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Training for Community Educators PROGRAMME Training programme for community educators PORECO Project PMTCT Plus Week 1 Time Day 1 Day 2 Day 3 Day 4 Day 5 08:30 – 09:00 Registration HIV/AIDS Infant feeding Personal PORECO OPT-IN Introductions Stages in PMTCT Leadership PACKAGE Clinical (options) 09:00 – 10:30 Expectations Manifestations Cont. Personal PORECO Client flow (from Objectives Common Leadership community to PORECO Overview opportunistic Clinic) (PORECO) infections 10:30 – 11:00 Tea Tea Tea Tea Tea 11:00 – 12:00 PORECO Common Challenges of Disclosure and The role of community String game myths and infant feeding challenges educators misconceptions at options community level (discussion) 12:00 – 13:00 String game MTCT: during HIV testing Disclosure Expected outcome discussion Pregnancy Challenges (discussion) Delivery Advantages Breastfeeding 13:00 – 14:00 Lunch Lunch Lunch Lunch Lunch 14:00 – 15:00 HIV/AIDS Basic Effects of HIV/AIDS ARV in PORECO Community Adjourn facts Individual and issues for mobilization Definition Family consideration Mode of Community transmission 15:00 – 16:00 Cont. Group work and Cont. Cont. feedback 16:00 – 16:30 Tea Tea Tea Tea Week 2 Time Day 1 Day 2 Day 3 Day 4 Day 5 08:30 – 09:00 Introduction to Story telling (practice) Home visit scenarios Field visit pre-test Door-to-door exercise PORECO string game 09:00 – 10:30 Tips on story telling Cont. Role plays Field visit pre-test Site approach 10:30 – 11:00 Tea Tea Tea Tea Tea 11:00 – 12:00 Story telling Cont. Role plays Field visit Implementation discussion pre-test Logistics Materials 12:00 – 13:00 String game Door-to-door exercise Role plays Field visit pre-test Way forward and closing presentation of Approach scripts Guidelines 13:00 – 14:00 Lunch Lunch Lunch Lunch Lunch 14:00 – 15:00 Identification Community String game Field visit of issues Community skills Clarifications Feedback from script 15:00 – 16:00 Group work and Dress code Conclusions Challenges feedback Barriers 16:00 – 16:30 Tea Tea Tea Tea OBJECTIVES Training programme for Community Educators PORECO: PMTCT PLUS Overall Goal To sensitize communities on site on PORECO PMTCT PLUS concept, thus creating demand for available services/interventions and ensure community support participation and ownership of project. Specific objectives To discuss basic HIV/AIDS facts including MTCT and prevention Discuss the role of ARV therapy in PMTCT Plus Discuss infant feeding in PMTCT Provide guidance for door-to-door exercise PRESENTATIONS Group Dynamics 1. What is your name? 2. How do you like to be called? 3. What are your personal strengths? 4. What makes you laugh in a group? 5. Two things you do not like in a group? 6. You will be working as a team, give two suggestions to build a team? PROJECT OVERVIEW Pilot operational research and community based project (PORECO) Ministry of Health and Social Welfare in partnership with Swaziland Infant Nutrition Action Network (SINAN) Project is a response to the HIV/AIDS situation in the country Overview Cont….. Aims to prolong the lives of parents in HIV/AIDS situations long enough to care for their children Offers a care package made up of: free ARV drugs, nutritional support through food baskets, psychosocial support and continued care for the mother, baby and partner. Project scope and duration Project duration is 3 years Site includes all 12 Mbabane wards Project will enroll 200 mothers, 200 babies and 200 partners (twins and triplets will also be accommodated) Entry point is HIV positive pregnant mother Project components Clinical component is hospital based and offers; baseline screening, continued monitoring of physical/medical health, client enrollment into the project, signing of consent form, ART counseling. follow up care Components cont…. Community component: (Community based) - offers community mobilization at household level, pre and post test counseling in Feeder Clinics, HIV testing, comprehensive ANC services, advice on infant feeding, partner tracking, monitoring Rx adherence, nutrition support and follow up care. THE STRING GAME STORY Joseph gets infected with the HIV Virus This is Joseph and this is his wife Nonhlanhla, and his son Majozi. He comes from Nobody’s Village, in your Region, Swaziland. Joseph went away to the city to work for a few years. He left his wife at home to take care of the child and the homestead. Unfortunately, one year he brought along some unwanted and unnoticed gifts: the HIV virus. One of Joseph’s girlfriends in the city had given him that unasked for gift. Nonhlanhla escaped HIV infection When Joseph came home at Easter time, in late April he had sex with his wife Nonhlanhla. They did not use a condom, and Nonhlanhla even became pregnant. But none of those viruses found a doorway that time. [USE THE STRING TO SHOW HOW IT MAY NOT CATCH… THROW THE STRING FROM JOSEPH AT THE BUTTON ON NONHLANLA, AND LET IT SLIP AWAY TWO OR THREE TIMES] Nonhlanhla discovered that she was pregnant at two months and wrote a letter to her husband in the city telling him about the pregnancy. Joseph was excited by the news of the coming baby and he assured his wife that he would be home for Christmas. Nonhlanhla then went to the local clinic for ante-natal care and that was where she heard about the PORECO programme that was supported by ………………. In nobody’s clinic. “We have improved our ante-natal care to make sure that you have a safe birth and a healthy baby,” Nurse Cynthia told all the pregnant women at the clinic. “We examine you for high blood pressure, and check your blood for anemia, syphilis, and HIV” “I don’t think we want to know about HIV,” One of the pregnant women said. “It will just make us frightened and sad, and perhaps our husbands will run away.” “We want your husbands to come with you for the test,” Nurse Cynthia said. “We want to make sure both of you are HIV negative, then we know you can safely breastfeed your baby and we don’t need other precautions. But if you are HIV positive, then we have to help you to have the right foods and to give you some special vitamins to help your immune system stay strong. When you are giving birth, we can also give some medicine that will help prevent the virus from going from you to your baby. And after the baby is born it will also be given some medicine that will further reduce the risk of HIV transmission. We can help you to decide how to feed him, in ways to avoid passing the virus through the breast milk.” “But nurse what will be the use of saving the baby if the mother will die. Who will look after this orphan?” Nurse Cynthia told the women that the programme is also concerned about the lives of the baby’s parents. She told them that all the people that will join the programme will be followed up even after the birth of the baby and tests will be run. She reminded them that one objective of the programme was to prolong the lives of the mothers as well as that of their partners if they decide to join the programme. The women wanted to know how that could be done and Nurse Cynthia told them about which test will be run. These tests will show the time when the load of HIV in the body is too high and it has destroyed a lot of the regiments that the body uses to get rid of diseases. This is when they will be given some medicine that is called ARVs. “Then why should our husbands come for the test?” Another woman asked. Then Nurse Cynthia explained how it was possible the wife might be HIV negative, but the husband was HIV positive. Then they would need to take special precautions to make sure the wife did not become infected during her pregnancy. The same thing was possible the other way, that the wife might be HIV positive and the husband was negative, and special precautions were also required to protect the husband. “We can learn to live with HIV,” Nurse Cynthia said, “if we can just learn to live with each other.” She also reminded them that the PORECO programme included their partners as well. Nurse Cynthia was a very good educator most of the women wanted Nurse Cynthia to take their blood for the tests. She told them that she was not in a position to do that since the entry point was the VCT centre at the clinic. She told them that at the VCT centre the client is counseled and then tested for HIV. If the test result is positive, she is then told in detail about the programme. The client that wants to join the programme then signs a consent form. Some of the women at the clinic wanted to know why one had to sign when joining the programme. Nurse Cynthia assured them there was nothing to worry about having to sign documents. She told them that by doing this, it allows the health personnel to run tests that will give them information about the wellbeing of the client. These tests will determine the time when the body needs ARV drugs. There will be instances where the tests will reveal that the pregnant woman needs to take the ARV’s immediately. As long as the client is more than 3 months pregnant, she will start taking the ARV drugs. Care is taken when this woman is given the drugs. The drug is given to someone who has someone to support her. Nurse Cynthia stressed the need for the client to have a buddy. Nonhlanhla wanted to have her blood tested for HIV but she wanted to consult her husband before doing so. She knew that her husband would be coming home for Christmas and there would still be time to take the test since she would be eight months pregnant in December. Peter Dlamini escapes infection (for a time) Peter Dlamini was another classmate of Joseph’s from school. Peter stayed in Nobody’s Town with his mother and two younger sisters. He was a kombi driver and a mechanic, who used to travel up and down from Nobody’s Town to Manzini. Peter loved his job as a kombi driver – or rather what he loved was the “fringe benefits”. He often gave rides to school girls and women, and took the opportunity to strike up affairs with them. Peter’s philosophy was, “there’s no harm in asking.” He would ask little girls, big girls, married women, widows, and even an occasional grandmother ……..for him, the adventure in life was to see who would say “yes.” Peter had started to visit Joseph’s wife Nonhlanhla as soon as he saw that she was pregnant. He told her that if she didn’t have sex during her pregnancy, she would have difficulty getting the baby out. But when Joseph came home for Christmas and for the birth of the baby, Peter stayed away. Joseph infects his wife Nonhlanla with the HIV virus When Joseph came home the following December, Nonhlanhla told Joseph about the PORECO programme and asked for permission to go for the HIV test. She also expressed her desire to have her husband go for the test as well. Nonhlanhla was surprised by Joseph’s reaction. Joseph started accusing her of unfaithfulness. He asked her what her reasons were for going for a test if she has not been seeing anyone in his absence. He started questioning her about other relationships she might have had in his absence. Joseph never suspected that his wife had been unfaithful. He just thought about the numerous relationships he had in the city, the STI he had treated and he was reluctant to test. Nonhlanhla did not want to have a further discussion on the issue since she feared that Joseph would find out about Peter. He told her that I was already late in the pregnancy. Joseph’s main concern at this time was adding the “missing parts” onto the baby. He had been taught that for a baby to develop fully, the father had to have sex with the mother from time to time during the pregnancy, to “add on the missing parts” of the infant. Some men who know they are HIV positive use condoms when they have sex with their wives during and after pregnancy. Of course, Joseph was not doing this. He didn’t know that he was HIV positive and he didn’t want his child to be born missing a nose or an ear. Nonhlanhla was also very anxious to have sex with Joseph during her late pregnancy, to make sure that the baby would look like her husband. So around Christmas time that year Joseph and Nonhlanhla made sure to have sex together, as soon as they had finished the discussion about the PORECO programme. Unfortunately, the HIVirus found a doorway to infect Nonhlanhla. Once inside, before her body could recognize this enemy, it made millions of copies of itself. With so much HIV in Nonhlanhla’s body, some got into her womb and infected her unborn baby. When the child was born, it was a healthy looking boy, but he had the HIvirus in him already. [ATTACH THE STRING FROM JOSEPH TO NONHLANHLA] During this visit, Joseph infected two more people. He raped Thandi, a 16 year old girl that came from the Hlophe family. He also had sex with Nosipho, his school days sweetheart who had a herpes infection at the time when they had sex. Nosipho had a 16 year old sister, Thuli who was Thandi’s best friend. [ATTACH 2 STRINGS FROM JOSEPH TO THANDI AND NOSIPHO] Joseph saw both Nosipho and Thandi a few more times before he went back to the city after the New Year holiday. He especially enjoyed teaching Thandi all the tricks of sex, and watching her grow from a shy child into a hungry woman. He left behind four people infected with HIV. You could say that that New Year was really “party time” for the HI virus. After Joseph went back to work in the city, Peter started having sex with Nonhlanhla again. But he was afraid she might get pregnant, so he used a condom. He didn’t know it, but that condom was protecting him from HIV infection as well. Thandi Hlophe makes the Pastor’s son Sipho to be her new boyfriend After Joseph left for the city, Thandi decided she should find a regular boyfriend who was closer to her own age. She chose Pastor Gule’s son, Sipho, who was just one year behind her in school, and who sang in the choir with her. Her mother and father never suspected anything, because he was younger than she was, and he was the pastor’s son. She eventually infects Sipho with HIV. [SHOW THE STRING PASSING FROM THANDI TO SIPHO] Another family in Nobody’s Town was headed by Mr Welile Shongwe, a cousin to Pastor Gule. His wife Esther was a Dlamini, and they had three children; a daughter named Pholile who was 11 years old, and two boys aged 9 and 7. Mr Welile Shongwe sometimes became suspicious that his wife was promiscuous, and to punish her he would refuse to have sex with her. In fact, Esther Shongwe had stopped having affairs with other men, because she had read about AIDS, and was afraid of becoming infected. But she got so angry when her husband began to “starve” her that she decided to find a young boy to seduce. Esther Shongwe’s nephew Sipho, the pastor’s son, had always been a favorite of hers, since he was a little baby. Now she began to give him presents and pocket money, and to ask him to do little jobs around the house for her. Then she started asking him to rub her sore legs for her, until one day she seduced him. Of course, Sipho already knew what he was doing, but he pretended like it was something new to him, when his auntie smothered him in hugs and kisses and passionately lay on top of him. Sipho liked the presents and pocket money he was getting, so he continued for some time to do those little jobs for his auntie, and after some months the HIV virus found a door into her. [SHOW THE STRING TRYING TO CATCH ON THE BUTTON FROM SIPHO TO ESTHER, AND FINALLY IT CATCHES] Mrs Esther Shongwe got pregnant during that time. Now Sipho, Welile and Esther were all HIV positive. But you know, it’s not always the case that the HIV goes from the mother to the child. In fact, on average it happens in only about one in three cases. So Mrs Esther Shongwe had a baby, and the baby was HIV negative. [ATTACH A BABY BETWEEN MR AND MRS WELILE SHONGWE] Esther was very eager to resume her activities as a hawker. When her baby was two weeks old she started giving her baby formula. Esther had never really listened to Nurse Cynthia when she was talking about the PORECO programme during one of her rare visits at the clinic. So she didn’t know about the dangers of practicing mixed feeding. Nurse Cynthia had stressed the early initiation of exclusive breast feeding or exclusive replacement feeding depending on the mother’s informed choice. Some of the women had wanted to know why. Nurse reminded them that HIV can be transmitted through breast feeding and that mixed feeding enhances transmission. Esther did not even know that need of visiting the clinic after the birth of the baby. She employed a nanny to look after the baby and the nanny was the one who took the baby to the clinic. Esther’s baby got infected through breast milk. [ATTACH STRING TO BABY] More marriages in Nobody’s Village Do you remember Peter Dlamini, the Kombi driver? When Joseph and so many others died, Peter became frightened. “I am almost forty years old,” he told his friend Joseph just before his death, “and I don’t even have a child, much less a wife.” So after Joseph died, Peter determined to find himself a wife. Do you remember Thuli? She was staying with the Hlophe’s after her sister died. Now she was almost 25 years old, and becoming worried that she would become and “old maid” if she didn’t soon find a man. So when Peter Dlamini came calling, she was glad to welcome him. And it wasn’t long at all before Peter Dlamini had “not only a wife, but a child on the way as well.” And now who is left. Oh, yes, here is Thandi. You remember Thandi stopped having affairs and was living a very healthy life. So even though she had been HIV positive for more than eight years, she was still healthy. Human beings need companionship and love, and the time did come when Thandi finally fell in love, for real. She fell in love with David’s brother, Solomon Thwala. He took her to his home in the traditional way, and “teka’ed” her, and she also became pregnant. A fool’s family line disappears in dust When Thuli went home and proposed to Peter that they should go together for a test, he thought she must be crazy. “Never!” he said. When Thuli came back the next time from the clinic, she brought her HIV test result with her. “It is negative,” she said. “Now you have to test as well, or if you don’t want to test, then you should use a condom with me. I don’t want to get infected while I am pregnant, and pass the virus to my child.” Peter was annoyed to hear his wife talk as if she could tell him what to do. But he was a clever fellow, who had had many women in his life, so he didn’t say anything at the time. But in the night, when they were locked in the bedroom, he came to her without a condom. When she demanded that she put on a condom, he slapped her and pushed her down on the bed, and then he raped her. He wouldn’t call it rape, of course, because he thought it was his right to have sex with his wife, anytime he wanted to, and whether or not she agreed. “Justice goes to the strong” he told her after he had raped her, and when she complained, he slapped her. Peter Dlamini, when he forced sex on Thuli that night, infected her with the HIV virus. [ATTACH A STRING FROM PETER DLAMINI TO THULI] After that night Peter Dlamini refused to allow his wife to go back to the clinic. Thuli went behind her husband’s back to get advice from the clinic. The nurse had told her about the window period and the importance of having a second test. Thuli tested positive. This devastated her because she knew that her husband had infected her with HIV. Nurse Cynthia tried comforting her and encouraged her to go through the PORECO programme to reduce the chances of passing on the virus to the baby. During the pregnancy, Peter would from time to time rape her. The Nurse had given her the tablet to take when labor started but she had gone to her parental place and could not take the tablet. She could not deliver the baby at the clinic and was assisted by a TBA when giving birth. It was a long and difficult labor. The TBA ruptured the membranes to quicken the labor. Nurse Cynthia had told the women that the new born baby had to be immediately taken to the clinic after birth in cases where the mother did not deliver at the clinic. The baby had to be given some medicine and it was very important that this was done within the first three days. In cases where the baby’s mother did not take the medicine during labor, the nurse told them that the baby should still be taken to the clinic and will be given two doses of medicine. The first dose is given to the baby immediately after the delivery and the second after 12 hours. Thuli was very unlucky, she was not able to take the tablet that Nurse Cynthia had when she went into labor. She also could not make it to the clinic until her baby was two weeks old. Her in-laws told her that according to the family tradition, a baby is not supposed to leave the house before she is three months old. They even thought that they were doing her a favor by allowing her to take the baby to the clinic at two weeks. Thuli’s baby got infected during delivery and giving the medicine to the baby at birth might have helped in destroying the HIV before taking root in the baby’s system. The nurse stressed to Thuli that the baby should still be taken to the clinic for immunization. The baby was also given some medicine that was going to help protect the baby from opportunistic infections. E.g. Pneumonia. [PLACE BABY ON THE BOARD, AND THEN ATTACH A STRING FROM THULI TO THE BABY] This did not disqualify Thuli from the PORECO programme. The baby died within two years. Make Mokoena, a lay counselor from Nobody’s village supported Thuli during this time. She was encouraging her from time to time to go to the clinic. When the time came for Thuli to start taking the ARV, make Mokoena offered to be her buddy. Thuli could not disclose to her husband about her HIV status because Peter had threatened her with expulsion from their home if she went back to the clinic. Thuli had difficulty taking the drugs without the husband noticing because the ARV drug has to be taken every day at a particular time of the day for the rest of the client’s life. Peter would question what the medication was and when they went to visit relatives who were staying far from their home, Thuli could not explain why she had to return home earlier. Thuli now understood what Nurse Cynthia had meant when she told them about the benefits of disclosing to your partner and having him in the programme as well. Since Peter was questioning her about the medication, she asked her buddy, Make Mokoena if she could keep the drugs for her. She promised that she was going to go to her place everyday to take the drug. But that was not possible and Thuli failed drug compliance. She also was not eating properly so she quickly developed AIDS and died. Peter also began to become sick with AIDS. But he didn’t die until he had first seen his baby die, his first born, his only born son. He also watched his wife die and was very guilty because he knew that he had infected her with HIV. Then he died himself, with the knowledge that he was the last in his family line. [REMOVE PETER DLAMIN AND HIS BABY FROM THE BOARD] Life goes on, if only we will allow it to….. When Thandi came home from the clinic, her husband Solomon Thwala welcomed the idea of getting a test. It was nothing new to him, because he had seen how his brother David and Sibongile had been tested before their marriage. “But what if you find out I am HIV positive?” Solomon teased his wife. “Will you still love me and stay with me?” “Till death do us part,” Thandi said. “You are my only man. And do you love me?” Solomon was embarrassed by this kind of talk. But he did love her, and he answered, “I do”. Solomon should have realized that it was possible that his wife was HIV positive, because he knew she had been a girlfriend to Sipho Gule, who had later died of AIDS. But for some reason, he had pushed this thought out of his mind. That is the way many of us are. We don’t want to think about the things we don’t like to think about. Now, as they waited for the test, he began to get nervous. If Thandi was positive, then he thought to himself that he was too. He was imagining how they would live together, both positive, loving and caring for one another. He was glad he was married, in case they were positive, because they could stick together that way. He thought he was well prepared for the results, whether positive or negative. But he wasn’t prepared for the results that came. His wife was positive, but he was still negative. He could hardly hear her words, as Nurse Cynthia was giving Thandi a lecture on how she must insist that they always use a condom, so that she can protect her husband from infection! As they went home, Solomon was deeply confused. How could he live with a wife who was HIV positive. If he was still HIV negative, then shouldn’t he leave her, and find a wife who was negative like him? What if the baby was born with HIV? These and a thousand more questions overwhelmed him. Thandi was less bothered by her result. What was bothering her more was her husband’s silence. Although she had never tested, she was already almost certain of her status, because she had watched both Joseph and siphon die. She wanted to feel bitter towards Joseph, but then she thought of how she had done the same thing to Sipho, that Joseph had done to her. She felt sorry for Pastor Gule. She wondered how she would feel, when the child in her womb was growing up. Would her child suffer the same ways that she and her whole generation was suffering? Or would there be a new generation, able to find different ways? “I understand how you must feel,” Thandi said. “When you married me, you must have known already what happened to me – there are no secrets in such a little place as Nobody’s Village. But I know it’s not the same, when you see the test results, and it tells you it’s time to face the truth. If you want to leave me, I will understand. As for me, I love you, and I am happy that I am carrying your baby, and I will do all I can to keep myself and the baby healthy.” Solomon was thinking about something his brother David had said to him, about why he was happy he had Sibongile, even though many men thought she was too strong and forceful a girl. She knew the difference between right and wrong, David said, and was not afraid to stand up and fight for what is right. She would be the mother of Africa’s next generation, the survivors. Only the men who could learn to respect women like that would see the survival of their own family line. When they went home, they went into the house together. Across the threshold, Solomon put his arms around his wife. “I Love you,” he said. “today more than ever. We, the three of us, we are the future, and we will survive, all three of us together, I promise you.” And they have. They have a healthy baby girl, and they are taking care of two boys from the extended family of Thandi’s father, and Thandi is still healthy (ARV’s) and plans to see all three of those children graduate from high school, and she will…. TRAINING FOR COMMUNITY EDUCATORS Sample slides to assist PMTCT+ Training of Community Educators These slides may be supplemented by training materials on HIV/AIDS from Resource # 6, 7and 9 To access the above slides, please double click on the blue box above.
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