reaches the base of the penis.
I
Check to make sure there is space at
the tip and that the condom is not
broken. With the condom on, insert
the penis for intercourse
After the intercourse
After ejaculation, hold onto the
condom at the base of the penis.
Keeping the condom on, pull the penis
out before it gets soft.
I
Slide the condom off without
spilling the liquid (semen) inside.
\J Dispose of the used condom.
L
52
Handbook| for Link Worker
A
;*
//
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needed squeeze it from the extra
Female condom
lubricant provided in the package.
The female condom is a female
controlled method and is empowering
2. The closed end of the female condom
women to protect herself from unwanted
goes inside the vagina. Squeeze the
pregnancy and STIs. The female condom
inner ring and insert it into the
is a strong, soft, transparent
vagina. Using the index finger push it
polyurethane sheath inserted in the
into the vagina as far as it can go.
vagina before sexual intercourse,
providing protection against both
3. The ring at the open end should stay
outside the vagina. Make sure the
pregnancy and STIs. The female condom
condom is not twisted.
prevents contact between male and
female genital secretions, avoiding the
transmission of STIs, including HIV. It is
lubricated, disposable and can be
4. During intercourse if the condom
tears then remove it and insert a new
one. Make sure the penis is guided
inside the female condom.
inserted up to 8 hours before
intercourse. It is not dependent on the
male erection, and does not require
immediate withdrawal after ejaculation.
5. After intercourse the condom should
be removed while the women is lying
down so that there is no spilbage.
The female condom has no known side
effects or risks. It does not require a
Then wrap it up and throw in the
dustbin.
prescription or the intervention of a
health care provider.
Female Condoms should not be used if:
However, female condom may not be
•
The packet is open
readily available every where and it is
costly. The Link Workers and volunteers
must explore if these are being made
available locally through a government
h
• The colour is uneven or changed
or private agency, at subsidised rates.
•
It is unusually sticky
Use of female condom
• The expiry date has passed
1. Remove the female condom from the
package carefully. Rub it between
two fingers so that the lubricant is
spread evenly. If more lubricant is
•
''
’•
5
Handbook| for Link Worker
53
II
HOW TO USE A FEMALE CONDOM: A Pictorial presentation
Outer
ring
9
The open end covers the vagina
and the inner ring is used for
I
insertion and to hold the
condom in place.
Inner
ring
Ok
Hold the inner ring between
/ your fingers and squeeze or
twist the ring into a figure 8.
Push the inner ring into the
Uterus
vagina with your fingers
v
Outer ring
Vagina
canal
With your index finger, push
the inner ring up as far as it
can go
\
.nnerdna
5
I
Open end
X’ Remove the condom before
standing up. Squeeze and b
the outer ring, pull gently, <
dispose
I
54
Handbook| for Link Worker
X inner ring
4.4 GETTING TESTED FOR HIV
A person may have HIV without knowing about it. The only way to know if a
person has HIV is through a blood test called - HIV test. If antibodies
against HIV are present in the blood then the person is said to be HIV
'positive'.
If one has any suspicion of being exposed
to HIV, or has been involved in behaviour
that increases the risk of exposure to
the virus it is advisable to take a HIV
test. Such behaviours could be
unprotected sex and/or shared injecting
drug use with a partner whose HIV status
is not known, transfusion of untested
blood /blood products and use of un
sterilised needles.
To know definitely if a person has HIV,
the test should be repeated after 3
months. However HIV can be passed even
during the ‘window period'.
HIV tests:
ICTC
1.
Screening test: this is the fist test
performed to know if a person is HIV
1
^1
During this period the test results will
be negative.
Types of HIV Tests - There are 2 types of
A
r
u
This is known as the ’window period'.
positive or not. They are easier to
j
perform and less costly. ELISA test is
the most common screening test. If
the test results are positive then a
1
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Sometimes a person who is infected with
HIV may show a negative test result.
This is because the body takes 3-12
confirmatory test is performed.
2. Confirmatory test: This test is done
when the results of the screening
test are positive. They are expensive
but more specific than screening
tests. The Western Blot test is the
most common confirmatory test.
weeks to produce antibodies against HIV.
Handbook| for Link Worker
55
■
Pre-Test Counselling: The person is
Voluntary counselling and
informed by the counsellor of the
testing (VCT)
benefits and implications of taking the
Voluntary counselling and testing is a
process by which a person takes
test. The correct information about HIV
& AIDS is also provided and myths and
misconceptions are dispelled.
counselling voluntarily so that s/he can
make an informed choice about HIV
testing. HIV testing is done only when a
j
person has consented for it, following
the counselling. The HIV test results are
\
kept completely confidential and given
only to the person.
The benefits of counselling and testing
are:
1. Knowledge about one’s (HIV) status
2. Protecting one's partner
3. Early access to care and treatment
Post-Test Counselling: The counsellor
4. Preventing mother to child
transmission
helps the person understand the
5. Adopting healthier lifestyle
handing it over to him/her. If the result
is positive, the counsellor provides
emotional support to the person. When
implications of the test results before
6. Improved planning for the future
.
i-'
'
7. Motivation to initiate or maintain safer
behaviours
I
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11 [IHy*
8. Reduce stigma and discrimination
■
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VCT process consists of:
1. Pre-test Counselling
!
2. Testing (described above)
3. Post-test Counselling
4. Follow Up Counselling
56
Handbook| for Link Worker
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the person is ready, the counsellor
informs about various health care
services and advice about nutrition, safe
behaviour practices, and adopting a
healthy lifestyle. Ways to prevent
transmission of HIV to sexual partner/s
is also explained to the person. The
counsellor may also advice the person on
how and whom to share the test results.
the information about the availability of
ICT services in his/her district and
motivate and encourage people to take
up the VCT.
Under NACP-III it is proposed that all
VCTC will be re-modelled as a hub to
integrate all HIV related services and
called Integrated Counselling and Testing
Centre (ICTC). ICTC will provide entry
If the test result is negative the
point for both men and women requiring
counsellor may discuss safe behavioural
practices and other methods of risk
different services. For instance,
pregnant women will be referred to
reduction. The person is also advised
PPTCT centres, those with STI symptoms
about repeat test after three months.
to STD Clinics and those with TB
symptoms to DOTS (RNTCP) Centres, etc.
Follow-Up Counselling: The counsellor
will help the person deal with his/her
HIV status and give information about
various services available depending on
the need and requirement of the person.
*
Integrated counselling and
testing centre (ICTC)
One can avail Voluntary Counselling and
Testing at ICTC located at all District
Hospitals. NACP-III has proposed to scale
up the ICT services to sub-district and
CHC level. Link Worker should explore
-A
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Handbook| for Link Worker
57
1
■1
I
4.5 PARENT TO CHILD TRANSMISSION OF HIV
HIV can be passed from mother to baby during pregnancy, during labour and
birth, or during breastfeeding. But, not all babies of HIV+ mothers will be
infected. With no prevention, about 1 out of 3 babies of HIV+ women will
get HIV.
A baby is more likely to get HIV if the mother has other infections, anemia,
poor nutrition, or if she gets full blown AIDS while she is pregnant. If a
mother has unprotected sex with on infected person while pregnant, she will
have even more of the virus in her body, and the baby will be more likely to
get HIV.
Preventing parent to child
, transmission (PPTCT)
Before Pregnancy
Link Workers can help young women and
couples prevent pregnancies that they
do not want, and help them stay healthy
and safe if they are pregnant. For this
they can:
• Make sure that all people in the
community know about and have a FP
method of their choice, especially
male or female condoms to prevent
STIs, HIV, and unwanted pregnancy.
Refer them to a nearby clinic or
provide condoms directly. Make sure
people know about Emergency
Contraceptive Pills (ECP) if they have
had unprotected sex and where they
can get ECP (or Link Worker can
distribute the ECP directly).
58
Handbook| for Link. Worker
■
x\
fli
Get people to go for ICT because if
they know they are infected, they
can choose not to get pregnant or get
PPTCT services right away if they do
want to be pregnant.
•
Help PLWHA and their partners
protect themselves from getting
pregnant, or if they decide to
become pregnant, help them prevent
transmission and re-infection.
•
Raise awareness in the community
about PPTCT and why it is good to go
for ICT before deciding to have a
baby.
PPTCT during pregnancy
• Make sure that the mother has ARVs
for herself and the baby by
facilitating her linkage to the ART
centre
• Work with local birth attendants (like
TBAs, midwives, and others) to refer
To prevent parent-to-child transmission
during pregnancy, the Link Workers can:
•
•
HIV+ women to a facility.
Find pregnant women in the
PPTCT during birth and delivery
commuity and refer them to the
clinic for at least 3 Antenatal Care
Both Health facilities and Link Workers
(ANC) visits and VCT.
can help prevent parent-to-child
transmission during delivery by:
Help young couples understand their
Linking to PPTCT Centre for:
risk for HIV and why PPTCT is
important.
•
ARVs late in pregnancy (or during
labour) and after birth for the baby
•
Help couples practice safer sex, by
telling young women and men why it
Promotion of safer sex and cbndoms
is important to use condoms during
during follow-up after delivery
pregnancy.
•
•
(like iron, folic acid, and vitamins)
Help women and their families plan a
safe birth in a facility, or with a
midwife trained in PPTCT. Work with
the mother-in-law and/or partner so
they understand and support safe
Nutrition advice and supplements
•
Promoting institutional delivery
•
Advise regarding breastfeeding
delivery.
Handbook| for Link Worker
59
.
■
PPTCT during infant feeding
HIV is parent in breast milk in some
quantity HIV can be passed to the baby
through breastfeeding. The safest way to
prevent transmission is not to give any
oreast milk to the baby. But for many
women, breastfeeding alone is the best
choice because it is very healthy, does
not cost money, and prevents a lot of
other infections that could harm the
baby. However breast feeding can be
stopped early (at 6 months) and baby
switch to complementary foods/feeding.
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60
Handbook| for Link Worker
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4.6 ANTI RETROVIRAL THERAPY (ARTs)
There is no cure for HIV & AIDS. But there ore certain medicines called Anti
Retroviral Drugs which can help a person who is HIV positive to live longer
and hove a better quality of life. The Anti Retroviral Drugs prevent the
growth of HIV in the body and reduce its activity but cannot eliminate it
completely.
When a person gets HIV, the virus enters
The person can stay healthy for a longer
the WBCs present in the immune system
time. When the body has enough WBCs it
of the body. The HIV attacks these WBCs
and starts to multiply in large numbers
will be able to fight off various other
infections. ARTs can also decrease the
everyday. The number of WBCs starts
chances of mother to child transmission.
decreasing and after some years they
fall below a critical level. This is when
the person is said to have AIDS. At this
stage the person gets various infections
because there are not enough WBCs to
fight the infections.
HIV+
999999999
999999999
999999999
9999^S«S«
After infection with HIV
•99999999
999999999
991999999
999999999
999999999
Without ART
AIDS
• 9999’m $
HIV+
After infection with HIV With ART
999999999
999999999
999999999
999999999
999999999
999999999
9 9 9 9«* £
Virus multiplication slowed, less virus, more
WBCs intact
«««««*«*«
9VWWWWWWWW
999999999
9999^®®^®
«WWW ®«&
Legends: W - White Cellsf $ - HIV cells
ARTs once started have to be
taken life long:
After 5- 10 years without ART
Legends: W - White Cellsf W - HIV cells
If a person with HIV starts taking ARTs,
before the WBCs fall below the critical
level, the HIV will not be able to
multiply very fast or destroy the WBCs.
PLWHA on ART need to achieve 100
percent adherence to ART to keep the
correct amount of drugs in their bodies
to fight the virus. Thus a person taking
ARTs must always take the medicines in
the right dosage and at the right time.
-W
Treatment should be followed strictly
Handbook| for Link Worker
61
ft
and not even a single dose should be
nissed. Only then will the treatment be
To facilitate adherence the Link
Workers can do the following:
successful.
Poor adherence to ART leads to drug
resistance, increased viral load,
increased sickness and increased
•
to support the patient and not to
blame, isolate or make him feel
guilty.
oossibility to death.
Even when a HIV positive person is
•
Understand the regime of the
medicine prescribed for the patient.
taking ARTs, they can still pass on the
infection to others. They should
(^therefore always practice safe sex with
Counsel and advice family members
•
Help and support the patient and
family members develop adherence
their sexual partners.
plan to ensure that medicines are
taken by the patient exactly as
prescribed by the doctor.
*
'JF
1^
It is important to involve a treatment
supporter - a friend or family
member chosen by the patient to
help him/her remember to take the
drugs and keep clinic appointments.
■7
•
\
A PLWHA support group in the
district/block/village can be
yA
i
____
identified and the patient can be
linked with the group for
psychological support and to
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62
Handbook| for Link Worker
encourage adherence.
4.7 CONTINUUM OF CARE (PREVENTION, CARE,
SUPPORT AND TREATMENT SERVICES)
It is observed that HIV related health services provided at the tertiary and
district levels are not easily accessible to vulnerable and high risk
populations like the CSWs, A1SA4, IDUs, truckers and migrants. The low
demand for services from the general population in VCTCs and STI clinics is
also a matter of concern. Therefore under NACP-III, it is proposed that
services be integrated and scaled-up to ensure delivery at sub-district and
community levels through existing infrastructure in the public and private
sectors. Special attention will be given to demand generation, some level of
which can be achieved in rural areas through the Link Workers.
Since many components of the National
AIDS Control Programme will be
The following preventive
services will be provided at sub
delivered through the health system, the
district level:
NACP-III will synergise its services with
the NRHM, the Reproductive and Child
STI services
Health (RCH) programme and the Revised
National TB Control Programme (RNTCP).
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Integrated Counselling and Testing
Services and
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Access to Condoms
Safe Blood
f
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Prevention of Parent to Child
Transmission
Besides preventive services, care and
support and treatment for people living
with HIV & AIDS will also be made
available.
Handbook | for Link Worker
63
Integrated counselling and
ART Centres) will also focus on
testing services
preventive strategies, thus ensuring that
HIV spread is reduced from the affected
Under NACP-III, existing VCTCs and
PPTCT centres will be re-modelled as a
individuals. This will also ensure that
stigma and discrimination is reduced and
hub to integrate all HIV related services
’•and called Integrated Counselling and
more people living with HIV & AIDS are
Testing Centres (ICTCs).These will be
covered through interventions designed
to change high risk behaviour.
established with the district, sub
district hospitals, CHCs and RNTCP
Health service providers at
microscopic centres.
village level
ICTCs will provide entry points for both
•
men and women requiring different
services. For instance, pregnant women
Auxiliary Nurse Midwife - provides
primary health care services,
Antenatal care, Delivery & Postnatal
care, immunization, and referrals.
will be referred to PPTCT centres, those
with STI symptoms to STI clinics and
those with TB symptoms to RNTCP
Accredited Social Health Activist -
centres. Additional counselling services
will be provided in PPTC centres for
community mobilization and
awareness on health and increase
counselling and testing of pregnant
women attending ANC clinics. All clients
utilization of existing health services
who access services from the ICTCs will
•
nutritional
be provided advice on prevention also.
support, recreational and primary
Further, counsellors at these centres will
education to the children in the age
ensure access to the following services
group of 0-6 years, support ANM to
through linkages: IEC/BCC; Condom
provide ANC and PNC to women
promotion; STI treatment linkages;
Prophylaxis and early management of 01;
•
Linking care and support with
Lady Health Visitor - provide health
education
DOTS for TB; and ART Services.
•
Traditional Birth Attendant - provide
prevention
care during pregnancy, attend
delivery and support postnatal care
Under NACP-III, all care centres
(Community Care Centres, TB Clinics and
of pregnant women.
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64
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PART -5
Understanding Risk & Vulnerability
5.1 POPULATIONS WITH HIGH RISK BEHAVIOURS
Not all people in a given community (or a population) are at the same risk
of HIV. A variety of factors place certain people at the higher risk of
contracting HIV and other STIs. Some of these risk factors include, having
multiple sexual partners, unsafe sexual practices, injecting drug use and drug
and alcohol use followed by unprotected sex.
As mentioned earlier, certain groups
However many of these individuals are
identified to be at high risk of HIV are
dispersed in the communities in rural
sex workers, men having sex with men,
areas and are difficult to reach out.
injecting drug users and their partners
and/or clients in the act. Certain groups
like truckers, migrants and mobile
populations, are also at increased risk of
HIV and other STIs.
Both sex workers and their clients (e.g.
truck drivers) travel for or in search of
work. Many of the sex workers in the
rural areas may move along the highways
An important aspect to remember is that
during the day and return home (in the
village) at night or may travel to close
sex worker-client interaction has been
by towns for work and periodica'lly
identified as one of the factors that is
return home. Their engagement in the
driving HIV epidemic in India. The sex
workers may be male, female or
commercial sex work may not be known
to their families or the community
around them.
transgender. The clients may buy sex
from any of the sex workers. Many of the
clients and commercial sex workers have
other steady partners (like spouses) as
well. Such partners become highly
vulnerable to HIV because of high risk
behaviour of their partners
This mobility of the commercial sex
workers and their clients makes
effective and sustainable prevention
work more difficult as most of these
populations are on the move or their
behaviours are unknown.
These high risk groups may be present as
communities (such as brothel based sex
workers, transgender, men having sex
with men), mostly in urban and peri
urban areas where they are being
reached through ’Targeted Interventions'.
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67
5.2 SEX WORKERS : HIV RISK AND VULNERABILITY
Significantly higher rates of HIV infection have been documented among sex
workers and their clients as compared to most other population groups.
Several factors contribute to people turning to sex work: socio-cultural
r
tradition, social isolation, low education, scarcity of jobs, low pay, and being
a wage earner for the family (including children who are living with
relatives).
Risk of HIV infection is, in part, a consequence of lack of social and economic
power. The factors that can increase sex workers' vulnerability to HIV
infection are:
Stigmatization and marginalization:
Sex work is not considered
respectable. This results in isolation,
social stigma resulting in
discrimination. This limits sex
workers’ access to legal, health and
social services, thus increasing their
vulnerability to HIV.
local police and do not have legal
recourse. They may be exploited by
those in position of power or
authority. Also many of the health
care providers have a judgmental
attitude towards those involved in
sex work.
Limited access to information and
Limited economic options, in
prevention means: Limited
particular for women: As the
economic opportunities are limited,
information, skills, negotiating power
and access to means of prevention
sex workers may agree to have sex
without condoms so as not to lose out
may lead directly to behaviour that
puts sex workers and clients at risk
on clients to earn more. Sometimes
of HIV infection. Unprotected
clients are also willing to pay more
for having sex without a condom.
commercial sex usually occurs
Many a time they are coerced by
their employers into unprotected sex
participants do not care to protect
their sexual health, do not know how
as well.
to do so, or lack of means to do so
(e.g. condoms, lubricant, safe-sex
Limited access to health, social and
skills). Sex workers also often lack
the personal power to negotiate safe
sexual practices, and may be working
under the threat or fear of violence.
•
legal services: Sex work is illegal,
and therefore clandestine. Sex
workers are routinely harassed by the
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Handbook| for Link Worker
because one (or both) of the
• Gender-related differences and
inequalities: As male dominance in
sexual matters is emphasized by
cultural norms and traditions, women
are often not in a position to decide
the conditions under which the sex
• Exposure to risks associated with
lifestyle (e.g. violence, substance
use, mobility): When sex work takes
place in the environment influenced
by drug use and alcohol, the
act takes place. In addition, the
possibility of condom use or its
correct use is significantly reduced.
possibility of being subjected to
Sexual transmission of HIV between a
violence becomes a potential or real
threat. Same is true for transgender
non-injecting partner and an injecting
and male sex workers as they have
transmission. In some regions, men
and women engage in sex work to
little or no acceptance in the society.
drug user is another mode of
earn money to buy drugs.
• Sexual exploitation and risk of
violence: Violence, including sexual
violence, against sex workers by
clients, pimps and police has been
reported in all settings. Sex workers
may find, for example, that trying to
negotiate safer sexual practices
and/or insistence on condom use may
result in violence. Violent sex often
causes sensitive mucous membranes
in the genitals to tear, further
increasing the possibility of HIV
transmission.
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69
’5.3 MEN WHO HAVE SEX WITH MEN OR MSM:
HIV RISK AND VULNERABILITY
Sex between men can occur in different circumstances, which is also a matter
of one’s liking and choice. It may involve men who identify as homosexual,
heterosexual, bisexual or transgender. In our country many of the men who
have sex with men are often married. Social situations such as lack of
availability of female sexual partners or social taboos preventing
socialization between members of the opposite sex may play a role in such
same sex sexual behaviour. Sex between adolescent males can also be a part
of sexual experimentation.
In terms of HIV transmission, sex
extremely low access to STI treatment
between men is significant because it
services, high levels of anal bleeding,
and no lubricant use leads to high risk of
involves anal sex. Unprotected anal sex
carries very high risk of HIV
transmission. As many of the men who
have sex with men may also have sex
- with women, if infected they can
transmit HIV to their female partners or
HIV. In addition most of them are
married and have children. Some of
these men from low-income groups
become sex workers as a source of
generating an income.
wives.
'It is recognized that because of denial,
invisibility, stigmatization and illegality
(often under both religious and civil laws
and codes), men who have sex with men
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already face considerable risks of
harassment, violence, and
imprisonment. The risk of HIV & AIDS
leads to further victimization.
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The males who are penetrated (Kothis)
are the most vulnerable in terms of
male-to-male sex. Multiple penetrations
in a day, multiple partners, extremely
low condom usage by their penetrating
partners, low levels of knowledge,
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The men who generally penetrate
(Panthis) are men of all ages, married
What this clearly shows that many of the
men who have sex with men are more
and unmarried, from different socio
economic groups and occupation. They
often than not also have female sexual
enjoy sex with other men either because
female partners at risk of HIV even if
they like it; could not access female
they themselves have no high risk
partner; and could not control their
behaviours or have been ’faithful' to
“body heat” and “need to discharge”.
their male partners/husbands.
partners. This places such men’s wives or
Most of the Panthis are either married or
will eventually get married. However
most of them seldom inform their wives
about their extra-marital behaviour with
other males or transgender.
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71
5.4 INJECTING DRUG USERS: HIV RISK AND VULNERABILITY
In context of HIV & AIDS, the terms "drug user" and "injecting drug user" are
very commonly used. These terms only refer to a person's behaviour; the fact
that they use or inject drugs. More often than not, the drugs used by them
are illegal drugs and against the law. The drug use is also socially
unacceptable. Such nature of drug use makes the population of drug users
clandestine and difficult to reach, especially in rural settings. It is also to be
noted that a significant section of the drug users are youth.
People may use drugs for a wide range of
Anyone who has unprotected sex,
reasons. Most choose to do so for
whether they use drugs or not, is at risk
of getting HIV. However, people who use
drugs may be at higher risk of HIV
recreation. People also use drugs to
alleviate pain, to help them in the work
they are doing or to cope with feelings
of depression. A smaller number of
people have drugs forced on them
without their knowledge or consent, or
infection. This is because:
•
Drug use negatively influences the
decision making power of a person
specially regarding condom use and
usually leads to unprotected sex.
have started under peer pressure.
•
Many forms of drug use are known to
remove inhibitions, specially
inhibitions about sex. This can mean
that when people are taking drugs,
they may be less likely to use
condoms (or to use condoms
properly) during sex.
•
Stigma and Discrimination: As using
drugs is against the social norms and
law, and perceived poorly by the
general population, those using drugs
often face high levels of stigma and
discrimination. This generally leads
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Handbook| for Link Worker
to increased vulnerability to HIV.
Many of the women are also forced
into commercial sex work, which
multiplies their vulnerability to HIV
infection.
efficient means of HIV transmission
from one person to another.
• Because of inequalities in power
based on gender, female drug users
are often more vulnerable to HIV &
•
Many drug users live in poverty, have
poor access to health and welfare
services and suffer ill-health and poor
nutrition. All of these factors are
known to increase vulnerability to HIV
& AIDS. Certain drugs (for example,
alcohol, cocaine and amphetamines)
are known to damage the immune
system, making users of these drugs
potentially more susceptible to HIV
infection, when exposed.
• Drug use and sex work are sometimes
linked. People may sell sex in order
AIDS.
Through unprotected sex the drug
users who have HIV may pass it on to
their sexual partners who do not use
drugs and thus make them highly
vulnerable.
Link Workers can identify the drug de
addiction and rehabilitation centre as
well as targeted intervention programme
for injecting drug users. The drug users
can be referred to such programmes and
centres for drug de-addiction, ¥
rehabilitation and harm reduction.
to earn enough money to pay for their
drug use. Some sex workers use drugs
In many of the hospitals the Psychiatry
’'occupationally", to make their work
departments also provide drug de
less traumatic. "Pimps" sometimes
provide sex workers with drugs in
order to entice them into it, or keep
them in the sex work. Drugs and sex
addiction and rehabilitation services.
may be sold from the same locations.
• Drug injectors who share
contaminated drug injection
equipment (needle, syringe, cooker,
cotton, water glass) are at high risk
of getting HIV Et AIDS, as well as other
blood-borne diseases. This is because
blood-to-blood contact is the most
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73
5.5 MIGRANTS AND MOBILE POPULATIONS:
HIV RISK AND VULNERABILITY
The term migrant refers to people who choose to move to other ports of the
country or state for work or to establish a new residence, which may be
temporary or permanent. Many of them are mobile people who do not
establish fixed points of residence for significant periods of time.
In India, rural to urban migration of men
productivity, population growth, and
is the most common form of migration.
lack of economic opportunities in rural
Movement from rural to urban areas is
areas.
driven by poverty, low agricultural
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reproductive age groups i.e 15-29. They
travel to their work setting, mostly in
Some migrant workers leave and return
to their place of origin one or more
times to rest and visit their families
urban areas without their regular sexual
between trips or during festivals and
partners.
holidays. During their stay away from
Most migrant workers are men in prime
home many of the migrant workers
Key factors that place migrant
engage in high risk behaviours and may
men at Risk for STIs and HIV:
contract STI and HIV infection. They can
transmit the infection to their regular
•
•
•
Living at major work sites, far from
sexual partners back at home in the
homes and families;
villages.
Living and working in dangerous and
Young women are particularly vulnerable
stressful conditions;
to STI/HIV infection. Faced with
extreme economic hardship, women
Feelings of isolation and loneliness
migrants are at particularly high risk of
HIV infection.
that may foster sexual partnerships
•
with sex workers or multiple sexual
partnerships with both women and
men;
migrants at risk of STIs and HIV:
Complacent beliefs and attitudes
•
Key factors that place women
Economic need, lack of employment
opportunities, and low-wage jobs;
about sexual risk and prevention and
the unlikelihood of using condoms;
•
Disproportionate rates of illiteracy
•
Prior STIs;
and poverty;
•
Consumption of high quantities of
Poor access to STI/HIV & AIDS
alcohol and/or drugs;
education and information;
Lack of access to basic health
•
support themselves and their
families;
services,specially treatment of STIs;
•
Women practicing survival sex to
High prevalence of HIV in the
community.
•
Sexual exploitation, rape, and
physical violence;
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75
o
Inability to negotiate condom use;
The Link Worker can identify and
increased restrictions in labour
contact the migrant and mobile people
in their villages to inform and educate
importing countries, leading to Illegal
them about HIV & AIDS. The Link Worker
status, leading to police harassment,
can also refer them to STI management,
ICTC and other relevant health services.
raids, and detention;
••
High prevalence of HIV in the
community.
Female partners of male migrant workers
may know their partners are not
monogamous while away from home.
Wives of migrant men are also at high
risk because of their limited negotiating
power for safer sex. Wives are usually
rendered powerless to demand safer sex
because sex is viewed as a spousal
responsibility or they are economically
dependent on their husbands. Other
factors that prevent women from
insisting on condom use are social
expectations and fear of disrupting
family life.
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Handbook| for Link Worker
The Link Worker can develop rapport
with the families of the migrant people
in the villages and provide them
information about the vulnerabilities of
migrant people to HIV infection and
STIs.
The Link Worker can educate the
partners of the migrant people to
protect themselves from HIV infection
and STIs and can also provide them
condoms.
5.6 TRUCKERS: HIV RISK AND VULNERABILITY
The term 'trucker' refers to both drivers and their helpers, called cleaners in
Indio. They are men who travel along the truck routes of the country.
Truckers spend long hours driving across
dangerous and often remote highways.
to condoms and lack of much privacy
often leads to unprotected sex. In
They face monotony, exhaustion, and
addition, the competition among sex
workers for clients not only drives prices
loneliness. Driving along truck routes
and spending time waiting at truck
depots removes men from the social and
cultural norms they live with while at
down, it also adds to their lack of
power. For example, it is difficult at
times for a sex worker to insist that the
home with their families. The all-male
environment attracts and also reinforces
client uses a condom when other sex
workers are offering unprotected sex.
risk-taking.
Some truckers also have sexual
encounters with other males e.g. with
their helpers. Many a time the truckers
who have sex with other men do not
i
identify themselves as homosexual.
Lack of gender equity is an important
element in the spread of HIV among
truckers and their partners. Sex workers,
casual and regular partners, and wives
often have less information about
Some truckers believe that after driving
for many hours their bodies accumulate
heat that only alcohol and sex can
release.
reproductive health, including HIV
prevention, and less access to
information and services. Low level of
education also limits their exposure to
the channels of information.
Many of the commercial sex workers
move along the highways and get their
clients on the road and/or at stopovers,
In addition, female sex workers often
have less power to control their
interactions with truckers and other
men. Even when they know about safe
e.g., Dhaba etc. With little or no access
sexual practices, that this is important,
Handbook| for Link Worker
77
and have the skills necessary to practice
themselves from HIV is less of a priority
safe sex, they do not have the power to
than other risks they face, partially due
successfully negotiate health enhancing
to fatalism and partially due to the need
behaviour. Or they cannot afford to
insist on condom use, either because
to provide for themselves and their
families, often including children.
they will lose clients and income or
Furthermore, most sex workers have
because they fear being physically
several “regular” partners or repeat
harmed.
customers. It is more difficult for women
Wives of the truckers, in many cases do
not know about their husbands' sexual
to ask these men, with whom they have
long-standing relationships, to use
activities while they are away from
home. Using condoms with their wives
condoms.
In some cases, women want or are
pressured to have children and therefore
would imply that the truckers are being
sexually active during their journeys, so
resist using condoms with their
many do not use them. Because of rare
husbands.
use of condoms the truckers place their
Link Workers can identify the families
that have one or more members that are
working as trucker. The actions to be
wives, sexual partners at risk of HIV
infection and other STIs.
For these women (and for some of the
taken by the Link Worker in such cases
men), the risk of getting HIV is one
are same as for migrant and mobile
among many hardships of their lives.
people.
Some women feel that protecting
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PART -6
Working with the Community
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6.1 CREATING AN ENABLING ENVIRONMENT
Effective prevention, care and support for HIV&AIDS is possible in on
III
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environment in which human rights ore respected and where those infected
with or affected by HIV live a life of dignity, without stigma and
discrimination. This requires reducing stigma and discrimination associated
with the infected and affected persons and improving their access to various
services (for prevention, treatment, core, insurance and legal services).
Greater involvement of people
marginalised populations such as sex
living with HIV & AIDS (GIPA)
workers, MSM and IDUs is one of the
People living with HIV & AIDS are
most serious obstacles to an effective
response to HIV & AIDS. Stigma &
important partners in the fight against
the epidemic. They can be strong
advocates for prevention as well as care,
support and treatment programmes.
PLWHA have now organized themselves
into networks/formal and informal
organizations/ groups at the national
and state level and in some cases
district and sub-district levels. Some
organized groups of PLWHAs are now
engaged in treatment education,
positive living counselling, psychosocial
support and positive prevention
programmes. Their involvement can
reduce stigma and discrimination in the
society and contribute towards creating
an enabling environment.
Reducing stigma and
discrimination
I
discrimination often emanates from
service providers - medical, non
"'■1
medical, government and private
sectors. It is also manifest in a variety
of ways at work places and at CQmmunity
and family levels.
Addressing stigma and discrimination at
'"'1 $1
all levels requires that awareness is
created on various aspects of HIV &
•W
AIDS, service providers and counsellors
are sensitized, media is sensitized to
1
deal with issues related to sexuality,
condom use and unsafe sexual practices
11
and advocacy takes place on the rights
-
based approaches with various
constituencies (for example, members of
Parliament and members of legislatures,
Panchayat leaders, women’s group
leaders, youth leaders and faith-based
organisations).
-
• J.;
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Stigma and Discrimination (S&D) faced
J
by people living with HIV & AIDS and
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81
I
1
6.2 INTERPERSONAL COMMUNICATION
Interpersonal communication can be one to one or one to group and is the
most common communication channel that will be used by Link Workers.
Some important aspects to
as 'victims'. Avoid using language that
remember are:
is stigmatizing. Do not use terms like
AIDS patients, AIDS victims, AIDS
Communication is a two way process-
sufferers, AIDS orphans etc. The more
both have to talk, both have to listen
(in one to one or one to group)
sensitive language is to refer them as
'people living with HIV Et AIDS',
Listen attentively, maintain eye
'positive people'.
contact
Be attentive to a person's verbal as
I
9
Avoid non-verbal communication that
well as non verbal communication.
portrays disgust or disrespect (facial
expression, hand expression when
Use a positive body language that
touching a client’s utensils or
shows that you are interested in what
the others are saying. Use gestures,
clothings etc.) for a positive person.
facial expressions and voice
modulation that expresses interest
Effective communication involves
and concern.
Encourage people to ask questions
or clarify doubts.
■3
Use simple, non technical language
while providing information.
Ensure confidentiality-do not share
with others the personal
information that has been shared
with you.
Do not judge other person's
behaviour.
|
Use sensitive language (for
•
example do not refer to HIV
positive person or affected persons
s
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Handbook| for Link Worker
Right skills
• Observation
• Listening
• Use of appropriate language
• Using body language and
tone of voice effectively
Right values
• Respect
• Sensitivity
• Trust
• Confidentiality
6.3 BEHAVIOUR CHANGE COMMUNICATION
Behaviour Change Communication (BCC) is a process of understanding people's
situations, developing relevant messages, and using communication processes
to persuade people to change their attitudes and behaviours and practices
that place them at risk.
The target audiences in BCC includes the
Behaviour change communication
primary audiences whose behaviour
needs to be promoted or changed or
can bring about following
developed, the society and communities
which influence individual behaviours
a
S
changes:
•
and health service providers to promote
JI
Increased knowledge : BCC can
positive practices.
ensure that people are aware of the
basic facts about HIV&AIDS in a
BCC recognizes individuals as active
language or visual medium that they
rather than passive receivers of
can understand and relate to.
€
■■
information and messages, who act on
messages if they see a benefit for
•
Stimulate community dialogue: BCC
themselves.
can encourage community discussions
on HIV Et AIDS such as risk behaviours
Sustained behaviour change is effective
and risk settings, environments and
only when combined with changes in the
cultural practices related to sex and
broader environment. The broader
sexuality that create the conditions
environment can be changed by mass
o
awareness programmes, group
meetings and discussions about the
situations (e.g.gender inequality,
'i
stigma and discrimination etc.) and
mobilising community actions to
promote safe behavioural practices.
Promoting gender equality and
empowerment of women through
education and other means are other
ii
methods to bring about positive
changes in the broader environment.
■'T
Handbook| for Link Worker
83
(VCT), PPTCT; clinical care for
opportunistic infections; and social
for HIV transmission. It can also
stimulate discussion of healthcare
seeking behaviours for prevention,
and economic support.
care and support.
•
Promote essential attitude change:
efficacy. BCC programmes can focus
BCC can lead to appropriate
attitudinal changes about, for
on teaching or reinforcing new skills
example, perceived personal risk of
and negotiating safer sex. It can
HIV infection, non-judgmental
contribute to development of a sense
provision of services and greater
of confidence in making and acting
open-mindedness concerning gender
on decisions.
roles.
Communication about HIV prevention
and AIDS and attitude towards
marginalised communities and people
communication among high risk groups
and highly vulnerable populations
(young people, and women) will be to:
•
Increase condom use
living with HIV & AIDS can address
•
Reduce number of partners
stigma and discrimination.
•
Increase appropriate health care
and services: BCC can encourage
seeking behaviour (like STI
treatment, VCT etc) resulting in
increased utilisation of available
individuals and communities to
services
Create a demand for information
demand information on HIV & AIDS
and appropriate services. BCC can
also promote the utilisation of the
services like STI Management,
4
voluntary counselling and testing
84
■
and behaviours, such as condom use
The ultimate goal of behaviour change
• Reduce stigma and discrimination.
J
Improve skills and sense of self-
Handbook| for Link Worker
• Reduce stigma and discrimination
Stage
Effective communication bring about change in behaviours
Unaware to Aware
Tell the groups about STIs, including HIV and the risk to health their own and their partner’s.
Help them understand the need to know whether they have an
STI or HIV.
Awareness to Concern
Concern to acquiring
knowledge and skills
"'v
d
Point out those unsafe sexual practices can cause STIs/HIV in
anybody. Emphasize the need to seek counselling and testing for HIV
if there is exposure to HIV or high risk behaviour
Reassure the groups that most STIs can be cured with complete and
proper treatment and this also reduces the risk of HIV. Inform them
that safer sexual practices can help prevent STIs and HIV.
-
1
Give them information on HIV 8t AIDS and its modes of transmission.
Encourage them to ask questions so that you can clarify doubts.
Outline different ways in which they can safeguard themselves.
Demonstrate the use of condoms as a preventive measure.
Give information on where to buy condoms.
Acquiring knowledge and Convince them that early and complete treatment can cure most
skills to motivation
STIs totally. Listen to any doubts/problems that they may have about
I
ji
treatment.Give information about or refer them to health facilities
that are easily accessible to them.
Reiterate that STIs and HIV can be prevented by adopting safer
sexual practices.
Motivation to Trial
Trial to Success
Encourage them to seek health services, remind them to visit the
health facility again if required or if advised by the doctor.
Reiterate the need to continue treatment or practise a safe
behaviour Encourage them to use a condom every single time,
with every partner. Clarify doubts and help resolve problems
related to condom use.
fl
1
-7
Appreciate their efforts towards caring for their own as well as
their partner's health -- using a condom, going to a doctor,
completing the treatment.
Encourage them to continue health-seeking practices
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85
6.4 STIGMA AND DISCRIMINATION
Stigma refers to unfavourable attitudes and beliefs towards people perceived
to have HIV & AIDS and the individuals or communities with which they ore
associated. Because of its association with behaviours that are considered
socially unacceptable, HIV infection is widely stigmatized.
Discrimination refers to unjust or unfair
to stigma, hospitals sometimes refuse
treatment of certain people because of
admission or care to those having HIV or
their confirmed or suspected HIV
AIDS.
positive status.
Addressing stigma and
Stigma is a barrier to HIV prevention and
discrimination
care programmes. They deter individuals
a
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from finding out about their HIV status.
The cases of Stigma and Discrimination
It inhibits those who know they are
can be reported to DAPCU as well as the
infected, from sharing their diagnosis
Link Worker can log onto website of
and taking action to protect others and
from seeking treatment and care for
NACO by typing the address
http://www.nacoonline.org/stigma.htm
themselves.
and report such cases.
Family members and community often
shun a person living with HIV because of
Stigma can be decreased when
knowledge increased in the community
the feeling that the person indulged in
at large, by promoting discussion about
what they consider an inappropriate
HIV & AIDS. This can be done through
behaviour.
Often people have misconceptions about
how HIV is transmitted, and this
increases the discrimination as people
are afraid of contracting the infection.
|
Stigma and discrimination from key
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people such as health care workers and
family members can lead to limited
access to basic care, support and
treatment for HIV positive people. Due
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involvement of people living with HIV &
treating people living with HIV & AIDS
AIDS, through awareness programmes,
with compassion and understanding.
and media.
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Moreover the availability of treatment
Information alone is insufficient to
makes this task easier, where there is
tackle stigma and deep seated fears
hope of a better quality of life, people
about HIV. Greater contact with people
living with HIV & AIDS can help to dispel
are less afraid of AIDS, they are more
willing to be tested for HIV, to disclose
these fears.
their status, and to seek necessary care
Local leaders like the PRI members ,
if, necessary.
■
religious leaders and key community
persons can play an important role in
fighting stigma by imparting prevention
messages, by acting as role models and
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My Action Plan to address Stigma and Discrimination
(To be prepared by the Link Worker in consultation with the supervisor, volunteers and key
member of the community)
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My Action Plan to address Stigma and Discrimination
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6.5 HIV a AIDS AND HUMAN RIGHTS
Lack of recognition of human rights causes unnecessary personal suffering and
loss of dignity for people living with HIV or AIDS. It also contributes directly
to the spread of the epidemic since it hinders an effective response. For
example, when human rights are not respected, people are less likely to seek
counselling, testing, treatment and support because it means facing
discrimination, lack of confidentiality or other negative consequences. The
spread of HIV & AIDS is disproportionately high among groups that already
suffer from a lack of human rights protection (example, sex workers), and
from social and economic discrimination (example, migrants), or that are
marginalized by their social and legal status (example, men having sex with
men and transgender).
Recognizing and protecting
•
They ensure confidentiality of
information.
•
No HIV testing of the candidates is
human rights can help to:
•
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Empower individuals and
communities to respond to HIV &
AIDS.
done before employing them.
•
Reduce vulnerability to HIV infection.
Lessen the impact of HIV Et AIDS on
Right to treatment
those infected and affected.
The Medical Council of India says:
To protect rights at the workplace:
No doctor can refuse to treat a
patient without any reason.
Management must make sure that:
There is no discrimination with a
person who is HIV positive.
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HIV testing should not be a part of
*
the annual medical check-up.
They have a written workplace policy
to protect the HIV infected person to
give them a sense of security.
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•
He cannot refuse to treat a patient
because he is afraid of getting the
disease himself. He has no reason to be
afraid of getting the infection if he is
following the universal precautions.
15
• These rules apply to everyone working
•
Information about a person’s HIV
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status may not be disclosed to
in a hospital.
anybody without that person’s fully
Right to confidentiality and
informed consent.
■■
privacy
•
•
After death, the HIV status of the
People with HIV infection and AIDS
deceased person may not be
have the right to confidentiality and
disclosed to anybody without the
privacy about their health and HIV
consent of his or her family or
status.
partner - except when required by
law.
•
Health care professionals are
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ethically and legally required to keep
all information about clients or
patients confidential.
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PART -7
Working with the Volunteers
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7.1 ABOUT THE VOLUNTEERS
Under the Link Worker Scheme, the Link Worker would be the key personnel
in the scheme. The main responsibilities of reaching out to key populations
and highly vulnerable populations will lie with the Link Worker. The
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volunteers will support the field level activities of the Link Worker at village
level.
1. Identification of volunteers
•• Volunteers should represent the caste
and other key marginalised groups/
One female and male volunteer each
HRGs present in the village.
to serve 750-1000 population.
•
•
Young women/men will be selected
working within the community as well
as good rapport with the peer group
and other community members.
as volunteer.
•
Should be Madhyamik higher
secondary school examination
appeared or equivalent. The
selection would be based on their
interest to understand and address
the HIV & AIDS issue, specially stigma
and discrimination against positive
people and key populations. Their
willingness to participate in the
programme without any remuneration
would be crucial.
Should be a resident of the same
village for which s/he will be
selected.
•
Willingness to offer their time for
Preference to be given to SHG
members/members of youth clubs,
peers educators of NGOs, volunteers
of NYKs, members of positive
•
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3
Prepared to address the sensitive
issues of condoms and sexuahity and
to work with key populations and
vulnerable population.
11
2, Selection process of volunteer
Link Worker in consultation with the
Gram Panchayat and local NGO wherever
available will select the volunteers from
their respective areas of operation.
Although volunteers won't be paid any
remuneration, some sort of recognition
would have to be given to them, such as
a badge identifying them as volunteers
and a bag for carrying papers/aids etc.
This is in addition to a citation/
certificate to be given by DAPCU and
District Health Committees.
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Though the scheme speaks of one female
•
Coordinate the day to day
and male volunteer for every 1000
population each Link Worker can look at
2 additional volunteers to take care of
functioning of RRC
•
Can be a condom depot holder
•
Establish rapport with local groups in
the drop outs.
Role of volunteers
•
order to gather more information
about the possible key populations /
individuals with high risk behaviours
Act as information post for services,
linkages and referrals
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7.2 TRAINING PROGRAMME FOR VOLUNTEERS
The Link Workers will orient the volunteers over o period of 5 days, as part
of training. The section of the handbook provides brief guidelines on how to
approach ‘on the job" training for the volunteers which is envisaged as a 10
hour package to be delivered over 5 days in the first month after
recruitment.
Issues/ Themes to be covered
Time allocated
First day
Introduction and Overview
120 minutes
Second day
What are STIs and how are they
transmitted?
30 minutes
HIV & AIDS-Understanding the terms 45 minutes
Modes of HIV transmission
45 minutes
Third day
Materials to be used
Pictures and text in
the Handbook
Pictures and text in the
Handbook
Pictures and text in the
Handbook Transmission game
from the tool kit
*
High Risk behaviours and reducing
risk
60 minutes
Text in the handbook
Women and HIV & AIDS
60 minutes
Text in the handbook
Fourth day
Skills for Condom demonstration
60 minutes
Pictures and text from the
handbook. Use penis model
for demonstration of male
Promoting condom use
60 minutes
condoms
Text from the handbook,
Fifth day
Links to health care services
60 minutes
Pyramid game from the Tool kit
(for VCTC)
Role of volunteers
60 minutes
Total
10 hours
Share pamphlets from SACS,
dapcu;
Described above
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Notes for the Link Workers :
a brief overview of the Link Worker
Scheme and its objectives.
6
Use locally recognized terms and
words to ensure that volunteers
understand the information
Introduction and Overview
1. Welcome the volunteers and tell
them that, “We are all going to work
Assess the level of knowledge of the
as a team in the future. We have a
volunteers before the training (You
common goal to achieve and that is
can do this by asking some basic
questions about HIV, condoms, STIs)
to reach out to as many people with
high risk behaviours as can be
identified in the community and to
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Training should be participatory and
link all those who need services,
interactive. Use the tool kit to
specially High risk groups, women
convey the key messages
and young people, with appropriate
health facilities. This brief training
Update the information available
with the volunteers so that they can
share any new information with the
community (for example any new
health facility or health service that
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has recently become available)
Identify any new needs that emerge
from the volunteers in terms of the
information (or skills ) that they
should have
Plan the interactions and meetings
5
that will be a regular feature
Explain to them about your activities
•
and the support that you will need
from them
I
Day One of the Training
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The aim for the first interaction is to
familiarize you and the volunteers with
each other and at the same time provide
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will help you to develop required
understanding of the issues and help
them to carry out your roles and
responsibilities more effectively”.
2. Introduce yourself briefly and then
ask the volunteers to introduce
themselves to the group. They can
talk about the villages that they
come from and about previous
experience (if any) of working on
health issues. You can also ask them
what motivates them to be a
volunteer in this scheme.
3. Spend the first half hour to brief
them on the Link Worker Scheme and
its objectives.
4. Explain clearly what you mean by
’high risk groups’ and the 'bridge
population' and what are the factors
that enhance their risk to HIV. If you
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have information about certain high
risk behaviours that are more
common in the villages that you are
going to cover, share it with the
volunteers. Emphasize on the need to
maintain confidentiality right from
the beginning of the training.
Many STIs are curable when treated
adequately.
H-
STIs increase risk of HIV
transmission.
STIs can affect the anal region as
well (in case of unprotected anal sex)
5. Explain that there are others in the
community who are vulnerable as
well and these include women and
young people. Discuss the most
common reasons for it.
6. Tell them briefly about the status of
the epidemic in the state and
district.
7. Ask them if they have any questions.
Decide the time and venue for the
next day's meeting.
Day two of the training
The aim for the second interaction is to
provide basic information about sexually
transmitted infections, HIV & AIDS, and
the modes of HIV transmission.
1. Ask the volunteers if they have heard
about sexually transmitted infections
or STIs. Do they know the local names
for it or the terms that people use to
describe STIs in the local community?
2. Explain what STIs are and how they
are transmitted. Emphasize on
following three key points:
3. Explain the common symptoms of STIs
in men and women. Tell them that if
someone from the community has
these symptoms or asks for more
information; guide them to the
nearest PHC as the services for STIs
management are available at primary
health centres and all facilities up to
district level.
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4. Explain about HIV (that it is a virus)
and AIDS (a disease condition). Use
pictures in the handbook to explain
how HIV affects the immune system
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and leads to AIDS.
5. Use pictures from the handbook to
explain how HIV is transmitted. Use
the 'transmission game* from the tool
kit to allow volunteers to revise what
they have learnt.
11
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6. Take time to discuss the
misconceptions and myths that
prevail locally regarding the
transmission of HIV. Discuss how
these myths should be addressed by
them in the community.
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Day three of the training
•
Vaginal sex with multiple
partners; condom use every time
The aim for this interaction is to discuss
high risk behaviours and also the factors
•
Anal sex with a condom
that make women more vulnerable to
Oral sex on a man without a
HIV.
condom
1. Share the following list of behaviours
with the volunteers. Discuss with
Oral sex on a woman without a
them the risks involved in each one
barrier
•
of them and why some of them are
high risk behaviours while others
Vaginal sex using spermicides or
diaphragm and no condoms
•
Withdrawal
have a low risk for transmitting HIV.
Vaginal sex without a condom
Abstinence
Anal sex without a condom
Masturbation
•
9
Sex with a monogamous
uninfected partner
J
Sexual stimulation of another
person's genitals using hands
Vaginal sex using hormonal
contraceptives or IUD and no
condom
• Sharing needles, syringes, drugs,
or other equipments
Oral sex on a woman with a
barrier
100
2. Share the following case studies and
ask the volunteers to discuss the'
Oral sex on a man with a condom
conditions or factors that make
Vaginal sex with a condom
women more vulnerable to HIV/STIs.
Handbook| for Link Worker
Case study one
Case study two
My name is Jayanthi. We are eight children
in all. My mother and my uncle fought over
property when I was eight years old. My
uncle got us into debt and then left us. My
family had problems. I wanted to study but
no one encouraged me. My education was
stopped as soon as I passed Class Five. At 15,
I was married off to a man who turned out to
be an alcoholic. A woman in the
neighbourhood, noticing our poverty, told me
I could earn money by participating in sex
work. She told me she made a living selling
sex. I listened to what she said, but was
reluctant to do it for fear of the reactions I
might get from my husband and the elders in
my family. A year later my husband passed
away. I went to this woman and she
introduced me into sex work. I was very
careful that no one should come to know
about it. Gradually our family finances
improved through my work. Whilst I was a
sex worker I delivered a boy and I got him
educated through my earnings. Now I want
to give up commercial sex work. I want to
stop because of the fear of HIV & AIDS. In
the past not very much was known about HIV,
but now I hear of many people getting AIDS.
I want to give up the sex business for fear of
leaving my son an orphan. But I cannot see
any other option for me till the time my son
starts to support both of us.
My name is Lalitha. I lost my father at the
age of nine. I have two sisters and a brother.
My mother couldn’t maintain the entire
family so gave me to her brother. I was the
only one who was given away like that. When
I was 14 my uncle married me off to a
middle aged man who used to work in a
factory in Calcutta. He said that he earned
well and will be able to give me a better
life. I was too young to understand the
implications of such a marriage. My husband
promised to take me to Calcutta when he
had saved enough money to rent a room for
us. I only saw him occasionally; he used to
return home on every Durga Puja with a lot
of gifts for everyone.
Points for discussion:
1.
Identify the High Risk behaviours of the
main characters in the case study?
2. What are the factors (vulnerabilities)
that have made her choose sex work as a
livelihood option?
3.
What are the likely factors that make her
vulnerable now that she is into sex work?
Five years ago my husband tested HIV
positive and he died two years ago. Till then
I had never heard about HIV. I was also
advised to take a test. My test came back
'Positive'; I had been infected through my
husband. Thankfully my two children have
tested negative.
When my husband’s infection came to light,
other problems poured on to us; we were
treated as outcast. There was no money
even to continue the children’s education.
When I was grief stricken and trying to cope
with the situation due to my husband's much
stigmatized illness, it was an organization
which came to my support. They counselled
me, supported me to work with them and
encouraged me to counsel others who are
affected by HIV. They have even put my
children into their school where many other
children who have lost their parents are
studying.
Points for discussion:
1.
Identify the high risk behaviours of the
main character/s (Lalitha, and her
husband) in this case study.
2.
What are the factors that made Lalitha
vulnerable to HIV?
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1. Identify the High Risk behaviours of
the main characters in the case
study?
Resource sheet 2
•
Unprotected sex (may be vaginal or
even anal sex)
1. Identify the high risk behaviours of
the main character/s (Lalitha, and
her husband) in this case study.
Having mulitpartner sex
Lalitha:
2. What are the factors (vulnerabilities)
that have made her choose sex work
as a livelihood option?
I
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•
Poverty and limited economic
opportunities
•
Lack of employment opportunities
•
No support from family
•
Limited /no access to information
•
Gender inequalities (not having the
same status as the male members in
the family/community)
•
Gender Inequities (not having equal
ownership of resources as men in the
family/community)
3. What are the likely factors that make
her vulnerable now that she is into
sex work?
•
•
Fear of losing out on daily income
(compulsion to earn so as to let her
son complete his education)
Fear of being stigmatized if the
community finds out (may also
reflect on her son)
102
Unprotected sex with her husband
(who has high risk behaviours, and is
probably HIV positive for some time
before he is tested and status
confirmed)
Unprotected sex with multiple
partners /sex workers
2. What are the factors that made
Lalitha vulnerable to HIV?
•
Gender inequality
•
Traditional norms (like early
marriage)
•
Circular migration of her husband/
partner
'
•
Unaware about their partner's sexual
behaviours/unaware of risks to their
own sexual health
•
No negotiating power(huge spousal
age gap) or limited negotiating
power for safer sex
•
Sex viewed as a spousal responsibility
(hence cannot refuse sex)
•
Economically dependent on husband
•
Limited economic resources (that
made her husband migrate)
•
Suggestion of condoms seen as a sign
of ’mistrust', 'admission of guilt*
Inability to or limited skills to
negotiate with clients (for safe sex)
No access to means of prevention
(like female condoms or male
condoms)
•
•
Lalitha's husband:
Limited information
4
Sexual exploitation by people in
authority (like local policeman, etc.)
Resource sheet 1
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3. Summarize the day's discussions by
referring to the text used in the
handbook (Women and HIV /AIDS and
High Risk Behaviours )
Day four of the training
The aim for this day's interaction is to
provide the skills for condom
demonstration to the volunteers and also
discuss ways in which volunteers can
promote condoms.
1. Ask the volunteers if they know about
the commonly available brands of
condoms in the local area. What do
they cost? Are there places from
where free condoms can be procured?
Are they aware of any programmes or
agencies which are involved in social
marketing of condoms locally?
2. Share the information that you may
have about condom availability in the
local area.
3. Explain to the participants that
demonstrating correct condom use is
as important as guiding people to the
source of condoms. Most often failure
of condoms is due to faulty technique
(of using it) rather than the quality
of the product.
4. Use the penis model from the tool kit
and demonstrate how to use the
condom. Explain all the precautions
that need to be taken while buying
and using a condom.
5. Let all the volunteers practice the
demonstration of various steps in
using a condom. Make sure that they
are confident about doing it
independently and are not
embarrassed.
■a®
6. Discuss how and where volunteers
can access condoms or maintain
condom store so that they can make
it available to those who need it.
Help them to establish linkages with
the local condom social marketing
programme. In case they procure free
condoms from the government health
facility for distribution; explain the
conditions in which the condoms
should be stored.
Day five of the training
The aim of this day's interaction is to
discuss about the health services
available in the vicinity and to discuss
the role of volunteers and make plan for
the future.
1. Share the maps that you have
prepared of the local area and the
health facilities that have been
mapped by you during the training.
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2. Point out the various health facilities
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located close to the village. These
may include government and private
health facilities.
*
3. Discuss the services that are
available at these health facilities
and those that are not available
locally. Explain to them about the
Handbook| for Link Worker
103
i
services that are available at the
district and sub district level. (These
services should include STI
management, testing for HIV/ICTC,
PPTCT programme, ART centres,
treatment for opportunistic
infections, RNTCP).
4
If pamphlets are available from the
SACS, distribute these to the
volunteers. Otherwise discuss the
location of each of these facilities
and the modes of transport (including
cost) available to reach them. This is
important information that should be
available with all volunteers. Up date
them regularly about any new
services that become available
(either through government or NGOs).
5. Discuss the activities that you will
undertake in the local area. Explain
to them about the support that you
will need (for example, to carry out
mapping in initial phase, and to
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conduct community meetings with
vulnerable populations like young
men and women in later phase.)
6. Chalk out a plan for the next two
months, clearly defining the role of
each volunteer. Reassure them that
you will be available for providing
them support just as they should
facilitate your entry into the local
community.
7. The volunteers who can read should
go through the entire content of the
handbook. Share the handbook and
the toolkit with them. Orient them
on the use of the tool kit.
PART -8
Maps of Population & Services
8.1 VILLAGE - 1
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8.2 VILLAGE - 2
*
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8.3 VILLAGE - 3
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8.4 VILLAGE - 4
*
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8.5 VILLAGE - 5
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8.6 AVAILABILITY OF SERVICES
*
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Position: 2629 (2 views)