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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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