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NATIONAL AIDS CONTROL PROGRAMME
INDIA
. 'i
HIV/AIDS : PREVENTION, CARE & CONTROL
SELF INSTRUCTIONAL MODULES
FOR PRESERVICE AND INSERVICE
NURSES AND MIDWIVES
(MODULE NO : 1 TO 15)
1996
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NATIONAL AIDS CONTROL ORGANISATION
MINISTRY OF HEALTH & FAMILY WELFARE
GOVERNMENT OF INDIA
f
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NATIONAL AIDS CONTROL PROGRAMME
INDIA
HIV / AIDS : PREVENTION, CARE & CONTROL
SELF INSTRUCTIONAL MODULES
FOR PRESERVICE AND INSERVICE
NURSES AND MIDWIVES
I
1996
»
NATIONAL AIDS CONTROL ORGANISATION
MINISTRY OF HEALTH & FAMILY WELFARE
GOVERNMENT OF INDIA
1
I
i ABLE OF COM ENTS
PAGE
PREFACE
i)
ACKNOWLEDGEMENTS
iii)
INSTRUCTIONS FOR USING THE MODULES
v)
MODULE - 1
EPIDEMIOLOGY & TRANSMISSION OF HIV
INFECTION
Section - 1
Section - II
MODULE - 2
SIM
Visual Aids
HIV INFECTION AND DISEASE
Section - I
Section - II
Visual Aids
5.1-5.29
SIM
Visual Aids
MODULE - 6 HEALTH EDUCATION
Section - 1
Section - II
4.1-4.27
SIM
Visual Aids
MODULE - 5 DEVELOPING COUNSELLING SKILLS
Section - I
Section - II
3.1-3.44
SIM
Visual Aids
MODULE - 4 PSYCHOSOCIAL IMPACT OF HIV INFECTION
ON THE INDIVIDUAL AND THE COMMUNITY
^Section - I
Section - II
2.1-2.19
SIM
MODULE - 3 PREVENTION OF HIV TRANSMISSION IN
HEALTH CARE SETTINGS
Section - I
Section - Il
1-44
SIM
Visual Aids
6.1-6.23
f
MODULE - 7 NURSING CARE OF THE ADULT WITH HIV
DISEASE
Section - I
Section - II
SIM
Visual .Aids
MODULE - 8 THE IMPACT OF HIV INFECTION AND
HIV-RELATED ILLNESS ON WOMEN
Section - I
Section - II
MODULE - 11
GLOSSARY
REFERENCES
10.1-10.27
SIM
Visual Aids
EDUCATION OF TRADITIONAL
PRACTITIONERS TO PREVENT HIV
TRANSMISSION THROUGH
SKIN - PIERCING PRACTICES
Section - I
Section - II
9.1-9.14
SIM
Visual Aids
MODULE - 10 TERMINAL CARE IN HIV DISEASE
Section - I
Section - II
8.1-8.25
SIM
\’isual Aids
MODULE 9 NURSING CARE OF THE INFANT AND
CHILD WITH HIV INFECTION
Section - I
Section - II
7.1-7.42
SIM
Visual Aids
11.1-11.5
1
PREFACE
HIV / AIDS is a deadly condition and has spread all over the country crossing
all geographical, socio-cultural and socio-economic boundaries. It is recognised as one
of the most serious public health problems in present world and in the country'.
There is a crucial need for the training of all health personnel at various levels
including the nurses who provide direct care. They need to be knowledgeable and
trained to give safe, competent and compassionate care
In 1988, guidelines containing basic information on the nursing of people with
HIX' infection and related illness were jointly developed by World Health Organisations
(WHO) : Global Programme on .AIDS (GPA) and International Council of Nurses
(ICN). Teaching modules for basic nursing and midwifery education in the prevention
and control of HIV infection were then developed by WHO / GPA and were adapted
and used throughout the world.
In addition to the materials presented by WHO / GPA, it was considered
helpful to incorporate additional specific materials relating to nursing in India. WHO
collaborating centre for research in Nursing Development accordingly initiated plan in
February 1993 to prepare a revised form of the modules at Rajkumari Amrit Kaur
College of Nursing, New Delhi.
A core group was then constituted by National AIDS Control Organisation
(NACO) with following representatives from various nursing institutions, who wrote
the modules and provided the vital inputs to give a final shape to the modules.
•
s
Dr. (Miss) Aparna Bahaduri,
Professor cum Consultant, College of Nursing,
Manipal Academy of Higher Education, Manipal, Karnataka.
andformer Prof of Nursing,
Rajkumari Amrit Kaur College of Nursing, New Delhi.
•
Miss Krishna Kuniari Gulani, Senior Lecturer
Rajkumari Amrit Kaur College of Nursing, New Delhi.
•
Mrs. Binila Kapoor, Senior Lecturer
Rajkumari Amrit Kaur College of Nursing, New Delhi.
*
Mrs. Unia Handa, Reader
School of Health Sciences,
Indira Gandhi National Open University, New Delhi.
•
Miss Jaiwanti P. Dhaulta, Assistant Secretary
The Trained Nurses’ Association of India,
New Delhi.
ii
•
Miss Surekha Sama, Acting Principal (writer only)
College of Nursing,
L.N.J.P.N. Hospital, New Delhi.
There are eleven self-instructional modules and eleven teaching modules.
These modules were pretested for ‘Trainers’ as well as ‘Trainees’ in three institutions
i.e. Rajkumari Amrit Kaur College of Nursing, New Delhi; College of Nursing,
Manipal; Academy of Higher Education, Manipal; and School of Health Sciences,
Indira Gandhi National Open University, New Delhi.
On the basis of feedback from the pretesting sessions, further modifications
were made to finalise the content and organisation of the modules. Several steps were
thus taken for developing content editing and critiquing these modules.
WHO sponsored "Think Tank Workshop - I for Nurse experts, to plan the
strategy for country-wide training of nurses on HIV / AIDS” was convened by
Christian Medical Association of India, in New Delhi in December 1995 in
collaboration with NACO and Government of India.
"Think Tank Workshop - II for developing State-wise Operational Plan for
training of nurses in HIV / AIDS” for seven states of India was held at Bangalore in
February 1996.
Both group of experts recommended modification of the modules to make the
modules more concise and convenient for workshop presentation. The steering
committee constituted on the basis of recommendation of the same group, then met
and constituted a sub-committee to complete the job. Modules were modified, edited
and divided into two parts as Self-Instructional Material (SIM) and Teaching
Strategies by the following members of the sub-committee.
<<•
Miss Krishna Kumari Gulani (Original writer)
Senior Lecturer, RAK College of Nursing,
New Delhi.
•
Mrs. Bimla Kapoor (Original writer)
Senior Lecturer, RAK College of Nursing,
New Delhi.
•
Mrs. Reena Bose (Convener)
Secretary, Nurses League,
Christian Medical Association of India,
New Delhi.
Dr. Mrs. Betsy Lehman (Co-opted member)
Nurse Consultant, CMAI, New Delhi
Professor Emeritus, Pace University,
New York.
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iii
AC KNOW LEDG EM ENT
i
‘HIV / AIDS : Prevention, Care and Control Self Instructional and Teaching
Modules for Preservice and Inservice Nurses and Midwives’ has attained the present
form due to the hard work and sincerity’ of core group workers, and guidance of a
number of people.
The basic document was put together by Rajkumari Amrit Kaur College of
Nursing, New Delhi, with the assistance of the Trained Nurses’ Association of India
and the School of Health Sciences, Indira Gandhi National Open University, New
Delhi. A team of peer group reviewers have greatly contributed towards developing
the content validity of the modules. The participation of the nurse administrators, nurse
educators, nurse practitioners and nursing students, in its field testing have greatly
contributed to establish the effectiveness of the modules.
We gratefully acknowledge the support and guidance from Dr. Shiv Lal, Addl.
Project Director (1EC), National AIDS Control Organisation and Dr. D. Sen Gupta,
National AIDS Consultant, NACO without whose support this project would not have
been possible.
Sincere appreciation is extended to Mr. Dileep Kumar, Nursing Adviser,
Government of India for his contribution and sustained support to bring this project of
preparing training modules for nurses, to completion.
We are deeply indebted to WHO for sponsoring the project and providing all
encouragement and support.
Great appreciation is extended to Mrs. Bandana Bhattacharya, Principal, RAK
College of Nursing,. New Delhi, for her constant support and encouragement in the
preparation of this module. Thanks are also extended to Secretarial Staff who have
helped in the preparation of this document.
Thanks are extended to Dr. Cherian Thomas, General Secretary Christian
Medical Association of India, New Delhi, Secretary, Nurses League CMAI and
support staff of CMAI for facilitating in finalisation of these modules.
We are indebted io Anupam Associates, D-64 Hauz Khas, New Delhi for
computerisation and printing of the modules.
We thank ail those associated with this project and whose names may not have
been mentioned. We appreciate their valuable contributions.
IV
PEER REVIEWERS
Miss Hashmath Huque,
former Co-ordinator,
Continuing Education Department,
Kajkumari Amrit Kaur College of Nursing,
New Delhi.
Miss Subha Das Gupta,
former Principal,
College of Nursing,
Calcutta, West Bengal.
Miss Manju Vatsa,
Principal,
College of Nursing,
All India Institute of Medical Sciences, New Delhi.
Mrs. Sujata Sen Gupta,
Associate Professor,
All India Institute of Hygiene & Public Health,
Calcutta, West Bengal.
Mrs. Bimla Kapoor,
Senior Lecturer,
Kajkuinari Amrit Kaur College of Nursing,
New Delhi.
^liss Jaiwanti P. Dhaulta,
Assistant Secretary,
The Trained Nurses’ Association of India,
New Delhi.
Mrs. S.K. Pillai,
Lecturer,
College of Nursing,
All India Institute of Medical Sciences, New Delhi
?
Mrs. Kamlesh Bajaj,
Tutor,
:
College of Nursing,
Lok Nayak Jai Prakash Narain Hospital, New Delhi.
j-
V
Instructions for Using the Modules
INSTRUCTIONS FOR USING THE MODULES
APPLK A 1 ION
The Modules are designed as self-instructional material (SIM) for pre-service
and in-service nurses. They cover the basic knowledge and skill which nurses need to
acquire for effective and safe practice. The Modules are consecutive, each one
building the knowledge and skill described in the previous module. They can also be
presented separately.
STRUCTURE OF THE MODULES
The course is divided into 11 separate Modules. Each module has two major
sections. Section-I deals with the Self-Instructional Material (SIM) for individual
learning. Section-II contains examples of visual aids.
All nurses will need the information contained in Modules 1-11, irrespective
of their area of expertise or geographic location. The suggested content and learning ’
activities have been limited to basic information. Nursing and midwifery schools
might find it challenging to incorporate additional material in their curricula.
Section - I :
SIM
I.
Overview
di.
Specific Objectives
IH.
An Introduction
IV.
Description of Content
N
(Self-Instructional materials incorporating examples, visuals, activities,
check your progress along with the content).
V.
Answer to check your progress
Section - II : Visual Aids
>
i
Lnslruchpijs. fbrlJsiijg.thc.Modujes
vi
USE OF SIM
SIM is a learning package designed for learners to achieve prespecified
objectives The learner can study at home without disruption and at his or her own
pace. Here the subject matter is presented in an organised manner and follows a
logical sequence. Each module has specific objectives, major areas of learning and
their description. Illustrations, case histories, diagrams, activities are given at
appropriate places, self checking questions are given to check the learner's
progress. Exercises or assignments / activities are given wherever felt necessary.
I he learner can check his / her answers with the possible answers given at the end of
the module. It is important for you to start at the beginning of the material and go
through this material in a systematic way. The exercises or the assignments are
designed to help you to study further and to clarify your doubts. A Glossary' and
References are given at the end of the eleven modules. The Glossary will help you to
understand common technical terms used in the modules.
L
Module 1
MODULE 1
EPIDEMIOLOGY AND TRANSMISSION
OF HIV INFECTION
SECTION ! : SIM
I.
OVERVIEW
For a better understanding of epidemiology of HIV infection, learners are
expected to have an understanding of the basic principles of epidemiology and
dynamics of disease transmission. On completion of this module, the learners will have
an understanding of epidemiology and transmission of HIV.infection and their role in
preventing further spread of infection.
II.
SPECIFIC OBJECTIVES
On completion of this Module, the learner will be able to:
•
•
•
•
•
•
III.
5
identify personal and community fears and worries about HIV infection. ’
describe epidemiological features of HIV infection.
explain how HIV infection is and is not transmitted.
describe the role of the nurse in preventing the spread of HIV infection in
the community.
discuss the local, as well as the national and global epidemiological picture
of the HIV / AIDS epidemic, including the importance of surveillance in
understanding and responding to HIV infection in the community.
describe ways in which information can be collected to help identify the
demographic characteristics and risk behaviours of people reported to be
infected with HIV.
INTRODUCTION
Human Immuno-deficiency Virus (HIV) infection is a disease which may give
rise to fear and misunderstanding. It is a new disease, transmissible, life long,
incurable, eventually fatal. It is frequently associated with behaviour patterns
considered to be unacceptable by society. Acquired Immuno-deficiency Syndrome
(AIDS) is the last stage of HIV infection. Being part of the community, nurses are
likely to share the same fears and misconceptions as other members of the community.
It is essential, therefore, for nurses to have a clear understanding of their own fears and
concerns; only then will it be possible to separate the unfounded fears from the real.
They need to understand the scope / extent of HIV / AIDS epidemic, its epidem
iological feature and mode of transmission. This is the first step in preparing them to
be informed professionals with the expertise needed to address the problems of the
infection.
1
2
Epidemiology & Transmission of HIV Infection
-7
IV. DESCRIPTION OF CONTENT
Description of content is organized under the following headings
1.
2.
Personal and community fears and anxieties.
Epidemiological feature and transmission of HIV.
3. Global, National and Local Epidemiology.
4. AIDS Control Programme and Surveillance Resources.
5. Nurses’ role in Prevention of HIV.
Personal and Community Fears and Anxieties
You all know that HIV infection / AIDS is a new and serious problem. It is but
natural to have fears and anxieties. People in general and HIV / AIDS patients and
their families in particular are afraid of many things which are described as under.
1.1
Fear and Anxiety of Common People
(i) Misconceptions : Fear of getting HIV infection / AIDS by coming in
casual contact with HIV-infected or AIDS cases e.g. shaking hands, sharing of
utensils, clothes, furniture etc.; curse of God or punishment, evil spirit, shadow
of an AIDS patient; going to hospital for care and treatment etc. These
misconceptions are due to misinformation and superstitions. .
(ii) Fear of moral judgement on sexual behaviour pattern : It is
considered a shame disease because of its co-relation with sexual behaviour of
people and people are, therefore, afraid of getting exposed to their character
which is culturally not accepted by society. Having multiple sex partners,
Jiomo- sexuality are seen as immoral acts by society.
(iii) Fear of stigma / disgrace : This is also due to the fact that this problem
emanates from the involvement of one’s behaviour, especially extramarital sex.
Sometimes it is also due to myths that this is the curse of God for wrong
deeds etc.
1.2
Fear and Anxieties of Persons Affected with HIV Infection / AIDS
Persons with HIV infection / AIDS face many difficulties. These are physical,
social and emotional.
(i) Physical :
a)
This includes fear of:
Threat to Health : HIV is a life-long infection which makes the
body weak and susceptible to many other diseases like
3
Module I
4
tuberculosis, skin infection, cancer, repeated spells of diarrhoea,
fever etc.
b)
c)
Pain and a^ony of AIDS itself which is the eventual outcome of
the infection.
Death as HIV / AIDS is incurable and ultimately proves fatal.
(ii) Social : Social fears include fear of:
a) Ostracism i.e. getting condemned, rejected or abandoned by their
friends, relatives, neighbours, health-care providers or even by their
families. See Example 1 for ostracism.
b) Stigma /disgrace because most of the time the disease is associated
with personal behaviour which includes sex and drug abuse by an
individual. These are considered immoral behaviours by society.
c) Exposure and loss ofprivacy and economic burden
d) Pear or risk of infecting others - There may be a genuine fear-of
infecting their sexual partner.
Example - 1
Batwa, a 32-year-old man, is a known case of AIDS. He was working
as an Assistant in C.T. Hospital’s Mortuary. Since his diagnosis as a case of
AIDS, he is not allowed io work, his fellow workers have asked him to leave
his hut. He says : “People have abandoned me and I have been forced to
abandon my children”. Batwa now cries, no one around him says a word, no
one tries to console him. (India Today)
(iii) Emotional : Emotional fears include fear and anxiety about :
a) death which is the ultimate end, particularly fear of dying alone and
in pain or without dignity.
b) children getting orphaned, being isolated from friends, neighbours
and school, giving a feeling of insecurity.
c) future social and sexual unacceptability.
d) loss ofphysical andfinancial independence.
e) the ability of loved ones and family to cope with the problem.
4
EpidcniioFogv & Transmission of HIV Infection
1.3 Fears and Anxieties of Family and Friends of Persons with
HIV Infection/AIDS
(i)
Gening infection by coming in casual contact with HIV / AIDS persons because
of misinformation and misconception.
(ii) Stigma, getting exposed and social rejection or segregation by the community,
friends and relatives. This may reduce their social contacts, and the family may
feel isolated.
(iii) Losing a near and dear one and all the more losing someone in a young and
productive age.
(iv) Loss ofjob and increased expenses due to sickness - Exclusion or rejection from
the work place can be highly stressful to the family.
(v) Increased demand of care from the family and friends leading to neglect of family
responsibilities. The family members, partner and friends are often the main
sources of care and support for the people with HIV infection. As the care
becomes more demanding, the burden on the family increases and the emotional
involvement becomes greater day by day. See Examples 2,3,4 & 5 given below
depicting fears and anxieties of affected people.
Example - 2
Chitra, 23, caught the virus from her husband, Mohan, who died of AIDS. Now
their daughter has it too. She says : “The first few days, I had a lot of difficulties with
people’s jeers and comments. But now I have become more used to it”.
Example 3
In Imphal, Anjan Das, 29 years, has not yet managed to muster the courage to
tell his mother about his HIV status. “My mother will die of shock, so I don’t keep in
touch with her,” he says. “Life has ended. I can’t marry or get education. So what’s
the use of living ?”
Example 4
In Bombay, a young man who tested positive harbours dreams of taking up
where Dominic D’Souza left and reviving the self-help group called Positive People.
But he is afraid of revealing his identity. “My sister will never be able, to marry,” he
says, “our family will be ostracised.”
(India Today)
Example 5
Rohit and Vincct, who arc haemophiliacs, are coping with physical pain but the
emotional hurt runs deep
Their entire world has shrunk to the confines of a room. A room they are scared
to emerge from, for each time they look out they have to meet those eyes. Insistant
eyes that glare, sneer, condemn and ridicule. Haemophiliacs since birth, Vineet, 25,
and Rohit Oberoi, 31, are now battling with the HIV infection. Rohit’s whole world
was shattered in April 1989, the moment the nurses at AIIMS put up a board saying
positive at the corner of his bed. All of a sudden, everyone stopped coming to see him
He knew what AIDS meant. He has read about it on the labels accompanying the
blood bags. What he didn't know was what having AIDS meant He could not
understand why he was being treated like an untouchable. Physical pain Rohit has
learnt to live with, but the emotional hurt runs deep. Rohit’s father, a retired section
officer from the Lok Sabha Secretariat, remembers how his colleagues refused to
shake hands with him. Their mother is humiliated each time she goes to the hospital or
to the neighbourhood dispensary. Wherever she goes, people want to know if she is
negative or positive. And when Rohit goes for his routine check-up, he is asked to sit
on a stool in a corner of the room and not next to the doctor.
"Like all men of my age, 1 too thought I would get married and have a family",
he reminisces. He had even met his partner - a girl who, on seeing the two brothers’
advertisement for blood, had come to their house offering to donate some. Rohit and
she talked and liked each other. “I am still in love with her,” says Rohit, pausing to
add, ‘"but what is the point ? Now it is only
friendship and love". Each blow has brought with it pain but has also helped Rohit
become a little more stole. Now all he says is : “I am at peace inside my home. Please
let me be.”
'(India Today)
You have learnt about fear and anxieties which the affected individual, his
family and the common people may have about HIV infection and AIDS. Nurses being
part of the community may also have similar fears, anxieties and notions regarding
AIDS, which is a new and serious problem. It is, therefore, advisible to examine
personal fears and anxieties so as to identify false notions or myths if there is any and
rectify that by giving correct information about the scientific facts.
2.
2.1
Epidemiological Feature and Transmission of HIV Infection
Epidemiological Feature of HIV Infection :
(i)
Historical Genesis : The disease, what we call as Acquired Immuno
deficiency Syndrome, (AIDS), was first reported among homo-sexuals in
USA, and other developed countries like Australia, New Zealand and
Europe in 1981. The prevalence of AIDS and HIV infection rapidly
(»
iniolo.uv & Transmission of HIV Inlcciioi)
Hared up (accelerated) in a pandemic form. In other countries, AIDS was
diagnosed among
heterosexual men and women
injecting drug users
recipients of blood transfusion and in particular children and adults
with haemophilia.
In the South-East Asia Region (SEAR) it was first detected in Thailand in
1985
In India, HIV infection was first detected in 1986 when six
commercial sex workers from Tamil Nadu were found positive for HIV
antibodies. Since then there is an explosive increase in HIV infection in
female commercial sex Workers in Vellore, Tamil Nadu, Bombay and
Delhi and injecting drug users in Manipur
(ii)
Agent Factors : Agent factors include the causative agent that causes
AIDS, reservoir and source of infection and are described as under
(a)
A^cnt - The virus that causes AIDS is known as I luman Immuno
deficiency Vims (HIV). It was first discovered around mid-1983
at the Pasteur Institute in Paris from the lymph glands of a male
homosexual.
We now know that there are at least two different major types of
this virus, one called HIV-1 and the other known as HIV-2. HIV1 is the principle AIDS virus while HIV-2 is found in West
African countries. Of late, HIV-2 infection is also reported in
India.
HIV is very small - l/IO.OOO of a mm in diameter, sensitive to
heat and is a member of the retrovirus family. The retrovirus
enters the host cell by attachment to a specific cell receptor. In
the case of HIV infection, the cell receptor is CD-4 molecules on
the surface of the T4 Lymphocytes, which is part of the body's
immune system. The viruses are released to the exterior of the
cell by a process known as budding (see Exhibit II. Figures I &
2)
HIV takes a long time to do damage because after getting into the
host cell, viral DNA lies dormant for several years before it
stimulates multiplication and destruction of the cells.
As the virus get multiplied, each one invades the fresh
lymphocytes and the process goes on. Thus, the number of
lymphocytes goes on decreasing which impairs the body's immune
system (see Exhibit 1.2).
5
7
Module I
(iii)
(b)
Reservoir of Infections : The infected person and AIDS cases
are the reservoir of' infection. Once the person is infected, he
remains infected for the rest of his life. The infection remains in
a latent state for several years before it shows any signs and
symptoms of disease, but the infected person (carrier) can give
infection to other people. The Virus lives in dead bodies of an
infected person upto 10 hours.
(c)
Source of Infection : HIV has been isolated in almost all body
fluids of infected persons. However, only blood and semen have
been found to transmit the virus to a-greater extent and vaginal
fluids and breast milk to a lesser extent.
Host f-actors
HostJactors include age, sex, risk behaviour and
immunology of the host. The description follows :
(a)
.•l/sre : Infection can occur in all age groups but most cases have
been reported in the 21-50 age groups who were sexually active.
Less than 3 percent of cases have been reported in children under
15 years of age.
(b)
Sex : Infection can occur in both the sexes. However according
to WHO estimates, almost half of newly infected adults are
women. But it is observed that certain sexual practices increase
the risk of infection more than others e.g.- multiple sexual
partners, anal intercourse, and male homosexuality. Infection
rate is very high in female commercial sex workers (prostitutes).
(c)
High-Risk Groups : High risk of getting HIV infection are male
homo-sexuals and bisexuals, heterosexual partners, including
female commercial sex workers, injecting drug users using
common syringe, recipients of blood transfusion, haemophiliacs,
thalassemics, persons having STD and children of infected
mothers.
However, in India, the general population is now at risk. For
example, with unsafe sexual practices, a man like Mohan had
given the infection to Chitra, an ordinary housewife, and to their
eight-month-old daughter (refer to example 2). The India Today
magazine reports .... "It is clear that the virus has spread beyond
female commercial sex workers and their most frequent clients :
migrant labourers, truckdrivers and students. Among the new
victims are salesmen, executives, armed forces personnel,
housewives and more sadly the new-born children.”
X
<VLn.m^issioiLo!'l^^
(ci)
Immunology
The virus invades the T4 lymphocytes of while
blood cells and gradually destroys them, leading to profound
lymphopenia and thcieby deficiency in the immune system of the
body
(e)
Incuhmion Period \ The incubation period i.e. the period between
HIV infection and the onset of AIDS symptoms is uncertain. It
is observed by scientists that HIV / AIDS is preceded by a
variable period of a few months to two to five years or even
more i.e. 10 to 17 years. The incubation period is much shorter
in poor undernourished people and in children with HIV
infection. Around 75% of those infected with the infection
develop AIDS by the end of 10 years. During this period the
person is asymptomatic and physically healthy but his blood is
HIV positive and he is infective to others See Examples 6 & 7
below indicating asymptomatic long-duration incubation period
are quoted below.
Example 6
Deb, 37, a teacher in a Delhi School, discovered that he was a carrier of H!V in
the last stage of AIDS. He probably contacted the infection several years ago
as he admitted about his sexually promiscuous behaviour in Zambia.
Example 7
A 29 year-old-Navy man. with over 10 years in service, was tested for HIV
infection in 1992 while donating blood. He was certified as HIV positive in
INS Aswini. He gave the history of sexual contact with a female commercial
sex worker at Vishakhapatnam in 1988. He did not show any other signs of
4IIV infection.
He looked apparently healthy.
In other words, he was
^asymptomatic.
India Today
2.2
1'ransmission of HIV Infection
Epidemological studies have shown three modes of transmission, which are as
follows :
(i) Sexual Transmission : 'This refers to transmission through unsafe sexual
activity, that is genital and / or oral sex. This is the most frequent mode of
transmission. The virus can be transmitted from any infected person to his
or her sexual partner (man to woman; woman to man; man to man, but less
likely woman to woman).
I ..
9
MydiikJ.
(ii)
1
Parenteral Transmission : This refers to transmission through the
infected blood or blood products. That is, this may occur through blood
or plasma transfusion when the donor is an infected person, and use of
blood contaminated needles, syringes or other skin- piercing instruments.
Refer to Rohit and Vineet’s case (Example 5). Both of them were
haemophillics and they contracted HIV infection through blood
transfusion.
It is said that the recipients of a single unit of HIV-infected blood have
hundred percent possibility of acquiring the infection. In Manipur, the
incidence of HIV infection is high among the I.V. drug abusers.
(hi)
Perinatal Transmission . T'his refers to transmission of infection from
mother to foetus before, during or shortly after birth. The risk of HIV
from mother to child transmission is believed to be 30-40 percent in the
uterus and during delivery. The issue is debatable. It is believed that
during the post-natal period, transmission of HIV infection from mother
to child occurs through breast milk but the possibility is low. Refer
Exhibit 1.4 to know about HIV transmission in South-East Asia.
(ivj HIX' infection Is Not Spread Through
Casual Contact e.g. by :
•
•
•
•
•
Shaking hands, embracing, contacts with objects in phone booths, public
transport, door-knobs, money (coins and notes).
Shared use of china, crockery, silver, towels, bedding linen, toilet articles.
Eating and drinking from common dishes (Holy Communion).
Caressing, petting, kissing (cheek).
Masturbation
Coughing, sneezing, tears.
Normal use of public toilets, swimming pools, community showers, saunas
(unless unsafe sex is practised there).
•
•
Massage, physical therapy, cosmetic treatment, hair dressing.
Scratches and bites by pets or insects.
Caring for AIDS victims or HIV positive people.
In Module 5, you will have an opportunity to learn methods to help
reduce the risk of becoming infected sexually with HIV and to explore ways of
teaching this material to students and patients.
It is important to stress at this point that in most work activities, nurses
are not at risk of becoming infected by people with whom they work. This will
be discussed in more detail in Module 4^
If)
I p.i(lcini<»k>e\
2.3
Transniissipn of IIIV Inlcciion
( HECK YOUR PROGRESS - I
(i)
(iive a brief account oi'individual's. family's and community's fear of
and HIV infection
(ii)
Briefly describe the agent that causes AIDS
AIDS
(iii) Answer the following :
(a) Reservoir of HIV infection.
(b) Source of HIV infection.
(c) High-risk groups of HIV infection
(d) Incubation period of AIDS
(iv)
3.
Briefly describe the modes of HIV infection
(Jobal, National and Local Epidemiology
Epidemiological information on AIDS has helped scientists understand the
occurrence, distribution and causes of the disease in man and also its projection in
future As such, nurses need to know how people may become infected in their
communities and what the major risk factors are, which may dilfer in each community
3.1
Review of Background Information :
Review the following concepts before you proceed further for a better
understanding of the information presented here.
^')
Incidence
Incidence means the occurance of new AtDS cases
presenting each month or the number of new HIV infections being
detected during a specified period of time.
(ii)
Prevalence Prevalence means “the total number of specific conditions,
in existence in a defined population al a precise period in time" e g the
number of AIDS cases or the number of HIV infections which have so
far been reported in the country.
(iii)
Surveillance . The systematic collection of facts (data) on disease
occurrence is called surveillance It is very important to learn about
AIDS and HIV infection in every country through national surveillance
programmes
*
11
Module I
3.2
(Jobnl HlV/z\H)S Epidciuiology
HIV / AIDS is recognised as one of the most serious global public health
problems of the present time. It has spread like a wild fire, and emerged as pandemic
since 1081.
(i) Epidemiological Pattern : Three distinct epidemiological patterns of HIV
infection have been identified on the basis of a predominant mode of
transmission in different parts of the world.
(a)
1
Pafteni I . This pattern is typical of certain industrialized countries,
including North America, Western Europe, Australia, New Zealand
and parts of Latin America. In these areas :
'
•
•
•
•
•
•
extensive transmission of HIV appears to have begun in the late
1970s.
most cases occur among homosexuals or bisexual males and
injecting drug-users.
heterosexual transmission is responsible for a small percentage of
cases but is increasing.
transmission through blood and blood products is rare because of
strict safety measures.
male-to-female ratio of cases ranges from 10:1 to 15: 1.
overall seroprevalence is generally less than 1 percent but can be 50
percent in high-risk groups such as homosexual with multiple
partners and injecting drug-users.
(b) Paliern 11 : This pattern is typical of Sub- Saharan Africa and some
Caribbean countries. In these areas :
c)
•
extensive transmission appears to have begun in
•
most cases occur among heterosexuals. As a result, the male-to
temale ratio of cases is 1:1 and perinatal transmission is common.
•
transmission through homosexual activity or intravenous drug use
is minimal.
•
overall seroprevalence is more than 1 percent but can be upto 15
percent or more in sexually active people in some urban areas.
the .1970s.
Pattern HI: This pattern is found in North Africa, Eastern Europe, the
Eastern Mediterranean, Asia and most of the Pacific region, tn these
areas
i
12
Epidemiology Transinis^
•
HIV has appeared to occur in early to mid 1980s
and only I
percent cases have been reported
•
initially, the infection
had contact with
who
occurred in persons
travelled in oi
individuals from pattern I and pattern 11 areas o:
those who received imported blood.
•
presently the infection is transmitted through
homosexual and
heterosexual contacts, use of contaminated blood for transfusion
and -unsterilized injecting equipment especially by
injecting drug
users.
•
is
transmission
still in a latent
•
proceed.ng silently and rapidly
rhe infect ion is
stage
awareness of the problem among professionals and the common
people is \ ery low
(ii) Global HIV/AIDS Status
(a)
.
(’u.sv.v
Throughout the world there has been a steep increase in
the number of cases.
Of the total cases reported in 1992. 39 5% are from the USA’ 34 5° o
from Africa, 13%
from Europe. 12%
from Americas and 0 5% each
from Asia and other countries. ( Exhibit 1.6 )
(b)
Hll' injection .
Il is estimated by WHO that by 1992 there were about
10-12 million people infected with HIV
pass on the infection to others
They
are asymptomatic and
Infected women have already given
birth to 1 million HIV-infected children
It is estimated that 10-3’0°-o of
these infected people will develop AIDS during the next five years
Estimated continent-wise or region-wise distribution of cumulative HIV
infection among adult
is indicated in Exhibit 1.7
It shows maximum
distribution in Sub-Saharan Africa (7.5 million), followed b\ South East
.Asia (1.5 million)
01 these 15 million, one million are estimated to be
in India.
c)
(liohtil projection \
WHO estimated that by the year 2000 AD. lheie
will be a total ol 30-40 million men. women and children infected with
Hl\
more than I million adults would get AIDS every year i e
million ol AIDS cases, 10-1
I 2-1 X
million children would become orphans
The great majority of these cases will be in developing countries of
Africa and Asia
.
I >
Module 1
3.3 National and Locaf-HiVZ AIDS Epidemiology
India is one of the 1 I countries of the South-East Asia region of WHO. It is,
therefore, important to describe H1V/AIDS status of this region to understand
National HIV / AIDS epidemiology which is as under:
(>)
South-East Asia HIV / AIDS Status : In this region, the first case was
detected in 1985 in male commercial sex workers in Thailand and later in
1986 in most other countries. Since then the infection has spread rapidly,
AIDS cases are reported from eight of the 1 I countries as is seen from
Exhibit 1.8.
(a) HIl’ Infection : HIV infection pandemic in this region is in its early
stage but it is spreading at a very fast rate like it was in Sub-Saharan
Africa in the early 1980s.
Seroprevalence surveys carried out in different countries of this
region confirm the alarming increase in HIV infection rates in
selected high-risk groups like commercial sex workers, injecting
drug- users, haemophiliacs and thalassemics.
The estimated number of HIV- infection cases in all the 1 I countries
of this region is shown in Exhibit 1.8. The largest number
(1,001,000) was recorded in India, followed by Thailand
(45.00,000) and Myanmar (1,50,000).
5
(b) Duture Projections;-. HIV infection will continue to increase and
will appear in general public because the predominant mode of
transmission is through heterosexual contact, which is mostly
unprotected sexual activity. Besides, there are high rates of STDs.
The annual infection rate would far exceed what is seen in SubSaharan Africa by the year 2000 AD (see Exhibit 1.9).
It is also
projected by WHO that there will be a total of 2 million AIDS
cases by the year 2000 AD. See Exhibit 1.10.
(ii) National (India) HIV / AIDS Status : In India, the first AIDS case was
reported in May 1986. Since then there has been a consistent increase in
the number of cases and the prevalence of HIV infection in the country.
But the epidemic is still in its early phase except in some of the States like
Manipur, Maharashtra and Tamil Nadu.
(a) AIDS Cases : Since 1986, a total of 310 AIDS cases had been
reported from 18 States and Union Territories by 31st March, 1993.
Majority of the cases are in Maharashtra (95), Tamil Nadu (92),
'I
j
14
‘
Epidciniolo»v & Transmission of HIV Infection
Punjab/Chandigarh (47), Delhi (3 !), Kerala (16). See 1 able 1.2 and
refer to exhibit 111 to see the steady increase in the number of
cases over the years.
Majority of these cases are among high-risk groups i.e. female
commercial sex workers, sexually active males, haemophiliacs and
injecting drug-users (mainly from Manipur). Almost 90% of these
cases are below the age of 50 years. The estimated number of
AIDS cases will be between 5,000 and 10,000
(b) ////’ Injection : From October 1985 to 31s1 March 1993, a sample
of 1,659,4 12 persons of high-risk behaviour have been screened for
HIV infection and 11,849 have been found positive. This represents
a seroprevalence of 7.4 per 1.000. The seropositivity rate has
increased from 2.5 per 1000 in 1986 to 11.2 per 1000 by 1992
(refer Exhibit 1.12).
Unprotected Heterosexual behaviour is responsible for the majority
of these infections except in North-Eastern States where
intravenous drug use is the predominant mode of transmission.
J
x
Prevalence rate of HIV infection varies in different states, the
highest rate is found to be in Manipur. Based on the prevalence of
AIDS cases and HIV infection, three epicentres of HIV epidemic
have been identified.. These are: Bombay (Maharashtra), Madras
(Tamil Nadu) and Manipur (see Exhibit 1.13). The term epicentre
refers to a point from where the problem originates. It is reported
by WHO that there is an increase in sero-prevalence rates in these
epicentres from 1986 onwards. In Manipur from 0% in 1989 to
54% in June, 1990, in Bombay from 2% in 1989 to 40% by 1991
and in Vellore & Tamil Nadu from 0.5% in 1986 to 34.5% by 1990.
(c) Future Projection : It has been estimated that if the transmission of
HIV continues at the same pace, then by the year 2000 there is a
possibility of having 5 million infected persons and more than one
million AIDS cases. The increase in the number of AIDS cases and
HIV prevalence in India as projected by WHO can be seen in
Exhibit 1.14.
This is alarming statistical information on AIDS / HIV infection,
whiciremphasizes the need for dealing with this problem right from
the National level to the community level.
I
I
15
Mpdiilc_l
(d) Local Hll7 / AIDS Status : Using local resources try to obtain
information on the incidence and prevalence of HIV infection and
AIDS cases in your own community i.e. District / Town / Block /
Village and record them in your diary or on paper and insert in this
module.
3.4
Check Your Progress - 2
(i) Biiefly describe the epidemiological pattern of South-East Asia.
/ii) Where was AIDS first reported in SEAR ?
(iii) In which region of the world the largest percentage of cases is reported ?
(i\j Answer the following :
a) Distribution of estimated number of HIV infected persons in South-East Asia
by. 1992
b) Distribution of estimated number of HIV-infected persons in India by J 992
c) Estimated number by the year 2000 AD
HIV-infected in the world
, and in India
AIDS cases in the world
and in India
, in South-East Asia
4.
National AIDS Prevention and Control Programme and Local
Surveillance Resources.
4.1
National AIDS Prevention and Control Programme
The Government of India launched the National AIDS Control Programme in
1987. The ultimate aim of the programme was prevention of HIV transmission and
reduction of morbidity and mortality due to HIV infection and AIDS. The major
activities included are : surveillance among high-risk groups, screening of blood and
blood products to ensure blood safety and information education communication.
The programme is planned and managed by the National .AIDS Control
Organisation (NACO), Ministry of Health and Family Welfare with financial support
from the World Bank and technical assistance by WHO. Major components of this
programme are discussed briefly.
1
16
}-'d’hfe’’J>& Transmission ol'I IIV Infection
(i)
Surveillance and Research : There are two aspects of surveillance
considered in the AIDS control programme. These are :
(a) Si/rvci//ancL' of HIV infection : There are 62 surveillance centres
(1992) located throughout the country. These centres are involved
in sentinal surveillance, which includes screening of a selected
population in selected sites over a period of time. You may find out
the surveillance centres existing in your State.
These centres have testing laboratories and are placed at the state
and district levels. ELISA test is done free of charge at these
centres. There are also nine reference centres which perform a
confirmatory Western Blot Test (refer Exhibit 1.18).
(b) Surveillanceo[ AIDS Cases : All medical institutions are expected
to participate in the identification of suspected AIDS cases. Final
diagnosis of cases will be done by nine reference centres which will
also report to the Health Authority.
(ii)
Behaviour Change through Information, Education and
Communication and the Reduction of Impact
This component includes activities aimed at creating awareness
of HIV / AIDS and bringing about positive changes in the risky
behaviours of people for prevention ad control of HIV / AIDS. This
component also aims at reducing the psychosocial impact of epidemic by
providing appropriate and adequate counselling services and clinical care
services. Hence, this component is linked with other components of the
programme.
It includes various strategies which are media campaigns,, social
mobilization, targeted intervention for high-risk groups, collaboration
and support to NGOs, counselling, care and treatment inside and outside
the clinical setting with an individual’s right and dignity, training and
operational research.
t
(iii)
STD Control Programmes : Increasing emphasis is given to STD
control because STD and AIDS are not only closely associated with the
same high- risk behaviour but STDs increase the risk of AIDS, as
mentioned earlier.
(iv)
Condom Programme : This programme aims at ensuring good quality
of affordable and acceptable condoms. The major strategies included
are :
17
Module 1
a)
manufacture of condoms as per quality standard laid down by
WHO.
b) strengthening of condom distribution network developed by the
Department of Family Welfare.
c) promoting market research.
(v) Blood Safety Programme
This programme aims at developing and
strengthening the national blood transfusion system and ensuring adequate
supply of safe blood to the blood banks. The strategies included are :
a) Mandatory testing of blood for HIV .? As many as 150 HIV Zonal
blood testing centres have been established in 112 cities.
b) Upgrading and strengthening of all blood banks operating in public
sectors with central assistance. There are altogether 608 blood
banks in the public sector. Of these I 87 are planned to be upgraded
during 1993-1994.
c) Setting-up of blood component separation facilities to promote use
of blood products. Thirty one such units are planned to be opened
by NACO, in phases, all over the county.
4.2
Local Surveillance Resources
(i) Awareness : Nurses need to be aware of the National AIDS Prevention
and Control Programme in order to :
•
•
•
plan relevant health-care interventions at the local level.
refer suspected cases and HIV-infected and AIDS cases to
appropriate support services e.g. testing centres, surveillance
centres, referral centres and counselling centres .
influence developing priorities of the programme.
(ii) Surveillance Resources : Tiy to obtain the following information on
surveillance centres, blood testing centres and reference centres so that you
can develop a working relationship with the centres and help clients utilize
their services effectively.
•
•
•
•
•
1
location accessibility
working schedule
policies, any formal procedure to avail the services / referral system.
kind and nature of services rendered
feedback and follow-up . Also try to find out the counselling and
clinical care facilities available in your area and obtain similar
information on these facilities.
IX
i jmlcniiology <K: Tniiismission of IIIV Infcclion
r>.
Nurses’ Role in Prevention of HIV Infection
in the ( (immunity
5.1
III V I’m ns in ission
HIV is transmitted through specific individual behaviours and through readily
identifiable practices in health-care settings eg. infection control technique,
intravenous infusion and transfusion. Further HIV transmission requires the active
participation of two persons ; the chain of transmission can be broken by the individual
behaviour of either the infected or the non-infected person or even both.
5.2
Nurses’ Role
Nurses’ role can be identified based on the background information discussed
above and it includes :
(i)
providing information and education on prevention and control of HIV
infection / AIDS to health workers, people at large and high-risk groups in
particular
(ii) informing people about health and social services available and making
referrals.
(iii) participation in counselling of vulnerable groups and infected persons to
motivate a behavioural change.
(iv) mobilizing community support to find a solution to the problem of rejected
HIV-infected / AIDS cases, orphan and terminal cases.
5.4
check Your Progress - 3
(i) State the objectives of the National AIDS Programme.
(ii) What is NACO ?
(iii) What are the nurses’ role in prevention of HIV transmission 9
V.
ANSWERS TO CHECK YOUR PROGRESS
2.3(i)
•
•
•
•
Fear of getting infective even through casual contact.
Fear of moral judgement on sexual behaviour.
Fear of stigma / disgrace; getting segregated
Exposure and loss of privacy
19
Module 1
•
bear of physical pain, AIDS-related problems etc. diarrhoea, fever, skin
infection, cancer etc.
•
•
Fear of death and loss of dears and nears.
Physical and financial loss.
•
Increased demand of care from the family.
2.3 (ii) AIDS is caused by Human immuno-Deficiency Virus, popularly known as
HIV. This Virus has two different strains, which are responsible for causing AIDS.
These are HIV-I and HIV-ll. The former is the principal AIDS virus, and the latter is
found only in West African countries. Lrtely it is reported in India. The virus is
sensitive to heat and it is retrovirus.
2.3(iii)
a. Persons infected with HIV.
b. Almost all body fluids but greater content from blood and semen and lesser
content from vaginal fluid and breast milk.
c. Multiple sexual partners, male homosexual & bisexual, commercial sex workers,
d.
receipient of blood transfusion, injecting drug user person’s having STD &
children of infected mothers.
A few months to two to five years or even more.
2.3(iv) Three modes of HIV infection .
(a) Sexual transmission i.e. man to woman, women to man, man to man but less
likely from woman to woman.
(b) Parenteral transmission i.e. transmission through infected blood or blood
products and through contaminated injecting equipment.
(c) Perinatal transmission from mother to her foetus.
-\
3.4(i) Epidemiological Pattern-Ill is found in South-East Asia.
•
HIV occurred from 1985 onwards.
•
•
To start with, the infection was imported from Pattern-1 and Pattern-II areas.
The infection is now transmitted through sexual contacts, use of contaminated
blood, use of unsterile injecting equipments.
The infection is progressing silently but rapidly.
Low awareness of the problem
•
•
3.4(ii) Thailand.
3.4(iii) A large percentage of the total number of cases in the world is reported in the
USA (39.5% in 1992).
3.4(iv)
(a) In South-luist Asia - 1.5 million infected persons
20
Epidemiology & Transmission of HIV Infection
(b) In India, I million infected persons.
(c) Estimated number by the year 2000 AD
HIV-infected in the World
- 30-40 million men, women and children
- India - 5 million
AIDS cases in the World - 12-18 million
- SEAR - 2 million
- India - 1 million
5.4(i) - To ascertain surveillance of I IIV infection and AIDS cases so as to prevent the
further spread of the infection.
•
•
•
•
•
«
To create awareness of HIV / AIDS so as to change risky behaviours.
To reduce the social and psychological impact of HIV / AIDS by educ
ational and counselling services.
To ensure adequate continuum of care to affected people.
To strengthen STD control programme.
To ensure easy access to good quality, affordable and acceptable condoms.
To ensure adequate supply of safe blood through a national blood trans
fusion system.
5.4(ii) NACO - It refers to the National /VIDS Control Organisation. This organisation
has been set up by the .Ministry of Health and Family Welfare for effective
implementation of the National AIDS control project.
5.4(iii) Surveillance and research.
5.4(iv) Participation in information, education and communication on prevention and
control of HIV/ AIDS.
•
•
•
•
J
1
Help utilization of health and social services available.
Making referrals
Participation in counselling services.
Mobilizing community support.
21
Module 1
II. VISUAL AIDS
Exhibit 1.1
FIGURE I
A virus must attach itself to another cell and
use its equipment to produce more viruses
VIRUS
host
DNA
FIGURE 2
A
The Human I in mu no-Deficiency Virus (HIV) consists of genetic
information surrounded by a protein layer
©
CORE
PNA
REVERSE
CELL
Eni dciniolo^v
Transmission of IJIV In feel ion
Exhibit 1.2
How HIV alTccLs the I in in une System
HIV enters the blood stream
I he virus attaches itself to T4 Ivmphocvte
1
\ iral enzyme reverse transcriptase transforms single stranded
RNA into double stranded l)NA to form provirus
J
Provirus is integrated into genetic code of the host, and throuiih
a series of steps manufactures new viruses which are
released to the exterior of the cells by budding
flic virus remains dormant
and the infected T4
'1'4 cell
continues to live.
The
infection
without
persists
causing any symptoms in the
person.
The virus becomes active reproduces
itself, which results in release of virions
that can infect other H Ivmphocvtes.
When a large number of the body’s T4
cells have been destroyed by the vims,
the immune system is impaired
23
-Module I
Exhibit 1.3
I I1V7 Transmission
HIV can be transmitted :
Sexually, via contact with infected blood, semen and cervical and vaginal fluids.
This is the most frequent mode of transmission and HIV can be transmitted
from any infected person to his or her sexual partner (man to woman, woman
to man. man to’ man and but less likely woman to woman.
<a
Following transfusion of blood or blood products from donor blood infected
with HIV.
•
Using HIX' contaminated injecting or skin-piercing equipment.
•
From a mother infected with HIV to her child during pregnancy, at birth or
after birth from breast-feeding.
HI\Z cannot be transmitted by
•
Coughing, sneezing or handshakes
•
Insect bites, work or school contacts
•
Touching, hugging or using toilets
•
VX'ater, food or using telephone
•
Kissing, swimming pools
•
Public baths. Sharing cups, glasses, plates and other eating utensils.
•
Donating blood
j
i
?J
l;pi(.lciiiioh>i?\ \ Tiunsiii)s>ion ol IH\' Int’uclion
Exhibit L4
HIV TRANSMISSION IN SOUTH-EAS I ASIA, 1992 |
i
ROUI E OF
TRANSMISSION
EFFICIENCY
% OF
FOIA I.
SEXUAL INTERCOURSE
0.1-1.0%
<S()-9()%
• 00%
3-5%
0.5%
7o- 1.0%
5-10%
■ 0.5%
■ 0.1%
15-45%
• 0.1%
BLOOD
TRANSFUSION
INTRAVENOUS DRUG USE
EQUIPMENT / NI J-J >1 l-S
PERINAIAL
■* s
Xkxliilc I
Exhibit 1.5
EPll)EMl()L()(;iCAL PA I I ERN
I'hree distinct patterns are identified
Pattern - I : This pattern is typical of certain industrialized countries, including North
America. Western Europe. Australia, New Zealand and parts of Latiri America.. In.
these areas :
-
•
extensive transmission of 111V appears to have begun in the late 1970s
most cases occur among- homosexuals or bisexual males and injecting drug
users.
heterosexual transmission is responsible for a small percentage of" the cases but
is increasing.
•
transfusion through blood and blood products is rare because of stiict safety
measures.
•
inale-to-female ratio of cases ranges from 10:1 to 15:1
•
overall seroprevalence is generally less than 1 percent but can be 50% in highrisk groups such as homosexual with multiple partners and injecting drug
users.
‘
; .
Pattern = 11
This pattern is typical of Sub-Saharan zXIrica and some Caribbean
countries. In these areas :
•
extensive transmission appears to have begun in the 1970s.
•
most cases occur among heterosexuals. As a result the male to female ratio of
cases is 1:1 and perinatal transmission is common.
•
transmission through homosexual activity or intravenous drug use is minimal
•
overall seroprevalence is more than I percent but can be upto 15% or more in
sexually active people in some urban areas.
Pattern = HJ
fhfs pattern is found in North Africa, Eastern Europe, the Eastern
Mediterranean, Asia and most (M-'-die Pacific. In these areas :
26
Ej)ideiniplof>Y & Transmission of HIV Infection
•
HIV appears to occur in early mid-1980s and only 1 percent cases have been
reported.
• ; initially, the infection has occurred in persons who have travelled in or had
contact with individuals from Pattern-I and Pattern-II areas or those who have
received imported blood.
•
presently the infection is transmitted through homosexual and heterosexual
contacts, use of contaminated blood for transfusion and unsterile injecting
equipment especially by injecting drug users.
transmission is proceeding silently and rapidly. The infection is still at a latent
stage.
’ .
' .
j
i
•
awareness of the problem among professionals and the common people is very
’ow-
Module I
Exhibit 1.6
(’UMIIATIVE AIDS ( ASES IN MEN. WOMEN
AND ( IIIEDREN
LAIE 1992
Reported : 6.1 1.5X9
Africa
34.5%
Other
0.5%
\ Americas*
f
12%
Europe
13%
(■■I
(■■I
Asia
0.5%
IBBI
»»■»_!
USA
39.5%
Estimated 2,50,()()(>
(* Excluding USA. Jan 93)
Africa
71%
Wi
LSI
iai
/
Europe
O /o
Asia
1%
I
USA
13%
Other
under 1%
Americas*
9%
28
Epidemiology & Transmission of HIV Infection
Exhibit 1.7
ESTIMATED DISTRIBUTION OF CUMULATIVE HIV
INFECTIONS IN ADULTS, BY CONTINENT
OR REGION
LATE 1992
j
29
Exhibit i.S
AIDS AND HIV INFECTIONS LN SEAR COUNTRIES
AS OF 28 FEBRUARY 1993
COUNTRY
REPORTED
AIDS CASES
< 20,000
BANGLADESH
BHUTAN
0
<300
DPR KOREA
0
< 1,000
INDIA
307
1,000,000
INDONESIA
26
< 20,000
MALDIVES
0
< 100
MONGOLIA
I
■200
MYANMAR
16
150,000
NEPAI
12
< 5,000
< 1.000
SRI LANKA
)
>
>
ESTIMATED
HIV
INFECTIONS
IHAILAND
946
150,000
TOTAL
1,331
< 1,500,000
i
|
I•pklcmiolo.^.AJja11s11 hsskjn_of H!3’ I’‘Ipclion
Exhibit 1.9
ESTIMATED / PROJECTED ANNUAL ADULT
HIV INFECTIONS
M i 11 ion.3
M i 111 o n s
1.4
EJa/rica
... 1.2
@ Asia
n
mYs; ■
4
A
L America
J ml! ■
1.2 t
im
i N. America
:::|
* 1-
IHil
fi!
OS
°-2r i
2 3 -1 5 5 7 8
o nn i
Year
J .
J
,'fr ■
■ 'j 0.5
/ll
i Jo.e
im
ri ■ L.,
45 6 7
r|
U
51
0.4 ’
r
SOlifSi I!
1 L2J Europe
0.8
'
o
■ 0.2
31
Module T
Exhibit 1.10
PROJEC TED ANNEAL AIDS CASES
SOUTH-EAST ASIA
Cumulative AIDS cases by the end
of the 1990s v.'ill be close to 2 million
500 r
‘■A
. te
-00
3 00 O'
200
'J
1 oo K
tew I
0
1 992
93
94
95
96
Years
91
U(
:
A
■
oocO’
0
•'
32-J5-
05582
97
93
99
2000
I .piclciniologx (K: Transmission
H1011
Exhibit Ell
AIDS ( uses Reported in India Yearvvise
Cases
200
187
1 50
100
50
6
26
43
1990
1991
20
3
1986
1987
1988
1989
1 992
Year
lable 1.2 :
( iiinulative number of AIDS cases reported in India by States /
Union Territories, March 1993.
Stale / Union TciTitoi)
Andhra Pradesh
Assam
Delhi
Goa
Gujarat
I laryana
Himachal Pradesh
Jammu & Kashmir
i
No. of cases
I
1
2
2
I
■>
Kerala
Madhya Pradesh
Maharashtra
Manipur
Pondicherry
Punjab / Chandigarh
RajasihaiL
Tamil Nadu
Uttar Pradesh
West Bengal
I
16
I
91
4
(>
47
I
92
I
(>
TOTAL
310
33'
ModuleJ.
Exhibit 1.12
i
;
i
I
h
i
Progress of HIV Seropositivity Rates Nationwide
for all Groups J ested, 1986-1992
Period
No. tested
No. positive
Prevalence
per/1000
October 1985
to
October 1987
56,934
145
2.5
November 1987
to
October 1989
307,343
1505
4.9
November 1989
to
December 199 I
863,1 10
4,764
5.5
January 1992
to
December 1992
437,563
4916
1 1.2
Tot a!
t .664,950
11,330
Progression of HIV Seropositivity Rates
Nationwide, for all Groups Tested
03
O)
Cl)
.<13
X
o
s
n
1
Oct’S? to()ct’X7
Nnv’X7 to Oit’89
1
Nov’X9 to Dec’91
Jan to Dcc’92
>4
Epidemiology & -Transmission of HI V, Infection
• 7-
Exhibit 1.13
THREE EPICENTRES OF HIV EPIDEMIC
IN INDIA
chaxdigarh
DELHI
o
SIKKIM
HARY/W'A
D
RAIASTI IAN
NAGALAM
BIHAR
MANIPUR
CLIARAT
0
madhyapradesh
ORISSA
o
maharashtim
BOMBAY
KARNATAKA
MADRAS
KERALA
< TAMIL
NADU
.
PONDICIIERRY
MEGHALAYA
ModulcJ.
Exhibit 1.14
i
■
---------------------------------------------------------------------------- - --------------------------
! PROJECTIONS ON HIV PREVALENCE AND
|
CUMULATIVE AIDS CASES IN INDIA
•lOOOOOO
1’9X59(1
.UH)OO(H)
2512502
T
ZlMfGJiiii)
I75.MX2
II360S4
1000000
(.66000
I I 1051
22 <70
2O-I2(..<
M900
. 7170
1991
1992
HIV PREVALANCE
i
1993
1994
1995
36
Exhibit 1.15
TEST ON EPIDEMIOLOGICAL ASPECTS AND
DYNAMICS OF DISEASE TRANSMISSION
I.
Define epidemiology.
2.
What is.epidemiological triad ?
3.
What is agent 9 Outline the types of agents.
4.
List the host factors which influence the occurrence of disease.
5.
Lisi the environmental factors which influence the occurrence of disease.
6.
What do you understand by risk factors ?
What is prepathogenesis phase of the natural history of disease ?
8.
What is pathogenesis phase of the natural history of disease ?
9.
What is incubation period ?
10.
What is ice berg of disease ?
I 1.
Outline the links in the chain of transmission of infectious disease.
12.
What is reservoir of infection ?
13.
WLat is source of infection ?
14.
List the routes of transmission of disease.
15.
What is direct contact ?
16.
What is transplacental transmission ?
17.
What are the postulates of successful infection ?
18.
What do you understand by susceptable host ?
Module I
Exhibit 1.16
ANSWER KEY FOR TEST
(FOR EXHIBIT 1.22)
fhe study of the distribution and determinants of health-related stales and events in
populations, and the applications of this study to control health problems (Last
I M . 1983).
The occurrence and manifestations of any disease, whether communicable or noncommunicable, are determined by the interactions among the agent, the host and
the environment, which together constitute the epidemiological triad (Mahajan,
B.K.,1991).
3
The agent is defined as an organism, a substance or a force, the presence or lack of
which may initiate a disease process or may cause it to continue. There may be
single or multiple agents for a disease.
Classification of Agents :
A
Living or Biological Agents :
(i) Arthropods
(ii) Helminths
(iii) Protozoa
(iv) Fungi
(v) Bacteria
(vi) Virus
B
^on-living or inanimat** :
(i) Nutrient agents
(ii) Chemical agents
(iii) Physical agents
(iv) Mechanical agents
4
Host factors which influence determining of a disease are also called
factors and include .
intrinsic
(i)
Demographic characters - age, sex, race
(ii)
Biological characteristics - genetic factors, physiological and biochemical
characteristics (e g. blood cholesterol, blood sugar level etc ); immune status,
nutritional status; personality
rS
EpFdcjnioliH’v & Transmission of FIIV Infection
(iii) Socio-economic characteristics - economic status,
education, occupation, marital status, place of living.
social class, religion,
(iv) Life Style - living habits, food habits, sexual behaviour, use of alcohol,
tobacco, drugs etc.', degree of physical activity, personal hygiene etc.
5
Imvironmental factors which influence the occurrence of diseases are also called
extrinsic factors and include .
(i)
Physical environment - e.g. air. water, soil,
heat, light, noise, radiation etc.
housing, climate, geography,
Hi) Biological environment - e.g. micro-organisms, insects, rodents, animals and
plants.
'
■
■
■
(iii.) Psychosocial environment - e.g. cultural values: customs, habits beliefs,
attitudes, morals, religion, education, life styles, community life, health
sen ices, social and political organizations etc.
b.
Risk factor is an attribute or exposure that is significantly associated with the
development of a disease. This factor can be modified by intervention, thereby reduces
the possibility of occurrence of the disease. The presence of risk factor suggests that
disease may occur or the disease may be due to this factor. Risk factors are observable
and identifiable prior to the event they predict, e.g. smoking, drinking, obesity, high
blood cholesterol, hypertension, air pollution, unsafe water, etc. These are modifiable
risk factors. There are unmodifiable risk factors e.g. age, sex, genetic factors, family
•history. They act as foreseeable signals and timely prevention measures can be taken.
7
Prepathogenesis phase refers to the period prior to the onset of the disease in
man. The causative agent has not yet entered a man’s body, but the factors which
favour uhe interaction of agent with the human host are there in the environment.
1 hus. we are in the prepathogenesis phase of many diseases.
K.
Pathogenesis phase begins with the entry of the causative agent in the
susceptible human host. The agent multiplies in the body and brings about change in
the tissues and physiology. The disease progresses through a period of incubation
followed by clinical signs and symptoms. The final outcome of the disease may be
recoveiy, disability or death.
9.
IIncubation
* •
period - It is the period which lapses between the entry of organisms
in the body and the appearance of clinical signs and symptoms of diseased
10.
Iceberg of disease represents the prevalence of disease in the community. The
clinical cases are like the floating tip of the iceberg which are known to the physician,
Majority of the casesjare undiagnosed, unknown, presymptomatic / subclinical which
Module I
aie like submerged portion oi the iceberg which cannot be seen
in this module
See fmure I I
niven
There are three iiiajor links in the chain of transmission oi an infectious disease
I I
(i)
(ii)
Source and reservoir of infection
Modes of transmission
(iii) Susceptible host.
12.
A reservoir of infection is any person, animal, arthropod, plant, soil
oi
substance in which an infectious agent lives and multiplies and depends for its
survival.
ls.
A source of infection - The person, animal or substance from which an infectious
agent passes to a host.
14. I. Direct Transmission
(i)
Direct contact
(ii) Droplet infection
(iii) Contact with soil
(iv) Parenteral
(v) Transplacental
II. Indirect transmission
(i) Vehicle-borne
(ii) Vector-borne
(iii) Air-borne
(iv) Fomite-borne
(v) y Unclean hands and fingers
15.
Direct contacts - Infection which is transmitted from a reservoir or a source to
a ;susceptible host without any intermediate agency eg. skin-to-skin contact by
touching, kissing or sexual intercourse or continued close contact,
Examples of'
diseases transmitted through direct contact are STD, AIDS, Leprosy
16.
I ransplacental through the placenta.
17.
I ransmission of infection from mother's blood to the foetus
Postulates of'successful infection
(i)
I he organisms must enter the body through the appropriate protal of entry.
(ii)
I he organisms must reach the appropriate site after gaining entry into the
body.
40
Epidemiology & Transmission of HIV Infection
(iii) The organisms must find way out of the body to infect another host so as to
propagate its species.
(iv) The organisms must survive outside the body till they invade the new host.
18. Susceptible Host - It is the host that is at the risk of getting infection through the
appropriate portal of entry and who does not has natural / acquired resistance to resist
against infection.
■■
-II
MQdulc_!.
Exhibit 1.17
Guideline for Educational visit to Surveillance Centre
e.g. Department of Microbiology, Maulana Azad Medical
College, New Delhi.
Group : Nurses number not more than 40.
Date
Date convenient to the institution and to the learners.
Time
According .to the Centre’s convenience. It can be 10 AM to 12 Noon or 2
PM to 4 PM:.
-
I.
OBJECTIVES
By visit to this surveillance centre, the learners will :
1. Get acquainted with its :
a)
b)
c)
d)
location and physical set-up
historical background of surveillance work
objectives, policies and function
administrative set-up.
2. Be. able to :
a) describe the surveillance of HIV and AIDS cases.
Ab) identify referral and reporting system for HIV / AIDS cases.
c) discuss the surveillance centre’s role in prevention and control of HIV /
AIDS locally and nationally.
d) describe the local epidemiological picture of HIV/AIDS.
11. GUIDELINE
Use the following guideline for making observation and writing the report
I. Location
Address
Significant land marks
2. Historical background of surveillance :
42
Epidemiology & Transmission of HIV Infection .
4
■ 7
Initial Phase
when was surveillance first stalled 9
what was the form of surveillance 9
•
which were the two institutions that were given this responsibility
•
which institution detected the first case 9
Second Phase
•
When did the second phase stai! ?
•
What development took place in. this phase 9
•
What were the findings of surveillance in this phase 9
Third Phase
•
•
•
3.
What were the factors of surveillance in this phase 9
What development took place in this phase 9
When was this department declared as a surveillance centre 9
Objectives and policies of the surveillance centre
•
State the objectives
•
State the policies
4
Function of the surveillance centre :
<
5.
Surveillance components :
A. Surveillance of HIV infection - find out the testing methodology for :
•
testing blood for transfusion safety
•
detection of IIIV positive cases
sentinal surveillance
number of institutions involved in HIV surveillance.
B
Surveillance of .AIDS cases
What is meant bv surveillance of AIDS cases
Which ape the institutions which will / arc participating in identification of
AIDS cases 9
What are referral institutions '?
*>
4•
Module 1
4
•
What is the future plan for referral institutions
6. Analyse the referral and reporting system of this centre for HIV / AIDS cases.
4
7.
Surveillance centre’s role in prevention and control of HIV / AIDS locally and
nationally.
8.
Local epidemiological picture of HIV / AIDS
•
High-risk group screened
•
HIV positive cases, annual and cumulative detected and estimated
Projected HIV-infected persons.
•
AIDS case
•
reported and estimated.
Please Note : -
•
Be alert. Keep your eyes and ears open to make an accurate observation
•
Ask questions for any clarification or any information missed / not gi\ on.
)
}
<
)
).
44 -
Epidemiology & Transmission of !-irVr Infection
■ 7:
Exhibit 1.18
List of HIV Reference Centres
1.
National Institute of Communicable Diseases, Delhi
9
All India Institute of Medical Sciences, New Delhi
3
Indian Institute of Immunohemaiology, Bombay.
4.
National Institute of Cholera and Enteric Diseases, Calcutta.
5.
School of Tropical Medicines, Calcutta.
6.
Madras Medical College, Madras.
7.
National Institute of Virology, Pune.
8.
Regional Medical College, Imphal.
9.
Christian Medical College, Vellore
The reference centres should be entrusted with the responsibility of carrying
out confirmatory test.
They should also be made responsible for diagnosis, quality
control of HIV kits, guidelines for HIV testing, training in HIV testing and any other
activity which may be necessary for standardization of HIV testing.
2.1
Module 2
MODI LE 2
HIV INI E( I ION AND DISEASE
Section - I :
1.
SUM
OVERVIEW
In preparation for this module, the learner will need
•
•
to have completed Module I
•
to have knowledge of sexually-transmitted diseases, malnutrition, cancer,
tuberculosis, leprosy etc. which
either facilitate development of HIV
infection or occur as opportunistic infections.
an understanding of the basic concepts of the immune system and the
nervous system.
On completion of this module, the learner will have a broad understanding of
the clinical consequences of HIV infection and will be able to discuss the positive role
of serological testing for HIV infection.
II.
SPECIFIC OBJECTIVES
On completion of this module, the learner will be able to:
•
•
•
' •
III.
explain how HIV affects the immune system;
present the national definition of AIDS;
describe the clinical course and staging of HIV disease.
identify appropriate situations in which HIV antibody testing is beneficial.
INTRODUCTION
HIV disease is one of the greatest mysteries of the world. It takes several
months to several years to develop the symptomatic HIV disease. There are examples
of HIV positive people being asymptomatic and they remain carriers during this
period. However, when the virus gets to work on the body's immune system, it
destroys white blood cells (CD4) As a result, CD4 count drops low from 1200 cells
per l/IOOOth of a ml of blood to 500. The danger of contracting deadly diseases,
associated with HIV infection increases drastically if this count falls below 200. You
will be learning in detail about HIV-associated diseases in Module - 7.
Content of
this module mainly will focus on the HIV infection and its disease development
process and differential diagnosis.
u
HIYJnn^FrE’<LJ^^ls<:
IV.
1>ES( RIP HON OF CONTENT
I his module will cover the following contents.
I. Basic Concepts : HIV Infection.
2. Natural Jlistory of HIV Disease.
3. Definition and Case Diagnosis.
I. Ser ological l esling for IIIV infection.
5. Differential diagnosis in HIV disease.
L
/
Basic Concepts : IIIV’ Infection
Definition
IllV is defined as a Human Immuno Deficiency Virus (retro-virus), the
causative organism of HIV disease. The virus specifically infects and destroys the Thelper cells, which is a class of lymphocytes that plays a central role in organising the
bodvls immune defence.
1.2
The hnniune Svsteni
N on have learnt in anatomy and physiology that the immune system of the
body is a biochemical complex which protects the body against different pathogens
invading the. body. It is comprised of lymphoid related organs such as the bone
marrow, thymus, spleen, tonsils, adenoids, appendix, peyer’s patches, lymphnodes,
blood and lymphatic vessels. When the disease producing micro-organisms enter the
) ody through the skin or the mucous membranes, the immune system produces
antibodies to neutralize the micro-organisms and activates special blood cells which
kill arr^ remove these organisms or toxins from the body. In doing so the T-helper
cells of the lymphocytes stimulate B-cells, which multiply and produce antibodies that
attack the invading virus.
When the immune system is not functioning as it
should, the person is described as having an immuno-deficiency. There are other
causes ol immuno-deficiency either temporary or permanent, including :
Primary immune dysfunction e.g. congenital defects in the immune system.
Secondary immune dysfunction e.g. due to:
-
drugs, e.g. immunosuppresant therapy, anti-cancer drugs, etc.
cancers
malnutrition
irradiation (both accidental and therapeutic)
infections, especially viruses.
Module 2
1.3
Pnthogenesis
You have read in Module I that HIV infect and destroy special lymphocytes
(1'4 helper cells) in the immune system and monocytes that are essential
for the co
ordination of the body's immune defence mechanisms. When HIV penetrates a cell it
combines with the host cell's own genetic material and gets itself processed into HIX’
production which greatly helps the infection to grow and endanger life
When these
white blood cells are destroyed, a process that may even take many years will lead
to a
slowly
system.
persistent,
progressive
This .makes an
and
of the
impairment
profound
immune
individual susceptible to various life-threatening infections
and malignancies. Infected persons are likely to be infectious for life
course
HIV
aifecis both the central and peripheral nervous system
of
infection, causing a
variety
conditions, in children and adults,
system leaves the
cancers
1.4
nervous
system
of'
neurological
early
•he
in
and
neuropsychiatric
In addition,
the impairment
of the immune
vulnerable
to opportunistic
infections
and
You will learn more about these in Module 7.
Opportunistic Diseases
An opportunistic disease is one which normally would not be a problem because
of' the body's ability to control it by the immune system.
major problem when
occurs.
immuno-deficiency
this can
But
become
a
('onsequently. opportunistic
diseases only occur in individuals whose immune system is depressed.
There are manv microbes which commonly inhabit us without causing
any
illness, but when the immune system is depressed, they can pose serious problems
One example of an organism that causes an opportunistic disease is Candida, a fungus
found-in the mouths of most people but
rarely causing'thrush' unless the immune
system is depressed and not able to
control
the growth
of oral
Candida
Pneumocystis carinii (flora), which is found in the lungs of people without causing
any illness, causes pneumonia in immuno-depressed
(mycobacterium tuberculosis), also commonly
persons.
found . in
the
The tubercle bacillus
lungs, can reactivate
when the immune system is depressed, causing pulmonary tuberculosis, a common
Another common example in
opportunistic infection seen in HIV disease.
is
can
Cryptococcus neoformans
(also
known
as
in Module 7
1.5
Filobasidiella
cause meningitis in an immuno depressed person.
( heck 'SOur Progress - I
(i)
I KTmc immuno-dclicicncv
di)
List four causes of iinniuno-dclicicncv
neoformans)
Africa
which
Details of these are given
IHV Infection and Disease
(i:i)
Read the following statements carefully and encircle (O) these
statements either as True or False :
i!
I ’1\' in ice is red blood cells
T
I.
\ person on anticancer drugs is likely
to undergo immunosuppression
T
HIV infection predisposes a person
to manv oppoitunistic infections
T
d.
T4, the helper cells in our immune
svstem, are special types of monocytes
F
F
F
■\;»turaHlistorv of HIV Disease
2.1
DeFinit ioii
111 \ infection is caused by a virus known as Human Immuno Deficiency Virus
(HIV) which invades the body's immune system and nervous system. The Acquired
Immuno Deficiency Syndromes (AIDS) is the end stage of HIV infection. It is referred
to as syndrome because the range of acquired immuno deficiency may include a variety
of opportunistic infections, neurological disorders and several types of malignancies.
>2.2
Stages of Hl\ Infection
HIV infection progresses through several stages. A person, once infected,
remains infectious (able to transmit the vims to other people) for life. The stages of
HIX' infection are as follows :
<(0
Acute Seroconversion Illness . Within three to eight weeks of
infection, some (but not all) persons develop an acute illness lasting
two to three weeks with symptoms such as fever, rash, joint and
muscle pain, swollen lymph glands, diarrhoea and sore throat. The
symptoms may be mild and eventually disappear completely. This
self-limiting condition is known as an acute seroconversion illness.
During this period the vims continues to reproduce itself inside the
body and the
person's immune system responds by developing
antibodies to the virus. Within six to 12 weeks after infection, it is
usually possible to detect HIV antibodies in the blood.
(")
Asymptomatic Infection : During the asymptomatic period, the persQn
is able to transmit the vims to others via sexual, parenteral and perinatal
transmission and, as the
virus continues to replicate, progressive
damage to-both the immune and nervous systems results over the time.
If their blood is tested during this stage it will test positive for HIV
u
Mptlnjc 2
-
». ■
antibodies. Some individuals will ha\c persistently enlarned lymph
glands (prisisient generalized Ivmphadenopathv or P(il.) dm me the
asymptomatic stage of the HIV disease.
(iii)
Early Symptomatic Illness : Many individuals eventually show signs
of ill-health due to HIV infection without developing AIDS These
constitutional syniptoms and signs are sometimes referred to the AIDS
related Complex (AK(') After a variable period of few months to years,
or in continuation of the acute phase, the person may develop persistent
lymph-adenopathy, persistent / prolonged or intermittent fever with
rashes, unexplained splenomegaly, painful repeated oropharyngeal ulcers
not responding to any measure, prolonged cough, any type -of
neurological deficit or psychiatric symptoms, periods of weight loss
and iiiglii -sweats, persistent severe exhaustion, altered mental function,
diarrhoea, tuberculosis; etc. The person recoxers from the illness but
only after a prolonged period of experiencing sex ere illness.
(iv)
Late Symptomatic Illness i.e. AIDS / IIIV Disease
Eventually,
individualswill have episodes of AIDS specific opportunistic diseases,
such as pneumocystis
carinii pneumonia, encephalitis caused by
toxoplasma gondii, severe and chronic diarrhoea caused by-crypto
sporidia and microsporidia. Pulmonary tuberculosis is
increasingly
being recognised as one of the most common opportunistic diseases
associated with HIX’ infection, especially in the dexeloping world.
Opportunistic cancers, such as Kaposi's sarcoma and undifferentiated
B-cell lymphomas may also be seen. In addition there will be a significant
weight loss and both neurological and neuropsychiairic syndromes may
be present
Ultimately, patients in this stage will enter a terminal
phase and die (See Module 10). See Figure 2.1 depicting the Natural
I listory of 11IV represented by four stages described abox e
III \ Inluvlioii and I)isc;isc
si \(,i:s
1)1 RA HON
HIV
SIGNS << SYMPTOMS
Infection
Infection:
Stage I
(Acute Sero
conversion
Illness)
Acute
3-8 weeks
Illness
Fever, rash, joint
and muscle pain.
sore throat but
may be mistaken
for any other infection
Months to
Years
Stage II
(Asymptomatic
Stage)
Stage III
(Early
Symptomatic
Illness)
AIDS-related
complex
(Chronic
Illness) ARC
Opportunistic
infection night
sweats, weight loss
lymphadenopathy,
headache, diarrhoea
fatigue,
neurological change
and peripheral
neuropathy
Months to
Years
Stage IV
(End stage)
AIDS
DEATH
Kaposi's sarcoma.
(tumours), commonest
opportunistic
infections
pneumocystic carinii
pneumonia, cryptococcal meningitis
encephalopathy k ARC
signs <V symptoms
Months
Figure 2.1 : Natural History of Human Immuno Deficiency Virus
Modified from 1 caching Modules. WHO. Regional Office of Western Pacific. 1990. p.jn
Source
i
I
u
2 *
Module 2
2.3
Check Your Progress - 2
i
(i) Why is HIV disease called as a syndrome ?
I
Example-1
Mr. 'Deb', a teacher in a well-known Delhi school, discovered that he was an
HIV disease carrier only in the last stages when he was admitted to AllMS with a
debilitating attack of fungal meningitis and he refused to respond to treatment,
doctor tested his blood and found it to be positive for HIV. Later, he admitted to
have a sexually promiscuous behaviour in Zambia seven years ago. He had an 1 I
month old daughter and wife, both of whom were found to be HIV positive. Mr. "Deb
died.
(ii)
3.
Read this case carefully and answer the following questions :
a.
How long did it take for Deb to develop the HIV disease •’
b.
In which stage of the natural history’ of HIV disease will you place Mr.
Deb when admitted ?
c.
What opportunistic disease did he develop
Definition and Case Diagnosis
■^According to the Centre for Disease Control (CDC.) in USA. a diagnosis of
AIDS is made when a person has a positive HIV antibody test, has one of a list of
specified diseases (opportunistic infections and selected cancers).
3.1
Definition
HIV disease in an adult is defined by the existence of a: least two of the
following major signs associated with at least one. minor sign, in the absence of ’
known causes of immunosuppression, such as cancer or severe malnutrition or
other recognised causes.
3.2
Signs and Symptoms
0)
Major Sfgn s :
(WHO. 1991)
- Loss of weight - 10 percent of body weight
- Chronic diarrhoea - one month
2’x
IIIV Inl’cclioii .iihI I Jisc.i
Prolonged lever - one month
tn)
Minor Signs
-
Persistent cough for one month
Generalised pruritic dermatitis
Recurrent herpes zoster
Oropharyngeal candidiasis
Chronic progressive and disseminated herpes (simplex) infection
Generalised lymphadenopathv
The presence of generalized Kaposi's sarcoma or cryptococcal meningitis
is sufficient in itself for the diagnosis of AIDS Refer Figure. 2 1 .
.
3.3
Check Your Progress - 3
Mr. Shyam has been admitted to hospital with tuberculosis and he has
told that he has HIV disease
been
(i) List three facts known about Mr Shyam from his diagnosis of MIX’ disease
(ii) Give information not known about Mr. Shvam from the above statement
4.
HIV Testing and Screening
Serological testing for HIV infection is a laboratory procedure which is
carried out to determine the presence of specific HIV antibodies produced by the body
against the vhus. A person who has antibodies to HIV is said to be HIV positive or
seropositive A seropositive person is not only actively infected, but is also a carrier
of the virus and can infect others.
Out of 16.13,870 individuals screened in India from 1985 to 1993, 12,519
were found to be seropositive, fheir descriptions are given in fable 2.1
i
I
2.9
Module 2
Fuble 2,i
Details of Seropositive individuals in India
( Period of Report : October, 1985 to July 1993)
Category
Seropositive
%age of Total
Heterosexuaiiv active
5,380
42.97
Homosexuals
41
0.33
Blood Donois
1.862
14.87
I dialysis Patients
I 14
0.91
Antenatal Mothers
60
0.48
Recipient of Blood/
blood products
267
2.13
Relatives of HIV patients
I 17
0.93
Suspected ARC / AIDS
556
4.44
(V Drug Users
1,726
13.79
Others
2,396
19.15
TOTAL
12,519
100.00
Sourctf :
4.1
Adopted from Simday Magazine., Nov. 30, 1993, page 30.
HIV lesting
HIV testing determines the infection or disease status of an individual.
individual. Testing
Testing
C jgrammes may be voluntary or mandatory'. The emphasis here is on a voluntary
programme.
(i)
3
Purpose of Voluntary Testing :
-
To confirm HIV diagnosis (As in case of Mr. Deb, Example 1)
Promote a sustained
«
behaviour change along with information,
counselling and other support services.
2.H'
1UYlnlecijojHind Pjsosc
Encourage those individuals
who are concerned and consider
themselves at risk of being HIV positive
(")
Pvpes of J ests :
A serological test to detect antibodies against lll\
became available for general use in 1985
I he most frequently used
method is Elisa (Enzyme- Linked Immuno Sorbent Assay), but other
types of antibody tests such as .those based on the agglutination of
particles and "dot" ELISAs are now being developed. These tests are
rapid and simple to perform and do not require sophisticated equipment
These can be classified under three main headings
a. Screening lexis for HI\' amibodies
ELISA (Enzyme Linked Immuno Sorbent Assay) which is
further classified as Antiglobulin ELISA, Competitive ELISA
and Capture ELISA.
Antiglobulin is the one which is
commonly used.
- Agglutination tests
-
- Rapid tests
b. ('onfirmatory tests
- Western Blot Test : This detects and identifies antibodies to
specific structural components of HIV
- Immunoflourescence
- Radio immune precipitation test
c
I iral A miyen De!eelion lest
- HIV Culture
- Electronic microscopy
- Polymerace chain reaction
Although the above mentioned tests are mgmy
highly sensitive, they are
not completely free from false results and a reactive sample in
l-LISA will require further confirmation by a supplementary lest such
as Western Blot Test (Immuno Blot).
ELISA test is a preliminary test for HIV positive If the blood sample
is found positive, it is sent for the Western Blot fest which confirms
the presence of infection. Generally, if the ELISA test, done twice,
shows HIV positive, then there is no real need for the Western Blot
fest
It is iHso possible to detect directly the presence of HIV antigens (virus
of viral proteins) »n semen. Kits for this are commercially available ~
2.13
Module 2
5.
Differential Diagnosis in HIV Disease
Often nurses are required to manage certain aspects of medical treatment in
community setting. Knowledge of differential diagnosis is essential for arriving at a
nursing diagnosis, assisting and interpreting diagnostic results and implementing care
effectively. In this, the main focus is on the relevant components of history taking,
assessment of the clinical manifestation and the common diagnostic measures.
The symptoms of HIV disease and the associated opportunistic diseases are
often life threatening. There is no cure for HIV infection but many of the
opportunistic diseases can be treated. Nurses in a clinic or community health care
setting must be able to recognize the signs and symptoms in order to refer the person
to a medical centre for possible diagnosis and treatment of these diseases.
In determining whether a person has HIV infection, the following
factors must be considered :
5.1
three
History Taking
History taking is essential to determine possible risk behaviours or factors.
This will be determined by knowledge of how HIV is transmitted in the localitv.
Below is a list of possible risk factors and behaviours :
High-risk exposure to a known HIV-infected person (sexual intercourse,
sharing of skin-piefeing equipment)
Unsafe sexual behaviour, multi-sex partners;
- Male homosexual or bisexual activities;
Sexual partners of a high risk person;
- Sharing needles during drug injection use or other exposures to potentially
unsterilized needles.
-
5.2
Assessment of the Clinical Signs of the Disease
The nurse will look for the following clinical signs in her client :
Duration of sickness
General : weight loss, fever
Neurological examination : peripheral neuropathy, cognitive disorders.
Skin changes : herpes zoster, herpes simplex, folliculitis tinea,
Kaposi’s sarcoma, prurigo, seborrhoeic severe psoriasis.
- Oral cavity : thrush, hairy leukoplakia, gingivitis, Kaposi’s sarcoma,
lymphoma.
- Lymph nodes : focal or diffuse enlargement.
- Lungs : pneumonia, pleural effusion
- Abdominal examination . hepatosplenomegaly
-
J1LY.Infctioii and Disease
2.14
Gennalia : cancer / ulcers
Anus : ulcers, warts.
5.3
Diagnostic Measures
Regular laboratory testing should be limited where resources are scarce.
Where available, some of the investigations to be performed include :
Check Your Progress - 5
Example
A woman has.a chronic cough, shortness of breath on walking,
and has' had fever in the afternoon for the last six months. She eats poorly
and is always tired. She has had several sexual partners in the past two year's.
(i) Whai is \ cur diagnosis and why ?
i
ANSWERS TO CHECK YOUR PROGRESS
1 5 (i) Immuno deficiency is a condition which occurs when the immune system does
not function as it should. The person is described as having immunodeficiency.
l-5(ii) a. Cancer or congenital defects
b. Irradiation - accidental or therapeutic
c. Immunosuppressive therapy
d. .HIV disease / infection.
1.5(iii) a. F
b. T
? c. T
d. F
2.3(i) HIV disease (AIDS) is referred to as syndrome because the range of acquired
immuno-deficiency may include a number of opportunistic
infections,
neurological impairment and malignancies.
2.3(ii) a. More than one-year, probably 7 years.
b. Stage four.
c. Fungal meningitis.
3.3(i)
Known about Mr. Shyam :
- He has an opportunistic disease.
- His white blood cells are infected with HIV.
- He is infected for life.
- He is a carrier and capable for passing infection to others through sexual
mter-course / infected blood
^>>7 v
A 05582 ^6
n
2.15
Module 2
3.3(ii) Not known about Mr. Shyam are :
- Other opportunistic disease he is suffering from
- Symptoms he is having
- How and when did he become infected.
4.5(i) Serological test is carried out to determine the presence of specific HIV
antibodies produced by the body against the virus.
4.5(ii) a. When a test result shows the presence of HIV antibodies in
the blood but in reality they are not.
b. The test shows that the blood does not have HIV antibodies when in reality
it does.
5.4(i) The woman could be suffering from tuberculosis because she gives the history
of fever for six months, chronic cough and shortness of breath. She also tires
easily and eats poorly. She has engaged in sexual risk behaviour and is at risk
for HIV infection. Thus she is prone to opportunistic infections like
tuberculosis. She may be suffering from HIV disease. The symptoms given in
example 3 are typical clinical signs of this disease.
Exhibit 2.1
OPPORTUNISTIC INFECTION AND HEALTH
Example-1 : Mr. Deb, a teacher in a well-known Delhi School, discovered that he
was an HIV disease carrier only in the last stage when he was admitted to AIIMS
with a debilitating attack of fungal meningitis and he refused to respond to treatment.
Doctors tested his blood and found it to be positive for HIV. Later he admitted to
have a,sexually promiscuous behaviour in Zambia, seven years ago. He had an 11
montfrold daughter and wife. Both were found to be HIV positive. Mr. Deb died.
(Stage IV)
Example-2 : A woman has had a progressive weight loss for six months. She is
weak and has to sit down after walking to the clinic. She has a poor appetite and has
had diarrhoea for the past five months. She comes from a village in which there has
been a history of dysentery. She has had no fever, her lymph nodes are normal and
she has no cough. (Stage III)
Example-3
Rama has been diagnosed as a case of AIDS. On testing it was
observed that Shiela, his wife, and Meenu, his daughter, have seropositive blood. They
do not show any sign of weight loss or diarrhoea but have had an attack of sore
throat and fever in recent weeks. The condition was treated by antibiotics and
antipyretics. At present they have no symptoms of illness.
(Stage I & 11)
2.16
111Y.111lection <»
Exhibit 2.2
LABORATORY EVIDENCE OF HIV INFECTION
TEST
RESULT
HIV INFECTION
Positive
Doubtful
j
Initial Test El.ISA or
Agglutinition
■;1.
Second Elisa
fest
I
;
3.
Western Biot
Test
Conventional
Supplementary
'fest
->
Positive
Yes
Negative
ZZJ
* Positive
Yes
* Negative
No Antibodies to
HIV present
Definite Evidence
of HIV Infection
)
2.18
HIV Infection and Disease
)
I-
Use of razor in a Barber’s
shop, tattooing, using common
needles for ear-piercing.
IL
SYMPTOMS
1.
MjUtlLSyiniitonis
(i)
H/o Loss .of weight
- Duration
- Percentage of body .weight
lost
(ii) H/o-Chronic diarrhoea
- Duration
(iii) H/o Prolonged fever
2
MjnoLSYinptojns
(i)
H/o Persistent cough
- Duration
(ii) 1 l/o Pruritus / skin rash
(iii) H/o.Herpes zoster / simplex
- Frequency
(iv) H/o Sore mouth/sore throat
- Duration
- Frequency
(v) H/o Swollen glands
(vi) H/o Muscle/joint pain/fatigue
i-
1
'
t--
2.19
Module 2
I
Exhibit 2.4
I
SIGNS AND SYMPTOMS IN HIV INFECTION COMPARED
WITH OTHER DISEASES
Directions : Signs and symptoms arc listed in the
the left-hand
left-hand column.
column. Using
Using diseases
diseases that
that
arc common to your locality in the top boxes, check those symptoms that are present in the other
diseases.
HIV Infection
Malaria
Mal
nutrition
Intestinal
parasites
Tuber
culosis
Anorexia
Diarrhoea
Unexplained weight
loss
Anaemia
Fevers, night
sweats
Lymphadenopathy
Fatigue
Cough, shortness
of breath
Skin rash
Oral thrush
Purple/dark skin
spots
Headache
Change in mental
state
Other motor or
cognitive deficits
related to
neurological changes
Other possible diagnosis which need to be considered in areas where they arc.endemic
includsJcishmaniasis. filariasis. trypanosomiasis. Burkitt’s lymphoma.
Kaposi's sarcoma, syphilis, herpes zoster.
3.1
Module 3
MODULE 3
PREVENTION OF HIV TRANSMISSION IN
HEALTH-CARE SETTINGS
SECTION ! : SIM
I.
OVERVIEW
In order to acquire knowledge and develop skills for prevention of
transmission of HIV infection in health-care settings, the learners are expected to
have an understanding of epidemiological features ot HIV transmission as well as
dynamics of disease transmission. They should also have the basic knowledge of the
principles of infection control.
On completion of this module (3), the learners will have an understanding of
the methods of prevention and control of HIV transmission in health-care settings, by
taking infection control precautions in general and in specific situations.
II.
SPECIFIC OBJECTIVES
On completion of this module, the learner will be able to:
•
•
•
•
•
identify possible ways of HIV transmission in health-care settings.
describe universal infection control precautions and rationale for their use in
clinical practice.
discuss the universal control precautions in specific situations / conditions.
apply problem-solving skills in the prevention of exposure to HIV transmission in
the health-care setting.
work out teaching strategies for preparing other staff to integrate universal
infection control practices in their clinical settings.
III. INTRODUCTION
HIV and other blood-borne pathogens, such as hepatitis B virus (HBV) may
be transmitted in health-care settings from patient to patient, from patient to health
care worker or, in rare cases, from the health care worker to the patient.
3.2
Transmission in Health-Care Settings
!
The high level of anxiety and fear that exists among the nurses about earing
for AIDS patients is due to their insufficient and inaccurate knowledge of the
disease. Today, AIDS epidemic presents a challenge to the nurses to maintain a safe
and healthy environment to protect themselves and their clients.
Since it is not practical or desirable to identify everyone who is infected
with HIV, the strategy for preventing its transmission in a health-care setting is to
view everyone as having the potential to be infected.
In Ibis module we will review the basic principles of disease transmission and
discuss in detail its prevention and control in
health care settings by the
application ' of universal infection control precautions in general and in specific
situations.
'
IV.
I)ESCRIPTION OF CONTENT
The description of content is organized under the following sub-titles :
1.
2.
3.
4.
1.
HIV transmission in health-care settings.
Universal infection control precaution for prevention of
HIV transmission.
Health-care workers and HIV-related issues.
Changing practices in health-care settings.
/
HIV Transmission in Health-Care Settings
411V is a fragile organism. It is unable to survive outside the body except in
purposefully contrived laboratory conditions. HIV is transmitted directly from person
to person by sexual contacts, or from a mother to a newborn during child-birth. The
virus is found in a variety of body fluids. The infected persons can transmit the virus
to others at all times. However, studies of health-care workers and non-sexual
household contacts of HIV-infected individuals suggest that exposure to the virus may
not always result in infection. The risk of transmission is important to understand
the basic underlying factors and routes of transmission of HIV infection.
1.1 Factors of Transmission
The transmission of infection depends on five factors including:
(i)
An infected source / reservoir
3.3
Module 3
(ii)
An appropriate site / portal of exit
(iii) A vehicle or mechanism of spread of infection.
(iv) A susceptible host
(v)
An appropriate site / portal of entry
These factors are represented in the form of a model in Figure 3.1 "Chain of
Infection". The model explains the links in the process of disease transmission. Each
link represents an opportunity for the interruption of the process and helps in the
prevention of transmission of infection.
r AGENT
SUSCEPTIBLE HOST
RESERVOIR •
PORTAL OF ENTRY
PORTAL OF EXIT
METHOD OF TRANSMISSION
k
X_______________________________ _____ ____________________________ s
Figure 3.1 : Chain of Infection
The links of the drain are defined and described specifically for 111V and 11BV
in Figure 3.2 Figure 3 3 depicts the cycle of HIV transmission
i
3.4
E[cveiition of HI V Transmission in Health-Care Settings
I
Link in Chain and Definitions
HIV and HBV
AGENT - Micro-organism which causes
infection.
Agents include bacteria,
viruses, fungi and parasites.
The agent causing HIV infection is
human immunodeficiency virus. The
agent causing hepatitis B infection is
hepatitis B virus (HBV)
RESERVOIR - Refers to the humans,
animals, insects, soils, food, plants, air or
water where micro-organisms live,
multiply and can reproduce themselves to
be transmitted to the susceptible host.
HIV and HBV live inside humans.
PORTAL OF EXIT - Routes from where
the micro-organism’s leave the reservoir.
HIV and HBV leave the human body
via the penis (semen), vagina (vaginal
secretions), breaks in skin (blood) and
rarely, the breast (breast milk).
;
'MODES OF TRANSMISSION - Refers
to different ways the micro-organisms
(infection) travel from reservoir to the
susceptible host.
i
jl
HIV and HBV are transmitted via :
• sexual contact & semen donations.
• blood contact
transfusion of
contaminated blood and blood
products.
• skin-piercing
practices
e.g.
injections, ear-piercing, tattooing
etc.
• perinatal : from an infected mother
to her unborn infant or shortly after
birth.
PORTAL OF ENTRY - Routes from
where the micro-organisms enter the
susceptible host, usually the same way as
they leave the reservoir.
HIV and HBV enter the host via the
penis, vagina, rectal lining, breaks in
skin and rarely, blood transfusion and
breast feeding.
SUSCEPTIBLE HOST - Persons or
animals who are exposed to the risk and
may become infected.
HIV and HBV infection can occur in
any one who has sexual or blood
contact with an infected person, and in
infants of infected mothers.
Figure 3.2 : The Definition <&. Description of Links in Chain of
HIV & HBV Infection
)
)
Module 3
AGENT HIV
SUSCEPTIBLE HOST
RESERVOIR : HUMAN-
- HUMAN BEING
BEING, VIRUS LEAVES
THE BODY THROUGH
MODES OF TRANSMISSION
* SEXUAL CONTACT
BLOOD, CERVICAL
* BLOOD CONTACT
SECRETIONS, SEMEN
><-
- BLOOD TRANSFUSION
BREASTMILK
- SKIN-PIERCING PRACTICES
- I/V DRUG USERS
* MOTHER TO FOETUS / INFANT
Figure 3,3 : The Cycle of HIV Transmission
1
Picychtion-of HIV Transmission in Health-Care Settings
3.6
1.2 The Risk of HIV Infection in A Health-Care Setting
(i) Source of infection : ”
You have learnt that HIV can be transmitted by
exposure to infected blood
- - J or other body fluids. Body fluids which can
transmit HIV include blood, semen, vaginal and cervical secretions,
wound secretions, cerebro-spinal fluids, pleural fluids, synovial
fluids, peritoneal fluids, pericardial and amniotic fluids.
Body excretions and secretions which ;are not associated with
transmission of HIV in a health-care setting; are faeces, urine, sputum.
nasal secretions, tears, sweat and vomitus. But these are potential sources
ol nosocomial and community-acquired infections with other pathogens.
Nurses must exercise caution in handling tnem.
(ii)
Extent of Risk : There is a risk of HIV being transmitted in a health
care setting but this risk is minor. Studies done in the United States
have indicated that the rate of infection after exposure to HIV infection
from a needle-stick injury is 0.4 percent, whereas the risk of HBV after
such exposure is 6 percent to 30 percent. Nearly all cases of HIV
transmission in a health-care setting were due to negligence.
I he risk of transmission following mucus membrane or skin exposure
to HIV-infected blood, other body fluids or tissues is even lower. The
risk in a health-care setting is low but it does exist. Blood-borne
diseases, including hepatitis and HIV infection, can be transmitted in a
health-care setting as described below.
uu) Possible Ways of Transmission of Infection : The infection can be
transmitted as described below :
a) Patient to Health-Care Worker : HIV transmission from a patient
to a health-care worker can occur when the latter is exposed to the
blood and other body fluids of an infected person. An example
of nils/ is parenteral contact, such as a needle-stick injury when
the patient's blood is accidentally injected into the health-care
workers skin (the risk is less than 1%). It can also occur through
muco-cutaneous contact, such as a splash of body fluids into the
health care worker's eye or nose. Non-intact skin can be a point of
HIV entry, e.g. a splash of blood on to open wounds or broken
skin due to dermatitis, acne or chapped skin. But the chances are
veiy low. These are preventable accidents.
(b) Patient-t^Patient Transmission : Patient-to- patient spread of
HIV infection is usually by an indirect route. This transmission
can occur through needles, syringes or other equipment which has
been contaminated with blood and not properly sterilized or
disinfected between use.
Module 3
Patients can also be infected when they receive a transfusion with
contaminated blood or blood products. HIV infection by blood
or blood product transfusion can be greatly reduced by screening
blood products for HIV and by requesting potential donors who
practise high-risk behaviours not to give blood. Sometimes only
specific cells from the blood stream are removed from donated
blood and administered to the patient. One example is Factor
VIII, a blood product which helps blood to clot so that haemo
philiacs will not bleed to death. These blood products are heat
treated in a way which inactivates HIV and HBV
(c) Health-Care Worker to Patient Transmission : No cases of HIV
transmission from healtii-caie worker to a patient have been
documented. Although this route of transmission is possible, the
chances of it occurring are very smalL Thus. HIV-infected health
care workers are not considered a risk to patients during routine
work activities. Transmission might occur if an HIV-infected
health care worker mixes his blood with the blood of a patient.
For example, an infected surgeon might nick his hand during
surgery, causing some blood to enter the patient's wound
However, no such case has been reported.
Also refer exhibit 3.1 to summarize the risk
workers and patients in health-care settings.
to health
care
You must remember that the principal risk of HIV infection is
from sexual exposure to the virus and if appropriate infection
control precautions are taken, the transmission of HIV or any
in a
other blood-borne infectious agent is unlikely to spread
health-care setting.
AIDS is not a casually contracted disease. If it was. it would have
been a disease of general public from the onset of case reporting.
Those activities that are common to the general public are not
the source of the viral transmission.
Coughing, sneezing,
breathing the same air, touching door knobs, swimming in
public pools, using the same bathroom, eating in the same
household or restaurant or being bitten by mosquitoes are no
ways in which HIV can be transmitted. Neither are hugging,
touching, feeding, working with or using items used bv an AIDS
patient. There is absolutely no evidence to suggest a casual
transmission in any patient diagnosed as AIDS positive
)
)
(iv)
HlVr Testing : It is sometimes suggested that all patients and health
care providers / nurses be tested for HIV antibody as a means ot
protection for nurses. However, routine and / or mandatory' testing
' X
Prevention of HIV Transmission in Health-Care Settings
of either health-care workers or patients for HIV antibody is not an
effective strategy for controlling HIV transmission in a health-care
setting and is not recommended by the World Health Organisation, as
it is impossible to identify all infected individuals. For example, a
person may have been infected and may not yet have developed
antibodies. Consequently, this person’s test result will be a false
negative (see Module 2). Therefore, even if everyone is tested foil HIV
antibodies, it is not possible to identify everyone who is infected. In
addition, it is time-consuming and costly and may lead to a false
sense of security.
1.3 Check Your Progress - 1
(i) List the body fluids :
a. which can transmit HIV infection.
b. which cannot transmit HIV infection.
(ii) List the possible ways the health worker can get HIV infection in a health-care
setting.
2.
Universal Infection Control Precaution for Preventing HIV
Transmission in A Health-Care Setting
2.1 Importance of Infection Control Precaution :
Infection control measures are important for prevention and control of
cross-infection in the health-care settings: This can be achieved only by having
appropriate infection control guidelines. Every hospital has; an infection control
committee which is responsible for developing and monitoring of these guidelines
to ensure safety of workers, patients and visitors.
You have learnt that HIV is one of the blood-borne diseases and is found in
various body fluids of the people infected with the virus. However, only blood,
semen and vaginal / cervical secretions (and rarely breast milk) have been implicated
in
HIV transmission. Nevertheless, as all body fluids (including pus and other
infected discharges and infected body cavity fluids, such as pleural fluid,
cerebropsinal fluid) may contain blood or white blood cells, it is essential that all
body fluids should be handled as though they were infectious
2.2 Universal Precautions :
(i)
Defiifitioii
Infection control precautions are referred to as universal
precautions when all patients' body fluids are treated as infectious, since
it is not known who is infected with HIV
Consequently, the
I
3.9
Module 3
precautions devised to prevent HIV transmission in health-care
settings apply to all patients, all the time, in all clinical settings.
(ii) Purpose : The purpose of universal precautions is to prevent transmission
of infection from blood-borne pathogens.
I
(iii) Rationale : The rationale for applying universal precautions is that
health-care workers may not know who is and who is not infected with
HIV. fhe actual number of asymptomatic, HIV-infected persons is not
known, it is much larger than the number of reported cases of AIDS
(recall Module 1). A Patient's history taking and examination may not
help identify majority of the clients/.patients with HIV / other blood
borne pathogens. HIV testing is not practicable for all (refer content
1.2 (iv) in this SIM and also recall Module 2). However, even though
there are no signs, infection can still be transmitted. It is, therefore,
essential to implement a programme of infection control precautions that
is used consistently with all patients in health-care settings.
2.3 Universal HIV Infection Control Precautions
You have learnt that transmission of HIV infection is possible from a patient
to a health worker through injury with needles or any other sharp instruments which
ha\ e been contaminated with infected blood / body fluids and exposure of mucus
membranes to blood The infection can also be transmitted from patient to patient
through the re-use of improperly sterilized needles and instruments for invasive
procedures. Patients may also get infection through infected blood transfusion,
skin graft, organ transplant, donated semen, and contact with blood or body fluids
of HIV-infected health care workers. Accordingly, the infection control precautions
can.be in relation to:
'■ (i) blood and other body fluids
(ii) injections and skin-piercing and invasive procedures
(iii) cleaning, sterilization and disinfection of equipment and supplies
(iv) special situations / settings.
Also refer exhiBit 3.2 and 3.3 for general infection control guidelines for
HIV infection.
(i) Precaution in Relation to Blood and other Body Fluids
(Refer exhibit 3.4)
a) Hand washing : Hands and other parts of the body that have come
in contact with blood and other body fluids must be washed
thoroughly with soap and water. Hands should be washed even if
gloves were worn immediately after their removal. Hands should
also be washed before and after providing care to the patient.
3.10
Prevention of HIV Transmission in Health-Care Settings
b) Use of Gloves and other Protective Devices : The use of gloves
and other protective garments (gowns, masks,
goggles) is
recommended when direct contact with blood and / or other body
fluids or a splattering of body fluids is expected, such as
during bronchoscopy and certain surgical and delivery room
procedures. Ordinarily, the use of a full protective covering is not
warranted when providing routine care to the AIDS patient. While
HIV has been isolated from saliva and tears, these secretions have
not been implicated as a means of viral transmission.
When gloves are not available other methods should be used to
prevent direct contact with blood e.g. forceps, towel or gauze
may be used to hold the contaminated needle and syringe.
If gloves are not disposable, they should be changed, washed,
disinfected or sterilized after contact with each patient, When
cleaning
sharp instruments, extra heavy duty gloves are
recommended.
c) Prevention of Needle-stick and other injuries : Prevent injuries
with sharp equipment
and instruments such as needles,
scalpels, blades and razors. Health-care workers can prevent
injury
by taking time with
procedures
involving
sharp
instruments. Remember that the more a needle or intravenous line
is manipulated, the greater is the risk of needle stick injury.
Refer exhibit 3.2 for detailed precautions.
d) Mouth-to-Mouth Resuscitation :
Although HIV
has been
recovered from saliva, there is no conclusive evidence that saliva is
involved in HIV transmission. Nevertheless, to reduce occupational
exposure to HI V, mouth-to-mouth suctionshould be replaced by
mechanical or electrical suction devices. Mouth pieces, airways,
resuscitation bags or other ventilation devices should be available
and used. Resuscitation equipment should be used only once and
discarded or else be thoroughly cleaned and disinfected.
e) Handling of Laboratory Specimens . Always wear gloves when
handling and processing specimen of blood and other body fluids
(e.g. in taking and collecting blood). All open wounds on hands
and arms should be covered with a water proof dressing. Hands
should always be washed with soap and water immediately after
exposure to specimens.
Specimens should be placed in a container with a secure lid to
prevent leakage during transport. Care should be taken to avoid
contamination of outside of the container.
-.3.1 I
Module 3
Working surface should be covered with a non- penetrative
materia) which is easy to clean e.g. plastic film. Any spillage of
l-lood or other body fluids should be decontaminated with an
appropriate disinfectant such as sodium hypochlorite 0.5% before
cleaning.
Specimens should be carefully disposed of by pouring into flush
drain. If this is not possible,
the specimens should
be
decontaminated with a disinfectant such as 0.5% sodium hypo
chlorite before disposal.
j
f) Spi/is of blood and other body fluids : For visible spills of blood
and other body fluids, the area should be flooded with an .
appropriate disinfectant such as sodium hypochlorite, 0.1% to
0.5%. The mixed body fluids and disinfectant should be'removed,
and the surface wiped with a disinfectant. Refer exhibit 3.2 for the
alternative method.
di)
Frecmrtioijs in Relation
Invasive Procedures
to Injection and Skin
Piercing and
j) i> i;ecl ions and other Procedures : Injections and other procedures
in which the skin or mucous membranes are pierced for
piewntive, diagnostic, cosmetic or therapeutic purposes play an
important role in both traditional and modern care.
Il is important to restrict injections and skin-piercing procedures
to situations in which the indications are clearly and appropriately
defmed. in many situations, drugs are given by injection when they
would be equally effective when given orally. Reducing the number
of unnecessary' injections is, therefore, important in protecting both
the patient and the health worker.
To avoid person to person transmission of HIV, single
use (disposable) instruments should be used once only.
To prevent reuse, they should then be destroyed under
carefill supervision. Multiple use (reusable) instruments
should always be washed and appropriately sterilized (or
disinfected) according to existing guidelines. Chemical
disinfection must not be used for needles and syringes.
If these procedures are always strictly observed, the risk of
transmission of HIV through injections and other skin
piercing procedures can be eliminated.
b)
Invasive Procedure : An invasive procedure may be defined as a
surgical entry into tissues, cavities or organs, whether for an
3.12
Prevention of HIV Transmission in Health-Care Settinns
operation or for the repair of injury. Strict blood and body fluid
precautions should be observed In addition
•
•
•
•
•
(iii)
Gloves and a surgical mask should be worn tor all
invasive procedures.
Protective glasses or face shield should be worn for
procedures which may result in the generation of droplets
or the splashing of blood or other body fluids.
A gown or apron should be worn if blood splashes are
likely.
Nurses who perform or assist in vaginal or caesarean
deliveries should wear gloves and a gown or apron when
handling the placenta, when cleaning the blood from the
infant’s skin, and until post-delivery care of the umbiicai
cord is complete.
If a glove is torn or a needle stick or other injury occurs,
the glove should be changed and the hands washed
carefully as soon as the safety of the patient permits. The
needle or instrument involved in the accident should be
removed from the sterile field.
Cleaning, Sterilization and Disinfection : HIV is transmitted via
needles, syringes and other invasive equipment contaminated with
blood, semen, vaginal secretions or fluids containing the blood of an
infected person. Such equipment includes sharp instruments used bv
traditional healers and birth attendants, and the instruments used in
tribal ceremonies and tattooing. To protect patients from infection,
these items should be cleaned and sterilized or appropriatelv
disinfected between each use.
a) Cleaning . Cleaning is the physical removal of organic material or
soil from objects. Cleaning is done with water and detergents.
Usually, cleaning does not kill or inactivate micro-organisms.
Cleaning should be done to remove dirt, dust and debris from
items which will later be sterilized or disinfected. If microbes
are protected by dirt or protein aqueous material such as blood,
chemical disinfectants and moist heat will not inactivate them
Environmental surfaces such as floors, walls, tables and counter
tops should also be cleaned
Always clean and rinse items before sterilizing or disinfecting them
If items are grossly contaminated after use. decontaminate by
soaking in a disinfectant, clean with soap and water, then sterilize
or disinfect again before use.
3.13
Module 3
b) Sterilization : Sterilization is the complete destruction of all
micro-organisms and is carried out by steam under pressure, dry
heat, and gas or liquid chemicals. Sterilize objects which enter
the blood stream (needles, syringes, catheters and surgical
instruments) or other sterile areas of the body.
‘1
All forms of sterilization will inactivate HIV and HBV
The methods include :
- Steam under pressure
- Autoclave or pressure
cook at a pressure of
15 pounds for 20
minutes at 121 deg. centigrade.
- Dry heat
- 170 centigrade (338 deg
Fahrenheit) for 2 hours
- Chemical
-Use 2% glutaraldehyde
for at least 10 hrs.;
or 3% hydrogen peroxide
for at least 2 1/2 hrs.
c) Disinfection : Disinfection kills or inhibits most, but not all, micro
organisms through the use of chemical germicides or boiling.
Disinfect objects
and
equipment which
touch
mucous
membranes (respiratory equipment), items which cannot be
sterilized (laproscopes), and items which must be decontaminated
but do not need to be sterile (bedpans). In adverse conditions
when sterilization of equipment is not available, disinfection may
be used. Boiling is a form of high-level disinfection.
The following methods of disinfection are known to inhibit HIV.
Be sure that all parts of the equipment are separated and
completely immersed in the water or chemical disinfectant.
The
liquid must touch all surfaces of the object in order to be effective.
•
Boiling is an effective way to disinfect instruments and
equipment
(for example, needles and
syringes)
when
sterilization is not possible. To disinfect, boil in water for 2.0
minutes.
•
('hemical disinfection: Do. not use chemical disinfection for
needles and syringes used foi vaccinations
('hemical
disinfection for other invasive equipment should onlv be used
as a last resort
3.14
i^evcrition of HIV Transmission in Health-Care Settings
Chlorine compounds (bleach). HIV is rapidly killed by liquid
chlorine (household bleach), making it ideal for
de
contaminating large surfaces. The following are guidelines
for chlorine use :
* For small spills or clean equipment:
Dilution : liquid - 1 part in 10 pans of water
powder -1.5 gms. per litre of water
* f or large spills or to clean grossly contaminated equipment :
Dilution : liquid - 1 part in 10 parts of water
pov/der - 7.0 gms. per litre of water
Chlorine compounds are very unstable. Prepare solutions
daily or store in a covered brown bottle for upto 30 days. The
bottle must be tightly capped between use. Avoid direct
sunlight.
Other disinfectants which are active against HIV include 70%
ethyl or isopropyl alcohol, 2% glutaraldehyde, 3% phenol (or
lysol), 2.5% povidone iodine, 4% formaldehyde, and 3% to
6% hydrogen peroxide.
A summary of the definition and methods of cleaning,
sterilization and disinfection is given in Figure 3.4.
d) Storage : All items and sterile packs must be stored in a clean, dry
place, preferably under cover to protect from dust. Disassembled
items should not be reassembled until ready for use. Sterile items
should be separated from clean or disinfected items.
Definition
Method
Cleaning
Physical removal
of organic material
or soil.
- Water and
detergent
Sterilization
Complete destruction
of all micro
organisms and spores
- Steam under
pressure
- Autoclave or pressure
at 15 lb.for 20 minutes.
- Dry heat, Gas
- Liquid chemical
VI5
Module 3
Disinfection
Kills or inhibits
most, but not all,
micro-organisms
- ('hemical germicide
(alcohol, bleach)
Soak
clean instruments for 20
min. then for all
disinfectants except
alcohol, rinse in boiled or
st erile water.
- Boiling in water for 20 mt.
Figure 3.4 : Cleaning, Sterilization and Disinfection
(iv) Special Situations / Settings :
a)
Laundry
Soiled linen should be bagged where used and not
sorted or rinsed in patient-care areas. Linen soiled with blood or
other body fluids should be traced and transported in leakproof
bags. If leakproof bags are not available, the linen should be folded
with the soiled parts inside. When handling soiled linen, gloves
and a protective apron should be worn.
Linen should be washed with a detergent and water at a
temperature of at least 71 deg. centigrade (160 Fahrenheit)
for 25 minutes. If low - temperature laundry cycles are used
(less than 70 centigrade = 158 fahrenheit), chemicals suitable
for low-temperature washing should be used at the appropriate
concentration as recommended by the manufacturer.
b)
Post-tnorfeni procedures lust offices care of the body ' When
nurses are performing post-mortem procedures / last offices or
giving last care to the body, they should follow the precautions
outlined above and use the standard guidelines for the health-care
setting involved. Refer Module 10 for more details.
c) Disposal of infected wastes housekeeping :
Needles and other
sharp instruments or materials should be placed in a puncture-proof
container immediately after
use
and should preferably be
incinerated.
Liquid wastes such as bulk blood, suction fluids, excretions and
secretions should be carefully poured down a drain connected to
an adequately treated sewer system, or disposed of in a pit latrine.
z .Solid, wastes, such as dressings and laboratory and pathology
wastes, should be considered as infectious
and treated
by
P-rcvcntion.of HIV Transmission in Hcahh-(. urc Sellings
incineration, burning or autoclaving Other solid wastes, such as
excreta, may be disposed ot in a hygienically-controlled sanitary
landfill or pit latrine.
Solid waste materials in the home (dressings, diapers, menstrual
pads) should be considered infectious. They should preferably be
burned. If this is not possible, they should be deposited in a
domestic or public hygienically-controlled sanitary landfill or pit
latrine.
Environmental surfaces such‘i as walls, floors and other surfaces
are not associated
---------- with infection transmission and, therefore, do
not require extraordinary disinfectioni or sterilization. Routine
cleaning and
t... removal of soil on a regular basis, when spills or
soiling occursi or when the patient is discharged, is recommended.
Cleaning of walls, curtains, and blinds is recommended when they
are visibly soiled. Environmental spills should be flooded with a
liquid germicide before cleaning, then decontaminated with fresh
germicide. Gloves must be worn during such cleaning procedures.
d)
Food Service : Special dietary infection control precautions are
not necessary7 in HIV infection and are no longer recommended for
any communicable disease. Studies demonstrate the probability of
transmission of disease from a dietary tray to a worker to be one
in 5000. The key measure in insuring worker protection is hand
washing after handling used trays.
e) Ophthalmolo^ : While the AIDS vims has been found in tears.
there is no evidence to suggest that this is an effective means of
transmitting the virus. However, disinfecting instalments having
direct contact with the eye, including contact lenses used for
fitting trials, will prevent the transmission of other organisms that
can infect the eye (see exhibit 3.5). The tolerance of the
equipment to the disinfecting solution as well as the safety ot
any product that may make contact with the eye must be
considered.
For example, tonometers may be damaged by
sodium hypochlorite but not by alcohol.
f)
,k
Dialysis : Renal patients who have AIDS or an HIV antibody
positive may be dialysed in the hospital, using conventional
infection control precautions which are adequate to prevent
HIV transmission (refer exhibit 3.5 for specific details)
g) Maternal Child ('are h may be possible in some instances to
redetermine which women are most at risk for HIV infection
(intravenous drug users or those who have received transfusions in
the last five years or prior to blood bank screening programmes)
Module 3
However there is an ever-increasing number of women who are
at risk because of their sexual partners These women mav or
may not know that they are at risk. In communities where there
arealready large numbers of AIDS cases, it may particularly be
appropriate to utilize the universal infection control precautions
that protect the nurse from the risk of exposure to an
anticipated amount of blood and body fluid rathe! than relying on
an AIDS diagnosis or a history suggesting risk for HIV infection
Refer exhibit 3.6 for guidelines on AIDs’ comrol in the perinatal
area.
Products of conception (placenta and amniotic -.membranes)
should not be released for commercial use. The infectious waste
and specimen handling systems alreadv in place
;
-in the institution
are sufficient for the disposal of ' deliveiv room wastes and
specimens. Reusable items such as specula,
<
diaphragm fitting
rings etc. require terminal disinfection. Environmental cleaning and
disinfection can be done by the same methods freviotisly
approved for those settings. You will learn in detail in Module S.'
h) Psychiatric Unit : Patients with HIX’ infection admitted for
purely psychiatric reasons without loss of control of body
functions may be housed safely with other pi.ysicallv well patients.
These patients may share the same bathroom facilities, eat in the
same dining room, and even prepare food as part of patient activity
plans. A guiding rule of thumb for any patrent who prepares- food
for others is that they must adhere to basic hvgicmc measures as
prescribed by the unit (handwashing before beginning io cook.
not tasting out of the spoon used to stir the no: etc.).
Studies ofnon-sexual household contacts of people with AIDS have
shown that the usual household
activities, includimt food
preparation, kissing, and even the snarme of toothbrushes and
razors (not recommended) have not led to HIV transmission
These studies are the basis of the rationale behind the safety of
shared living quarters with HIV-infected individuals.
(i) Outpatient: Basic infection control measures, as previously discussed,
may be applied to outpatient departments and doctors'offices as well.
The ambulatory nature of the patient generally makes containment of
infectious agents easier. Patients with HIV infection who are in control of
the body functions may' share common waiting rooms with other patients
Patients with a cough should be seen as soon as possible
Since
tuberculosis may be associated with HIV infection, screenme .should be
considered when symptoms arise. Common toilet facilities may be shared
by these patients. Similarly, the use of drinking' water from taps ./ ,,
i
3.18
Prevention of HIV Transmission in Health-Care Settings
coolers and
transmission.
other
public facilities have not been implicated in
Clinics of any speciality may see AIDS patients along with other
patients, using standard hygienic and aseptic techniques appropriate for
the type of examination or procedure. There need not be two sets of
standards or two sets of equipment.
2.4 Home-Care Guidelines
People with AIDS are frequently in and out of the hospital for the treatment
of various AIDS-related opportunistic infections and neoplasms. However, between
bouts of illness, these patients live at home and continue to work and live a relatively
“normal" existence for many months and occasionally, years. Infection control at
home is as important as it is in the institutional setting. Patients being discharged
from the hospital or clinic and their care-givers or significant others need education
on infection control at home. They need to know how to protect the patient from
his / her environment and how to protect the family and the public from HIV.
Infection control practices for home-care personnel exposed to HIV
should be based on the principles previously described. The protective equipment
and practices used should be based on the degree of HIV exposure.
Many
activities at home, such as dishwashing, cleaning, and other sanitary practices
need not be different from any other household. Specialized cleaning solutions or
equipment are not required.
(0
General : Wash hands thoroughly before and after providing care,
when changing soiled linen or dressings, when changing diapers or after
any other contact with body secretions or excretions. Use gloves when
contact or exposure to body fluids is anticipated, and when cleaning
blood or other spills. Wear gloves when skin is irritated, is
chapped, has cuts, or has dermatitis. Wear gown, mask or protective
garments when cleaning blood, diarrhoea or other spills. Refer exhibit
3.3.
(ii)
Personal Hygiene : Bathrooms may be shared with other family
members as long as personal hygiene practices are followed. Encourage
regular bathing and the use of emollients to prevent dermatitis. Dr)' feet
well to avoid fungal infections. Razors and toothbrushes must not be
shared with other family members. Vaseline or certain creams may be
applied in winter to avoid skin irritation.
(iii) Household: Good home sanitation protects even'one in the household.
Commonly used soaps or cleaning solutions may be used since the
primary goal is physical removal of soil where organisms may thrive.
Household surfaces that are contaminated with human waste, first
4
k i
3.19
Module 3
require cleaning to remove solid waste and then disinfection with
a dilute household bleach solution. Bathroom sinks, tubs and toilets
require regular cleaning.
Prepare a 1 : 10 bleach solution daily (1 part chlorine bleach to 9 parts
of water). -Wearing heavy' duty plastic gloves, wipe oft' any surfaces
soiled with blood or body fluids, then disinfect with the bleach solution.
The same sponge used to wash dishes or clean the food* counter must not
be used to clean the bathroom or floor. Soak the cleaning mops and
sponges for five minutes in the bleach solution and pour contaminated
cleaning water into the toilet.-
The kitchen surfaces, sink and other furnishings may need to be
disinfected regularly if the patient is mobile and body fluids are in
contact with these areas. Covering, carpeting with plastic runners may
prevent contamination of carpeting, especially for the patient with
diarrhoea who has difficulty getting to the bathroom. The use of a
bedside commode may also be helpful in such cases. Recurrent
respiratory infections from
oxygen support equipment can be
prevented by cleaning the equipment and tubing regularly (1 to 3 times /
week).
'
i
(iv) Equipment : Rented medical supplies such as beds and wheelchairs
should be cleaned before returning to the company. Any commercially
available phenolic household cleaner is adequate to..control disease
causing organisms if the equipment is thoroughly cleaned. . Rental
company
personnel need not wear protective garments to come into
the home or remove the equipment.
(v)
Laundry : A patient’s clothing may be laundered or drycleaned in the
usual manner. Keep soiled laundry in a plastic bag. Any bedding or
clothing heavily soiled with blood or faeces may be rinsed and then
laundered as usual in hot, soapy water, but with the addition of a cup
of bleach to a full washerload of water. It is not necessary, or
desirable, to soak these items for long periods in the bleach. If a
dryer is available, diy clothing and linen at the highest temperature
setting.
(vi) Trash Disposal
Waste should be handled in a sanitary manner.
Line wastebaskets with plastic bags. Place soiled articles in a plastic
bag and tie securely. Empty wastebaskets frequently into a plastic-lined
garbage can with a tight fitting lid. Most household trash (soiled
tissues, dressings, disposable diapers etc.) will not contain infectious
agents in kind or quantity to require special handling. Needles used for
injection^ may be the exception. Patients and care-givers must be
provided with puncture-resistant containers for disposal of needles and
sharp objects. Empty plastic cartons or empty metal cans with plastic lids
/
Prevention of HIV Transmission in Hcaith-Carc Settings
3.20
may serve the same purpose. The local health department is generally
responsible for determining the means of disposal Normally,
needles for injection used by patients at home, even when infected (e g.
a diabetic who is a hepatitis B carrier) are disposed of with ordinary
trash. Laws regulating infectious waste handling normally concern only
those with a large volume of trash as hospitals.
(vii) Caring for Pets : People with AIDS may need help to keep their pets
safely. Since animals may carry disease, it is imponant to maintain
the health of the pet.
Cryptosporidium causes diarrhoea in many
household pets. Cat faeces may carry toxoplasma gondii cysts.
Mycobacterium avium-intracellulare has been identified
in bird
droppings. Appropriate precautions for pet owners include:
not
allowing outdoor cats to use an indoor litter box, not having an immuno
incompetent person clean
the fish tank, bird cage or litter box; not
handling animals that have diarrhoea or appear sick ; and washing hands
after handling animals.
(viii) General Health : Maintaining good health habits include avoiding
other infections ; eating a balanced diet; getting adequate rest and
activity ; observing good personal hygiene such as washing hands before
eating or food preparation and after use of the toilet and keeping a clean
environment. These activities maximize the chances of a person with
HIV infection remaining well.
2.5 Problem - solving approach to deal with various practical situations for
HIV prevention on health - care settings.
In a health-care setting you may come across various problematic situations
which may intervene in the application of infection control measures for HIV
prevention.
Refer to Exhibit 3.7. There is a list of five situations which mav occur in
a health-care setting. Go through these situations and decide whether the action
taken was appropriate or inappropriate and rationalize the decision. Check the
possible answers given in the exhibit 3.8.
Guidelines for Safety of Nurses.
•
Nurses with open skin lesions should cover the lesions with a waterproof
dressing or gloves to prevent direct exposure to blood and other body
fluids. To protect patients, nurses who have draining skin lesions should not
take pan irt direct patient care and should not handle equipment for patient
care.
3.2-1
Module-3
.
Nurses providing HIV-infected persons with home care are at the same lowrisk of infection as nurses in hospitals and other health care settings. Most
infected persons who do not need hospitalization can safely be cared for at
home. The precautions outlined above should be observed.
•
Since HIV infection in a pregnant nurse carries the additional risk of
subsequent perinatal transmission, pregnant nurses should strictly observe the
precautions.
•
In general, an HIV-infected nurse does not pose a
restrictions in work are not needed.
•
An infected nurse's personal doctor should advise on precautions or
restrictions to protect patients and on whether they pose a risk to the nurse
and, if so, suggest changes in work assignment.
risk to patients and
2.6 Check Your Progress - 2
(i) What is meant by universal precautions ?
(ii) List the universal precautions in relation to injection and skin-piercing
instruments.
(iii) What is meant by invasive procedure ?
(iv) Is there any difference in the infection control precautions in homes ot
HIV-infected / AIDS cases ?
3.
Health-Care Workers and HIV-related issues
3.1 Management of Health Care Workers exposed to HIV
If the universal infection control guidelines are adhered to, the risk of
acquiring a blood-borne infection, including HIV, will be significantly reduced. Even
so, it is not possible to guarantee that exposure will not occur. Work place should,
therefore, develop policies to meet those situations where health workers are injured or
are exposed to known or unknown cases of HIV infection. The following
guidelines are suggested for their management :
(i) Evaluate and record the type of exposure, e g needle stick injury, cut
with sharp instrument, splash on to mucus membrane or non intact skin.
(ii) If HIV testing is available - contact the source person and with his/
her informed consent test, the source patient for HIV.
i
3.22
Prevention of HIV Transmission'in Health-Care Settings
a. If the test is negative, there is no need for a follow-up.
b. If the test is positive, if the patient reRises to be tested or if
the source of exposure is unknown :
’
The health care worker should be counselled about the risk of
HIV infection and about subsequent risk to the community.
The health worker should practise safer sex, delay pregnancy and
not donate blood.
•
The health worker should be asked to report any febrile episodes
within 12 weeks after exposures. Rashes, fever or swollen lymph
glands should be noted during this period.
•
With his / her informed consent, the health worker should be
tested for HIV at the time of exposure, then at six weeks, 12
weeks and six months after exposure.
(iii) If HiV testing is not available or very expensive :
a) The source patient should be evaluated for risk factors for HIV
infection.
b) The health care worker should be counselled if it i$ determined that
he / she has been exposed.
c) The health worker should be asked to monitor and report signs
of infection such as fever, rash or swollen lymph glands within 12
weeks after exposure.
x
d) If feasible, HIV testing (informed) should be done in six months
after exposure. Monitoring the illness should be continued for one
year if HIV testing cannot be performed.
3.2 Health-Care Worker with HIV infection :
(i)
Risk of HIV infection from health worker to patients - The safety of
employing people who have HIV infection / AIDS in the health-care
field is another major issue. People with AIDS and those infected with
the vims have worked in health care, and there is no documented
evidence of HIV transmission occurring from worker to patient in this
setting. HIV-infected health care workers are not a risk to patients during
loutine woik activities but may be more so during invasive procedure
through cuts and injuries.
3.23
Module 3
(ii) Work Performance by HIV-infected health worker - In the absence
of clinically active infections that would otherwise restrict the individual
from performance of duties, a person with AIDS may continue to work
safely. However, HIV infection will progressively impair the immune
system and consequently, HIV-infected health-care workers are more
likely to acquire nosocomial infections from a patient with contagious
diseases e.g. pulmonaiy tuberculosis. Hence, an individual's work
assignment must be determined on a case-by-case basis.
Past experience with a health-care worker and the unknown carrier of
hepatitis B has shown the following practices to be prudent for the
protection of the patient and nurse. Infected personnel should wear
gloves when in contact with mucous membranes or non-intact skin, and
should wear gloves, or be reassigned from direct care when weeping or
exudative lesions are present on their hands or skin. These practices apply
to all personnel, regardless of risk for AIDS, since many other diseases
can be avoided as well.
3.3 Other issues
Pregnancy and 111V infection - Pregnant nurses who are exposed to
HIV at work fear transmitting it to their unborn children. Pregnant
women who become infected through the known means of transmission
(sexual contact, sharing needles with someone who is infected, or
receiving infected blood products) do have an increased risk of
transmitting the virus to their unborn children. Studies indicate that
pregnant nurses have the same probability of HIV infection through
-. occupational exposure like any other nurse. • However, because of the
increased risk of contracting herpes or cytomegalovirus from the
s
AIDS patient (both are known to cause birth defects), the pregnant
nurse should not provide direct care to this patient population.
(i)
!
(ii) Risk of HIV infection to Families of Health Workers Health-care
workers, including nurses, are concerned about taking the virus home to
their children. Unlike skin infections and diarrhoeal diseases where only
superficial contact is necessary to transmit the organism, blood-borne
viruses are harder to transmit. Surface contact is insufficient for
transmission of HIV disease. Transmission of HIV occurs through blood
or sexual contact; unless such contact has occurred, nurses are unlikely
to expose their families. Epidemiologic evidence demonstrates that even
when a family member is HIV- infected, transmission does not occur
through ordinary household contact.
3.24
Prevention of HIV Transmission in Health-Care Settings
(iii) Personnel Policies :
a) HIV Testing - AS explained earlier, routine serologic testing of
employees for the HIV antibody is not recommended. This
additional information neither adds to or changes the infection
control precautions observed by all employees nor does it affect
employee personnel policies regarding the nurse’s work assignment.
b) Labour Laws Most personnel departments already have policies in
keeping with the state and federal labour laws regarding disabled
employees or employees with a catastrophic illness. Employees
with AIDS can be included under these policies without creating
new ones.
c) Training - As professionals, nurses are expected to be well
informed about AIDS, HIV transmission and the basics of infection
control. This knowledge is important not only to ensure personal
safety and appropriate institutional policies, but also to teach
patients and family members about safety at home. Nurses are
also community resources for AIDS awareness and education.
Well-planned education programmes for patients, health care staff,
and community can help reduce the misinformation and anxiety.
Fear of contagion is an inevitable and perhaps normal reaction
to AIDS education. Helping patients, family, and staff to
acknowledge and overcome this fear is important for establishing
reasonable infection control practices and providing sensitive and
compassionate nursing care. Therefore, it is very important to have
a rigorous and well-planned training and orientation programme
for nurses and also for other health workers.
3.3 Check Your Progress - 3
(i) Should an employer try to find out if any workers are infected with HIV ?
4.
Changing Practices in Health Care Settings
There may be many practical situations in a health-care setting which
require modified practices to prevent the spread of infection. This can be achieved
through effective teaching strategies. The following steps should be followed to deal
with each situation :
(i)
/ >
Study the situation
____HULL
3.25
Module 3
(ii) Formulate learning objectives.
(iii) identify difficulties in meeting these objectives.
(iv) Determine the strategies of health education.
(v) Plan the content and conduct - teaching session / programme.
Examples of situations for working out teaching strategies for
changing practices in health care settings are given in exhibit 3.11. Study
these situations and answer the questions. You may discuss with your
fellow workers / supervisor / authority.
i
After you have answered all questions and discussed with others, refer
exhibit 3.12 for correct answers.
V.
ANSWERS TO CHECK YOUR PROGRESS
(i)a - Blood
- Semen
- Vaginal and cervical
secretions
- Wound secretions
- Faeces
- nasal secretions
- Urine -Sweat
b)
- Cerebrospinal fluid
- Pleural fluids
- Synovial, peritoneal
pericardial and amniotic fluid
- Saliva
. - Tears
- Vomitus
(ii)
«
Needle stick injury, injury with sharp instruments contaminated with blood
or other body fluids of HIV-infected persons.
Exposure of open wounds to blood or other body fluids from HIV infected
persons.
Splashes of infected blood or any other specific body fluids on to mucous
membrane and the eyes.
2.6(i) Refers to application .of infection control precautions to all patient, all the time
in all settings as all patients' body fluids are considered infectious since it is not
known who is infected with HIV.
2.6(ii)
•
Restrict use^of injections and
medicine by oral medicine.
skin-piercing instruments, replace injectable
Prevention of HIV Transmission in Ucahh-Carc Settings
Use of disposable syringes and needles and other skin-piercing instruments
Cleaning and sterilization and / or disinfection of reusable instruments.
2.6(iii) Refers to surgical entry into tissues, cavities or organs, whether for an
operation or for the repair of an injury.
2.6(iv) No, there is no difference. The principles are the same as those of any
other health care settings.
The general precaution of infection control, with
reference to safety of the self, patient, other members in the family and community
remain the same.
3 (i) No, the employer should not because it is not an effective strategy in HIV
prevention, it is not possible to identify all infected health workers, because there
may be false negative results, it is lime-consuming, costly and may lead to a false
sense of insecurity. The chance of infection from a health worker to a patient is
extremely rare. The HIV-infected person remains healthy for most part of her / his
life and can perform work like any other person. But as the infection progresses, a
suitable alternative job can be arranged on the basis of medical advice.
Exhibit 3.1
Summary List of Risk to Health-Care Workers and
Patients in a Health-Care Setting.
Blood-borne infectious agents, including some hepatitis viruses (e g. the
viruses which cause hepatitis B and hepatitis C) can be transmitted in a health-care/
setting in the following ways :
Risk to Health-Care Workers
a)
Injury with a needle or any other sharp instrument which has been contaminated
with blood or body fluids from an HIV- infected person.
b)
Exposure of open wounds to blood or other body fluids containing visible
blood and specific body fluids from an HIV- infected person
(It is important
to specify that HIV is not transmitted through unbroken skin).
c)
Splashes of infected blood or any other specific body fluids on to mucous
membranes and the eyes.
Risk to Patients
a)
/
Contaminated instruments (needles, syringes, scalpels and other instruments for
invasive procedures) that are being re-used without being sterilized or
disinfected.
3.27
Module 3
b)
Transfusion with HIV-infected blood.
c)
Skin graft, semen donation and organ transplants from an HIV-infected donor.
d)
Contact with blood and other body fluids from an HIV- infected health worker
(e.g. midwife, surgeon or dentist).;
Exhibit 3.2
Infection Control Precautions
I. To prevent injuries from needles and other sharp instruments :
•
Never bend, break or recap disposable needles, but dispose them immediately
with the attached syringe in a thick cardboard, glass, heavy plastic or metal
container. These containers should be located as close as is practical to the area
in which the. needles are used.
•
Place disposable sharp instruments in a thick cardboard, glass, heavy plastic or
metal container immediately after use. When full, seal the container carefully
and burn or bury' it in a hygienically-controlled sanitary landfill.
Place re-usable sharp instruments (e.g. needles, scalpels, etc.) in a glass, heavy
plastic or metal, container immediately after use. Wear thick gloves and carefully
clean needles and all other sharp instruments (and syringes) before disinfection
or. sterilization.
9
2.
/\\V)id unnecessary handling of contaminated sharp instruments, including needles.
To prevent exposure of open wounds and mucous membranes :
Cover broken skin or open wounds with watertight dressings.
•
Wash hands with water and soap immediately after any contact with blood or
other bodv fluids.
•
Specimens of blood and other body fluids should be placed in containers with
secure lids to prevent leakage during transport. Avoid contamination of the outer
surface of the container.
Wear suitable gloves when expecting exposure to blood or body fluids and when
handling blood specimens.
I
K /
3.28
Prevention of HIV Transmission in Health-Care Settings
•
Linen soiled with blood and other body fluids should be transported in a leak
proofbag or folded with the soiled part inside. It should be washed in hot water
with a detergent.
•
During assistance at childbirth, the nurse may be exposed to extensive amounts
of blood. Planning for childbirth in the hospital or at home should include
obtaining gloves, aprons, soap and water.
•
Wear protective glasses when blood splashes are expected, such as during major
surgery, childbirth or dental procedures.
•
Mouth-to-mouth suction of newborns should be replaced with mechanical or
electric suction devices.
Mouth pipetting should be replaced by mechanical pipetting in all laboratories
handling blood and other body fluids.
•
Resuscitation bags should be made available in health-care settings, in which
resuscitation is likely to be needed.
3.
Preventing HIV transmission via contaminated instruments :
•
All re-usable instruments must be cleaned and disinfected or sterilized between
use.
•
Disposable equipment must be used
discarded, i.e. burnt or buried.
•
Promote oral medication rather than medication by injection when possible. If
clients prefer injections, explain why oral medication is preferable.
•
Teach patients to avoid injections and skin-piercing carried out by practitioners
who do not sterilize their equipment.
only once and then appropriately
4. Preventing HIV transmission via transfusion of HIV contaminated blood
or blood products :
>
•
All blood for transfusion should be tested for markers of HIV infection. In areas
where testing is not feasible, blood transfusions should only be given when
absolutely necessary, to treat a life-threatening condition.
•
Where possible replace blood transfusions by other suitable intravenous fluids,
e g. dextrose and / or dextran 70 or Ringer's solutions.
')
Module 3
•>-
•
For patients who are anaemic, the cause of anaemia should be sought and treated.
It is better to prevent the cause of anaemia (hookworm, malaria or malnutrition)
than to give transfusions
5.
Preventing HIV transmission from HIV contaminated
transplant or semen donation :
•
Test all donors for HIV antibody prior to any donation.
6.
organs or tissue
Spills of blood or other body fluids onto surfaces e.g. Table^ Floor etc.
•
Remove blood or other body fluids with paper towels or old newspapers. Take
care not to get blood on the hands i.e. wear gloves where possible. Cloth towels
may be used, but will then be contaminated and must be handled as soiled linen
•
Wash surface with hot water and soap.
Decontaminate
hypochlorite.
with intermediate or low
level
disinfectant, e.g.. sodium
7.
Disposal of waste :
•
Liquid, such as blood can be flushed into a sanitary sewer or pit latrine.
•
Solid waste, e g. blood-soaked dressings, sanitary pads and napkins, placentas or
tissue biopsy specimens should be burned or carefully buried.
Caution
Avoid placing these materials in open dumps to which animals and
children have access, and avoid burying materials where there is a possibility of their
being dug up or where they might contaminate water sources.
Exhibit 3.3
General Infection Control Guidelines for HIV infection
I.
•
•
•
Handwashing :
The most important measure in infection control.
Correct technique is essential (soap, running water, 10 second thorough friction
cleansing)
Wash before and after direct patient care, even when gloves are worn.
>
3.30
Prevention'of HIV Transmission in-Hcahh-Carc Settings
2
Gloving :
•
•
Pare skin contact with any patient's body substance or secretions is potentially
unsafe.
Glove for direct contact with infectious material, especially when skin is not intact
or is chapped.
Use single use gloves, proper disposal after use.
3.
Gowns :
•
•
•
Gown for procedures where splattering of body fluids is expected.
Wear gown once only, discard properly for laundry or disposal.
Not required for most routine AIDS care.
4.
Goggles / mask :
•
•
Use goggles and / or mask for procedures where splattering of body fluids into
the face or mucous membranes is expected; (bronchoscopy, dental, specimen
processing etc.).
Wear mask once only, discard properly. Discard or disinfect goggles as directed.
Not required for most routine AIDS care.
5.
Needle Precautions :
c
o
Dispose of needles promptly and carefully
needle container.
Never resheath, bend or break needles.
Report needle stick injuries immediately.
in
labelled, puncture-resistant
46.
Blood Drawing :
•
•
Wear gloves
Hand washing after the procedure.
7.
Specimen Handling :
•
•
•
Place lab specimens in leak-proof containers.
Place container inside an impervious plastic bag for transport.
Label with ’’blood precautions".
Modiitc 3
8.
Private Room :
Recommended for AIDS
patients with respiratory' disease, diarrhoea,
tuberculosis, herpes zoster. or other highly contagious infections.
9.
•
10.
Reverse Isolation :
Considered an unnecessary measure for AIDS patients
Environmental Cleaning (surfaces) :
•
Remove ail body fluids by cleaning surface spill with an absorbent disposabie
material.
•
Disinfect with either high-level tuberculocidal disinfectant, or sodium hypochlorite
(dilute 1:10 or 1:100 with water)
11.
•
•
•
12.
•
Medical Equipment :
Clean equipment by washing or wiping off blood or body fluids
Disinfect at a level that is tuberculocidal or
Sterilize.
Waste and Linen Handling :
Use existing standards
Exhibit 3.4
Universal Blood and Body Fluid Precautions for all Patients (")
Universal precautions are guidelines based on the risk of exposure to blood
and body fluids rather than on a diagnosed disease. They encourage the nurse lo
take precautions with all patient secretions to prevent HIV transmission, regardless of
the diagnosis.
•
Use barrier precautions to prevent skin and mucous membrane exposure when
contact with blood or body fluids of any patient is anticipated
3.32
Rrcvcj !tiQfLo£illV_TnH
LL^liyiiarc^eUings
Cloves
for direct contact with blood, body secretions; for handling
soiled
laundry, equipment etc.; for performing venipuncture, other vascular access;
should be changed after contact with each patient.
Masks
protective eyewear : wear during procedures that are likely to generate
droplets of body of body fluids that may splash on mucous membranes of mouth,
nose or eyes.
downs : wear during procedures that are likely to generate splashes of blood or
other body fluids.
Wash hands and other skin surfaces immediately and thoroughly if contaminated
with bloo'd or body fluids of any patient. Wash hands immediately after removing
gloves and in between contact with patient.
fake precautions to avoid injuries from needles, scalpels or other sharp
instruments during procedures, or when handling, cleaning or disposing of such
items.
po not resheath needles; do not bend or clip needles.
Dispose of all sharp items in puncture-resistant containers that are located as close to
the use area as practical.
Adapted from CDC : Recommendations for Prevention of HIV Transmission in
Health-Care Settings. MMWR 36 (25) : 58 - 65, 1987.
•
Use disposable mouth pieces, airways, resuscitation bags, or <other ventilatory
devices during emergency resuscitation instead of mouth-to-mouth resuscitation;
have equipment readily available for use in the area.
Nurses with exudative lesions or weeping dermatitis should not provide direct
patient care or handle patient care - equipment.
Nurses who are pregnant must be especially familiar with and adhere strictly to
precautions to minimize the risk of HJV transmission.
•
Isolation precautions (e.g. enteric, AFB) should be initiated as necessary if
associated conditions are diagnosed or suspected.
?
■
u
? V'
Module 3
Exhibit 3.5
HIV Infection Control Precautions in Ophthalmology and Haemodialysis Unit.
I.
Disinfection of Eye Care Equipment (*)
Equipment
Tonometers instruments that
come into direct contact
with the external surface
of the eye :
Method
Wipe clean
Disinfect by exposing for 5-10
minutes to one of the following :
- fresh 3% hydrogen peroxide
- 1 to 10 dilution of sodium hypochlorite
- 70% ethanol
- 70% isopropanol
Rinse thoroughly in tap water; dry
before use.
Soft, hard, and gas
permeable contact lenses
fitting lenses
Use 3% hydrogen peroxide on soft,
hard and rigid gas-permeable
contact lenses
(check recommendations of lens
manufacturer)
Heat disinfect some hard lenses
(where approved by manufacturer)
at 78-80 deg. C( 117-176 deg. F)
for 10 minutes.
AdaptedJrom . RecommendationsJorpreYeulni^possible transmission of human
Tetymphotropic l inis type 111
lymphadenopalhy - associated vino from teens.
MMtVR 3d : 353 - 53-1. /(^5.
3.34
PjvYci>lionof HjV Jninsniissjon in Hcallli-Carc Settings
• ~z
II.
HIV' Infection Control Precautions in the Haemodialysis Unit.(*)
Whether the population of the haemodialysis unit includes known HIV or
hepatitis B virus-infected persons dialysed in the same area / separate machine or
separate area / separate machine, or unknown viral carriers sharing the same machine,
cue following precautions are recommended :
Immediately clean up gross spills.
Clean and disinfect frequently touched surfaces daily, including :
* all environmental surfaces;
* dialysis machine-knobs and exterior surfaces;
* non-uisposable equipment which has been touched.
3
(’lean and disinfect with disposable cleaning cloth using :
sodium hypochlorite (50-100 parts per million free chlorine), or any highlevel disinfectant.
Disinfect fluid pathway of dialysis machines (for control
of bacterial
contamination), using any one of the following solutions:
sodium hypochlorite or
formaldehyde or
glutaraldehyde
Re-use artificial kidney on the same patient only.
\
C) Adapted from Favero MS :
Recommendations for patients undergoing
haemodialysis who have AIDS or non-A, non-B hepatitis. Infection Control 6 : 301 305, 19 .
!
u
Module 3
Exhibit 3.6
AIDS Precautions in (lie Perinatal/Pediatric Areas
To be used with ail patients regardless of diagnosis : *
•
* .
*
Type of Precaution to be
followed
Area where precaution should
he practied
Situations requiring
precautions by providers
Handwashing
Labour and delivery;
nursery; postpartum; pediatrics
All providers before direct
care or invasive procedures;
before feeding or medications;
alter bodv substance contact
Handwashing; gloves
Labour and delivery;
nursery
All providers of direct care
when bathing infants and
during contact with :
• cervix; amniotic fluid
• urine; blood
• placenta; umbilical
cord
• scalp sample
• internal electrodes
• dressings
• diarrhoea
• lochia
Handwashing; gloves;
gowns (or water-proof aprons)
Labour and delivery;
nurse ry
Labour and deliver);
special procedures
Handwashing; gtoves; gowns
masks; eye covering
Resuscitation; before initial body
bath; artificial rupture of
membranes (AROM)
Providers at the patient
perineum bringing these
circumstance
• vaginal delivery;
•
AROM;
•
cesarean section
Use standard blood precautions and aseptic techniques as for hepatitis B :
gloves for contact of contaminated surfaces
gowns where splatter is expected
good handwashng technique
no eating bn the unit
(iiiidelines uckipledfrom Sun I ranuisco (icneral Hospital Medical ('enter.
Other conditions, such as burns or suspected communicable respiratory diseases,
may w arrant additional cure.
3.36
P^YviHjon
Exhibits.?
Situation which may occur in a Health-Care Setting
j ■ A nurse arrives at a health centre to collect supplies for the outreach immunization
service in a nearby village.
She gets sterilized syringes, and asks for a safe
container for the used syringes.
She is told to put them in a small bowl that is
only large enough for the syringes and not for the needles. She says she cannot
handle the needles and gets a big metal jar with a loose lid.
2. A nurse / midwife orders supplies for the following month. There is a budget but
the request is too expensive. She says, "Well, what will it be ? Gloves or a new
stethoscope ? My stethoscope is old, and I need gloves too. What shall I do ? I
will order the stethoscope."
3. A nurse gives a patient an injection. She reminds herself not to recap a disposable
needle, and looks around for a needle container. She does not see one and decides
to put the cap back on the needle. (N.B. Instructors should note that disposable
needles and / or syringes may not be locally available).
4. A nurse / midwife is responsible for the training of traditional birth attendants
in the district. She has ordered gloves for them, but has been told they are not
available.
5. A nurse throws disposable needles in the waste container, which is emptied once
a day into a plastic bag and taken to be buried.
4/
3.37
Module 3
Exhibit 3.8
Possible Answers for the Situations which may occur in a Health-Care Setting.
1. The nurse has found a good solution to her problem.
2. The nurse / midwife is not thinking of her personal protection.
She should
try very hard to have gloves always available for delivering babies. It is best to
have a few pairs per delivery so that she can change gloves, if necessary'.
3. This nurse is running a high risk. If she has no container to put the uncapped
syringes in, there is another solution. Use the "scoop method", by putting the cap
on the table, pushing the needle into it and without hiding the cap in the other
hand, securing it.
4.
If it is impossible to get gloves, the nurse / midwife should teach the traditional
birth attendants to wash their hands frequently with soap and water. They
should also be taught to cover any cuts they may have on their hands with
waterproof dressings. A good handwashing technique is always important.
5. fhe people who remove the waste are at a high risk of injuring themselves from
needles sticking through the plastic bag. People may collect needles. Needles need
to be kept in a hard container for storage, for example, in oil cans, beer bottles or
plastic bottles, until they are disposed of. (Strong cardboard boxes are better
than a plastic bag). If the needles can be burned, that is the best method of
disposal. If that is not possible, they can be disposed of in a pit latrine or buried
where they will not be dug up.
</
HcvcHlipfi pl LILYTraiiMnisM
Exhibit 3.9
Suggested guidelines for the Management of Health Care
Workers exposed to HIV.
If a health-care worker suspects that he / she has been exposed to HIV, the
following action is recommended :
1.
Evaluate and record the type of exposure, e.g. needle stick injury, cut with a sharp
instrument, splash onto mucous membranes or non-intact skin.
2. If HIV testing is available; with his / her permission, test the source patient (if
known) for HIV.
a) If the test is negative, there is no need for a follow-up.
b) If the test is positive, if the patient refuses to be tested or if the source of
exposure is unknown :
•
Counsel the health-care worker about the risks of HIV and HBV
infection and about subsequent risk to the community.
Recommend safer sex, delaying pregnancy and not donating blood.
Ask the health-care worker to report any . febrile episodes within
12 weeks after the exposure. Rashes, fever or swollen lymph glands
should be noted during this period.
With his / her consent, test the health care worker at the time of
exposure for a baseline result, then at six weeks, 12 weeks and six
months after exposure. Most seroconversions will occur within six to
12 weeks.
c) ^11 HIV testing is not available or is prohibitively expensive :
«
•
•
•
•
Evaluate the source patient for risk factors for HIV infection.
Counsel the employee if it is determined that he / she has been
exposed.
,
Monitor the worker for signs of infection such as fever, rashes or
swollen lymph glands within 12 weeks after exposure.
Perform testing at six months, since nearly all sero-testing cannot be
performed, continue to monitor the employee for illness for one year
or until testing can be performed.
Contact the National AIDS Committee, if there is any, for information.
Nurses, being frontline care-providers, are instrumental in preventin'’ the
spread of Hiy and other vireses or microbes. By becoming informed and utilizin'’
this 1 ■nowledge in -practice, nurses can prevent the spread of HIV infection to
patients and themselves. In doing so, nursing care can be provided to the infected
person with compassion and without fear.
}
Module 3
3J9
Exhibit 3.10
Health-Care Workers with HIV Infection
Questions with Answers
Q.
Is it safe to work with someone infected with HIV ?
Ans. Yes. Most workers face no risk of getting the virus while doing their work. If
they have the virus themselves, they are no risk to others because of their work.
Q.
If a worker has HIV infection, should he or she be allowed to continue work 9
Ans. Healthy Workers with the infection should be treated in the same way as any
other workers. Those with AIDS or AIDS-related illnesses should be treated in
. the same way as any other workers who are ill. Infection with HIV is not a
"reason in itself for termination of employment.
Q.
Does an employee infected with the virus have to tell the employer about it 9
Ans. Anyone who is infected or suspected to be infected, must be protected from
discrimination by employers, co-workers, unions or clients. Thus, employees
should not be required to inform their employer about their infection. If good
information and education about AIDS are available to employees, a climate
of understanding may develop in the workplace. It will be then be possible to
face the situation more openly.
Q.
' Should an employer try to find out if any workers are infected with HIV ?
Ans. Testing for HIV should not be required of workers. Imagine that you are a
worker with HIV infection and are healthy and able to work. As far as your
work is concerned, the information on the virus is private. If it is made
public, you could be a target for discrimination. If Al DS-related illness
makes you unfit for a particular job, yod should be treated in the same way as
any other employee with an illness. A suitable alternative job can often be
arranged by the employer. Employers in different parts of the world are dealing
with these problems. Their associations and unions can help stop the disease by
providing all workers with information and education and referring those
concerned for counselling about AIDS.
;■
Prevention oLl IlVM-ransiiiissron in Hc.ilili-( arc Scuiims
Exhibit 3.11
Examples of a Situation for working out Teaching Strategies for
Changing Practices in Health Care Settings
Situation 1
A woman brings her baby, who has a fever, to the clinic.
given tablets instead of an injection, the mother becomes angry.
When the baby is
This is a community
in which nurses have given a lot of medicine by injection when available, because the
people believe
it
works
better.
Sterilization
procedures
are difficult.
For,
sufficient equipment needed for daily use is not available.The nurse is worried that
clinic staff may be giving injections with unsterilsed equipment.
1.
What is your objective for your patient ? For the community9
(What do you want to accomplish ?)
2.
In meeting your objectives, what may be difficult to teach ?
3.
What could you do to convince the mother that unnecessary injections should be
avoided ?
4. How could you teach others in the community that injections are not always better
than pills ?
5.
What can you do to prevent staff from using unsterilised syringes and needles 9
What will you tell them 9
Situation 2
A man comes to the health centre with fever and a swollen arm. He says
he has gone to a lay practitioner for injection.
The practitioner is a local leader
who
is highly respected in the community.
You know, the man would respect
advice more than yours, and you are afraid he will stop coming to the clinic
his
if you
suggest that the practitioner is doing something wrong.
I.
What are your objectives for the patient 9
For the community 9 (What do you
want to accomplish ?)
3.
What problems could you face in meeting your objectives 9
What strategies could vou use to prevent the patient from seeking injections from
the practitioner 9
4
What
strategies
could’, you.use- to
teach
others
in
the community to avoid
seeking injections from lay practitioners '?
S
What strategies could you use to teach local practitioners to sterilize their
equipment
J
3.4J
Module 3
Situation 3
Your group is a management committee in a hospital working on the
development of new policies and procedures for infection control precautions to
prevent the transmission of blood-borne pathogens. You are to develop a plan for
leaching the staff how to use these procedures. The staff includes nurses on the
wards and in the emergency room, the housekeeping staff, and the laboratory
workers. They have used the same procedures for 20 years, and you have already
liiird some laboratory staff and nurses say they want to have all patients tested for
HJV antibodies.
1. What are your objectives ?
2. What.problems are likely to arise in meeting your objectives?
3. What changes should you make to the existing policies ?
4. Whom do you propose to teach about these changes ?
5. How will you teach them (e.g. in small or large groups, in lectures, or with
demonstrations of techniques ?
Situation 4
You are pan of a clinical management committee that has been formed to
study ways to limit the number of unnecessary blood transfusions. It has been
discovered that several children may have become HIV infected from blood
transfusions. Most are anaemic as a result of malaria. You have been told that
screening of blood for HIV may be done within one year.
1. What.are your objectives ?
2. What are the most common medical conditions requiring blood transfusions in your
wor^ setting ?.
j.
What other interventions are there, besides blood transfusions,which might
solve these medical problems once it exists) ?
4. Who needs to know about these solutions ?
5. How will you present these solutions to them ? (What kind of person will they
listen to ? What information will convince them that there is a problem ? How
can you convince them of the solutions ?)
i '■
' 42
Prevention of HIV Transmission in Health-Care Settings
Exhibit 3.12
Possible Answer to Situations given in Exhibit 3.11
Possible Answers - Situation I
1.
To give oral medication, whenever possible, and to avoid unnecessary injections;
to try to make the mother satisfied
with this;
to teach staff to use sterilized
needles and syringes; to obtain sufficient equipment; to teach the community
about unnecessary injections.
?
The mother thinks injections are Ibetter.
The
community
is used to injections
Hence, changing attitudes may be difficult.
3.
1 ell her how medicine is absorbed ; draw a simple diagram to show how medicine
goes into the blood stream from the stomach.
4.
Contact local community leaders and talk to them about
advice; request a meeting and teach groups
the problem; seek their
of people what you have told the
mother.
5
Plan
training for the staff immediately
after
Demonstrate the correct way of handling
needles.
there
the
clinic closes for the day.
and sterilizing
Provide information on how HIV is transmitted.
are not
enough
dirty
syringes and
If the problem is that
needles and syringes, oblige the clinic to re-use them,
disepss with your supervisor the possibility of writing
responsible at the national level, informing him
or
a letter to the person
her
of
your
your
concern
Discontinue the practice of unnecessary injections. Contact a local agency, such
as a church mission
or
the
Red Cross, and ask them for
more
needles
and
syringes.
Possible Answer - Situation 2
1 o encourage everyone in the community
untrained people
7
to
avoid
getting injections
I he patient trusts the practitiojier and the community also trusts him
from
You arc
seen as an outsider.
Explain to the patient the inode of transmission of HIV tetanus, and other
infections. I real the infection, which will help him gain trust in vou and your
u
3.43
ModulcJ
expertise. Draw simple diagrams to explain about micro-organisms. Find out
why people go to the practitioner.
4. Check the law to find out who is allowed to give injections. If lay practitioners
cannot by law give injections or buy medicines, contact your local supervisor
about the problem. Approach the practitioners and explain to them your concern
about possible HIV transmission and seek their advice. Call a meeting of the
local people in the community and explain to them the dangers of having
injections from equipment which is not properly sterilized.
5. If the practitioner is working within the law, explain the problem to him and offer
to show how to sterilize needles and syringes.- Consider ways to make more
syringes available, if necessary'.
Possible Answers - Situation 3
1. To implement universal precautions throughout the hospital and to have all staff
use and understand these precautions.
2. Possible problems include : the staff are used to disease-oriented infection control
precautions; they are used to other ways of doing things; they have no confidence
in what you tell them; and a general shortage of supplies may exist.;
3. To use precautions when dealing with blood and other body fluids’- from
everyone; not to label specimens as infectious, but to treat them all as infectious;
to wear gloves when drawing blood and during any.procedure in which contact
with blood or other body fluids is a possibility.
4. Everyone who may have contact with patients or specimens needs training in
universal precautions. Otherwise people will be confused when they see others
changing their procedures.
5. One method would be to visit each department individually (each nursing unit,each housekeeping team, the laboratory etc.) and provide information to small
groups. Those concerned can then ask questions.
Possible Answers - Situation 4
{•
1.
fo prevent HIV transmission by blood transfusion.
2.
Malaria, sickle cell anaemia; blood loss due to haemorrhage of childbirth trauma
or surgery.
,
. -
' 'r
-
4.*
Prevention of HT\\Iransimssion in Health-Care Settings
3
Malaria identify cases early and treat the disease before the anaemia develons
discuss vector control.
'
Sickle cell anaemia : give recommended childhood vaccines; treat all illnesses
eailv. treat exacerbations early. Blood loss due to surgery, childbirth, trauma
check the haemoglobin content and with minor blood loss, if possible, give
intravenous, high- molecular fluid replacement rather than blood.
antenatal services to prevent complicated labour.
4.
5.
Strengthen
Malaria and Sickle cell anaemia : parents need to know the symptoms; nurses in
district health centres need to identify cases early and to guide parents; and
treatment needs to be provided Blood loss : physicians aixfnurses in surgeiv,
labour and delivery rooms and in emergency rooms.
Nurses can teach parents and community
members.
Sometimes having
a
meeting and asking a respected community leader to introduce you, will »ive
even more importance to the problem. If members of the community know That
people are getting HIV infection from blood transfusions, they are more likely
to be concerned. If you then present beneficial solutions, they will probably be
interested in implementing them.
In addition, nurses can become local experts on HIV infection
arrange in-senace education for their colleagues.
and can
Module 4
•1.1
MODULE 4
PSYCHOSOCIAL IMPACT OF HIV INFECTIck
ON THE INDIVIDUAL AND THE COMMUNITY
SECTION -1 : SIM
I.
OVERVIEW
The learners are expected to have developed an understanding of’:
•
•
•
•
basic concepts of epidemiology and transmission of HIV / AIDS,
HIV / AIDS disease concepts and its prevention and control,
ethical guidelines of nursing profession,
any local policies or guidelines on HIV care,
the‘concepts of community based care in terms of socio-cultural pattern,
population mobility and community support.
On completion of this module the learners will be able to identify the
psychosocial factors that affect people with HIV infection, be aware of the nurse’s role
in relation to social attitudes and their effect on the individual and identify the
community support.
II.
SPECIFIC OBJECTIVES
On completion of this module, the learner will be able to :
•
•
•
•
•
•
discuss the ways in which some diseases are stigmatised;
discuss the social and cultural attitudes and beliefs that affect individuals with
HIV and their care;
describe the ways that HIV infection might have a psychosocial impact on
individuals in their community;
identify existing resources in the community that can meet the psychosocial needs
of affected individuals;
describe the constraints that nurses work with in meeting the psychosocial needs
of people with HIV (cultural, social, ethical and professional);
identify strategies for strengthening and developing community based support
systems for people with HIV infection.
i
4.2
Psvchosocial Impact of HIV Infection on
the Individual and the Community
III. INTRODUCTION
This module deals with the response of the individual and community to the
AIDS epidemic, the ways the psychosocial effects of infection are influenced by this
response and the role of nurses in reducing the impact of these effects and
strengthening community resources.
HIV and AIDS are more than medical problems. Due to their association
with sexuality, illness, loss and death, they arouse strong feelings and relate to our
values. The required attention needs to be given to analyse the impact of these
feelings and values on the families of patients or on patients and their dependents.
Nurses are, of course, members of the societies they live in and are influenced
by the prevailing cultural, social and religious attitudes. This can sometimes affect
their attitudes towards those they care for and lead to conflicts with professional
guidelines. Nurses who are working to change social attitudes towards any aspect of
AIDS care or prevention can find themselves at odds with their communities and
with local policies relating to HIV.
In order to communicate on HIV / AIDS, we need to clarify our own
values and attitudes on related issues and help those with whom we communicate and
understand their values and attitudes related to the same.
Whenever people discuss personal attitude and belief about controversial
subjects, there is a possibility of strong feelings. AIDS raises issues connected with
sexuality, drug use, death, morale, prejudice and many other difficult areas. It is
advisible not to exert on any' one to share their personal views; maintain
confidentiality of any information that is shared, respect the rights of others to hold
opinions with which we disagree and make sure that everyone has the opportunity to
speak.
IV.
DESCRIPTION OF CONTENT
Content for the module is organised under the following headings
1.
2.
3.
4.
Stigma and Disease
Attitudes to HIV and AIDS
Psychosocial Impact of HIV infection on the individual
Existing resources for support in the community
Constramts and strategies lor Nurses.
|
I
1.3
Mwlyk .1
Stigma and Disease
L
LI HIV / AIDS is Seen Different and Holds Stigma
HIX’ / AlDs holds a social stigma and is seen by member of the community
to be different from many other diseases prevalent in the community. People are
found to have different social attitudes and beliefs about HIV / AIDS. These
differences may be due to differences in attitudes, beliefs, theories, religious ideas and
so on.
Cultural values are the basis for the community response to HIV infection /
AIDS. The attitudes and , values that exist are affected by an individual's
preference for sexuality (homosexual, bisexual, heterosexual), intravenous drug use,
fear of contagion, death and dying,, religious or spiritual beliefs, health care facilities,
socio-economic condition and history of society.
1.2 Implications of these Differences on HIV / AIDS patients
(»)
Emotional and fearful responses : HIV / AIDS has often resulted in
highly emotional and fearful responses among the people in general and
HIV / AIDS patients and their families in particular. These responses
are because :
9
A
e
(K)
the mortality rate is very high
it is incurable disease
there is no vaccine to prevent it
it is.sexually transmitted disease
many of t hose affected may already be stigmatised in their societies.
Economic Loss and Feeling of Insecurity : Due to social stigma
patient's/ client's family face direct economic loss due to medical care
and loss of livelihood because often the person is ostracized and looses
his job.
i
(iii) Victimization : There is another cost which cannot be quantified, that is,
trauma of victimization for the person (Refer Content-1 in Module 1 for
details). An example of victimization from Kochi is reported below :
Example 4.1
A case of victimization reported from a village in Kochi. A young man
returned from a spell of employment in Bombay and fell sick as an outcome of HIV
infection. When the source of his illness became known, his elderly parents were
made socially outcast" and destitute and the young man was hounded from the
village. Not only does this case illustrate the need for confidentiality in HIV
diagnosis, but many other social and economic impacts and interactions, the
- Psychosocial Impaci of HIV Infection on
(he Individual and the Community
vulnerability of migrant workers; loss of livelihood for the patient and dependents;
loss of shelter and community support. Examples 1 to 5 narrated in Module I also
depict a similar reaction by the employer, neighbour and the communitv at large.
2.
Attitude to HIV and AIDS
HIV and AIDS, due to their association with sexuality, illness, loss and
death, arouse strong feelings and emotional reactions related to our values.
In
order to communicate on HIV / AIDS, we need to clarify our own values and
attitudes on related issues and help those with whom we communicate to understand
their values and attitudes related to the same.
2.1 Classification of Controversial Statements
To clarify the above mentioned controversial statements; the content is
under the following headings .
i.
ii.
iii.
iv.
v.
vi.
(i)
discussed
The faulty logic and prejudgemental attitude behind demands
for testing.
The trend towards scapegoating.
Understanding homosexuality.
The hesitation about condom availability and the spread
of
knowledge
about its use.
The rights of the HIV / AIDS affected person.
The Faulty Logic and Prejudgemental Attitudes behind
Demands for Testing : Advocates of testing believe that the test will
identify people who are likely to transmit HIV infection and will then
enable the society in some ways to prevent them from transmitting the
disease to others. This argument is a flaw, because this demand is
essentially the prejudice about groups that are seen at risk, e.g. sex
workers, homosexuals, intravenous drug users etc. Another reason may
be fear and a desire to punish the groups seen as “responsible” for AIDS.
In India, such tests are not available everywhere and counselling
facilities of a uniform standard are not available in all parts of the country'.
Availability of testing needs to be backed up by a strong counselling and
support services network
In its absence, testing will only identify
those who are infected but not help them to cope with HIV and live
positively.
(•i)
The Trend Towards Scapegoating (Blaming) : Babies with HIV
infection, haemophiliacs, those infected with untreated blood, spouses of
1.5
Modulejl
the HIV positive individual are seen as "innocent", deserving sympathy,
while the "guilty" viz. prostitutes, homosexuals, injecting drug users are
seen as deserving to die. This tendency to isolate some for responsibility,
leads to a chain of blame, anger and resentment, creates rifts between
people, and does not contribute positively to the control of AIDS.
(iii) Understanding Homosexuality : 'Gay' men are men who have sex with
men. It must be emphasized that though different from the majority
of the people in society, homosexuality does exist. Such individuals are
often victimised by the society because homosexuality is seen as a
moral error rather than a matter of psychological and social identity
and choice.. It is important to accept everybody even if we do not always
approve oft heir behaviour.
.
(iv) The Hesitation about Condom Availability and the Spread of
Knowledge about its Use : There are strong taboos - religious,
cultural and social that prevent the free availability of condoms,
especially for young people. It is feared that availability will encourage
sexual experimentation by the young. It is important to impart correct
information and to inculcate appropriate values about safe and
responsible sex. Non-availability of condoms may place people at the
risk of exposure to HIV infection. Prevention can be made easier if
placed in the.hands of the people themselves, i.e. condoms are made
accessible. This does not mean that one is encouraging young people to
have sex. However the knowledge on use of condoms should be
imparted.
(v)
A
The Rights of the HIV / AIDS Affected Persons : Society is often
conscious of its rights to protect the uninfected against infection from
HIV / AIDS. This is why there are repeated demands for isolation of
people who have HIV / AIDS, and for informing their near and dear ones
as well as acquaintances and colleagues. Several counter arguments can
be offered.
•
«
•
I
I
Isolation increases the conspicious presence of the person.
Isolation is stigmatizing as has been the case of in leprosy.
Prevention of transmission of the infection does not necessitate
physical isolation but preventive behaviour e.g. use of condoms.
Merely informing those in the social network may lead to rejection,
social isolation and discrimination. Counselling and seeking support,
however, may lead to a different outcome. The individual must be
given the right to decide whether he / she wants to inform, who
he / she wants and when, how he/she wishes to inform.
Psychosocial Impact of HIV Inl'cciion on
the Individual and the Community
2.2 Check Your Progress - 1
(i) Given below are'thc following statements.
encircle (T), if you find them false, encircle (F).
If you find the statements as True,
a. The mortality rate in HIV / AIDS is very low
b. HIV / AIDS is incurable
c. HIV is preventable
d. HIV / AIDS affects children also
e. HIV / AIDS is sexually transmitted
f. Community accepts the patient with
HIV / AIDS as patients with other diseases
3.
T
T
T
T
T
F
F
F
F
F
T
Psychosocial Impact of HIV Infection on the Individual
Persons with HIV infection / AIDS may not like to share personal experience
with any one because of its psychosocial implications influenced by social altitudes.
You need to understand the possible responses felt and experienced by persons with
HIV i AIDS and the related social issues which are discussed in this part. This
presentation would help you to appreciate and identify psychological and social, needs
of HIV / AIDS patients and thereby provide good psychosocial care to them.
3.1 The Psychological Issues Faced by most People with HIV / AIDS.
The psychosocial issues faced by HIV/ AIDS persons revolve around uncertainty
and adjustment.
■1
0)
Uncertainty : With HIV infection, uncertainty emerges with regard to
hopes and expectations about life in general, but it may focus on family
job and longetivrty and quality of life. They need to be discussed
openly and frankly, but- care should always be taken to encourage
hope and a positive outlook.
(■■)
Adjustment : In response to uncertainty, the person with HIV / AIDS
must make a variety of adjustments. Even the apparent absence of a
response or denial is an adjustment in itself People start adjusting to
news of their infection or disease from the time they are first told. Their
day-to-day lives will reflect the tension between uncertainity and
adjustments. It is this tension that causes other psychosocial issues which
requrie attention of health workers.
k /
-4 *
3.2 fhe Possible Emotional Response of Persons with HIV / AIDS
The possible emotional responses felt by HIV / AIDS people are described below
(i)
Fear : People with an HIV infection or disease have many fears The fear
of dying and particularly of dying alone and in pain is often ver)’ evident.
Fear may be based on the experiences of loved ones, friends or colleagues
who have been ill with, or died of AIDS. It may also be due to
ignorance of what is involved and how the problems can be handled.
They should be discussed in the context of managing the difficulties
including with the help of friends and family or the counsellor / nurse.
(ii)
Loss : People with HIV disease experience a sense of loss in terms of
decreased life span and ambitions, their physical attractiveness and
potency, sexual relationships, status in the community, financial
stability, and independence. As the heed for care increases, a sense of
loss of privacy and control over one's own life will also be experienced.
Perhaps, the most common loss is the loss of confidence.
(iii)
Grief : People with HIV infection often have profound feelings of grief
about the losses they have experienced or expecting to come. They may
also suffer the grief that is projected on to them by close family members,
lovers, spouses and friends.
(iv)
Guilt : A diagnosis of HIV infection often provokes a feeling of guilt of
having infected others, specially wife and children; or for the behaviour
that may have resulted in the infection
(v)
Depression : Depression may arise for a number of reasons. The absence
of a cure and the resulting feelings of helplessness, the loss of
personal control associated with frequent medical examinations, and the
knowledge that a virus has taken over one's body are all important
factors Similarly, knowing others or about others who have died or
are ill with HIV disease, and experiencing such things as the loss of
potential for reproduction.
(vi)
Denial Some people may respond to news of their infection or disease
by denying it For some people, initial denial can be a constructive wav
of handling the shock of diagnosis If denial persists, person with HIV
infection may not seek medical help.
(vii) .Anxiety
The reasons for anxiety reflect the issues discussed above and
concern the following
•
•
•
x
Prognosis in the short and long-icnn
Risk of infection with other diseases
Risk of infecting others with 111\
4.8
Psychosocial hnyact of HIV 1 n feed on on
the Itrdividual and the Cominunitv
'• 7-
o
4
9
»
»
(viii)
Social, occupational, domestic and sexual hostility and rejection.
Abandonment, isolation and physical pain.
Fear of dying in pain or without dignity.
inability to alter circumstances and consequences of HIV infection.
How to ensure the best possible health in future.
Ability of loved ones and family to cope.
.Availability of appropriate medical / dental treatment.
Loss of privacy and concern over confidentiality.
Future social and sexual unacceptability.
Declining ability to function efficiently.
Loss of physical and financial independence.
Anger
Some people become outwardly angry because they feel they
have been unlucky to contract the infection. They often feel that
confidentiality is not maintained. Anger can sometimes be directed
inwardly in the form of self blame for acquiring HIV, or in the form
of self destructive (suicidal) behaviour.
(ix) Suicidal Thinking : People who are infected with HIV will have a
significantly increased risk of suicide. Suicide may be seen as a way of
avoiding pain and discomfort or of lessening the shame and grief of loved
ones. Suicide may be active (i.e. deliberate self injury resulting in
death) or passive (i.e. concealing the onset of a possibly fatal
complication of HIV infection).
(x)
Self Esteem : Self-esteem is often threatened early in the process of
living with HIV. Rejection by colleagues, acquaintances, and loved ones
can quickly lead to loss of confidence and social identity, and thus
reduced feelings of self-worth. This can also be due to the physical
impact of HIV-related diseases
like facial disfigurement, physical
wasting, and loss of strength and bodily control.
(xi) Hypochondriajind Obsessive States Pre occupation with health and
even
the smallest
physical changes or sensations can result in
hypochondria. This may be for very short duration in most of HIV
infected persons but may persist in few.
(xii) Spiritual Concerns : Concern about impending death, loneliness, and
loss of control may give rise to an interest in spritual matters and a search
for religious support.
u
4.9
ModulcJ
1
3.3 Possible Social Responses Experienced by Persons having HIV/AIDS
The possible social responses experienced by persons with HIV / AIDS are
rejection, withdrawal or caring and support.
(i)
Rejection
The person with HIV / AIDS is often unwanted /
unaccepted or abandoned by the family, friends, neighbourhood and
community at large and employer. He gets the feeling of rejection.
Abandoning of a person with HIV / AIDS by the family can cause
problems and add to the pain. The children will certainly sutler if either
of the parents is affected. They need love and guidance from both the
parents. It is of no use to blame anyone about bringing HIV infection
in the family. It is more helpful to support each other, plan for the
future and enjoy the remaining days together.
Often friends, neighbours and community ostracize the people having
HIV ! AIDS due to social stigma and fear of contracting the infection
by casual contact with HIV / AIDS patients. The underlying cause for
such perceptions and responses is ignorance.
(ii) Withdrawal : The persons with HIV / AIDS often become quiet, feel
lonely and retreat. They may feel disgraceful because of involvement of
their personal behaviour, life-long infection and incurable disease and
resulting feeling’of helplessness.
(iii) Care and Support : Family and friends can give care provide love
and support and can share the financial burden. Community can develop
and establish a support system and provide help for comfort and
rehabilitation.
These are positive social responses experienced by the
person having HIV / AIDS;
3.4 Social Issues
Environmental and social pressures, such as (i) loss of income, (ii)
discrimination, (iii) social stigma (if the diagnosis becomes commonly known), (iv)
relationship changes, and (v) changing requirements for sexual expression, may
contribute to post-diagnosis psycho-social problems.
The case of Batwa from Bombay given below, explains the psychosocial impact
of l llV / AIDS on the individual.
j-
-i ill
Psychosocial Impact of HIV •Injection (in
~ the individual and the Community
Example 4.2
"1 have been forced to abandon my children. Each time I look at her, I die,
says Batwa about his four-year-old daughter Asha. Of late, he has given up looking
at her Asha with one hand hooked every six hours to a 25 percent glucose drip
silently awaits death. In the last 30 days, she has lost I kg. Now she weighs just .
kgs A blood test last month showed she was HIV positive. Her sister, mne-yearold Urmilla who cared for Asha at Bombay's G.T. Hospital, talking to her and feedmg
her left after the blood test. Urmilla and her six-year-old brother Ganesh have been
placed in a home for orphans. Says a doctor in the hospital's skin department :
"Asha has AIDS. There-is no hope for her." The irony of the child's name escapes
him.
Batwa's real name is Mohan Girdhar Wagela. He is an assistant in G T.
Hospital's mortuary. Over the past 12 years, he acquired the reputation ot bemg a
hard worker. In the past six months, his reputation has been replaced with that ot an
alcoholic. Says Bhishambar Muktaram, a sweeper if. the hospital who has known
Batwa for many years : "There was a time when all you heard was 'Batwa, Batwa,
Batwa' in the mortuary. He was so skilled, doctors did not want to use any other
help. Lekin, ab iska ticket kat gaya (But now, his days are numbered)." Because
Batwa too, like his little daughter, is a victim of AIDS.
For 12 years, he lived within the compound of the hospital, his bed spread
below the shade of a banyan tree. Roughly a year ago, his wife Meena, was admitted
to the hospital's TB ward. Fellow workers asked him to leave. He moved with his
three children to a hut nearby. But when Meena died five months ago, everything
crumbled. "This is my wife," says Batwa, pointing to a postcard Size photograph
photograph. I
know, s^e died of AIDS."
Batwa is not allowed to work now. Until recently, every time he met Asha,
she asked for biscuits and ice-cream. Batwa begged for the money so that he could
keep Asha happy "Now 1 can’t do it anymore. People have abandoned me. And
have been forced to abandon my children." For the next half-hour Batwa cues. No
one around him says a word. No one tries to console him. In Ward 14. Asha too
cries alone, unaware of the fate that awaits hei
■ lilill
4J1.
Module 4
3.5 Check Your Progress - 2
(i) Match the statements given in Column A with the terms in Column B. Place the
alphabet in the space given in Column A.
Column
I
4.
A
Column
B
A. He has been indulging in
all the sin, so it is good
that he is being punished.
Gives a feeling of
a. self-esteem
B. "No body will come to me
even though I am dying because
I have AIDS" Gives a feeling of
b. rejection
C. "After all 1 had been
enjoying sex with so many
partners. God had topunish me"
Gives a feeling of
c. Anxiety
D. "Now what is the use of
living 1 have AIDS" is due to
the feeling of
e. Fear
E. "Even though my tests arc
positive I have no symptoms"
.is due to a feeling of
g. Depression
d. Loss
f. Guilt
h. Denial
Existing Resources for Support in the Community
Since the beginning of any epidemic, nurses have assumed a leadership role
within their work environment and community. In communities which have not yet
determined how they will prevent the transmission of HIV or how care will be
provided, nurses may need to initiate the development of such services.
4.1 Existing Resources
Some health services may already exist within the community and may be able to
. provide some of the necessary sendees. For example, there may be :
i.
services which have been or are in the process of being developed which are
specifically forHIV / AIDS; within the community.
I
■i
-1.20
Psychosocial Impact of HIV Infection on
the Individual and the Community.
Feelin'js dfrKit HIV
AIDS
Loneliness
If you have HIV or AIDS,
remember you are not alone.
Many other people have HIV
or AIDS.
If someone you know has. HIV
or
AIDS.
give
them
companionship.
Jake oway
their loneliness.
Fear
People with HIV or AIDS fear
many things :
Pain
Losing their job
• Other people knowing that they are
infected
• Leaving their children
•Death
X
!r
It is frightening to have HIV or AIDS, but you may find that your
fear becomes less when you talk to someone who understands.
You may also find that you are worried about things that you de not
need to fear. For example, you may find that, when other people learn
you have HIV, they show you great love and kindness.
/
>
4.22
Pss'chosocial Impact of HIV Infection on
the Individual and the Community
Feelings about HIV * AIDS
Acceptance
After some time most people with
HIV or AIDS accept their
situation.
This is helpful.
They often feel more serene
(peaceful in mind). They often
feel able to begin to think about
the best way to live. They think
“What can I do to make the best of the rest of life ?"
"What foods should I eat to help me stay healthy ?”
‘What plans shall I make so my children
_i are provided for in future ?"
3
i
They might also think : “Let me be grateful for every day.
Let me appreciate my friends and family”.
4.23
Module 4
Feelings about HIV & AIDS
Hope
People with HIV or AIDS can have hope about many things :
• hope that they will live a long time
• hope that scientists will find a
cure
• hope that the doctor will be able to
treat each sickness as it comes
• hope because they are loved and
accepted for who they are
• hope because of their belief in a
life after death.
It is important to have hope.
Hope lifts your spirits and gives you
strength to face each situation. Hope can help you to fight HIV and
AIDS and 1 ive longer..
Remember : Even if you have hope today, it is possible to feel angry
or depressed tomorrow. This is normal. The important thing is to
try to regain the feelings of hope again and again.
)
4.24-
Psychosocial Impact of J {IV Infection on
the Individual and the Community
Living positively with
HIV and AIDS
Hope and acceptance can help you to live positively with HIV and AIDS.
But what does living positively mean ?
In the following pages, you can read about how families, friends and
neighbours can help people with HIV or AIDS to live posttiveiy.
4*2?
Exhibit 4.3
RolePlay Depiclinii (’onstraints of an IIIV Patient and Nurses
The nurse \ isits Mr. Kam in the community where he is living with his wife
and child Kam is sitting in the outer room, his wife is working m the kitchen and
his son has gone to school.
Nurse
Namaste. Kam
Kam
Namaste. Behanji
Nurse
1 low are vou. Kam ”
Kam
I am
Sister
Nurse
Kam. haven't vou told your wife about the problem as yel
Kam
No. What is the need 9 I will be alright. Please don't talk to my wife
(Wife enters).
Wife
Namaste, Behanji. What happened to my husband
Nurse
(even though she wants to discuss but restrains
herself). I came to visit all of you to find out if anvone is sick
in the family- I was telling your husband to come ‘o the Centre as
he looks very weak.
Wife
No,
Nurse
Kam, come to the Centre tomorrow at 10 AM to get some
tonic as you look pale. (Nurse instructs Kam's wife to send her
husband positively to the centre).
perfectlv alright. Why have you come
You should have called me at the Centre
Behanji.
here.
Everyone is alright - thank you very much
4.26
Psychosocial impact of HIV Infection on
the Individual and the Community
•<
Exhibit 4.4
INTERNATIONAL COUNCIL OF NURSES CODE FOR NURSES
Ethical Concepts Applied to Nursing
The fundamental responsibility of the nurse is fourfold: to promote health, to
prevent illness, to restore health and to alleviate suffering.
The need for nursing is universal. Inherent in nursing is respect for life, dignity
and the rights of man. It is unrestricted by considerations of nationality, race, creed,
colour, age, sex, politics or social status.
Nurses render health services to the individual, the family and the community
and coordinate their services with those of related groups.
Nurses and people
The nurse's primary responsibility is to those people who require nursing care.
•
The nurse, in providing care, promotes an environment in which the values,
customs and spiritual beliefs of the individual are respected.
The nurse holds in confidence personal information and uses judgement in sharing
this information.
Nurses and practice
The nurse carries personal responsibility for nursing practice and for maintaining
conif^etence by continual learning.
1 he nurse maintains the highest standards of nursing care possible within the reality
of a specific situation.
The nurse uses judgement in relation to individual competence when accepting and
delegating responsibilities.
I he nurse when acting in a professional capacity should at all times maintain
standards of personal conduct which reflect credit upon the profession.
Nurses and society
1 he nurse shares with other citizens the responsibility for initiating and supporting
action to meet the health and social needs of the public.
Psychosocial Impact of HIV Infection on
the Individual and the Community
4.26
Exhibit 4.4
INTERNATIONAL COUNCIL OF NURSES CODE FOR NURSES
Ethical Concepts Applied to Nursing
i
The fundamental responsibility of the nurse is fourfold: to promote health, to
prevent illness, to restore health and to alleviate suffering.
The need for nursing is universal. Inherent in nursing is respect for life, dignity
and the rights of man. It is unrestricted by considerations.of nationality, race, creed,
colour, age, sex, politics or social status.
Nuises render health services to the individual, the family and the community
and coordinate their sendees with those of related groups.
Nurses and people
I he nut sc s ptimary icsponsibility is to those people who require nursing care.
fhe nurse, in providing care, promotes an <environment in which the values.
customs and spiritual beliefs of the individual are respected.
'fhe nurse holds in confidence personal information and uses judgement in sharing
this information.
Nurses and practice
fhe nurse carries personal responsibility for nursing practice and for maintaining
competence by continual learning.
♦
1 he nurse maintains the highest standards of nursing care possible within the reality
of a specific situation.
•
1 he nurse uses judgement in relation to individual competence when accepting and
delegating responsibilities.
The nurse when acting in a professional capacity should at all times maintain
standards of personal conduct which reflect credit upon the profession.
Nurses and society
•
The nurse jshares
’
with other citizens the responsibility for initiating and supporting
action to meet
'eet the health and social needs of the public.
4 2"
X kxl 11 le 4
Nurses and co-workers
•
The nurse sustains a cooperative iclalionship with co-workers in nursing arid olhei
fields.
•
I he nurse takes appropriate action to safeguard the individual when his care is
endangered by a co-worker or any other person.
Nurses and the profession
•
The nurse plays the major role in determining and implementing desirable standards
of nursing practice and nursing education
•
The nurse is active in developing a core of professional knowledge.
•
The nurse, acting through the professional organization, participates iin establishing
and maintaining equitable, social and economic working conditions in nursing.
5.J
Module 5
MODULE 5
DEVELOPING COUNSELLING SKILLS
SECTION -1 : SIM
I.
OVERVIEW
The learners are expected to have developed an understanding of basic
concepts about epidemiology and transmission of HIV / AIDS, dynamics and
prevention of HIV / AIDS transmission in health care settings, and the psychological
impact of the infection on the individual, family and community.
On completion of this module the learner will be able to understand the basic
theory and practice of counselling skills in caring for people with HIV / AIDS and
in preventing the spread of HIV. The learners should be able to begin using the
skills themselves with adequate guidance and support.
II.
SPECIFIC OBJECTIVES
On completion of this module, the learner will be able to :
•
•
•
•
•
•
pinpoint the components, objectives and techniques of communication.
be aware of the barriers that obstruct effective communication.
identify the counselling skills that are appropriate when talking to patients in the
context qfTH V.
relate why counselling skills are important to HIV.
reject on examples from their own clinical practice / given examples where couns
elling skills could have been used more effectively.
specify the issues involved in pre -and post-HIV antibody test counselling.
HL INTRODUCTION
In the field of HIV7 AIDS, counselling skills can be used in any encounter
between nurses and patients. In practice, they are used in two basic ways :
•
•
)
Preventing transmission of HIV infection through motivation and behaviour
change.
Providing psychosocial support to those infected or affected (e.g. patient’s
family) by HIV.
Module 5
1.2
Components of Communication
Components of communication are source(s), message(m), channel(c) and
received R).
(i)
S - "source” :
message.
'sender' or encoder or person who initiates or starts
the
(ii) M - "message” : The content which is to be conveyed. It can be verbal or non
verbal. Verbal is obvious and recordable where as bulk of communication is
generally non-verbal by means of tone, voice, posture. Looking out for both
these components may help the counsellor to see beyond what the client is
obviously stating.
(iii) C - "channel” : Modes used for communication are :
seeing, touch, smell and taste and speaking.
Senses of hearing.
(i\j R - "receiver” : Decoder or receiver who receives the message.
Sender and receiver may be the client, friends, relatives or counsellor. Sender
and receiver needs to have similar communication skills, attitudes,
knowledge, understanding level and cultural pattern.
1.3
Objectives of Communication for HIV /AIDS
The objective of communication is to counsel the client to bring a
sustained change in his / her behaviour, refer figure 5.1 to understand the process
of behaviour change through communication.
For example, the objective of
counselling a person who smokes would be to achieve a change in his / her behaviour
pattern^ i.e. stop smoking. The first step is to create awareness about the ill- effects
of smoking on one's own health through education / counselling. This awareness is
not adequate if it is not personalized enough to cause concern. The combination of
awareness and concern can motivate a person to change, i.e. to quit smoking or cut
down on smoking.
j
A readiness to change needs to follow. This involves preparedness for coping
with the negative effects of a new behaviour. In the case of quitting smoking, some
negative effects could be : peers making fun of him, experience of uneasiness,
recognising that one may have to replace smoking with a less harmful habit etc. This
stage then leads tojrial of new behaviour perhaps with some anxiety about its success.
1 he response to the success of this new behaviour and experiences encountered
may lead to a sustained behaviour change.
5.4
Developing Counselling Skills
UNAWARENESS
EDUCATION / COUNSELLING
AWARENESS
PERSONALIZING THE INFORMATION CAUSING CONCERN
-
▼
MOTIVATION TO CHANGE
PREPAREDNESS FOR
COPING WITH NEGATIVE
EFFECTS OF NEW BEHAVIOUR
(CHANGE)
READINESS TO CHANGE
TRIAL OF NEW BEHAVIOUR
ASSESSMENT OF NEW BEHAVIOUR
SUCCESS IN
CHANGE IN
BEHAVIOUR
■>
SUSTAINED BEHAVIOUR CHANGE
Figure 5.1 : A Model Describing the Process of Behaviour
Change through Communication.
)
)
)
Module 5
1.4
('oinsnunication Techniques
Communication in irelation to counselling requires the establishment of rapport
i.e. a tru’sting relationship between the counsellor and the client. The counsellor should
be able to demonstrate and express sympathy. The various communication
techniques for effective counselling are as follows :
(i)
Observing : The counsellor makes an observation of overt and covert
behaviour of the client while interacting. For example, the client wipes
his perspiration, takes a glass of water, speaks in a low tone are
examples of overt behaviour. The counsellor makes an observation of
verbal and non-verbal communication.
(ii)
Questioning : Counsellors use the questioning technique to obtain
specific information, help the client communicate clearly, encourage
exploration and clarification of thoughts, feelings and attitudes. Openended questions, which require more than a "yes" or "no" answer are
more probing in nature. Example : "Would you tell me more about
your feelings ?" "Would you like to tell me anything else ?"
(iii)
Active Listening : Active listening demands extremely concentrated
listening on the part of the counsellor, who must pay attention to the
client's verbal disclosures, non-verbal cues and feelings that, are
indirectly expressed. Counsellors maintain and communicate their
active involvement with the client while listening through non-verbal
communication such as‘eye contact, nodding thehead, etc.
(iv)
Paraphrasing : The counsellor can restate in his or her own words
what the client said in order to let the latter know that he or she has
been heard. Example : ”So, what you are saying is that you can't
imagine how you could have been exposed to HIV".
(v)
Identifying and Reflecting Feelings : Counsellors can help clients
identify and clarify their feelings and reactions by listening for the
feelings being described and then reflecting them back to the client.
Reflecting gives the counsellor an opportunity to interpret, and then
compare with the client, what he/she has expressed. Example : "You
seem to feel very angry with your husband for becoming infected with
HIV, and deeply concerned about him at the same time. Can you tell
me more about your feelings towards your husband ?"
(vi)
Focusing : It is easy for the client to become sidetracked in the
counselling session because many thoughts and feelings emerge during
the process. The counsellor needs to help the client focus on the most
important issues at hand. Example : "Let us come back to the issue of
safe sex practices."
3
5.6
Developing Counselling Skills
(vii)
Appropriate Use of Silence : Silence in a counselling session is
important at times.
It gives the client an opportunity to reflect.
integrate feelings, think through an idea or absorb new information. It
is not always comfortable to allow the silence to continue, but
counsellors should not interrupt it prematurely because of their own
discomfort.
(viii) Providing Information : Providing information during a counselling
session requires skill and awareness. Counsellors should present
information in a clear and understandable manner, in an amount which
is sufficient but not an overload, and during a point in the session in
which it is appropriate and helpful.
(ix)
Assuring and Reassuring : Counsellors assure and leas-sure" clients
verbally and nonverbally. For example, a client who receives a positive
test may feel afraid of being rejected and "untouchable". The
counsellor can reassure the client that he or she does not fear the client
and will not back away. He / she does this by maintaining an open body
posture, leaning forward, or reaching out and touching the client's hand.
(X)
Acknowledging and Validating : Counsellors can let clients know that
they are aware of their feelings and understand how and why they
might be feeling that way by validating the response. Example : "1
can understand why you would feel so sad about testing HIV positive
and the losses you may face."
(Xi)
Confirming Realities : Counsellors need to confirm the truth and facts
of what clients are facing and experiencing, even when they may want
to protect them or cushion them from reality.
(xii)
Summarizing : Summarizing is a useful technique at the end of a
session, or in the middle, a time to pause, reflect on what has been
discussed so far and to propose a similar or new direction.
(xiii) Confronting : Confronting the client may be an effective response when
an issue is being denied or has not come out into the open.
(xiv) Supporting and Modelling Behaviours : Counsellors can support
and reinforce specific behaviours by modelling them for and with the
clients. For example, if a goal of the counselling session is for the client
to improve communication skills, the counsellor can model clear and
direct communication when he or she interacts with the client
When
the client responds with clear and direct communication, the counsellor
can comment on and support this type of dialogue.
3.7
Module 5
1.5
Barriers of Effective Coinniunication
Barriers of effective communication are :
(i)
Failure to listen
(ii) Probing questions for finding out mysterious things about the client.
(iii) Ambiguous question (question with double meaning): For example, the counsellor
asks the client: "So, you had been going out." The client may understand it as
“so, he has. been going out to another woman".
(iy) Failure to interpret for lack of knowledge.
(v) Too many intermptions during the session.
(vi) Partial or incomplete information to the client.
1.6
Check > our Progress - I
0)
Define communication
(ii) Stale the objective of communication to a drug- user (injecting). (iii)
2.
Ciive three reasons why communication may fail.
Basic Concept and Rationale for the Use of Counselling Skills in HIV / AIDS.
Fne content will be discussed under five headings:
)
2.1
2.2
2.3
2.4
2.5
Basic Concepts of Counselling
Rationale for Counselling
Essential Features of Counselling
Counselling Skills
Some Common Counselling Errors
2.1
Basic Concepts of Counselling :
)
>
Counselling is a helping process aimed at problem solving. It is face-to-face
communication in which one person helps another to make decisions and take
actions.
Counselling aims at making the client independent. It helps people to
understand themselves better in terms of their own needs, strengths, limitations and
the iesources
icsouices they can avail of to bring about changes through a supportive
relationship.
5.X
Developing Counselling Skills
The nurse in a clinical and community setting can help a client
decisions on problems related to HIV / AIDS.
(i)
What are the aims of counselling in H1V/AIDS ?
counselling in HIV / AIDS are :
to take
Major aims of
to prevent transmission either to the individual in question or from
an infected person to another.
to help infected individuals to cope with the infected status and to
help improve the quality of life.
(>>)
Who should be given counselling ? Counselling should be given to :
a. people worried that they might have become infected with HIV.
b. people who are being considered for HIV testing.
c. people who have been tested for HIV (whether or not they are
infected).
d. people who choose not to be tested despite past or present risk
behaviour.
e. people who are unaware of the risk of HIV infection involved in the
specific behaviour they have, or are engaged in.
f. people with AIDS or other diseases related to HIV infection.
g. people experiencing difficulties with employment,
housing.
financing, family etc.as a result of HIV infection.
h. the family and friends of people who are infected with HIV.
i health workers and other professionals who come into regular
contact with people infected with HIV.
s(iii)
Where can counselling services be provided ? Both preventive and
supportive HIV / AIDS counselling can be given in any setting where
there is or could be a discussion on HIV / AIDS.
Such settings
include :
a.
b.
c.
d.
e.
(iv)
Centres for sexually-transmitted diseases.
MCH & Family Welfare Centre.
Family Welfare Clinic in hospitals/dispensaries
PHC/Sub-Centre/Community health centres in rural areas.
Schools, organizations (social / industrial/religious) and all health
out-reach programmes.
Who could provide counselling ? In addition to nurses, doctors,
psychologists and social workers, ■ other people can readily be
encouraged and trained to provide counselling. Counsellors need not
be formal health care providers. Teachers, health educators, religious
and community leaders, youth group workers and members of self-help
groups can undertake both preventive and supportive counselling.
5.9
Module 5
2.2
Rationale for the Use of Counselling
(i)
Individuals diagnosed or suspected as having HIV infection / AIDS
have profound emotional, social and behavioural problems and medical
consequences.
(ii)
The type of personal and social adjustment required in the context of
HIV infection often has implication and effect on family life, sexual and
social relations, work and education, spiritual needs, legal status and for
civil rights.
(iii)
Adjustment to HIV infection involves constant stress management
and adaptation. It is a life-long process that makes new and changing
demands on individuals, their families and communities in which they
live.
2.3
’
(iv)
Most people have limited abilities or fee! that they have limitations in
what they can do and what changes they can make in their lives.
(v)
During the course of HIV infection, a broad range of physical needs
and problems are likely to be experienced. These may not remain
constant and may progressively become more serious and difficult to
handle. The changing nature of these needs imposes a variety of
psychological and emotional strains on individuals and those close to
them. Thus, the problems may threaten identity, independence, privacy
and social status and generate fear of loneliness, dying and death, and
feeling of guilt and anger.
Essential Features of Counselling
0)
> I
.
Privacy and Confidentiality : Physical set-up should be non-disturbing
and absolute privacy should be maintained so that the patient develops
trust in the counsellor. The counselling relationship must be based on the
understanding that whatever is discussed will remain confidential until
and unless the client decides to share that information with someone
else . There may be some instances where the counsellor or other
health care workers feel that confidentiality may need io be broken e.g.
that a decision should be made to notify the sex partners of an infected
person even when the client has refused them permission, to do so. In
such situations, the health care provider will be required to make a
decision consistent with medical ethics: and relevant law of the country /
state. When desired, anonymity should be maintained.
5.H) -
Developing Counsel I ini; SkiHs
(")
Time Management : Providing the client with time is important from
the start. Much of the content of counselling, such as helping to accept
the news about the diagnosis of AIDS cannot be rushed. Time is also
necessary to establish a rapport and trust
(iii)
Acceptance :
People with HIV infection and AIDS should always be
encouraged to feel that they are fully accepted by the counsellor,
irrespective of their life style, sexual preference, and socioeconomic, or
religious background.
2.4
(iv)
Accessibility : Counselling should be readily accessible and available
on a regular basis.
(v)
Consistency and Accuracy : Any information provided through
counselling (eg. about HIV infection, risk of infection, and risk
reduction) should be consistent.
(vi)
Supportive and Non-supportive Behaviour :
Some part of a
counsellor's behaviour readily supports the counselling process, while
others can bring it to a halt very .quickly. Some types of behaviour
are summarized in examples given below. It should be noted that they
are defined as supportive or non-supportive within a particular cultural
context. Wherever counsellors are working, they will need to take note
of the types of behaviour in the culture that would be supportive or
non-supportive in counselling. Refer examples of supportive and nonsupportive behaviour in a selected culture in Exhibit 5.2
Counselling Skills
^In addition to technical knowledge about HIV infection, counselling principles
and its values and information on resources, the counsellor must have awareness
1 his involves assessing and knowing one's own strengths and weaknesses, prejudices
and values.
Counsellors have their own needs and motivations, which they need to
examine. They should ask themselves, for example, whether they can honestly assure
other people that they will keep their secrets and maintain confidentiality. Will they
be able to continue to counsel someone they dislike or whose behaviour oifends them 7
I he counsellor's effectiveness depends greatly on self-knowledge, selfdiscipline and self-restraint, and on achieving a balance between warmth and
acceptance on the one hand, and objectivity on the other.
fhe following skills are required for counselling clients :
5.1 1
Module 5
(')
Forming a helping relationship : Counselling skills can be learned
and electively used only by people who are genuinely concerned about
others.
The helping relationship and the development of counselling skills also
depends on a feeling of commitment to the work to be done.
Counselling in relation to HIV infection is both intensive and difficult.
It requires the counsellor to deal with regular loss and sometimes accept
the behaviour which counsellor may not like himself / herself.
A supportive helpful relationship cannot develop if the counsellor does
not acknowledge both the gravity of the problem and the context
within which discussions take place.
For example, trying to ask
questions about sensitive personal topics in a crowded waiting room of •
a clinic obviously calls for an approach quite different from asking the .
same question in private.
Privacy is important in any form of
counselling, especially in relation to HIV infection because of the severe
stress and stigma associated with the condition.
(ii)
Assessment
(a) Assessment of Motivation : The counsellor needs to be alert to
signs of psychological strength and the desire to maintain
independence in the client. The counsellor must explore (and, where
necessary, attempt to change) attitudes which weaken motivation in
the following areas :
The client's self-concept / self-evaluation. Is the "self-concept"
one of the strengths or weaknesses, or is it worthy or
unworthy?
•
Level of self-knowledge. How conscious are clients of their
own thoughts, feelings, fears and actions ?
•
Self protection.
How do clients
react to threatening
information or events ? Denial is a common reaction.
•
Explanation. How do the clients interpret what is Ihappening
_:..o
to them and why.is it happening ? Do the client perceive within
or outside the self?
Anticipation. How do clients view the future ?
■)
(b)
)'
•
Assessment of 'Risk : HIV/AIDS counsellors play
.
a key role in helping
individuals to assess their risk for HIV and help modify their risk
behaviour.
5.i2
Developing Counselling Skills
«
•
The counsellor assesses the client’s current and past risk for HIV
infection.
Sexual behaviour and specific practices in particular, frequency
and high-risk practices, such as vaginal, anal intercourse without
using condoms, multiple sex partners, unprotected sexual relations
with commercial sex workers.
Injecting drug users
Being part of a group with known HIV prevalence or with known
high-risk life styles, e g. injecting drug users, male and female
prostitutes and their clients, prisoners,
and homosexual and
bisexual men.
History of blood transfusion, organ transplant, or administration of
blood or blood products.
Exposure to possibly non-sterile invasive procedures, such as
tattooing and scarification
The counsellor assesses the client's knowledge of how HIV is
transmitted and prevented, and identifies any misinformation.
(iii)
Recognizing Signs of Psychological Stress : The counsellor must have
skill in recognising and assessing signs of psychological distress and
incapacity.Distress is a normal reaction to fearing or learning that one
is HIV-infected. It can be alleviated only by expressing and discussing
it, and by support.
(iv)
Clarification of the Problems : Recognizing and clarifying problems
calls for counselling skill. Counselling depends on a clear definition of
problems.
Many a times the new counsellors feels insecure and
embarrassed about asking the kinds of questions needed to clarify the
client's view of the problem. Problem recognition includes :
•
•
•
•
•
•
J
defining the problem as the client sees it.
determining why the client is seeking help now.
ascertaining the duration and effects of the problem.
recognising what the problem means to and how it will affect the
client.
- repeating to the client the counsellor's interpretation of what has
been said.
finding out how the client is coping now and has coped with
serious problems in the past. Who are the support people available
in the family, among friends or religious organisations
i
5.13
Module 5
•
agreeing as to the problem (or part of a problem) to be tackled at a
time.
(V)
Supportive Behaviour : The counsellor needs to develop a skill in
practising supportive behaviour. This has been discussed earlier in this
section under 1.3 (vi).
(vi)
Establishing Goals : The goals of counselling in relation to HIV
infection are governed by the chronic nature of the infection and its
possibility of ending in an early death. The goals should be developed
related to what the clients expect to accomplish and what is to be
expected of support systems.
(vii)
Helping Clients to Develop Basic Competence : Many HIV-infected
people may not be able to think clearly about their problem or to decide
what should be done. They may withdraw socially, feel helpless and
seem completely unable to make decisions or solve problems. A key
counselling skill is to help them to regain a sense of competence and
skill.
For example, counselling must offer easy "how-to-do-it"
instruction (ordevelopment of skill) on prevention of infection, use
of condoms and maintaining caring relationships during a crisis.
The counsellor must always focus on the basic skills needed in
reducing risk and protecting others.
(viii) Enhancing Coping Skills of the Client : It would be useful to teach
the client methods which would enhance his / her coping skills. One
method which could be easily learnt is relaxation. A simple method to
relax is to close your eyes and concentrate on your breathing, while
letting your body loose. This should be practised for 15 minutes,
twice daily.
(ix) Problem-solving and Decision-making in HIV/AIDS Counselling
(a) Problem So/ving and Decision Making : To enable the clients to
think through their problems, the counsellor has to rely very heavily
on emotional support and sympathy.
Often, the counsellor helps the client to cope with the crisis of
HIV / AIDS and facilitates the problem-solving and decision
making process. To enable the client to solve the problems related
to HIV / AIDS the counsellor:
•
•
•
reviews/discusses the action the client has already taken;
discusses the personal and other resources available or
needed;
explains accurately the protective action the client will need
to take; and
i
5.14
Developing Counselling Skills
•
helps the client establish a plan of action.
The family is a very important social system in the Indian context
and performs a very essential function ranging from socialisation
to providing the basic means for survival.
The counsellor may need to be present when family members and
others are being told.
Many people will be reluctant to disclose the fact (i.e. HIV/
AIDS)' for feelings of shame and guilt, and for fear of being
rejected, or ostracised. The counsellor must accept that such
fears are understandable but, nevertheless, encourage the clients
to re-examine their objections to disclosure and looking to the
family or other close associates for support. One of the most useful
questions the counsellor can ask is : "What will happen to the
people you love if you do not tell them now about what is
happening to you ?" The counsellor may help the clients to
consider how a spouse or partner has reacted in the past to some
wrong doings, as well as rehearse the process of telling the family.
Some Common Counselling Errors
•
o
•
•
•
•
•
•
•
)
1
Directing and leading - controlling rather than allowing and encouraging the client’s
expression of feelings and needs.
Judging and evaluating, as shown by statements that indicate that the client does
not meet the counsellor's standards.
Moralizing, preaching, and patronising - telling people how they ought to behave
or lead their lives.
Labelling and diagnosing, rather than trying to find out the person's motivations,
fe^Ts and anxieties.
Unwarranted reassurance, diverting a client’s attention from an issue and
humouring the client - trying to induce optimism by making light of the client's
own version of a problem.
Not accepting the client's feelings - saying that they should be different.
Advising, before the client has had enough information or time to arrive at a
personal solution.
Interrogating - using questions in an accusatory way. "Why" questions almost
always, sound accusatory.
Encouraging dependence - increasing the client's need for the counsellor's
continuing presence and guidance.
5.15
Module 5
2.6
Check Your Progress - 2
(i) Enumerate five situations for counselling.
(a)
(b)
(c)
(d)
(e)
(ii) List the essential features of counselling.
(a)
(b)
(c)
(d)
(e)
(0
3. Counselling and Clinical Practice
The counselling skills improve with the practice in clinical and community
settings. These skills are difficult to learn in a classroom setting.
Case Study - 1
Ajitesh is an 18-year-old college student who lives in a small town. He has
from his. own College, a regular girl friend, with whom he has occasional sexual
relations. Ajitesh occasionally experiments with drugs and visited a prostitute for his
first sexual experience two years ago when his friends insisted him to accompany
them tb a brothel. His parents are keen that he marries a girl of their choice. They
have fixed a marriage which will take place when he will be 20 years old. Ajitesh is
upset for his visit to the brothel, and he goes for the HIV test. The result shows that
he is HIV positive. He gets restless and does not know what to do. He goes to a
nurse counsellor for help.
The above incident / example raises the following
questions :
3.1
How would you describe the incident ?
While describing the incident, no evaluative judgement should be passed on
any of the characteristics, like sex, sexuality, socio-economic background.
possible sources for transmission etc.
5.16
Developing Counselling Skills
3.2
How did the incident make you feel ?
The irrational nature of prejudices like anger, rejection, condemning,
punishing feelings for the client may emerge spontaneously. Once the nurse is
aware of her own prejudices and those of others it would help the nurse counsellor to
move towards greater acceptance and access to Ajitesh.
3.3 What do you feel about Ajitesh now ?
The nurse will develop sensitivity to the reality that Ajitesh will need special
counselling for medical, psychosocial and welfare aspects. She will make an effort to
help Ajitesh.
3.4 What would be your professional role in helping Ajitesh in this context ?
The nurse identifies that with her special counselling skills she is able to (i)
form a helping relationship, (ii) assess the motivation, (iii) recognize signs of
psychological stress, (iv) clarify the problem, (v) provide a supportive behaviour, (vi)
establish the goals to help her client to cope with the crisis situation.
In case further medical tests are required, she would refer the client
appropriate agency.
to an
3.5 What might help Ajitesh in making a decision on his marriage ?
Ajitesh may be given an opportunity to talk freely to have mental
catharsis. Informing and educating him about HIV and AIDS would help him to take a
decision for his marriage
3.6
Which counselling skill might help in this case ?
In the case of Ajitesh, the counselling skills that would be helpful are
observing overt and covert behaviour, listening attentively, informing about HIV /
AIDS, clarifying his doubts and quaries, providing support and helping him to
develop confidence to face his problems.
?
3.7
Is there anything that you would still like to do in relation to this incident ?
Follow-up care may be extended to Ajitesh. The nurse may also provide
exohin0?- 'T t
T b'V g'V"lg 'iteratUre thr°USh Aj'tesh' advise A^esh to
f
tnends and contacts to go through the HIV test, and arrange HIV
testing foi people at the brothel through social workers.
5.17
.Module 5
3.8
How would you benefit from such an experience ?
The nurse counsellor gains confidence to handle similar
incidents,
incorporate such experiences in the clinical experiences of the students. She may
also update her skill by attending short-term courses in counselling.
)
3.9 Check Your Progress - 3
)
(i) List the reactions the nurse may have towards Ajitesh.
(ii) Enumerate the special counselling skills the nurse could use in the case of Ajitesh
)
4.
Issues in Pre and Post-test Counselling
The content will be discussed under the following two headings :
4.1
4.2
Pre-test counselling
Post-test counselling
4.1 Pre-test Counselling
Pre-test counselling refers to counselling sessions between the client and the
counsellor before the client takes the decision for HIV testing i.e. to be tested or not
to be tested. Purposes of pre-test counselling are as follows :
•
the client understands what the test implies and what a positive or negative result
means.
to clarify the misconception of client about HIV antibody testing.
•
to alleviate the fear and anxiety of being positive.
(i) Counselling Issues related to Test Seeking
(a) Possible reasons for seeking test are :
•
•
•
•
■>
Prior to blood donation
Prior to tissue / organ transplantation
When there is a high-risk behaviour
When suspected of having HIV infection (from the clinical
signs).
5.18
Developing Counselling Skills
(b) Accessibility of testing facilities : People who are considering
being tested for HIV infection, must be given information on the
HIV testing facilities available.
(c) Provision of counselling services at HIV testing centres
To
facilitate pre-test and post-test counselling there should be
counselling services attached to the testing centres.
)
(ii) Principles of Pre-test Counselling :
i
•
Counselling before the test should provide individuals who are considering
being tested with the information on the technical aspects of screening and
on the possible personal, medical, social, psychological, and legal
implications of being found either HIV positive or HIV negative.
•
Informed consent implies awareness of the possible implications of a test
result. There must be a clear understanding of the policy on-consent in
every instance, and anyone considering being tested should understand
what he / she is being tested for.
•
Testing of HIV infection should be organised in such a way that minimizes
the possibility of information disclosure.
In screening, the rights of the individual must also be recognized and
respected.
•
Confidentiality should be ensured in every instance, both for the clients and
their records.
•
Pre-test counselling should be centred on two main topics : first, the
person's personal history and risk of being or having been exposed to
HIV; secondly, the client's understanding of HIV / AIDS and previous
experience in dealing with threatening situations. Refer to exhibit 5.4-A
for sample questions for assessment of psychosocial factors and knowledge.
•
ITe-test counselling should include a careful consideration of the person's
ability to cope with a diagnosis and the changes that may need to be
made in response to it. Refer to exhibit 5.4-B regarding issues of pre
test counselling.
4.2 Post-test Counselling
)•
)
)
Once a decision has been made to take the test for HIV antibody,
arrangements should be made to prepare for post-test counselling MIX' testing can
have three possible outcomes :
-5.19
Module 5
a.
•b.
c.
a negative result;
a positive result;
other issues with regard to HIV Testing
(i)
Counselling after a Negative Result : It is very important to
carefully discuss the meaning of a negative result (whether this was
expected or not). The news that the result was negative is likely to
produce a feeling of relief or euphoria, but the following points must
be emphasized.
a.
Following possible exposure to HIV, the "window period" must
have elapsed before the test results can be considered reliable. This
means that, in most cases, a minimum of at least three months
must have elapsed from the time of possible exposure before a
negative test can be considered to mean that infection did not
occur. A negative test result carries greatest certainty if at least six
months have elapsed since the last possible exposure.
b. Further exposure to HIV can be prevented only by avoiding highrisk behaviours. Safer sex and avoidance of needle-sharing must be
fully explained.
c. Some clients have false belief that since high- risk behaviour has
not led to infection so far, they have a natural immunity to HIV.
d. Other information on control and avoidance of HIV infection,
including the development of positive health behaviours, must be
provided. It may be necessary to repeat such explanations.
(ii)
Counselling after a Positive Result : People diagnosed as having
HIV infection or disease should be told as soon as possible. The
discussion should be held in private and under conditions of
confidentiality.
The pre-test assessment can be used to determine the best way to tell
the client about the test result. How the news is accepted will depend
on certain factors.
Refer to exhibit 5.6 regarding points for
consideration. The client must be told how to contact the counsellor
during periods of severe stress. There should be some discussion of
what may happen if employers or others learn that the person is HIV
infected. All the information previously given about safer sex,
prevention of transmission, and maintaining health must be repeated.
Follow-up visits must be arranged, often on a routine basis.
Counsellors must always stress on "positive living" and the individual's
responsibility for changing behaviour to avoid infection or to limit, if
>
"5.20
Developing CoiinscHiiiR Skills.
not eliminate, the risk of transmission, and the life-long nature of the
infection and of the risk of infecting others.
The following points need to be repeatedly emphasized :
a. HIV infection is not AIDS. Prognoses vary, but every infected
person should be encouraged to live a normal social and economic
life unless AIDS-related symptoms do not permit this. Since
normal living requires the support of others, those concerned may
need regular counselling to anticipate and cope with new needs.
b. A person who is HIV positive should take care of his or her
general health. The presence of other infections, such as other
sexually-transmitted diseases or any illness will affect the immune
response and may hasten the development of AIDS. The counsellor
must explain how the risk of infections can be avoided through
general hygiene and the prevention of other sexually-transmitted
diseases, emphasizing the use of condoms and
reducing the
number of sexual partners.
c. Spouses and partners will need support, telling them that HIV
infection has been found. Considerable support for this may be
needed from the counsellor. Bringing spouses or partners in for
counselling to prevent transmission.
d. Spouses and partners must be protected against infection; Condoms
should be recommended to prevent infection transmission and re
infection of the patient. The counsellor should stress the need for
care in ensuring that the condoms are of good quality and intact.
Latex condoms are much safer than animal membrane condoms.
The use of spermicide in conjunction with condoms should be
recommended.
(iii) Other Issues with regard to HIV Testing
a. A test result may show negative findings but in reality there may
have been insufficient time for full sero conversion (i.e. "window
period"). In such circumstances the counsellor needs to explain
the need for retesting after a period of three months for
confirmation. It is then important for the counsellor to emphasize
essential- preventive messages regarding sexual and drug-user
activity, body fluids and tissue donation. The person will need to
undertake the precautions recommended for HIV positive person
until proven otherwise.
b.
When someone is seeking to be tested and gives no history of
high-risk behaviour, the counsellor should enquire into the
1
Module 5
reasons why testing is sought, and offer preventive and supportive
counselling.
c. The counsellor may discourage people who do not want to know
the test result, but should make it quite clear to them that they
must behave as they were seropositive in order to prevent
infection of themselves or transmission to others
d.
4.3
A positive result in an ELISA test is reasonably accurate but since
the test can give both false- negative and false-positive results,
follow-up and confirmatory tests are necessary.
Check Your Progress - 4
(i) Example 1 : Jane, a 28-year-old working woman came to STD clinic
with complaints of burning micturition and a history of multiple sex
Partners. The nurse told her the need for HIV testing. She was reluctant.
The nurse explained her that it was upto her to agree or not and that the
information would remain confidential and anonymous. Jane asked a number
of questions about HIV infection and the need for the test. During the
conversation she clarified her concepts. She said that she was afraid of being
HIV positive and that was why she did not want to be tested. The nurse shot
back that her fear would still remain if she did not get tested. On the contrary,
the testing would indicate whether she was positive or negative. If she
was found positive, at least she would aim for positive living.
Read the example and answer the following questions
(i)
List three purposes of pretest counselling as shown in the example
^ii) What are the possible reasons for seeking HIV testing?
(iii) In the case of Jane (Example 1), who gives the history of multiple sex
partner, the HIV test result was found to be negative. Discuss the issues
of post- test counselling in the case of Jane.
V.
ANSWERS TO CHECK YOUR PROGRESS
I 6(i) Communication refers to the reciprocal exchange of information, ideas, beliefs,
feelings and attitudes between persons or among a group of persons through a
common system of symbols,, signs or behaviour
1.6(ii)
The objective of communication with a drug user will be to achieve a
motivation for change in his / her behaviour pattern, i.e. stop using injectable
drugs or stop sharing needles with others or use individual sterilized needles.
5.29
Module 5
Exhibit 5.6
How the news of HIV infection is accepted or incorporated
may depend on the following :
a. The person’s physical health at the time. People who are ill may have a
delayed reaction, Their true response may appear only when they have- grown
physically stronger.
b. How well the person was prepared for the news ? People who are completely
unprepared may react very differently from those who were, prepared and perhaps
expecting the result. However, even those who are well prepared may experience the
reactions described herein.
c. How well the person is supported in the community and how easily can he or
she call on friends ? Factors such as job satisfaction, family life and cohesion, and
opportunities for recreation and sexual contact may all make a difference in the way a
person responds. The reaction of the news of HIV infection may be much worse in
people who are socially isolated and have little money, poor work prospects, little
family support, and inadequate housing.
d.
The person's pretest personality and psychological condition. Where
psychological distress existed before the test result was known, the reactions may be
either more or less complicated and require different management strategies than
those found in persons without such difficulties. Post result management should take
account of the person's psychological and / or psychiatric history, particularly as the
stress of living with HIV may act as a catalyst for the reappearance of earlier
disturbance.
Hn some cases, news of HIV infection can bring out previously unresolved
fears and problems.
These can often complicate the process of acceptance and
adjustment and will need to be handled sensitively, carefully, and as soon as possible.
The cultural and spiritual values attached to AIDS, illness, and death. In
some communities with a strong belief in life after death, or with a fatalistic
attitude towards life, personal knowledge of HIV infection may be received more
calmly than in others. On the other hand, there may be communities in which AIDS
e.
is seen as evidence of an antisocial or blasphemous behaviour and is, thus, associated
with feelings of guilt and rejection.
■
I
■
5.22
Developing Counselling Skills
1.6(iii) Any three of the following answers :
a.
b.
c.
d.
e.
f
failure to listen.
unnecessary probing.
ambiguous questioning.
failure to interpret due to inadequate knowledge.
interruptions / disturbance during session.
partial / incomplete information given to the client.
2.6(i)
a.
people who are worried that they might have become infected with HIV /
AIDS.
b. - people who are being considered for HIV testing.
c. people who have been tested for HIV (whether or not they areinfected).
d. people who choose not to be tested despite past or present risk beha
viour.
e. family and friends of people who are infected with HIV / AIDS.
For other alternative situations see SIM 1. l(ii)
2.6(h) The essential features of counselling are :
a. privacy and confidentiality.
b. time management.
c. acceptance.
d. accessibility.
e. consistency and accuracy.
f. supportive behaviour.
3-9(i)
•
•
•
•
Anger
Punishing
Condemning
Rejecting
•
•
•
•
•
Forming a helping relationship.
Assessment of motivation.
Recognising signs of psychological stress.
Clarification of problems.
Supportive behaviour.
3.9(h)
'i
> l
4.3(i) In Jane the purpose of pretest counselling was :
To take an informed decision about HIV testing.
5.23
Module 5
•
•
To clarify the misconcepts on HIV testing, and Jane now understands what
the test implies.
To alleviate the fear and anxiety of being positive.
4.3(ii) Possible reasons for testing are :
•
•
•
•
Prior to blood donation.
Prior to tissue / organ transplantation.
When there is a high-risk behaviour.
When suspected of having HIV infection from clinical signs.
4.3(iii) As Jane gives the history of high-risk sexual behaviour along with complaints
of STD it is possible that she is in the "window period". She needs to be explained
the need for a repeat test after six months and refrain from high-risk behaviour and
adopt safer sex practices.
Developing Counselling Skills
Exhibit 5.1
An example of a Role play on Techniques
of Communication.
Counsellor
Namasto Mr. Sham
Client
Namaste Sisterji
Counsellor
Sham your are looking very weak, what has happened to you (Observation)
Client
Sisterji, I’ am having fever for last one month, loose motions, and I am loosing
weight.
Counsellor
Did you show yourself to Doctor? (Questioning)
Client
Yes, I have shown to Doctor, they have told me that 1 am having AIDS. (Keep
silence for 2 seconds) wipes face.
Counsellor
Keeps silent by putting hand on Mr. Sham’s hand (Observing and supporting)
Client
I do not know what will happen to my wife and children, they say that now I
have contracted the disease, and I will die.
Counsellor
It looks you are very much worried about your wife and children (Reflecion).
How many children you have. Is there any one in the family, who is earning.
(Questioning and sharing concern).
Client
No one' I am the only earning member.
Counsellor
You said that there is no one to look after the financial aspect,
thought of something. (Paraphrasing).
Client
Pause.... Startscrying.
Counsellor
Allows Mr. Sham to cry and sit quietly for 5 minutes (silence and listening). I
can understand, from your talk it looks you are very' worried about financial
loss you may have (Acknowledging and validating).
Client
Sisterji. I’m worried whether I can give infection to my wife and children.
Counsellor
Sham you need not worry about your children, but must take precaution while
having sexual relation with the wife (Informing). Use condom so that you do
not transmit infection to your wife. You must take care of your health, by
maintaining good hygiene and taking mixed and adequate food, so as to avoid
any infection (Informing).
Client
Thank you Sisterji for giving me help.
Have vou
5.25
Module 5
Exhibit 5.2
Supportive and Non-supportive Behaviour
<0
Supportive
Verbal
•
•
•
*
•
•
b)
Addresses the client in a manner
appropriate to his/her age.
Uses language that he understands.
liepeats, in other words, clarifies the
client's statements.
Explains clearly and adequately.
Summarizes
Responds to a primary message.
Encourages : "I See", "Yes, go on"
Gives needed information.
Uses humour or other means of
reducing tension.
Does not criticize or censure the
client.
Non-verbal
Uses a tone of voice similar to the
client's.
Looks the client in the eye,
maintains
eye
contact
with
him/her.
Nods occasionally; uses facial
expressions.
Occasional gestures.
Suitable conversational distance.
Docs not speak too quickly or too
slowly.
6
Non-Supportive
Verbal
Non-verbal
>
•
•
•
•
•
•
•
•
Advising
Preaching
Blaming
Cajoling (persuading by flattery or
deceit)
"Why" questions
Directing, demanding
Straying from the topic
Patronizing (condenscending)
attitude.
•
•
•
•
•
•
Looking away frequently
Inappropriate distance
Sneering
Frowning, scowling and yawning
Unpleasant tone of speech
Speaking too quickly or too
slowly.
i
.5.26
Deye]oping Coiniseilinu Skills
Exhibit 5.3
Obsen ation of Communication Techniques used
in the Role Play / Counselling Process
Communication Techniques
(i)
Observing
(ii)
Questioning
Place a
Taliy(l)
against
the tech,
when used
Total
No. of
tally
Rank most
to least
used
tech nique
(iii) Active listening
(iv)
Paraphrasing
(v)
Identifying and reflecting
feelings
(vi)
Appropriate use of silence
(vii) Focusing
(viii) Providing information
(ix)
Assuring and reassuring
(x )
Acknowledging and .validating
(xi)
Confirming realities
(xii) Summarizing
(xiii) Confronting
(xiv) Supporting and modelling
1
I
5.27
Module 5
Exhibit 5.4
Exhibit 5.4 - A
Assessment of Psychosocial Factors and Knowledge
1. Why is the test being requested ?
2. What particular behaviours or symptoms are of concern to the client ?
3. Has the client sought testing before, and if so, when, from whom, for what reason,
and with what result ?
4. What does the client know about the test and its uses ?
5. What are the client's beliefs and knowledge about HIV transmission and its
relationship to risk behaviour ?
6. Has the client considered what to do or how he/she would react if the result were
positive, or if it were negative ?
7. Who could provide (and is currently providing) emotional and social support
(family, friends, others) ?
Exhibit 5.4 - B
Issues of Pretest Counselling
---------------- -----------_______------
•
•
•
•
•
•
•
•
•
•
Determine what that person understands about HIV and AIDS.
Provide factual information as needed.
Discuss potential implications of positive and negative test results.
Explain and obtain formed consent.
Review the test procedure.
Assess the person's ability to cope with a positive result.
Establish who else should be informed and is likely to be supportive to the client if
tested positive.
Explain the meaning of false positive and false negative results.
Establish a relationship as a basis for post-test counselling.
Provide adequate preventive counselling.
1
5.28
Developing Counselling Skills
Exhibit 5.5
Points to be Emphasized while Counselling
•
No test can tell whether someone has, or will develop AIDS.
The tests available detect antibodies to HIV in the blood.
•
The presence of HIV antibodies (except for passive maternal antibodies in the case
of uninfected infants of HIV-infected mothers) is proof only of HIV infection; it
does not prove that the person is suffering, or will suffer, from an HIV-related
disease. It is impossible to tell from a positive HIV test when the person was
infected, or for how long. This point is important, and needs to be discussed with
clients so as to make sure that they understand that HIV infection may have
occurred before an existing relationship began and does not necessarily imply that
the current partner has been unfaithful.
•
Whether the test is positive or negative or even if not tested behaviour must often
be changed, either to remain negative or to protect others against HIV infection.
•
A negative result does not rule out infection; if there has been a risk behaviour, the
test should be repeated three months after the exposure has occurred, to allow
for the "window effect."
•
Some kind of behaviour and practices are dangerous to the HIV- infected person,
because they lead to exposure to other infections, including sexually-transmitted
disease. "Safer sex" must become part of the way of life both of the
seropositive person and the seronegative person who want to remain
serqhegative.
The counsellor should tell the client about any official policy on further testing
for confirming a positive result. For example, the policy may be to follow an initial
positive ELISA test with a second one and, if that is also positive, to confirm with the
Western Blot.
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