HIVAIDS Training Manual for Nurses and Midwives

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HIVAIDS Training Manual for Nurses and Midwives Powered By Docstoc
					Acronyms
AIDS       Acquired Immune Deficiency Syndrome
ART        Antiretroviral therapy
ELISA      Enzyme Linked Immuno Sorbent Assay
HIV        Human Immuno-deficiency Virus
MTCT       Mother to Child Transmission
OIs        Opportunistic Infections
PCR        Polymerase Chain Reaction
PEP        Post Exposure Prophylaxis
PLWHA      People Living With HIV/AIDS
STIs       Sexually Transmitted Infections
TB         Tuberculosis




                                                 1
Preface
We hope you will find this manual useful in your daily work. It has been designed for
ease of use, depicting major points in the subject area. The manual provide general
information and has been designed to target nurses and midwives. Nevertheless, it
will be useful for other health workers as well.

It is hoped that this manual will prove useful in keeping nurses and midwives up to
date in this important area of HIV/AIDS works. The manual has taken into account
the Zambian protocols on Prevention, Treatment, Care and Support. It is envisioned
that nurses and midwives will be able to apply the information in clinical practice.

The purpose of the manual is to help improve nurses’ clinical practice in terms of
HIV/AIDS diagnosis, treatment, prevention care and support.




2
Acknowledgement

We wish to acknowledge NORAD and Norwegian Nurses Organisation for financing
the review and production of this manual

Other thanks go to the ZNA/NoNO Project Staff at head office and at provincial level
for their contributions to this manual.




                                                                                   3
MODULE 1: HIV/AIDS THE INFECTION:

Definitions

 HIV- Human Immunodeficiency Virus. This is the virus that causes HIV infection
  and leads to AIDS

 AIDS- Acquired Immune Deficiency Syndrome. AIDS is the end of the clinical
  spectrum of HIV infection. It occurs when the immune system of a person who is
  HIV-infected becomes so suppressed that they are vulnerable to a variety of
  illnesses (Opportunistic infections).

Epidemiology of HIV/AIDS

New data show global HIV prevalence has levelled off and the number of new
infections has fallen in part as result of the impact of HIV programmes. At the end of
2007, 30.6 – 36.1 million people were estimated to be living with HIV, 1.8 -4.1 million
people became newly infected and 1-9-2.4 million people died of AIDS (UNAIDS
2007).
The number of people living with HIV in Eastern Europe and Central Asia has
increased by more than 150% from 630,000 [490,000-1.1million] to 1.6million [1.2-
2.1 million]

Sub-Saharan Africa:
HIV/AIDS is now the leading cause of death in sub-Saharan Africa. It is estimated
that 20.9–24.3 million people are living with HIV with 1.4 – 2.4 million new infections
occurring in 2007(UNAIDS 2007)

Zambia
Zambia has a population of approximately 10.9 million people (CSO 2002). At the
end of 2003 it was estimated that between 730,000 -1.2million Zambians were living
with HIV/AIDS, with 59% of adult infections occurring in women and approximately
150,000 infections in children. According to the 2001-2002 Demographic and Health
Survey (DHS) HIV prevalence is almost twice as high in urban areas as in rural
areas.




4
The socioeconomic impact of HIV/AIDS in Zambia is enormous because the most
affected are individuals at the peak of their productive and reproductive period.
HIV/AIDS has resulted in reduced productivity because of illness and premature
mortality due to HIV-related opportunistic infections and malignancies. The most
common opportunistic illnesses seen in Zambia include tuberculosis, bacterial
meningitis, bacterial pneumonia and oral thrush. The high prevalence of HIV-related
illness in Zambia has seriously overburdened the healthcare system at all levels.

HIV Natural History
It is impossible to say how long a person will live with HIV before developing AIDS
when treatment is not available; however the average length of time is about 10
years or more. It should be noted that each person is different and many factors
such as nutrition, stress levels and emotional support influence a person’s ability to
remain healthy. The general stages of illness follow this progression:

Fig1: Natural history of HIV infection
      Infection        Asymptomatic              Non-specific        Opportunistic           Death
                                                 symptoms            infections




May live without any    May experience             Begins to          Begins to develop       Death is the
symptoms of HIV for     vague flu like             experience         more severe             inevitable
10 years or more        symptoms for 1 or 2        some non-          infections such as      end result of
                        weeks such as sore         specific           candidiasis,            HIV infection
                        throat, muscle and         symptoms           pneumonia,              and AIDS
                        joint pain and swollen     such as chest      tuberculosis and
                        lymph nodes. These         infections,        severe weight loss
                        symptoms may go            diarrhoea and      and wasting. When
                        unnoticed                  weight loss.       the CD4 drops
                                                   These are          below 200per cubic
                                                   often treatable    millimetre, the
                                                                      individual is
                                                                      classified as having
                                                                      AIDS




HIV LFE CYCLE

HIV reproduces using the genetic machinery of the host cell, usually a CD4
lymphocyte. Currently most drugs available inhibit two critical viral enzymes- reverse
transcriptase and protease, which the virus uses to reproduce, while some target the
third enzyme, integrase.

   The Human immunodeficiency virus attaches to and penetrates the target cell,
    the CD4 lymphocyte.
   The HIV’s RNA (the genetic code of the virus), is released into the cell and to
    reproduce RNA must be converted into DNA. The enzyme that performs the
    conversion is called reverse transcriptase.
   Viral DNA enters the cell’s nucleus.
   With the help of an enzyme called integrase, the viral DNA becomes integrated
    with the cell’s DNA.


                                                                                                              5
    DNA now replicates and reproduces RNA and proteins. (Proteins are in form of
     chains that must be cut when virus leaves the cell)
    A new virus is assembled from RNA and pieces of protein.
    To become infectious another viral enzyme called protease must cut the
     structural proteins within the virus causing them to rearrange into mature HIV.

HIV Life Cycle
                  Reverse
             Transcriptase
                                                          Mature HIV
                       Reverse
    HIV
                                  Nucleaus
                CD4    HIV
                Cell
                CD4




                                 Integrase     Protease




Modes of Transmission

 Sexual transmission
Unprotected penetrative vaginal, anal or oral sexual intercourse with an infected
person

 Parenterally
Through blood transfusion of infected blood or blood products, donated organs,
exposure to infected blood through injection drug use or needle stick.

 Mother to baby
Mother to child transmission (MTCT) occurs during pregnancy, childbirth or breast
feeding where the mother is HIV positive.

 Note. Saliva, tears and sweat do not contain enough HIV, and there are no
  demonstrated cases of transmission from these fluids.




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MODULE 2            ESTABLISHING THE DIAGNOSIS

Introduction
Tests for HIV detect presence of antibodies to HIV, not the virus itself. Although
these tests are very sensitive, they may not be used during the window period which
is the period between the onset of infection with HIV and the appearance of
detectable antibodies to the virus. In the case of sensitive anti HIV test currently
recommend the window period is about three weeks.

In many clients the only evidence of HIV infection is a positive HIV test. For other
clients signs and symptoms of AIDS or immune deficiency make the chances of HIV
infection more probable.

The three main objectives for which HIV antibody testing is performed
 Screening of donated blood
 Epidemiological surveillance of HIV prevalence
 Diagnosis of infection in individuals

Indications for an HIV Test
 Clinical signs and symptoms suggestive of HIV infection
 Clinical indications. Testing during antenatal care. It is routine in PMTCT
 Voluntary Counselling and Testing
 In cases of rape , defilement etc
 Other purposes include:- Life insurance policies, part of blood donating screening
  process and post needle stick injuries

Benefits of HIV testing
 Motivates the client to ensure that they remain negative
 Motivates client to remain and/or adopt risk reduction behaviours
 Empowers the client to learn more about HIV/AIDS
 Gives client opportunity for self disclosure
 Promotes partner notification
 Stimulates individual responsibility for action
 Promotes self care and commitment.

TYPES OF HIV TESTS
There are two main types of HIV tests: antibody/antigen tests and virologic tests.
Antibody/antigen tests look for antigens or antibodies against HIV. They do not
detect the virus itself, while the virologic tests determine HIV infection by detecting
the virus itself.

Antibody tests

ELISA (Enzyme Linked Immuno Sorbet Assay) - HIV antibodies can be detected
by this test.

Rapid HIV Test - These are simple tests. Common tests used are Determine, Uni-
gold and SD Bioline. These tests come in a kit and require no reagent, equipment,



                                                                                      7
training or temperature controls. The results can be obtained within 5 – 15minutes
and are as accurate as ELISA.

Virologic tests

Polymerase Chain reaction (PCR) – is useful in defining or ruling out HIV infection
in infants less than 18 months of age.

P24 Antigen test- measures actual HIV virus in the blood and is a useful measure
of infection during the period before which the body has developed measurable
antibodies to HIV.

Other tests
CD4 CELL COUNT A specialised type of lymphocyte, the CD4 cell count is an
important component of the immune system. They are the most common “target”
cells. The primary way to determine the degree of immune damage from HIV is to
measure the number and percentage of CD4 cells.

HIV-RNA level (Viral load) - A measure of the amount of virus present – usually
measured in blood plasma – using molecular technique known as polymerase chain
reaction (PCR). The unit of measurement is number of copies per millilitre (ml). This
test is used to monitor the effectiveness of antiretroviral regimens. It also reflects
infectiousness.

HIV Test Results

Negative results                 HIV antibodies are not detected in the person’s sample, either
                                 because the person is not infected or the person is still in the window
                                 period.
Positive results                 Antibodies to HIV detected in the person’s blood. It means person is
                                 infected with HIV and he/she can transmit virus to others.
Indeterminate results            The presence or absence of HIV antibodies could not be confirmed.
                                 This could be because the person is in the process of zero converting;
                                 person may have prior medical condition that is affecting the test. (In
                                 this case person is asked to come back after 6 weeks for retesting.



STAGING SYSTEM FOR HIV INFECTION AND DISEASE

Clinical staging system for Adults and adolescents

Primary HIV infection
Unrecognised
Acute retroviral syndrome
Clinical stage 1
Asymptomatic
Persistent generalized lymphadenopathy (PGL)
Clinical stage 2
Moderate unexplained weight loss (<10% of presumed or measured body weight)
Recurrent upper respiratory tract infections (URTIs) (Sinusitis, bronchitis, otitis media, pharyngitis)
Herpes zoster
Angular cheilitis
Recurrent oral ulcerations



8
Popular pruritic eruptions
Seborrhoeic dermatitis
Fungal nail infections of fingers
Clinical stage 3
Conditions where a presumptive diagnosis can be made on the basis of clinical signs or simple investigations
Severe weight loss (>10% of presumed or measured body weight)
Unexplained chronic diarrhoea for longer than one month
Unexplained persistent fever (intermittent or constant for longer than one month)
Oral candidiasis
Oral hairy leukoplakia
Pulmonary tuberculosis (TB) diagnosed in last two years
Severe presumed bacterial infections (e.g. pneumonia, empyema, pyomyositis, bone or joint infection,
meningitis, bacteraemia)
Acute necrotizing ulcerative stomatitis, gingivitis or periodonitis
Conditions where confirmatory diagnostic testing is necessary
                                                                    3                                          3
Unexplained anaemia(8g/dl), and or neutropenia (<1000mm ) and or thrombocytopenia(<50 000mm )
for more than one month
Clinical stage 4
Conditions where a presumptive diagnosis can be made on the basis of clinical signs or simple investigations
HIV wasting syndrome
Pneumocystis pneumonia
Recurrent severe or radiological bacterial pneumonia
Chronic herpes simplex infection ( orolabial, genital or anorectal of more than one month’s duration)
Oesophageal candidiasis
Extrapulmonary TB
Kaposis’ sarcoma
Central nervous system (CNS) toxoplasmosis
HIV encephalopathy
Conditions where confirmatory diagnostic testing is necessary
Extrapulmonary cryptococcosis including meningitis
Disseminated non-tuberculosis mycobacteria infection
Progressive multifocal leukoencephalopathy (PML)
Candida of trachea, bronchi or lungs
Cryptosporidiosis
Isosporiasis
Viscera; herpes simplex infection
Cytomegalovirus (CMV) infection (retinitis or of an organ other than liver, spleen or lymph nodes)
Any disseminated mycosis (e.g. histoplasismosis, coccidiomycosis, penicilosis)
Recurrent non-typhoidal salmonella septicaemia
Lymphoma (cerebral or B cell non-Hodgkin)
Invasive cervical carcinoma
Visceral leishmaniasis

Immunological staging
Clinical staging can be used effectively without access to CD4 or other laboratory
testing. Where CD4 facilities are available they must be used to support and
reinforce clinical decision-making. Table below presents CD4 levels in relation to the
severity of immunosuppression.

CD4 levels in relation to the severity of immunosuppression
                                                                                               3
Not considered to have significant immunosuppression                                >500/mm
                                                                                                3
Evidence of mild immunosuppression                                                  350 – 499mm
                                                                                                3
Evidence of advanced immunosuppression                                              200 – 349mm
                                                                                             3
Evidence of severe immunosuppression                                                <200/mm




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MODULE 3:                  PAEDIATRIC HIV

CLINICAL STAGING FOR SYSTEM FOR INFANTS AND CHILDREN

Clinical stage 1
Asymptomatic
PGL
Clinical stage 2
Hepatosplenomegaly                                Recurrent oral ulceration
Popular pruritic eruptions                        Lineal gingival erythema (LGE)
Seborrhoeic dermatitis                            Angular cheilitis
Extensive human papilloma virus infection         Parotid enlargement
Extensive molluscum contagiosum                   Herpes zoster
Fungal nail infections
Recurrent or chronic URTIs (otitis media, otorrhoea, sinusitis)
Clinical stage 3
Conditions where a presumptive diagnosis can be made on the basis of clinical signs or simple investigations
Moderate unexplained malnutrition not adequately responding to standard therapy
Unexplained persistent diarrhoea (14 days or more)
Unexplained persistent fever (intermittent or constant, for longer than one month)
Oral candidiasis (outside neonatal period)
Oral hairly leukoplakia
Acute necrotizing ulcerative gingivitis/periodonitis
Pulmonary TB
Severe recurrent presumed bacterial pneumonia

Conditions where confirmatory diagnostic testing is necessary
Lymphoid interstitial pneumonia (LIP)
                                                            3
Unexplained anaemia (<8g/dl), and or neutropenia (<1000/mm ) and or thrombocytopenia
            3
(<50000mm ) for more than one month
Chronic HIV-associated lung disease including brochiectasis
Clinical stage 4
Conditions where a presumptive diagnosis can be made on the basis of clinical signs or simple investigations
Unexplained severe wasting or severe malnutrition not adequately responding to standard therapy
Pneumocystis pneumonia
Recurrent severe presumed bacterial infections (e.g. empyema, pyomyositis, bone or joint infection,
meningitis, but excluding pneumonia)
Chronic herpes simplex; (orolabial or cutaneous of more than one month’s duration)
Extrapulmonary TB
Kaposi’ sarcoma
Oesophageal candidiasis
CNS toxoplasmosis (outside the neonatal period)
HIV encephalopathy

Conditions where confirmatory diagnostic testing is necessary
CMV infections (CMV retinitis or infection of organs other liver, spleen or lymph nodes; onset at the
age one month or more)
Extrapulmonary cryptococcosis including meningitis
Any disseminated endemic mycosis (e.g. Extrapulmonary histoplasmosis, coccidiomycosis,
penicilliosis)
Cryptosporidiosis
Isosporiasis
Disseminated non-tuberculous mycobacteria infection
Candida of trachea, bronchi or lungs
Visceral herpes simplex infection
Acquired HIV associated rectal fistula
Cerebral or B cell non-Hodgkin lymphoma
Progressive multifocal leukoencephalopathy (PLM)
HIV-associated cardiomyopathy or HIV-associated nephropathy




10
Immunological staging

The absolute CD4 count and percentage values in healthy infants who are not
infected with HIV are considerably higher than those observed in uninfected adults,
and slowly decline to adult values by the age of 6 years. In considering absolute
counts or percentages, therefore, age must be taken into account as a variable. The
absolute CD4 count related to immuno suppression tend to change with age,
whereas the CD4 percentage related to immunological damage does not vary.
Currently measurement of CD4 percentage is recommended in younger children.
CD4 testing is not essential for initiation of ART.

CD4 levels in relation to the severity of immuno suppression

                                                                 AGE
IMMUNE STATUS                                  Up to 12      13-59          5 years or
                                               months        months         over
                                                                                     3
Not considered to have significant             >35%          >25%           >500/mm
immunosuppression
                                                                                         3
Evidence of mild immunosuppression             25-34%        20-24%         350-499/mm
                                                                                       3
Evidence of advanced immunosuppression         20-24%        15-19%         200-349/mm
                                                                                    3
Evidence of severe immunosuppression           <20%          <15%           <200/mm

Child counselling concept
Child’s basic needs are obvious and visible but the psychosocial needs are invisible.
With HIV/AIDS pandemic and child abuse on increasing scale, the child’s
psychological stress has been recognized by the community. Counselling with
children is a growing area of interest for people in the helping field. Counselling can
also prevent “normal” problems from becoming more serious. It can create a healthy
environment to help children cope with stress, trauma and conflicts.

Counselling is a process in which a trained professional forms a trusting relationship
with the person (child) who needs assistance. This relationship focuses on personal
meaning of experiences, feelings, behaviours, alternatives, consequences and
goals. Counselling provides a unique opportunity for individuals – children- to
explore and express their ideas and feelings n a non-judgemental, non-threatening
environment.

Child counselling process
The process involves supporting the child to identify his/her concerns, their causes
and effects and available potions in addressing them, including working through
painful emotions. It is an ongoing process that utilizes child friendly approach and
effective communication skills to help the child participate in exploring issues relating
to his/her general welfare.

Joining – establishing rapport with the child
     Greet your client and be ready to get to the child’s level
     Give enough time to the child and show interest in the child. Help child to talk
      freely with you.
     Discuss with parent/guardian of the child before starting off a direct
      discussion with the child in order to seek consent, find out their concerns and
      assure them that it is not an interrogation.


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Defining the problem
     Find out what brought them and what is going on in their life and what is
      difficult. Repeat definition of problem and get confirmation
     Identify child’s immediate need.

Widening the view of the problem – seeing the bigger picture
    The counsellor explores the child’s perception and relationship with various
     members of the in his environment. Counsellor needs to be creative.

Solutions – informed decision making
     Involve the child in finding solution of the problem
     Ask how the actions can make problem better
     Emphasize on child’s self esteem and achievements
     What are their future plans

Child counselling techniques
A lot of activities that children do naturally can be very useful if adopted and adapted
for use in counselling. The counselling room needs to be child friendly where a child
can feel relaxed, welcomed, respected and welcome. This can be achieved if a
counselling relationship is established with the child early enough in the session and
maintained through out. The counsellor can use variety of tools-activities which are
natural for the children, with which they are familiar and which they enjoy and are
age appropriate. These activities include:
     Play and games
     Drawing and painting
     Story telling or story reading
     Songs, poems and dancing
     Role play etc


Paediatric HIV Therapy

When to start ART in infants and children

Criteria for severe HIV immune deficiency

Immunological       Age specific recommendation to initiate ART
       a
Marker
                     ≤ 11 months             12 – 35 months        36 – 59 months     ≥ 5 years
       c
CD4%                 < 25%                   < 20%                 < 15%              < 15%
           c                          3                    3                    3                  3
CD4 count            <1500cells/mm           <750cells/mm          <350cells/mm       <200cells/mm
Notes:
   a. Immunological markers supplements clinical assessment and should therefore be used in
         combination with clinical staging.
   b. ART should be initiated by these cut-off levels, regardless of clinical stage; a drop of CD4
         below these levels significantly increases the risk of disease progression and mortality.
   c. %CD4 is preferred for children < 5 years of age




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TLC criteria of severe HIV immunodeficiency requiring initiation of ART
Immunological       Age specific recommendation to initiate ART
       a
Marker
                      ≤ 11 months       12 – 35 months     36 – 59 months      ≥ 5 years
                                    3                 3                   3                  3
TLC                   <4000cells/mm     <3000cells/mm      <2500cells/mm       <2000cells/mm
Notes:
a. Immunological markers supplements clinical assessment and should therefore be used in
combination with clinical staging.
b. A drop of TLC below these levels significantly increases the risk of disease progression and
mortality.
C. there are fewer data available to make recommendations on use of TLC for decision making in
children older than 8 years of age.



WHO recommendations for ART initiation in infants and children

Infants and children with established HIV infection should be started on ART if they
have:
     WHO paediatric clinical stage 4 disease (irrespective of CD4)
     WHO paediatric clinical stage 3 disease (irrespective of CD4 ); for children
       older than 12 months with tuberculosis or lymphocystic interstitial pneumonia
       or oral hairy leukoplakia or thrombocytopenia, if CD4 is available, ART
       initiation may be delayed if CD4 is above threshold values.
     WHO paediatric clinical stage 2 disease and CD4 and TLC value at or below
       threshold
     WHO paediatric clinic stage 1 disease and CD4 values at or below threshold
Where virological testing is not available to confirm HIV infection, HIV antibody
positive infants and children less than 18 months of age should be considered for
ART if they have been clinically diagnosed Presumed Severe disease.

Recommended preferred first –line ARV regimens for infants and children
Regimen of 2 NRTI plus 1 NNRTI
AZT + 3TC + NVP/EFV
D4T + 3TC + NVP/EFV
ABC + 3TC + NVP/EFV
Notes:
    The use of AZT, d4T, ABC with 3TC results in several possible dual nucleoside combinations
       including AZT+ 3TC; d4T + 3TC; ABC + 3TC.
    AZT should not be given in combination with d4T.
    Where available FTC can be used instead of 3TC in children older than 3 months of age.
    NVP should be avoided in post pubertal adolescent girls with baseline CD4 absolute cell
                        3
       counts >250/mm
    EFV is not currently recommended for children < 3 years of age or < 10kg, and should be
                                                                    st
       avoided in post pubertal adolescent girls who are either in 1 trimester of pregnancy or are
       sexually active and not receiving adequate contraception.
    The use of TDF in children is not encouraged until further data is available
    It is recommended that the PI class of drugs should be reserved for second line therapy
       because their use in an initial treatment regimen compromises any subsequent second line
       regimen.




                                                                                               13
MODULE 4:           OPPORTUNISTIC INFECTIONS

Opportunistic infections are infections that prevalent in an individual whose immune
system is suppressed and not capable of fighting disease. However in an individual
with HIV/AIDS whose immune system is suppressed and not capable of fighting
disease, opportunistic infections become prevalent.

Classification
Opportunistic infections (OIs) can be classified according to the type of organisms
causing the infection. They include:

1. Bacterial diseases

a. Mycobacteria: - mycobacterium tuberculosis
                - mycobacterium avium complex (MAC)

b. Gram positive bacteria: - streptococcus pneumoniae
                          - Staphylococcus aureus

c. Gram negative: - Escherichia coli
                   - Hemophilus influenza
                   - Non typhoid salmonella species

2. Parasitic diseases
a. Toxoplasmosis
b. Microsporidiosis
c. Cryptosporidiosis
d. Isosporiasis

3. Fungal diseases
a. Candidiasis
b. Pneumocystis Jiroveci Pneumonia (PCP, PJP)
c. Cryptococcosis
d. Other fungal e.g. histoplasmosis, blastomycosis and aspergillosis

4. Viral diseases
    a. Cytomegalovirus
    b. Herpes simplex virus
    c. Herpes zoster virus

2. HIV associated neoplasms
   a. Kaposi’s disease
   b. Non- Hodgkin’s Lymphoma
   c. Invasive squamous cell carcinoma of the cervix ( associated with HPV)

Common OIs seen in Zambia

The common OIs seen in Zambia include:
 Tuberculosis
 Meningitis


14
   Pneumonias
   Oral thrush
   Diarrhoeal diseases

HIV complications a various degrees of immunosuppression in adults
CD4 +cell count      Infectious complications                 Non-infectious complications
         3
> 500/mm             Acute retroviral syndrome                Persistent               generalised
                     Candida vaginitis                        lymphadenopathy (PGL)
              3
200 – 500mm          Pneumococco and other bacterial          Cervical intraepithelial neoplasia
                     Pneumonia                                Cervical cancer
                     Pulmonary TB                             B cell lymphoma
                     Herpes zoster                            Anaemia
                     Thrush                                   Idiopathic      thrombocytopaenic
                     Candida oesophagitis                     purpura
                     Cryptosporidiosis, self limited          Hodgkin’s lymphoma
                     Oral hairly leukoplakia                  Kaposi’s disease
                                                              Lymphocystic               interstitial
                                                              pneumonitis
          3
< 200mm              PCP                                      Wasting
                     Chronic herpes simplex                   Peripheral neuropathy
                     Toxoplasmosis                            HIV associated dementia
                     Cryptococcosis                           CNS lymphoma
                     Cryptosporidiosis                        Cardiomyopathy
                     Microsporidiosis                         Immunoblastic lymphoma
                     Military/extra pulmonary TB
                     Progressive                 multifocal
                     leukoencephalopathy (PML)
                     Candida oesophagitis
          3
< 50/mm              Disseminated CMV
                     Disseminated M avium complex

PREVENTION OF OPPORTUINISTIC INFECTIONS

PRIMARY
 Abstinence
 Use of condoms
 Good nutrition
 Good hygiene practices
 Avoid overcrowding
 Provision of safe drinking water
 Use of Isoniazid to prevent Tuberculosis
 Use of Cotrimoxazole/ dapsone as PCP prophylaxis
 Immunizations

SECONDARY
 Early identification through medical exams
 Early treatment of infections
 Good nutrition
 Avoid unhealthy foods
 Avoid smoking, alcohol




                                                                                                  15
MODULE 5            HIV THERAPIES

HIV THERAPIES

Introduction
While there are many medicines available for the treatment of HIV infection, none
can cure HIV infection. The drugs can reduce the ability of the virus to replicate and
hence, increase the ability of the body to fight disease.

General principles
Taking Antiretroviral (ARV) therapy requires a long term commitment from a patient.
Correct and consistent use is required for the drugs to be effective. ARVs have side
effects that can make them difficult for some patient to take. Thus the decision about
when to start therapy is an important one. Treating someone too early may lead to
unnecessary toxicity and premature development of drug resistance, while treating
too late can increase the risk of morbidity, mortality and treatment failure.

Goals of Therapy
   Reduction of viral load as much as possible for as long as possible
   Restoration and /or preservation of immunologic function
   Improvement of quality of life
   Reduction of HIV related illness and death
   Possible reduction in transmission to others

General principles of ARV therapy
   Use of combinations of at least three ARV drugs
   Maximise adherence to ARV regimen
   Rational sequencing of ARV drugs
   Avoiding resistance

Highly Active Antiretroviral therapy (HAART)

HAART consists of a combination of at least three drugs: namely, any of the
following three combinations:
      2 Nucleoside Reverse Transcriptase Inhibitor (NRTI) + 1 Non Nucleoside
        Reverse Transcriptase Inhibitor (NNRTI)
      2 NRTI + Protease Inhibitor (PI)
      3 NNRTI

Classification of ARVs

Nucleoside Reverse Transcriptase Inhibitors (NRTIs)
   Zidovudine (AZT, ZDV) Retrovir
   Didanosine (ddl) Videx
   Stavudine (d4T) Zerit
   Lamivudine (3TC) Epivir
   Abacavir (ABC) Ziagen
   Tenofovir (TDF)



16
Non Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
    Nevirapine (NVP) Viramune
    Efavirenz (EFV) Sustiva

Protease Inhibitors
    Indinavir, Cirxivan
    Ritonavir (Rt) Novir
    Nelfinavir, Viracept
    Saquinavir, Invirase ( hard gel)
    Saquinavir, fortovase ( soft gel)
    Lopinavir + Ritonavir(LPV/r) Kaletra

When to start therapy

Zambian recommendations for initiating ART therapy in adults and adolescents with
documented HIV.

Clinical staging of HIV disease based on WHO criteria 2006
Clinical stage                       CD4 available                     CD4 not available
I                                    CD4 guided                        Do not treat
II                                   CD4 guided                        TLC < 1200 *
III                                  Treat **                          Treat
IV                                   Treat                             Treat
    * CD4 count strongly recommended
    ** if CD4 >350, treat if there are more than one stage 3 sign or repeated stage 3 problem

CD4 criteria for initiation of ART
CD4 (cell/mm)                  Actions
< 200                          Treat irrespective of clinical stage
200 – 350                      Treat if in stage 3 or pregnancy
> 350                          Treat if there is more than one stage 3 sign or repeated stage 3
                               problem*
* For others- monitor more frequently and consider treatment based on clinical or immunological
deterioration. Always start well before CD4 decreases to below 200.
Note: measure CD4 after stabilisation of any inter current illness

What therapy to begin

Recommended Regimens
(For patients initiating therapy up to new 2007 guidelines)
First Line regimen                                                       Second Line Regimen
NRTI                    NRTI                NNRTI                        NtRTI/NRTI        PI
                                                                                     1
AZT                                         EFV                          TDF/FTC
 or                     3TC                  or                          (preferred)
                                                3
d4T                                         NVP                          or
                                                                                   4             2
                                                                         ABC/ddl           LPV/r
                                                                         (alternative   if
                                                                         there is renal
                                                                         insufficiency)
    1.   Lamivudine (3TC) or Emtricitabine (FTC) are continued in second line regimen because their resistance mutations
          decrease viral replication capacity, increase HIV susceptibility to Tenofovir (TDF) and AZT
    2.   If unable to tolerate LPV/r then refer to HIV specialist for additional options
    3.   For women who have had exposure to Nevirapine within 6 months for PMTCT, do not use a Nevirapine containing
          regimen
    4.   3TC resistance reduces efficacy of ABC, therefore ddl will be substituted for 3TC




                                                                                                                     17
New Recommended regimens
Based availability of TDF/FTC +/- EFV as fixed dose combination given once daily;
proved potency of TDF; favourable mutation pathway; lower incidence of anaemia.

(Patients initiating therapy after the new 2007 guidelines)
First Line Regimen                                     Second line Regimen
                                                                     1                   2                       6
TDF*                 FTC                  EFV                  AZT                  3TC                  LPV/r
                                          or                                        or
                                              3                                             5
                                          NVP                                       TDF/FTC
                                                                         4   2
                                                       D4T / 3TC
* TDF has been associated with renal toxicity: if CrCl <50ml/min, initiate therapy with ABC/3TC
     1.   AZT/3TC/LPV/r is preferred second line regimen for patients failing Tenofovir based first line.
     2.   Lamivudine (3TC) or Emtricitabine (FTC) are continued in the second line regimen because their resistance
          mutations decrease viral replication capacity, increase HIV susceptibility to Tenofovir (TDF) and AZT.
     3.   For women who have had exposure to Nevirapine within 6 months for PMTCT, do not use a Nevirapine containing
          regimen
     4.   Stavudine (d4T) is associated with long term toxicity and should only be used in the second line if AZT can not be
          taken.
     5.   TDF mutations can increase HIV susceptibility to AZT and may increase AZT efficacy, while TDF may maintain
          same activity.
     6.   If unable to tolerate LPV/r then refer to HIV specialist for additional options


ART for individuals with TB co-infection
Patient clinical status                   TB management
                                          No CD4 available                          CD4 available
                                                                                                      3
Smear +ve PTB, Smear –ve                  Start TB treatment immediately            CD4 <200/mm - start TB
PTB, EPTB, Smear –ve                      Reassess monthly and consider             treatment immediately.
relapse (patient clinically stable        ART if condition deteriorates             Start ART as soon TB
and history of other stage 2 or 3         If stable consider ART after TB           medications         are   well
conditions.)                              treatment                                 tolerated.(usually within 2-3
Smear +ve PTB, Smear –ve                  Start TB treatment immediately            weeks)
PTB, EPTB, Smear –ve                      Start ART as soon TB
                                                                                                             3
relapse (patient seriously ill with       medications        are        well        CD4 200-300mm – start TB
history of 3 or 4 conditions.)            tolerated.(usually within 2-3             treatment immediately.
                                          weeks)                                    Start ART after completion of
                                                                                    intensive   phase      of TB
                                                                                    treatment.
                                                                                                         3
                                                                                  CD4 >350mm           –start TB
                                                                                  treatment immediately
                                                                                  Reassess monthly and consider
                                                                                  ART if condition deteriorates
                                                                                  If stable consider ART after TB
                                                                                  treatment
Develops TB while on ART                      Start TB treatment immediately and if ART regimen includes
                                               Nevirapine, substitute it with Efavirenz and continue ART
                                              Evaluate for clinical failure and consider for second line ART
Patient on TB treatment                       If patient clinically stable initiate ART after completion of TB
diagnosed HIV +ve                              treatment.
                                              If patient in stage 3 and 4 and ART is required immediately
                                               avoid Nevirapine




18
SIDE EFFECTS

HIV – Related drugs with overlapping toxicities
Bone marrow Peripheral          Pancreatitis      Renal or kidney    Liver toxicity   Rash            Diarrhoea    Eye effects
suppression      neuropathy                       toxicity
Zidovudine       Didanosin      Didanosine        Indinavir          Efavirenz        Abacavir        Didanosine   Didanosin
Cotrimoxazole e                 Lamivudine        Aminoglycoside     Nevirapine       Efavirenz       Ritonavir    e
Dapsone          Stavudine      (children)        s                  NRTIs            Nevirapine      Nelfinavir   Ethambutol
Amphotericin     Isoniazid      Stavudine         Amphotericin B     PIs              Cotrimoxazole   Kaletra      Rifabutin
B                               Ritonavir         Acyclovir    (IV   Rifampicin       Dapsone         Tenofovir
Pyrimethamin                    Cotrimoxazole     high dose)         Ketaconazol      Sulfadiazine    Clindamyci
e                               Pentamidine       Pentamidine        e                                n
Sulfadiazine                                                         Isoniazid
Rifabutin                                                            Fluconazole
Primaquine                                                           Intraconazole
Ganciclovir                                                          Rifabutin
Flucytosine


Managing side effects and toxicity
Actions that can be taken regarding adverse drug effects include:
 Educate patients about possible side effects and toxicity associated with ARV
   regimens being considered or being prescribed.
 Decide on the specific regimen while taking into consideration situations that may
   increase risk for certain adverse effects including other medical conditions or
   other medication being taken.
 Follow recommendations for clinical and laboratory monitoring with specific ARV
   regimens.
 Provide education about things that can be done for prevention of mild side
   effects such nausea and headaches
 Educate patient about signs and symptoms that may indicate the development of
   more serious or life threatening adverse effects: jaundice or dark urine, severe or
   persistent abdomen pain, skin rash with blistering, skin sloughing or mucous
   membrane involvement, shortness of breath, severe nausea and vomiting, high
   or persistent fever.
 Make sure your patient knows you are available to help them if they think they
   may be experiencing an adverse effect from ARV treatment. They should know
   how to reach you or another care provider at any time.

Drug interactions

ARVs and Oral contraceptive (OC) and Rifampicin
 Some ARVs either increase or decrease the amount of hormone (oestrogen and
    progestin) contained in the OC that is measured in the blood stream. This may
    reduce the effectiveness of the oral contraceptive. Nelfinavir, Ritonavir, LPV/r,
    NVP, EFV, may each decrease OC effectiveness. When one of these drugs is
    part of the ARV regimen, another or an additional family planning method should
    be used.
 Rifampicin and co administration of PI or NNRTIs can result in decreased blood
    levels of the ARV agent (and decrease effectiveness) and possible increased
    liver toxicity.
Immune reconstitution inflammatory syndrome (IRIS)
Immune reconstitution inflammatory syndrome (IRIS) is an exaggerated
inflammatory reaction from a re-invigorated immune system presenting as


                                                                                                            19
“unmasking” of previously sub-clinical opportunistic infections or clinical deterioration
of pre existing opportunistic infection or development of auto immune disease.
 Onset: usually within 2-12 weeks after starting ART
 Most commonly seen with TB, cryptococcal disease and mycobacterium avium
    complex infection.

Adherence to HAART

Adherence: The extent to which a client’s behaviour coincides with the prescribed
health care regimen (ART treatment) through a shared decision making process
between the client and health care provider.

Good adherence means
 Drugs should be taken at the same time of the day to maintain constant drug
  blood level.
 Taking all the medication at the right time, in correct doses, with or without food
  (if indicated).
 Not skipping doses or starting and stopping therapy.

Factors that hinder adherence

Complexity of the regimen. The number of pills, times a day and duration of
treatment all affect whether or not a patient will adhere to therapy.
Side effects. If drugs cause uncomfortable side effects or make a patient ill, it is
likely that they will not take medication on regular basis.
Dietary restrictions- it is difficult for people to change their eating habits if this is a
requirement for effective therapy.
Patients forget to take their pill- this can include missing a night doe due to falling
asleep, waking up late and missing morning dose, run out medication, forget to take
to work or on trips.
Privacy concerns- some patients fear that being seen taking ARVs will reveal their
HIV status, hence some will miss dose.
Self -esteem, depression and mental illness- these factors will hinder adherence.
Lack of desire to take medication all the time – the ARV regimen can feel
burdensome and people feel like they need a break.

Factors that enhance adherence

    Thorough assessment of patient readiness. Assessment can take time before
     a patient understands the importance of adherence and accepts the concept of
     life long therapy. The health care provider and patient must partner as they
     develop an adherence plan.
    Treatment plans that fit into patients’ lives. The approach needs to be
     individualised so that the regime fits into patient’s daily activities and lifestyle.
    Preparation for possible side effects. If a patient knows what to expect and
     how to deal with the expected side effects, they are likely to adhere.
    An educated patient. The better understanding a patient has about HIV, how
     medications work and the relation between adherence and resistance, the more
     likely they will successfully adhere.


20
   A supportive health care provider/counsellor. Patients who have a trusting
    relationship and feel supported by their health care provider have greater
    adherence to ARV therapy
   Use of adherence tools. Reminder tools can help a patient in taking their
    medications as prescribed.
   Positive feedback. If patients are adhering, make sure to congratulate them.

Changing ART due to treatment failure

Treatment failure is defined by the following criteria:

Clinical failure
Clinical disease progression signalled by new or recurrent WHO stage 3 or 4
condition when ART has been given sufficient time t induce protective degree of
immune restoration (after 6 months). Often associated with weight loss and drop in
haemoglobin.

Immunological failure
A fall in CD4 counts 50% from the peak value on treatment or a decline to pre
therapy baseline or below or persistent CD4 levels below 50cells/mm 3 after 12
months on therapy.

Virologic failure
Plasma HIV viral load >400 copies/ml after 6 months on therapy

Factors leading to treatment failure
 Poor adherence to treatment
 Prior exposure to antiretroviral treatment with development of resistance.
 Primary viral resistance
 Inadequate drug absorption
 Suboptimal dosing
 Inadequate or inconsistent drug supply.




MODULE 6:            CONTINUUM OF CARE




                                                                                21
HIV/AIDS management is a continuum of care from prevention interventions through
clinical and terminal care. Seven main components of comprehensive care in
HIV/AIDS across the continuum of care are identified as follows:

     Voluntary counselling and testing
     Clinical management including management of opportunistic infections
     Antiretroviral therapy (ART)
     Prevention of mother to child transmission of HIV (PMTCT)
     Nutritional care
     Home based & Palliative care
     Linkage to support groups
These services are offered to the spectrum of HIV infection individuals from
asymptomatic to the terminally ill person living with HIV/AIDS. VCT is the entry point
to the other components of care.

Continuum of care: Refers to care that encompasses the care provided to an
individual in continuous fashion from the onset of illness up to the end.

Comprehensive care: Refers to the care provided to an individual, focussing on
addressing his/her total needs including the physical, social, psychological and
spiritual concerns in a holistic manner.

Principles for management of HIV/AIDS
 Prevention and education: Prevention and ongoing education about HIV and
   AIDS should be an important part of management and care for PLWHA.
 All patients with HIV/AIDS should receive full medical for OIs and other
   conditions they present with.
 All PLWHA should be treated with dignity by all health care providers and should
   not be discriminated against as a result of their status.
 Information about patient’s HIV status or details about his/her medical condition
   should be kept strictly confidential by health care providers and shared only with
   permission of patient.
 Healthcare providers should work to reduce the stigma associated with PLWHA
   at all levels of the health care system and in the community.
 Counselling of the patient about prevention, care and treatment should take
   place at initial visit and throughout the course of care. Counselling also involves
   psychosocial support, including stress- and anxiety reduction and promotion of
   positive living and planning for the future.
 Patients should receive referral to other to other services as needed, including
   family planning, antenatal care, tuberculosis treatment, hospitals or clinics,
   community based service, home based care, etc.

The principles of palliative and terminal care

    Enhance patient/family control and the quality of life
    Provide practical support/advice for the PLHA and their loved ones
    Provide adequate pain relief and symptom control
    Maintain the comfort and dignity of the individual



22
   Provide spiritual and emotional/grieving support for the PLHA and their loved
    ones
   Prepare the PLHA, their families and caregivers for death. This includes advice
    concerning avoiding any traditional death rites which could spread infection.
   Ensuring that appropriate provision is made for the children involved and that
    their rights are respected
   Provide bereavement support to the family and loved ones following death.

Bereavement counselling

Families and friends often have little social support, or may have become isolated
while caring for the PLHA. Bereavement support should be made available before
the person dies, and for as long afterwards as people need it. People react to death
in different ways, and need different types of support. For some, it can take months
or years to come to terms with loss. Additionally, people's responses may be
affected by the way the person died: For example, whether the PLHA died alone and
in pain, or died peacefully, surrounded by loved ones. Those left behind often blame
themselves if they think they could have done more.

Bereavement counselling should:

 Give people an opportunity to talk about events leading up to the death, about the
  death itself, and the observances and rituals immediately after the death
 Reassure people that feelings of disbelief, denial, sadness, pain and anger are
  normal
 Allow people to express their feeling and concerns, especially if it is difficult for
  them to do this with friends and family
 Enable people to accept their loss and start to look to the future Fear of death.
  Fear is a normal reaction and can make people angry, depressed, or aggressive.
  Caregivers should not give false reassurances, but should encourage the person
  to talk about their fears. Spiritual support might also be helpful. Loneliness and
  depression. Sometimes when death is impending, relatives/friends stop coming
  to visit because they fear death, or do not know how to react. Such isolation can
  lead to a sense of loneliness and depression. Relatives/friends should be
  encouraged to visit (if the PLHA wishes). In some cultures, close relatives will
  also need an opportunity to discuss their feelings about being with someone who
  is dying.

 Feelings of guilt and regret. The PLHA may feel responsible for exposing
  his/her partner to infection, or may feel guilty for having brought shame to their
  family or friends. Failure to settle debts, fulfil ambitions, or attend to their
  responsibilities to children can all cause feelings of guilt, sorrow, and regret. A
  person may seek forgiveness or wish to discuss ways of resolving problems for
  which he/she feels responsible.
 Spiritual support. This support can come either through an invited clergy, or
  through the exploration of the PLWHA's own spirituality, beliefs and values. The
  PLHA might have been cut off (whether by him/herself or by their community)
  from his/her religion. Caregivers should acknowledge a person's spiritual needs,
  respect their religious beliefs (or lack of them), identify an appropriate person who



                                                                                     23
     can provide spiritual support, and discuss whether the person wants any religious
     observances to be performed, including funeral arrangements, in the event of
     their death.

HIV AND NUTRITION
People with HIV/AIDS may have problems with digesting food. It seems that their
digestive systems do not function properly and may not therefore absorb the much-
needed nutrients. Apart from that, PLHA may have difficulties eating food because
of poor appetite or mouth sore, which make the individual unable to eat. Resulting
from this may be problems associated with malnutrition and weight loss. Malnutrition
is often the cause of death of people with AIDS. Food provides a medicine that is
cheap and easy to get. It takes time and patience to see the benefits of good food.
By eating foods that heal the body one lives a stronger and healthier life.

Practical suggestions on how to maximise food intake during and following
common HIV/AIDS – related Infections.

Symptom                        Suggested strategy
Fever and loss of appetite      Drink high energy, protein liquids and fruit juice
                                Eat small portions of soft, preferred foods with a pleasing
                                 aroma and texture throughout the day
                                Eat nutritious snacks whenever possible
                                Drink liquids often
Sore mouth and throat           Avoid citrus fruits, tomato and spicy foods
                                Avoid very sweet foods
                                Drink high energy, high protein liquids with a straw
                                Eat foods at room temperature or cooler
                                Eat thick smooth foods such as pudding, porridge, mashed
                                 potatoes, mashed carrots and other non-acid vegetables and
                                 fruits
Nausea and vomiting             Eat small snacks through out the day and avoid large meals
                                Eat crackers, toast and other plain, dry foods
                                Avoid foods that have strong aroma
                                Drink diluted fruit juices, other liquids and soup
                                Eat simple boiled foods such as porridge, potatoes, beans
Loose bowels                    Eat bananas, mashed fruits, soft rice, porridge
                                Eat smaller meals more often
                                Eliminate dairy products to see if they are the cause
                                Decrease high fat foods
                                Don’t eat foods with insoluble fibre (roughage)
                                Drink liquids often
Fat malabsorption               Eliminate oils, butter, margarine and foods that contain or were
                                 prepared with them
                                Eat only lean meats
                                Eat fruit and vegetables and other low-fat foods
Severe diarrhoea                Drink liquids frequently
                                Drink ORS
                                Drink diluted juices
                                Eat bananas, mashed fruits, soft rice and porridge
Fatigue, lethargy               Have someone pre cook foods to avoid energy and time spent
                                 in preparation (care with re-heating)
                                Eat fresh fruits that don’t require preparation
                                Eat snack foods often throughout the day
                                Drink high-energy, high protein liquids



24
                              Set aside time each day for eating
Adopted from Woods (1999)
Importance of using locally available foods in the management of HIV/AIDS
These can provide a healthy diet for PLWHA and can be used to meet nutritional
needs. Locally available and indigenous foods are generally wholesome, affordable,
accessible, unrefined or less processed and often have a lot of nutrients. Below is a
chart of locally available foods.
Body building foods           Groundnuts, beans, eggs, milk, caterpillars, milk
                              Fish, terminates, grasshoppers,
                              Kapenta
                              Lentils (ingolyolyo)
Energy giving foods           Nshima, sweet potatoes, cassava, rice, sugarcane
                              Maize, bread, vegetable oil
Protecting foods              Fruits-mangoes, oranges, guavas, avocados
                              Pumpkin leaves, sweet potato leaves,
                              Cabbage, bean leaf family. Rape
                              Lumanda, ibondwe




 Commonly used herbs

Aloe Vera (pure gel from leaves)
Curative properties: reduces burning sensations in the stomach and useful for
gastritis and gastric ulcers
Stimulates gallbladder when it functions sluggishly
External application eliminates rashes, alleviates eczema and makes blemishes
disappear from skin.
Alleviates injuries caused by burns and promotes healing of other injuries
Preparation soak 1 tablespoon of chunks of leaves in 1 cup of water for 4
hours Dosage 1 tablespoon every 6 hours or - Gel applied topically

Almond
Curative properties an extract of leaves and crushed bark applied externally is
useful for itching and infectious eruptions of the skin
Boiled liquid from bark and leaves useful in diarrhoea, GIT bleeding, haemorrhoids
Can be applied locally to alleviate chapping and cracking of nipples and other skin
lesions
Preparation boiled % cup of leaves and bark in 1 litre of water
Dosage % cup of liquid 8 hourly. For external use as cold
compresses

Avocado
Curative properties avocado salad is beneficial for stomach and intestinal
problems Leaves acts as bladder stimulates, useful in healing of injuries and
ulcers, stimulates movement of digestive system, strengthen female reproductive
system, stimulate and adjust menstrual flow, act as diuretics.

 Outer shell used to combat intestinal worms and dysentery
 Avocados cure colds and bronchial inflammations when a medicinal extraction or
 infusion is prepared
 Hot fresh leaves may be applied to forehead to combat headache


                                                                                   25
Leaves are known to help control hypoglycemia and decrease blood cholesterol.
Preparation pour 1 litre of water over a spoonful of crushed leaves and let it set for
a few minute for an infusion
Boil 2 tsp of chopped avocado seed in water for 5 minutes for decoction
Dosage for colds take ~ cup every 6 hours; diarrhoea ~ cud 4 hourly, toothache
soak cotton swab in the decoction and place it on cavity

Cabbage
Curative properties Cabbage soup or cooked leaves are used treatment of
stomach and intestinal ulcers, helpful in laryngitis and loss of voice .A leaf of
cabbage put on aching knee alleviates pain

Chamomile (Flowers)
Curative properties Used to relieve anxiety, for sedation, antispasmodic, for colic,
anti-inflammatory, soothes skin, rash,
Destroys candida albicans
Stimulant action on the macrophages and lymphocytes B of the immune
system Dosage - drink 3 cups per day tea or tincture taken internally

Comfrey
Curative properties useful in cases of bronchitis

Cucumber
Curative properties effective diuretic' dissolves uric acid and superfluous
fats Useful for treatment of bed sores for those in bed for a long time
Dosage applied locally

Fig tree
Curative properties helps alleviate constipation and inflammation of the throat,
bronchial coughs and burning sensations when urinating
To heal boils, tumours and inflammations of the skin, place hot figs directly on them

Garlic
Curative properties it possess cleansing action, is a microbicide, disinfectant,
cough suppressant, antirheumatic and remedy for gout, controls high blood
pressure, vermifuge
Useful in both external and internal infections

Ginger
Curative properties anti-inflammatory and anti coagulant and antipyretic

Ginseng
Curative properties improves memory
Stimulates immune system by increasing number of white blood cells. It also
stimulates interferon a chemical product of the body that combats bacteria and viral
infections Decreases cholesterol level

Lemon
Curative properties it combats gas, alleviates headaches, vertigoes and dizziness
Combats diarrhoea, dysentery, nervous ailments, palpitations, cancer, tuberculosis
and syphilis. Used in coughs. It has both bactericidal and anti inflammatory effects


26
combats hiccups

Mint
Curative properties promotes a relaxant effect, useful in treatment of fevers and
colds Combats nausea and vomiting

Onion
Curative properties fights infection, diuretic, vermifugal
It regenerates the body, relieves pulmonary and bronchial
diseases Good for relieving constipation and impotence

Pawpaw
Curative properties effective in dissolving fat deposits, relieving allergies,
accelerates scar tissue formation both internally and externally

Tea tree oil (Oil from leaves)
Curative properties - skin infections, fungicide, vaginitis, contact dermatitis

The above list is not exhaustive.




MODULE 7:            COUNSELING AND HIV/AIDS



                                                                                  27
Counselling is a helping relationship. It is an interaction process between a
counsellor and a client. It takes place in a face-to-face communication in which the
client is helped to identify, clarify and be able to make informed decision in order to
resolve his/her own problems.

Types of counselling

Preventive counselling- this refers to a counselling intervention designed to provide
continuous information and education for promotion, motivation and adoption of HIV
risk reduction behaviour. It seeks to promote awareness and understanding of the
adverse effects of HIV infection and to enhance coping capabilities of the people so
as to improve their quality of health and social well being.

Supportive counselling- it refers to a counselling intervention designed to provide
psychosocial, emotional, physical and spiritual support for those who are directly or
indirectly affected by HIV/AIDS through follow up, community/home based care and
social support which encourages the involvement and participation of the affected
persons.
Guidance counselling- refers to giving way, direction or leading a client by giving
alternatives to help the client find a solution or come up with a choice.

Qualities of a Counsellor

Genuineness
The counsellor must show herself to be a real person, with feelings that should be
expressed where appropriate. The counsellor is unified, integrated and consistent;
there should not be contradiction between what the counsellor is and what she says.
The client needs to feel that the counsellor is emotionally involved and hiding behind
a mask of professional impersonality, nor indeed, merely playing a role. This is the
most important of the three qualities.

Acceptance
The counsellor should be accepting of client as an individual, as the client is, with his
conflicts and inconsistencies, or good and bad points. Such an attitude or quality is
more than a neutral acceptance – is unconditional positive regard/respect for the
client as a person of worth. It also involves a liking for and warmth toward the client
– a total recognition of the client as a human being, with feelings and knowledge.
The counsellor must have a deep and authentic caring for the clients in their present
situation in non-judgemental way.

Empathy
To sense the client's private world as if it were your own, the ability of intellectual
and emotional identification with another person is what is referred to as empathy.
The counsellor must try to enter the client's internal world through a genuine,
attentive listening, which involves intense concentration. This may involve re stating
or paraphrasing what the client says as a way of clarifying the emotional significance
of what is said. The counsellor needs to be sensitive to what is currently going on in
the client's mind and to meanings, which are just below the level of awareness.
Empathic understanding is a necessary ingredient of virtually all-successful
counselling relationships. Such attitudes will enable clients to talk about themselves


28
more honestly. The counsellor needs to be perceived as dependable, trustworthy
and consistent and hence to be able to provide feelings of safety, security and
freedom from threat in the relationship.

Counselling skills and Techniques

Attending skill
This is sometimes referred to as rapport, although in practical terms, it implies much
more than just building or establishing rapport. The attending skills involve such
elements as friendliness, courtesy, eye contact, relaxed body, posture, body
language, vocal tone and speech rate.

Listening skills
This is the basic tool used to gather information. The skill involves listening to the
client's actual words, the factual information and details such as choices and
emphasis of words and misuse of words. It also involves listening to the mood, the
feelings and underlining message that are conveyed through verbal and nonverbal
communication.
 Verbal involves listening to the actual words, factual information and details such
    as choices, emphasis and misuse of words, voice tone and speech rate
 Non- verbal involves listening to the mood, the feelings and the underlying
    messages that are being conveyed, bodily behaviour, facial expression and
    general appearance.

Probing/ Questioning skills
A counsellor should ask questions that should encourage the clients to talk about
themselves. These should be open-ended questions that can not be answered with
simple yes/no.
A counsellor should as well instruct, explain and describe clearly and accurately
information on HIV. He/she should use words the client understands. The counsellor
should use visual aids such as pictures, drawings, charts or samples when
explaining difficult issues to understand.

Empathy skills
Empathy as a form of human communication involves listening to clients, clarifying
their concerns, and communicating this understanding to them so that they might
discover new meanings and perceptions in relation to their problem situations. A
great deal of the discussion on empathy centres on the kind of observing and
listening needed to develop an understanding of clients and their worlds.

Summarizing
A summary is an advanced type of clarification. By summarizing, the counsellor
synthesizes what has been communicated during a counselling session and clarifies
the major affective and cognitive themes. A summarizing response is useful in
beginning an on going counselling interview, or clarifying pertinent issues during a
counselling session, or to close the counselling session. Summarizing provides an
opportunity for the counsellor to encourage the client to share his feelings about the
counsellor – client relationship and the session.

Counselling, Testing and Care


                                                                                    29
This is a strategy considered appropriate to replace VCT intervention because of its
greater emphasis on the provision of quality supportive care for PLWHA. The CTC
concept is all embracing and signifies the components of intervention: counselling,
HIV testing and AIDS care.

Features of CTC

Information education and communication strategy (IEC) - it is a strategy used
to influence behaviour change of individuals, couples and families, or groups of
people in order to reduce the spread of HIV infection.

Pre-test and post-test counselling strategy- pre-test counselling addresses
implications of HIV test result; personal risk assessment; psychosocial concerns;
personal benefits of testing for HIV; and the importance of taking personal
responsibility of the outcome of HI test result. On the other hand post test
counselling addresses communicating the HIV test result, psychosocial concerns,
and specific needs presented by the client and developing action plans. (E.g. self
disclosure and partner notification, positive living, safer sex practices, adjustment
and acceptance)

Benefits of CTC

Improved health and medical treatment
 Prompt and effective treatment of OIs
 Early medical and nutrition care
 Anti-TB screening and therapy
 Antiretroviral treatment where applicable
Informed decision making
 Facilitates informed decision on issues such as safer sex practices, childbearing,
   breastfeeding and positive living.
 Empowers individuals, couples and families for affirmative action
Psychosocial support
 Strengthens referral to support groups and community networks
 On going supportive counselling
Shared confidentiality
 Promotes partner notification, openness and self disclosure
 Helps reduce stigma
Prevention of HIV transmission
 Promotes risk reduction behaviour

Barriers in CTC
 Problems with coping especially where test result is positive
 Stigma, rejection and discrimination
 Window period. It is likely that one may test negative when still in window period



MODULE 8:           GENDER AND HIV/AIDS



30
Gender is defined as the socially constructed roles, relationships, responsibilities,
status and privileges assigned to women, men, boys and girls in a given culture or
location. It is learned through the process of socialization. Gender relations are
dynamic, changeable and vary from culture to culture. The word gender
differentiates the socially attributed aspects of an individual's identity from the
physiological characteristics of men and women.

Sex refers to biologically determined differences between male and female. It is
characterised by certain physical attributes for male and female.

Gender roles are determined by patterns of behaviour in terms of rights, duties and
obligations assigned to men and women in society. They are dynamic and not static,
socially determined and vary from culture to culture.

Definition of Gender concepts

Gender equality- means having the same status, rights and responsibilities for
women and men. It is based on the idea that no individual should be less privileged
in opportunities or in human rights.
Gender equity- means being fair, socially just and impartial through fair distribution
of benefits and resources. It is a stage in the process of achieving gender equality.

Gender sensitivity- means to be aware of the difference between women's and
men's needs, role, responsibilities and constraints and being able to take action to
address the issues. It also means taking into consideration the impact of policies,
legislation, programmes on women, boys and girls.

Gender mainstreaming- means to integrate gender dimensions into development
plans, programmes and development models. To ensure that development plans do
not ignore, overlook or fail to take account of women's and men's boys and girls
issues. To incorporate gender at all stages of the project cycle and in national
policies, budgets, legal instruments, etc.
Gender bias- refers to the tendency to make decisions or take actions based on
one's sex. Favoring one sex over/against the other

Gender discrimination- refers to prejudiced treatment of an individual based on a
gender stereotype
Gender balance- having equal numbers or status between men, women, boys and
girls. Equal representation and decision making power in any intervention or
development being undertaken.

Gender concerns in HIV/AIDS
Women are biologically more vulnerable because as a receptive partner, women
have a larger surface exposed during sexual intercourse.
Semen has a higher concentration of HIV than vagina fluid.
Like many other issues, HIV/AIDS affects both women and men differently. Due to
several variables, the disparity of infection between young men and women is even



                                                                                    31
greater. HIV/AIDS has negatively impacted on women. Their lower socio-economic
status and cultural factors make it impossible for women to negotiate foe safer sex.

Care
HIV/AIDS has a serious impact on the family life particularly the situation of women.
Care of the sick continues to be the responsibility of the family with women serving
as the major caregivers. Since women are the major food producers in the family,
this can have a substantial impact on food security.
Men have to be encouraged to share the burden of looking after HIV/AIDS patients.
If the burden is not shared, the women will be over burdened with responsibilities. It
is frequently the case that when women suffer from AIDS related disease, there is
no one to take care of them, but also, because they have been made to believe that
taking care of patients is the responsibility of women.

Empowerment
Nurses need to know various NGOs and CBOs that under take women
empowerment initiatives e.g. Women for Change; YWCA and CARE International. In
the Zambian culture men control women and only use the condom when it pleases
them. It is even important that nurses become members of such organizations so
that they know where to go in cases, which need reference to women empowerment
organizations.

Gender Policy in Zambia
The government of Zambia has recognized the need for equal and full participation
of women and women at all levels of national development. In order to attain its
vision of gender equality, the government has adopted and will implement the
national gender policy.
Government will endeavour to sustain the provision of affordable and quality social
welfare services in areas such as water and sanitation; health and housing. In
addition, government will devise more poverty alleviation and reduction strategies
and programmes as well as simplify procedures for accessing benefits there under,
especially by women.

Some of the policy measures are:
 To integrate reproductive health education in the curriculum to prevent amongst
  others, early pregnancy as well as HIV/AIDS
 To redress the gender the gender imbalances in the health sector, government
  will institute measures that encourage male involvement in taking care of the
  chronically ill especially those with HIV/AIDS.

MOTHER TO CHILD TRASMISSION OF HIV

Introduction
Prevention of mother to child transmission (PMTCT) is a critical element in the fight
against HIV/AIDS. Almost 18% of all women of reproductive age in Zambia have HIV
and these rates are higher among pregnant women. Over 150,000 children are
already infected with the virus, and more than 90% of these infections are a result of
mother to child transmission of HIV. Mother to child transmission can occur during
pregnancy, child birth, or breast feeding. Without doing anything to prevent


32
transmission around 40% of the children born to HIV infected mothers will get
infected with HIV.

Modes of Transmission

Utero transmission
The HIV has been isolated both in foetal tissue and in babies at birth. This accounts
for transmission in around 5 to 10% of HIV positive mothers.

Transmission during the time of labour
Most of the HIV transmission in pregnancy occurs at the time of labour and delivery.
This mode accounts for 10 to 20% of the infected children from HIV infected
mothers. The birth canal is one of the areas with a high concentration of HIV.

Transmission during breastfeeding
HIV has been isolated in both the free and cellular portions of breast milk.
Approximately 14% or one third of infants who are infected through MTCT are
infected through breast milk. The longer the period of breast feeding the higher the
risk. This accounts for transmission in around 0 to 20% of HIV positive women
depending on whether they breast feed and duration of breast feeding.

Factors contributing to MTCT
Strong evidence                            Weak evidence
During pregnancy
     High viral load                            Viral strain
     New infection                              Immune response
     Clinical AIDS                              Nutritional status
     Poor immune status (low CD4)               Other diseases
     Advanced maternal disease
     STIs
Labour and delivery
     Prematurity                                Invasive obstetric procedures such as –
     Vaginal delivery                            Episiotomies and early rupture of
     Prolonged rupture of membranes              membranes
     Prolonged labour                           Chorioamnionitis
     Instrumental deliveries
Postnatal
     Breastfeeding                              Mixed feeding
     Mastitis

Minimum package of maternal care

Antenatal care
Early access to antenatal care – is being re emphasized with a reduction in the
number of visits. The WHO is currently recommending a minimum of four visits per
pregnancy

Counselling
 Voluntary HIV testing and counselling (VCT) should be available in antenatal
  clinics. Many HIV-positive women will be diagnosed for the first time during
  pregnancy; therefore, this service is critical to the ongoing treatment, care and
  support for the mother, her family and newborn child.


                                                                                      33
    From 16 weeks HIV group counselling is offered to 1st ANC attendants. This is
     followed by individual VCT. Partner involvement is encouraged from the start.
     MTCT counselling done for both individuals and couples.
    From 24-28 weeks infant feeding counselling with counselling on safe sex
     practices is done. Education on nutrition is also given to both HIV positive and to
     those of unknown status.
    From 32 weeks counselling on anti retrovirals (ARVs) drugs is done for HIV
     positive clients.
    34-36 weeks, commencement on ARVs including continued counselling on
     treatment.

Benefits of VCT in antenatal care:
 Knowledge of one’s HIV status can reinforce safer sex practices.
 Women who undertake an HIV test can encourage their partners to be counselled
  and tested.
 Accessibility to free ARV to prevent MTCT
 Knowing their HIV status enables women and their partners to make more
  informed choices related to breast feeding and future pregnancies
 A woman (and her family) who knows she is HIV infected can be encouraged to
  enter into the continuum of care in order to seek early medical treatment and care
  of opportunistic infections for herself and her child, as well as be linked to other
  health and social services and resources.

Mode of delivery
Vaginal deliveries are more likely to increase the risk of MTCT while elective
Caesarean sections have been shown to reduce MTCT. However, the potential
benefits have to be balanced against the risk to the mother. Higher rates of
postoperative death in HIV positive women have been reported, especially from
infective complications. In addition, elective Caesarean sections are not available to
the vast majority of women worldwide.

Prolonged rupture of membranes
Rupture of membranes for longer than 4 hours has been associated with an
increased risk of transmission. Artificial rupture of membranes is practiced routinely
in many countries. Membranes should not be ruptured artificially unless there is
fetal distress, or abnormal progress in labour.

Episiotomy
Routine episiotomy is not recommended. This procedure should only be used
where there are specific obstetric indications. Forceps deliveries and vacuum
extractions do not necessarily require an episiotomy.

Intrapartum Haemorrhage
This has been associated with increased MTCT transmission in some studies.
Should a blood transfusion be required, there is the added risk of receiving HIV
contaminated blood

Invasive fetal monitoring
Penetrating scalp electrodes may be associated with increased risk of transmission.



34
Multiple births
The first baby delivered of a multiple pregnancy has a higher rate of HIV infection
than the subsequent births.

Antiretroviral therapy (ARV)
Short course ARVs prophylaxis has reduced HIV transmission by 40-70%. The
impact is greater when breastfeeding is not practiced.

Short course ARV in pregnancy
course                 Antenatal                 Intrapartum               Postnatal
Zidovudine (ZDV) and   Mother: ZDV 300mg         Mother: ZDV 600mg at      Infant: NVP 2mg/kg
Nevirapine (NVP)       twice a day starting at   onset of labour and       oral          suspension
                       32 weeks or as soon as    every 6 hours until       immediately after birth
                       possible thereafter       delivery                  and ZDV 4mg/kg twice
                                                                           a day for 7 days
                                                 NVP 200mg single          starting     immediately
                                                 dose at onset of labour   after birth.

                                                                           Mother: ZDV 300mg
                                                                           twice a day for 7 days
                                                      Or                   Or
                                                 ZDV 600mg at onset of     Infant: NVP 2mg/kg
                                                 labour and single dose    oral         suspension
                                                 NVP 200mg at onset of     immediately after birth
                                                 labour
ZDV                    Mother: ZDV 300mg         Mother: ZDV 600mg at      Infant: ZDV 4mg/kg
                       twice a day starting at   onset of labour or ZDV    twice a day for 7 days.
                       32 weeks or as soon as    300mg at onset of
                       possible thereafter       labour and every 3        Mother: ZDV 300mg
                                                 hours until delivery      twice a day for 7 days
ZDV and NVP when                                 Mother: ZDV 600mg at      Infant: NVP 2mg/kg
mother has received                              onset of labour and       oral          suspension
less than 4 weeks of                             every 6 hours until       immediately after birth
ZDV or ART before                                delivery                  and ZDV 4mg/kg twice
delivery                                                                   a day for 7 days
                                                 NVP 200mg single          starting     immediately
                                                 dose at onset of labour   after birth.

                                                                           Mother: ZDV 300mg
                                                                           twice a day for 7 days
ZDV and NVP when                                 Mother: ZDV 600mg at      Infant: NVP 2mg/kg
mother has received                              onset of labour and       oral          suspension
ARV prophylaxis                                  every 6 hours until       immediately after birth
                                                 delivery                  and ZDV 4mg/kg twice
                                                 NVP 200mg single          a day for 7 days
                                                 dose at onset of labour   starting     immediately
                                                                           after birth.
                                                                           Mother: ZDV 300mg
                                                                           twice a day for 7 days
NVP                    None                      Mother: NVP 200mg         Infant: NVP 2mg/kg
                                                 single dose at onset of   oral          suspension
                                                 labour                    immediately after birth


Vaginal cleansing




                                                                                                35
The use of chlorhexidine 0.25% to cleanse the birth canal after each vaginal
examination and during labour and delivery has been shown to be effective in
reducing MTCT transmission.

Baby care at birth
 Immediate examination and stabilization of the baby
 Baby is weighed and height measured
 BCG/OPV 0 given
 Excessive suctioning is avoided
 Prophylaxis for opthalmia neonatorum is given

Infant feeding
For the non breastfed infant:
 Ensure access to an adequate supply of replacement milk substitutes,
 Educate the mother about safe preparation of replacement feeds, correct
   cleaning of utensils, and methods of sterilization.
 Monitor the growth and development of the child to ensure adequate infant
   feeding and nutrition.

For the breastfed infant:
 Teach the mother to inspect her child's mouth for thrush and breakages in the
  mucous membrane
 Teach the mother about the increased risk of HIV transmission should she suffer
  from mastitis, breast abscesses, and bleeding or cracked nipples.
 Discuss replacement feeding after three months and to stop breastfeeding after 6
  months when the baby can be safely weaned.
 Use expressed milk that is boiled and then cooled. (Boiling kills the virus.)

Follow up: Paediatric HIV care

HIV testing
For babies with access to infant HIV diagnosis, do PCR at 6 weeks. If first result is
positive, repeat PCR at 10 weeks.
The babies who have no access to infant HIV diagnosis should be tested at 9
months of age with re-testing at 18 months using rapid tests.

Cotrimoxazole prophylaxis
Cotrimoxazole is given to all HIV exposed babies, i.e. all babies born from HIV
positive mothers starting at 6 weeks of life and continues until at least 12 months if
the baby still test HIV positive

Cotrimoxazole administration in HIV exposed infants
Weight                       Daily dose                   Bottles (100ml) needed per month
<5kg                         5ml                          0.5
5 – 9.9kg                    7.5ml                        1
10 – 14.9kg                  10ml                         1.5
15 – 19.9kg                  15ml (1.5tablet)             2
>20kg                        2 tablets                    2.5

MODULE 7: HIV AND THE WORKPLACE AND UNIVERSAL PRECAUTIONS


36
Introduction

The transmission of HIV in the health care setting can occur from patient to patient,
from patient to health care worker and from health care worker to the patient.
Transmission is through exposure to the blood and body fluids but the risk of
transmission of HIV is depended on health care personnel practices, prevalence of
the illness and the amount of frequency of the exposures. The occupational risk of
HIV infection being transmitted from patient to health care worker is estimated to be
low (0.3%), however, it is a real incidence when it occurs as it affects a real life of
the health worker. HIV transmission from patient to health worker is mostly
associated with needle stick injuries with needles from patients infected with HIV.
Patient to patient infections results from use of equipment contaminated with HIV or
from blood transfusions.

Impact of HIV on Health Care Service Delivery

The impact of HIV/AIDS on the health care service system is greatly felt in respect
of:
 Increased demand for services by HIV/AIDS patients.
 Cost of treatment due to recurrent opportunistic infections and the need for
    frequent admissions of patients infected with HIV.
 HIV/AIDS related illnesses and deaths among health workers resulting in severe
    staff shortages
 Burn out resulting from overload in wards congested.
 High numbers of staff absenteeism consequent to HIV/AIDS related illnesses
    and attending funerals
 High expenditure on recruitment and training staff to replace those die from HIV
    related illnesses

Risk of HIV Transmission in the Health care Setting

To Patients
 Contaminated instruments that are re-used without adequate disinfect ion and
   sterilisation
 Transfusion of HIV-infected blood
 Skin grafts and organ transplants
 HIV-infected donated semen
 Contact with blood or other body fluids from an HIV-infected health care worker

To Health Care Workers
 Skin piercing with a needle or any other sharp instrument which has been
   contaminated with blood or other body fluids from an HIV infected person
 Contact of broken skin/ mucous membranes, open cuts or wounds with blood or
   other body fluids from an HIV infected person

Safe Work Environment
The environment in which health care is provided influences not only the quality of
care delivered, but also the safety and well-being of patients and care providers.


                                                                                     37
Measures that promote safe and supportive work environment include:
 Education of employees on occupational risks, methods of prevention of HIV and
  other infectious diseases, and procedures for reporting exposure
 Provision of protective equipment such as gloves, goggles, plastic aprons,
  gowns, etc
 Provision of appropriate disinfectants to clean up spills of blood and other body
  fluids e.g. Jik (Hypochloride), Cidex and Chlohexidine(Hibitane)
 Increasing the accessibility of puncture resistance “Sharps” containers.
 Maintaining appropriate staffing levels
 Ensuring that universal precautions are implemented monitored and evaluated.
 Providing post-exposure counselling, treatment, follow up and care.
 Implementing measures that reduce and prevent stress, isolation and burn out.
 Controlling shift length and providing supervision of inexperienced staff.
 Addressing the healthcare, compensation and financial needs of HIV positive
  health care providers;
 Providing flexible work allocation for HIV positive personnel and continuing their
  employment for as long as possible.

UNIVERSAL PRECAUTIONS

Universal Precautions are simple standards of infection control practices to be used
in the care of all patients, at all times, to reduce the risk of transmission of blood
borne infections. They include:

    Careful handling and disposal of "sharps";
    Hand washing with water and soap before and after all procedures under running
     water;
    Use of protective barriers such as gloves, gowns, aprons, masks, goggles for
     direct contact with blood and other body fluids;
    Safe disposal of waste contaminated with blood or body fluids;
    Proper disinfection of instruments and other contaminated equipment;
    Proper handling of soiled linen.

Safe handling and disposal of "sharps"

    Puncture-resistant disposal containers must be available and readily accessible
     for the disposal of "sharps".
    Alternative available objects, such as a tin with a lid, a thick plastic bottle, or a
     heavy plastic or cardboard box, can work as suitable "sharps" containers. These
     can be burned in a closed incinerator, or can be used to transport the "sharps" to
     an incinerator.
    Empty containers when they are 3/4 full,
    Wear heavy-duty gloves when transporting "sharps" containers, to incinerate
     used equipment at a hot enough temperature to melt the needles.
    Where the sharp container is not burned, bury it in a deep pit.




38
Safe decontamination of equipment
    All equipment should be decontaminated before cleaning in 0.5% chlorine for
      10 minutes.
    Heavy duty gloves should be worn for cleaning equipment and if splashing
      with body fluid is likely, then additional protective clothing such as aprons,
      gowns, and goggles should be worn

    The following table helps in selecting the method for decontamination:
LEVEL OF RISK           ITEMS                                   DECONTAMINATION METHODS
High risk               Instruments with penetrate the Sterilization, or single use of
                        skin/body                               disposables
Moderate risk           Instruments which come in contact Sterilization, boiling, or chemical
                        with non skin or mucous membrane        disinfection
Low risk                Equipment which comes in contact Through washing with soap and hot
                        with intact skin                        water

Cleaning
    Detergents and hot water are adequate for the routine cleaning of floors,
      beds, toilets, walls, and rubber draw sheets.
    Following a spillage of body fluids, heavy-duty rubber gloves should be worn
      and as much body fluid removed with an absorbent material. Discard in a leak
      proof container and later incinerate or bury in a deep pit.
    The area of spillage should be cleaned with a chlorine-based disinfectant and
      the area thoroughly washed with hot water and soap.

      All soiled linen should be handled as little as possible, bagged at the point of
       collection and not sorted or rinsed in patient care areas. If possible, linen with
       large amounts of body fluid should be transported in leak proof bags. If leak
       proof bags are not available, the linen should be folded with the soiled parts
       inside and handled carefully, with gloves.

Recommended methods of sterilization include,
    Steam under pressure (e.g. autoclave or pressure cooker)
    Dry heat such as an oven.

Disinfection will usually inactivate HIV. Commonly used disinfection methods are:
 Boiling- equipment should be cleaned and boiled for 20 minutes at sea level, and
   longer at higher altitudes.
 Chemical disinfection is not as reliable as sterilizing or boiling. However,
   chemical disinfection can be used on heat sensitive equipment,
 Chemicals that have been found to inactivate HIV include chlorine-based agents
   (for example, bleach), 2% glutaraldehyde, and 70% ethyl and isoproyl alcohol.

Safe disposal of waste contaminated with body fluids
Solid waste that is contaminated with blood, body fluids, laboratory specimens or
body tissue all should be placed in leak proof containers and incinerated, or buried
in a 7 foot deep pit, at least 30 feet away from a water source. Liquid waste such as
blood or body fluid should be poured down a drain connected to an adequately
treated sewer or pit latrine.



                                                                                          39
HIV Post exposure prophylaxis (PEP)
 PEP should generally be given when the source of exposure is known to be HIV
   positive or when there is information that they are likely to HIV infected or if the
   HIV status is not known.
 In Zambia and other high prevalence regions, PEP may be provided even if HIV
   status is unknown.
 If available, rapid HIV status may be used to determine HIV status of source
   patient if they agree.
 Immediately test health worker for HIV after exposure and repeat at 3 and 6
   months.
 Do not delay starting PEP. Treatment should be given only where the HIV test
   result is negative.

Immediately after exposure
 Clean the exposure site. If skin wound, wash with soap and running water. If eye
  or mucous membrane, flush with copious amount of clean water.
 Do not bleach or use disinfectants to clean the exposure site
 Contact your site in charge or supervisor.

Recommended prophylaxis
Risk category                    ART                              Duration
No risk: skin intact             Not recommended
Medium risk:
Invasive injury                  AZT 300mg PO 12 hourly           28 days
No blood visible on needle       3TC 150mg PO 12 hourly
High risk:                       plus LPV/r*
Large volume of blood/fluid
Known HIV infected patient
Hollow bore needle
Deep extensive injury
 for patients with haemoglobin less the 10gm/dl replace AZT/3TC with TDF/FTC
 PEP treatment should be started within 2-4 hours of exposure, and should be given within 72
    hours.




40
MODULE 8:           PSYCHOSOCIOL ISSUES AND HIV/AIDS

Introduction

HIV and AIDS is an emotionally charged issue that is frequently associated with fear,
stigma, and prejudice. Myths, misunderstandings and mistreatment of clients can
result from the sense of panic that surrounds HIV and AIDS. Fears and worries
about HIV and AIDS in the workplace can increase health care staff stress level,
diminish job satisfaction and decrease quality of services if they are not addressed
adequately. As health care staff it is important to be aware our feelings, thoughts
and attitudes about HIV and AIDS. Fears about HIV in the workplace can also lead
to additional stress and decreased job satisfaction and performance for some
providers.

Where rates of HIV/AIDS infection are high, there are significant numbers nurses
and care givers who are themselves infected. As they care for PLHA, they witness
how they to will become sick and die. Below are some of the issues that affect
health workers when they are infected or affected by HIV and AIDS.

Emotional Issues
 Fear
 Stigma
 Isolation
 Discrimination
 Marginalisation
 Rejection etc

Cultural
 Multiple partners
 Sexual cleansing
 Dry sex
 Use of condoms
 Child sexual abuse

Care for the care giver
Understandably, many nurses and midwives fear becoming infected with HIV.
Stigma, prejudice and discrimination surrounding HIV and its life threatening effect
may compromise their ability to provide quality care, and even their commitment to
remain in the profession. Particular attention should be given to:

   Continued employment
    o Being HIV-infected is not a cause for termination of employment, regardless
      of whether HIV was acquired on the job or not.
    o As with any other illness, HIV-infected nurses/midwives should be allowed to
      work as long as they are fit, provided they practice universal precautions. HIV
      infected health care workers
    o Make considerable contributions to care by helping to educate others,
      reducing the stigma and discrimination associated with HIV
    o Providing sensitivity training, support and counselling.


                                                                                   41
 Workplace issues
Health care providers, like the general population, may
  o Feel fear, stigma and discrimination towards HIV-infected individual. In fact,
      HIV- infected health care workers are
  o Often subjected to severe sanctions from their colleagues. As a result, many
      health care providers
  o Reluctant to be tested and to enter into counselling, treatment and care. This
      is problematic, because if nurses/midwives do not know their HIV status, they
      can put themselves and others in the health care setting at risk. Therefore,
      employers should develop policies that:

    Protect the privacy of the HIV-infected employee;

    Prevent social isolation of the HIV-infected employee by co-workers;

    Keep HIV-positive personnel in a supportive occupational setting as long as
     possible;

    Educate all employees, management and union leaders about the rights and
     care of HIV-infected health care workers.

Supporting Staff with HIV/AIDS
 The inclusion of people living with HIV/AIDS in the program planning and
  implementation is very essential as the program addresses them.
 Formation of support groups
 Provision of required treatment and care including ARVs if available
 Placing them in appropriate job positions
 Providing counselling services

Understanding Stigma

Stigma- is defined as an undesirable or discrediting attribute that a person or group
possesses that results in the reduction of that person’s or group’s status in the eyes
of society. It is the quality in a person, which diminishes or discredits that person in
the eyes of others. Stigma can result from a physical characteristic, such as the
visible symptoms of a disease, or from negative attitudes toward the behaviour of a
group.

Discrimination - occurs when a person is treated differently because he or she is
seen to belong to a particular group. It can be expressed as both negative attitudes
or particular behaviour or actions.

Distinguishing between prejudice, stigma and discrimination
Prejudice is a prevailing attitude inside a person, usually related to more than one
group of people. It leads this person to label others into groups, often in terms of a
negative stereotype, which stigmatizes the person. This negative label (stigma)
leads the prejudiced person to discriminate against the stigmatized person, and
even leads the stigmatized person to discriminate against him or herself.



42
Triggers of stigma
 Lack of understanding of the illness
 Myths about how it is transmitted
 Prejudice against other group
 Irresponsible media reporting

Factors contributing to HIV/AIDS stigma
 It is life threatening and incurable
 People are scared of contracting HIV
 The disease is associated with behaviours that society disapproves of.
 People are often seen as being responsible for becoming infected with HIV.
 Religious or moral beliefs lead to thinking that HIV/AIDS is the result of sin or
   faulty living that deserves to be punished.

 Process of stigmatizing
 Distinguish and labelling differences
 Associating differences with negative attributes
 Separating “us” from “them”
 Decreasing status and increasing discrimination.
 Stigmatizing can only happen if the one group has power over the other group.

Types of discrimination
Direct discrimination – the person is devalued, rejected, blamed, discredited
and/or excluded
Structural discrimination - the group is identified, excluded, devalued or blamed by
non-personal rules, structures and systems.
Self-stigmatizing- the person internalizes society’s labels, believes them and lives
accordingly.

Results of HIV/AIDS stigma
 Lack of disclosure, leading to lack of support
 Denial leading to: - further spread of the disease, poor health behaviour and
  limited access to prophylactic treatment.
 Social isolation
 Increased psychological suffering, internalized shame, and poor self concept.
 Decreased access to services due to disclosure and due to attitudes and
  practices of health care providers.
 Poor communication between health care providers and PLWHA.
 Financial insecurity
 Poor quality of life.

The effect of HIV/AIDS on nurses
 Many nurses themselves are HIV positive or have AIDS
 Many have lost family members, even children or colleagues
 Working with PLWHA leads to depression and burn out in nurses
 Nurses working in identified HIV/AIDS services are themselves stigmatized.
 Nurses have become infected through occupational exposure


                                                                                      43
    Nurse themselves stigmatize patients.

Discriminatory actions and practices in the health care setting
 Coding of HIV positive patients’ charts
 Double gloving when taking pulse of HIV positive patient
 Change of facial expression when treating HIV positive patient
 Denial of full, unconditional, high quality care and treatment
 Isolating HIV positive patients in a corner
 Refusing to touch an HIV positive patient
 Expressing a fatal prognosis – that there is nothing we can do.

Non-discriminatory actions
 Warm greetings, showing care and compassion
 Not labelling or coding client’s files
 Touching an HIV positive patient
 Respect, privacy, dignity, rights to opinion
 Listening
 Emotional support
 Ensuring confidentiality
 Positive non-verbal communication

Strategies to reduce stigma of HIV/AIDS

Information based approaches - people are often negative because they do not
know how to deal with a situation and this makes them afraid. Teaching families and
nurses how to deal with people who are HIV positive in a supportive and safe way
decreasing stigma. Factual information on all aspects of the illness decreases
stigma.
Counselling approaches- counselling, supporting and caring for theses people
affected by the disease, decrease self stigmatizing and stigmatizing of HIV positive
people.
Increasing involvement with PLHWA- talk about the illness in similar tones and in
the same breath as you would talk about other illnesses e.g. diabetes, cancer etc.
Confronting human rights abuses- if there is a legal framework that outlaws
discrimination, it is much easier for stigma and discrimination to grow if it is not
challenged and cost nothing. It helps all concerned if there is a person or group to
whom discrimination can be reported, and who will investigate and take appropriate
action.
Make working with people who are HIV positive safer- create safe workplaces for
nurses who see HIV positive patients as a personal threat because there is
inadequate policies in place or inadequate provision of protective clothing. Every
effort should therefore be made to make nurses safe.
In the face of lack of support, they become burnt out, and this leads to negative
attitudes such as stigmatizing. Any action that provides support for nurses can
therefore also decrease stigma.

Coping with stress
While there is no single definition of stress most people have experienced it at one
time or another in their lives and, because of its potential psychological and


44
physiological harm, it is essential to try to understand stress in order to prevent,
minimise or manage it.

Causes of stress
 Frustration- results from perceived personal inadequacies, failure to achieve
  personal goals etc.
 Life changes- adverse life changes such as separation, divorce, sickness, etc
 Hassles and uplifts of the day- arguments, misplacing things, expenses, etc
 Chronic life strains- the work environment contains stresses that may outstrip
  your capacity to adapt to them such as type of work schedules, managing large
  family with little income or caring for patient with AIDS.
 Personal worry and fear- a client who seeks HIV testing may face problems of
  stress before having a test and after result is positive.
 Professional burnout- caregivers involved in providing care and support to HIV
  positive clients may experience stress due to inability to respond to client’s
  needs, work overload and disinterest.

How to manage stress
Coping strategies: the strategies include search for informant about particular
stressors, recognising your true feelings and establishing goals to deal with the
problem. Talk about the stress.
Life skills training: learning new skills to help a person cope with stress. Life skills’
training enhances the capacity with which your values, beliefs and attitudes can be
positively channelled to help you live more resourceful. E.g. relaxation technique,
exercises, problem solving skills etc.
Counselling: the main aim is identification of stressors, the way your thoughts tend
to work when stress is imminent and how you respond to the situation.
Social support: implies being cared and valued by other people and belonging to a
social network e.g. family, friends, support group etc. having someone respected to
talk to who will listen empathetically and in confidence and who will provide practical
advice or moral support.
Acceptance and adjustment: a person living with HIV/AIDS needs to maintain a
positive attitude towards life and be able to adjust according to the changed
situation. Developing the following attitudes can greatly help cope with stress:
 Willingness to seek supportive counselling
 Acceptance of one’s changed status
 Openness about oneself and HIV/AIDS
 Not feeling guilty or ashamed about having HIV/AIDS
 Not blaming oneself
 Sharing information about one’s HIV status with others
 Promoting self disclosure and partner notification




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