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Facilitator Guide Basic IMAI Training Course For Nurses
Facilitator Guide Basic IMAI Training Course For Nurses
for the
Basic IMAI
Training Course
FOR NURSES
(Chronic HIV Care with ARV Therapy and
Prevention)
Based on the
IMAI Chronic HIV Care with ARV Therapy guideline module
(Integrated Management of Adolescent and Adult Illness)
Table of Contents
Page
Preparation for the Clinical Courses 5
Overview of Basic IMAI and Acute Care Training Courses….. 6
Course Materials, Supplies, Venue, Timetable…………… 7
Facilitator techniques common to all courses………………….. 15
Chapter Facilitator Guide for the Basic IMAI training course 18
Chapter 1 Introduction to Chronic HIV Care with ARV Therapy………….. 19
Chapter 2 Communication skills……………………………………………… 29
Chapter 3 Stigma and discrimination………………………………………… 35
Chapter 4 Introduction to HIV/AIDS and opportunistic infections…………. 39
Chapter 5 HIV and antiretroviral drugs………………………………………. 43
Chapter 6 Adherence and resistance………………………………………… 47
Chapter 7 Assess and provide clinical care…………………………………. 49
Chapter 8 Use the Patient Treatment record………………………………... 55
Chapter 9 Prophylaxis………………………………………………………….. 57
Chapter 10 Adherence preparation……………………………………………. 61
Chapter 11 Four first-line ARV regimens……………………………………… 65
Chapter 12 Managing side effects and other causes of new symptoms and
signs in patients on the four first-line ARV regimens…………... 69
Chapter 13 Support ART initiation, then monitor and support adherence 71
Chapter 14 Integrating prevention with treatment……………………………. 73
Chapter 15 Universal precautions, occupational exposure and PEP………. 77
Chapter 16 Special considerations for ART in pregnant and post-partum
women………………………………………………………………. 81
Chapter 17 Special consideration in children…………………………………. 85
Chapter 18 Is ART working?......................................................................... 91
Target audiences:
District medical officers without other ART training: to introduce them to chronic HIV
care and basic ART.
Nurses and medical assistants who work in a district outpatient clinic or in peripheral
health centres and clinics
Objectives of training:
To prepare doctors and nurses, to provide chronic HIV care and basic ART including
initiation, support and monitoring.
To review common symptom/sign management using the acute care guidelines with an
emphasis on opportunistic infections.
In the Basic IMAI training courses for doctors and for nurses, PLHA are trained to present
specific HIV cases with the course participants during the skill stations sessions two hours
per day in addition to joining small groups during the interactive classroom training. PLHA
trained as Expert Patient-Trainers (EPTs) add much needed experience and reality to
instruction of HIV care and ART.
Agenda
Basic IMAI Training Course for Doctors Acute care and Opportunistic
Infections short course
Medical Officers Medical Officers
Basic IMAI course for DOCTORS Basic IMAI course for NURSES
And Acute care short course
Pre-test Pre-test
Chapters 1-3 Chapters 1-3
Day 2 Chapters 4-9 Chapters 4-8
Tuesday Skill Station: 1 hour Skill Station: 1 hour
Each small group will need the following course materials in the classroom setting. Some
can be used again and again; reusable materials include wall charts, photo booklet, cards for
card sorts, and (when available) training videos. Other material is given to each participant
and facilitator and used in exercises. You will need a supply of these for each course.
When planning continuous training for scale-up, photocopy enough for the first course, make
any small corrections identified during the course, then print a large number for subsequent
training.
Use the checklists below to plan your course. Figure the totals needed and when each item
has been reproduced and delivered to you in the quantity necessary, and has been checked
for accuracy and readability, check this off as ready in the far right column. All materials
should ideally be prepared at least 2 weeks before the course is scheduled to begin to allow
time to correct any errors in reproduction.
Facilitator guide
Facilitator manual for the 1 for each facilitator Day 1
preparation of the Expert Patient
Trainers
Participant handouts
Handouts for the preparation of the 1 for each Expert Patient Day 1
Expert Patient Trainers and each facilitators
Case-specific checklists (for EPT 6 checklists for each case
skill stations for the Basic IMAI (lose sheet) + one
training course complete set for each Day 1
participant and facilitator
Others
Clinical Review Forms (Annex A of Some forms as a support Day 1
Participant Manual for the Basic tool for the for skill station
IMAI Training Course)
Patient Education Flipchart one for each EPT and Day 1
facilitator
Side Effects Cards (for use in 1 set
class and skill stations) Day 1 skill
HIV Clinical Staging Cards (for 1 set station
skill station use) recto-verso
cards = to prepare
HIV/TB Cards (for skill station 1 set
use)
Wall charts: Day 1
The WHO staging 1 of each for the
The General principles of good classroom and will used in
care the skill station room
The sequence of care
The 5 As
Coordinated approach to chronic
care
Supplies needed for each facilitator and participant during the course:
name tag
notebook/stationary
folder to organize manuals and loose forms or cloth bag (avoid binders with punching-
each guideline module and participant manual needs to be used actively during the
course)
ball point pen
1 pencil
white putty or high quality very sticky tape to fasten large, laminated wallcharts and flip
charts to wall (test this out ahead of time—tape is often too weak to hold the laminated
posters)
pencil sharpeners (few per group)
scissors (1 per group)
stapler and staple remover (1 per group)
extra pens
extra pencils
erasers (few per group)
paper clips
blank flip chart pad
set of markers
Highlighter markers (one for each facilitator)
Supplies for demonstrations, role plays, and group activities for each small group:
General Instructions:
1. Administrative support
Arrange for secretary or administrative assistant to work from 2 to 3 days before the course
begins through the end of the course or one day later.
Arrange for photocopy machine accessible to classrooms in good working order, with extra
toner, and if possible, capable of collating pages.
2. Size of classes
3. "Housekeeping"
After the first day, set aside about 10 minutes daily to discuss with each group the rules and
responsibilities concerning breaks, cell phones, group discussion, set up and breakdown of
the classroom, etc.
4. Facilitator meetings
It is important to schedule a daily meeting of all facilitators and the Course Director at the
close of each day to review progress, solve problems, and to plan for the following day. This
may last from 10 minutes to an hour, depending on the situation and how things are
proceeding.
Arrange for special speaker to Inaugurate and close if desired. Invite the key stake holders in
the community for the inaugural or closing functions, like District Collector, JD/DD Health
services, etc. Be sure to thank patients for the work they have done. Thank all staff and
collaborators who have supported the training. Let participants know what future plans are
for post training activities and hand out course completion certificates.
A. How to give pre and post test (there are different tests for each cadre)
Explain to participants that the purpose of the pre test is to give facilitators a sense of
baseline knowledge of the group, and is not an evaluation. Allow 20-30 minutes for the test of
approximately 30 questions. Decide beforehand if test should be anonymous (in which case
participants will not know their scores) and what, if any, feedback will be given on test
results. Do not discuss answers to the questions when test is finished, as the same test will
be given as the post test, but explain that all material will be covered in the course. At least
two persons should score the test on the same day it is given so that facilitators can gear
each course to the level of knowledge of participants.
1. Gather the participants together and tell them you will conduct a drill. During the drill,
they will review how to decide, for example, if a patient has come for an acute problem,
follow-up of an acute problem, or follow-up of a chronic problem.
Ask the participants why this is an important decision. They should answer that it is
necessary in order to determine which guideline module and section of the guidelines to
use to care for the patient.
This is not a test. The drill is an opportunity for participants to practise making this
decision.
You will call on individual participants one at a time to answer the questions. You will
usually call on them in order, going around the table. If a participant cannot answer,
go to the next person and ask the question again.
4. Allow participants to review the text for a minute or two before the drill begins. Tell the
participants they may refer to the text during the drill, but they should try to answer the
question without looking.
5. Start the drill by asking the first question. Call on a particular participant to provide the
answer. He should answer as quickly as he can. Then ask the next question and call on
another participant to answer. If a participant gives an incorrect answer, ask the next
participant if he can answer.
6. Keep the drill moving at a rapid pace. Repeat the list of questions or make up additional
questions if you think participants need extra practise.
The drill ends when all the participants have had an opportunity to answer and when you feel
the participants are answering with confidence.
Written exercises can also be read aloud and discussed in the group.
D. Reading
When the facilitator manual says participants should read part of the manual or guideline
module, you can have participants read silently on their own, or ask for a volunteer to read a
section in a loud, clear voice. Which method you choose depends on factors such as level of
education of the group as a whole, differing levels within the group, their understanding of
English, and what the group prefers. Make sure everyone is on the same page before
beginning. If you are reading aloud, make sure that all participants who are willing, get
chances to read during the course (do not force anyone). Sometimes it is helpful to ask
someone to read who seems particularly sleepy or inattentive to wake them up. You may
also choose a mixture of silent reading and reading aloud.
At times the facilitator is directed to explain certain important concepts. Explanations should
be short and to the point, using a flipchart and/or referring to the manual. Avoid lecturing as
this is not an effective way to learn. Occasionally, when pressed for time, it may be feasible
to present certain material as a short, interactive lecture, rather than having participants read
through a number of pages themselves, but this should not be the norm.
Skill stations are a crucial part of competency based training for HIV care. During the
approximately 2 hour-long sessions, participants work with individual EPTs and participate in
card sort exercises which reinforce learning of material. Participants are introduced to skill
stations on the second day of training. Before this time, the Expert Patient Trainers need to
have been trained (see Expert Patient Training materials). Complete instructions for the
facilitator on skill stations are provided in this Guide on pp. 71 to 76, and for the participants
in their Participant Manual. Facilitators need to be present during skill stations to answer
questions and give guidance as needed.
Objectives:
To provide health workers with the chance to practise skills they are learning in class
with the EPTs who will give each health worker feedback.
Scheduling of skill stations needs to be done on a daily basis so that each group has the
time to work separately. Often 3 groups will be going to skill stations (2 clinician groups and
one ART Aid group).
Medical Doctors use of skill stations: It is advisable to have physicians spend at least one
full session with the EPTs as this presents a rare chance for PLHAs to give feedback on
physician interviewing skills and address issues of stigma around HIVAIDS experienced from
the patient perspective.
G. Singing competition
This is often an effective way to raise group spirits and to reinforce key points. Each group
should be told about this and encouraged to enter the competition which takes place during
the closing ceremony.
In the Masaka, Uganda course, the winning groups sang about the "7 requirements"; another
group presented the 5 A's. The facilitators entered a jingle on the first-line ARV regimens
(insert) which is helpful to sing during the class to reinforce learning of these regimens.
It is useful to have a prize or prizes that can be shared among the winning group.
H. Energizers
Ask individual participants to be responsible for a few exercises or songs during the course
of each day to make things livelier when attention is lagging or when people are tired but the
day is not over. This should be decided as part of "housekeeping" activities at the start of
each day. The facilitators should also have some energizers of their own to offer.
To prepare nurses and medical assistants for comprehensive chronic HIV care
including ARV therapy and prevention.
To support chronic HIV care at the district and health centres in functioning as
an overall effective clinical team
In general the nurses working in district and sub district level hospitals do OP, IP care, follow
up ANC, conduct deliveries, follow up immunization schedule for children, and assist in
conducting family planning clinics and special clinics.
IMAI training course is designed to train the hospital based nurses (ex. staff nurse, SHN) to
do following activities:
1. Suspect HIV and refer the patient for counseling and testing.
2. Do HIV clinical staging
3. Do Adherence preparation and support.
4. Do adherence follow up in the lost to follow up patients who are on ART.
5. Facilitate linkages with community support groups.
6. Do education and support for PLHAs, including positive living and nutritional counseling.
7. Assist the doctor in physical examination and in dispensing the drug refills.
8. Identify OIs earlier and refer for proper medical management.
9. To follow up referral and back referral.
10. To fill up and maintain the forms, registers and documents as suggested by the district
administration.
Duration: Purpose:
2 hours and Pre-test as baseline assessment of knowledge
Overview of materials for the course
15 minutes Introduction to chronic care including ARV therapy
Wallcharts:
Sequence of
care; Principles Content Methods Duration
of Good Chronic
Introductions to each Interview someone you 20 minutes
Care; 5 A's
other don’t know and introduce to
group
Introduction to the Explanation 10 minutes
Preparation: course and the material
Prepare a
wallchart with the Pre-test Written 20 minutes
national/local
health system Introduction of the Discussion, Q&A 20 minutes
sequence of care
Meet with expert
patient-trainer Introduction to the Lecture 20 minutes
(EPT) or one of general principles of
your co- good chronic care
facilitator, to The 5 A's Explanation, demonstration 30 minutes
prepare with EPT, discussion
demonstration
What is locally Exercise 1.2 15 minutes
available?
The expert patient-trainer (EPT) is a PLHA who has been trained to role-
play specific HIV clinical cases in class and in the skill stations (see
Facilitator's Guide to the Basic ART Expert-Patient Trainer Course).
Welcome the participants and organize a game to introduce each other (participants and
facilitators)
Ask to the group of participants to define the ground rules for the group
Introduce the different documents and manuals that will be used during the course
Pre-test 20 minutes
Before giving the pre-test, let participants know that they are not expected to know all of the
answers, as the test covers much of what they will be learning in the course itself. The
purpose of the test is to give facilitators, and participants, a clear idea of what participants
already know, and what they need to learn.
3. Ask what is chronic care? What is acute care? Have participants give examples of what
the difference is between acute and chronic care.
4. Explain that currently most HIV care is episodic acute care, and this is a different
approach from good chronic care. Comprehensive HIV care includes both acute and
chronic care.
Have the participants read the Acute and chronic HIV care and prevention page of
chapter 1 which talks about acute and chronic care. Explain that you are training them both
as individuals and as a clinical team
5. Ask a volunteer to read the Introduction to the General Principles of Good Chronic
Care in the participant manual.
6. Introduce the General principles of good chronic care, providing a short comment on
each of the principle, using the Annexe D: General Principles of Good Chronic Care of
the Chronic HIV care guideline module, and the wallchart.
8. Ask for volunteers to read about the 5 A's in the participant manual AND/OR comment
each of the 5 A’s, providing examples and asking additional examples to the participants.
9. Ask: What step of the 5 A’s do we tend to skip? Discuss in the group how they already
use the 5 A’s, and to consider how they could help you both in your individual encounters
with patients and as a clinical team.
10. Ask: Why are the 5 A’s helpful for ARV therapy? Which step is the most important?
Why?
11. Now introduce the role-play to the participants (the role play can be done with an expert
patient-trainer or with one of your co-facilitators).
Give a brief history of the patient, including the purpose of the visit: “An HIV+ woman
get married sometimes ago; she wants to start a family and to have children”
Introduce who will play the doctor and who will play the patient
Ask participants to listen carefully and to identify the 5 A’s
Lead a discussion at the end of each role play
2. Ask the EPT/or co-facilitator how he/she would like to be introduced to the students.
Note details.
3. Confirm details of demo—time, place, etc. Determine any possible time conflicts for the
EPT/or co-facilitator in case your session is behind schedule.
2. Set up the role-play in the front of the room and ensure that everyone will be able to
hear the entire role-play.
3. Ask your co-facilitator to time the exercise and to give you a two-minute warning at 10
minutes so you will have time to complete the most important learning objectives of the
exercise.
4. At the end of the exercise, ask the EPT / or co-facilitator to complete the Feedback
form out loud with the class as he/she fills it in (have EPT bring the generic feedback
checklist with him/her).
Assess
Health Worker (HW): Hello, how are you doing today? What is the reason for your visit
today?
Patient (P): Hello, I would like to talk to you if you have some time.
P: As you know I am HIV-positive. I got married some time ago, and my husband and I
would like to start a family and have children.
HW: This is good, let us start by checking how you are and then we can talk further about
this. How have you been since we last met?
Can I do a check on your health to be sure we do not to miss anything? (Use Clinical
review on H10)
Have you had any of the following: Cough? Night sweats? Fever? STI signs?
Diarrhoea? Mouth sores? New skin rash? Headache? Fatigue? Nausea or vomiting?
Poor appetite? Tingling, numb or painful feet/legs? Sexual problems? (EPT: shakes
head “no” after each symptom)
HW: Let me just check your eyes, mouth, glands, skin (should go through the motions).
HW: Ok, so that is good. Now, you wanted to talk about having children, is that right? Can
you tell me, do you have children at the moment?
HW: I hope you do not mind, but it is important to know if your husband has ever been
tested for HIV and if he is positive or not.
HW: Can you tell me what you know about the risks of having children when you are HIV-
positive?
P: Well, I don’t know what the risks are. Would I pass HIV on to my child?
HW: Well, perhaps it would be helpful if I gave you some information about this, would you
like to hear it?
P: Yes, please.
HW: It is possible for you to pass the virus to your baby but not all HIV-positive women
pass the virus to their babies—only about 1 in 3 will have babies born with HIV
infection. The infection can happen during pregnancy, birth, or breastfeeding.
There are things you can do to reduce the risk. There are drugs that you can take and
give to the baby at birth, and taking care with breastfeeding can make a significant
difference.
Agree
HW: Perhaps you might come with him and we could talk together about being tested and
having a baby? What do you think?
HW: And, would you like to have an appointment with PPTCT, or shall we leave that until
you have come here with your husband?
HW: Of course. I can make an appointment with them whenever you want me to.
Assist
HW: So, we have agreed that you will talk to your partner about coming in to talk about
having a test and the risks of having a baby. Will you have any difficulties with that?
P: I think if I tell him that if we try for a baby I might be putting him at risk of HIV infection
himself, he might want to talk about it a bit more.
HW: So, let's make a date for next Wednesday, if that suits you.
HW: OK, here is a note to remind you of the date. My phone number is at the top, please
ring me if you have any difficulties and need to cancel it. You can also ring me
anytime during work hours if you want to ask any other questions.
Do you have any other questions right now?
HW: Thank you for coming today and I look forward to seeing you next Wednesday.
Assess
P: Hello, I have come for my regular check-up appointment and I would like to talk to you
if you have some time.
P: As you know I am HIV-positive. I got married some time ago, and my husband and I
would like to start a family and have children.
HW: This is good, let us start by checking how you are and then we can talk. How are
you? How have you been since we last met?
P: Fine.
HW: Ok, so that is good. Now, you wanted to talk about having children, is that right? Can
you tell me, do you have children at the moment?
Advise
HW: Well, you know you can pass the virus to your baby. The infection can happen during
pregnancy, during birth or through breastfeeding.
Agree
HW: So, you will talk to your partner about going to have a test. Is that right?
HW: And you will go to see the PPTCT clinic for more information.
Arrange
HW: So, I'll make an appointment for you to come back to tell me how things are going. I
can make Tuesday at 4 pm. Do you have any other questions right now?
This exercise can be used to illustrate the 5 A’s “ASSIST” (= assist the patient by referring
him to NGOs, other services, group support….). It is important for the participants to know
the local network.
Explain: One of the task of the health care provider will be to link patients to all services
for HIV available within their health district and in the local community. In order to do so,
he/she must be very familiar with the local reality.
In order to perform this exercise well, you should have gathered information on the
following:
If somebody in the group is very familiar with the local organizations and existing structures,
it would be important to get his/her contribution in the discussion.
Based on the information you gathered beforehand, you may need to briefly explain the
structure of health care within your country/ State.
MOH
Tertiary Level Medical College Hospital
District Hospital
Taluk Hospital
Community Health Centre/ Block Primary Health Care Centre
Primary Health Care Centre NGOs and CBOs dealing
with HIV/AIDS
Additional Primary health Care Centre
Faith based organizations
Work based organizations
Subcentres
Village support groups
Women’s organizations
Family and friends
Individual patient
Ask them to list all the support services available for people living with HIV in their area, and
in particular, any services that will support ART
Go through the lists created by each group and confirm what services are provided by each.
Add any extra information you or the other facilitator might have.
Explain that these lists form the basis of an information resource they can continue to use.
13. Review the objectives at the beginning of this chapter and confirm that they have been
met. If you suspect that an objective has not been well understood by all, answer questions
and provide further explanation as needed.
3. Explain that it is often important to ask patient questions to find out more about what they
are saying or feeling.
EXERCISE 1.3: Ask the participants for examples of questions they might ask a
patient who has come to them (for any reason)
OPEN questions: Identify any open questions from the list provided by the
participants.
Explain that open questions open up the discussion and should be used as much as
possible. If relevant examples have not been provided by participants use the following
ones:
How have you been since we last met?
What might happen if you tell your partner?
What difficulties have you had with taking your drugs?
Explain that closed questions lead to one word answers. They can be helpful in
obtaining information but do not open up a discussion. Usually they will make the
health care provider ask another question. If relevant examples have not been
provided by participants use the following ones.
Do you have children?
Do you practise safer sex?
Where do you live?
How old are you?
A closed version of the question “What difficulties have you had taking your drugs?”
would be “Have you had any difficulties taking your drugs?” Note the difference – open
question gives the person a chance to bring up a variety of things; the closed question
can be answered yes or no and the conversation is over.
Explain that checking questions can be used for checking you have understood the
patient and for checking that the patient has understood you.
If relevant examples have not been provided by participants, use the following ones:
Tell me what you need to remember about taking your drugs? What actions have we
agreed upon today?
Remind me how you said you were going to remember to take your drugs?
You said that you could take the drugs at 7 in the morning and 7 in the evening, is that
right?
You said that you felt sick each time you took your pills, Have I heard you correctly?
LEADING questions: Identify any leading questions from the list above.
Explain that when you ask a leading question you expect a particular answer.. It gives
the person less opportunity to give their own answer so provides you with less
information
You take the drugs as I told you to, don’t you?
You wouldn’t have unsafe sex, would you?
You know everything about ART, don’t you?
You are single, aren’t you?
You don’t want more children, do you?
Explain that why questions can be used for exploring issues with the patient when
there is something you do not understand. If relevant examples have not been provided
by participants use the following ones:
Why did you forget to take your drugs?
Why haven’t you told your wife about being HIV+?
Why did you miss your last appointment?
Why do you still have unsafe sex?
Why did you sleep with that person?
Ask how patients feel about being asked “why…?” Explain that patients can feel
judged and threatened by questions beginning with ‘why’. Instead of asking ‘why”’ you
can turn a why question into a more open-ended question. For example instead of
“Why do you still have unsafe sex?” you can ask “Can you tell me more about the
difficulties you are having negotiationg safer sex with your partners?”
4. Explain that:
Listening means to pay close attention to someone; to hear with intention. Good
listening involves listening ACTIVELY.
Listening is one of the key roles of a counsellor, a nurse and any health care
provider.
A good listener doesn’t interrupt, allows silences, does not speak until they have
listened, lets the other person see you are listening by nodding, maintaining eye
contact and asking questions.
Good listening skills include good body language too.
5. EXERCISE 2.2: The following exercise will help the participants understand the effect of
good and bad listening skills.
Explain that one person should be the “listener” and one the “talker”.
The “talkers” should talk about something that is good in their lives. Something that is going
well, is important, or they that they are enjoying.
Take the group of “listener” outside of the classroom to give them the instructions: tell them
to listen carefully their colleague (and to show that they are listening carefully) at the
beginning, and after one minute, tell them to not listening: e.g. answering to the phone,
looking somewhere else, starting to read something…
Stop the exercise after few minutes and ask the following questions to the person who were
talking:
What shows you are listening What shows you are not listening
Facing the patient Looking away or around the room
Looking at the patient while s/he speaks Being distracted
Nodding Not acknowledging what is being said
Smiling or frowning appropriately Fidgeting
Being calm Writing notes, finding papers
Being patient Interrupting
6. Ask the participants the definition of empathy. Ask the difference with sympathy.
Correct and complete as needed I think people are unlikely to know this – so have
facilitator explain the difference. (where is def?)
7. Drill: Explain that you are going to read statements that are examples of what a
patient might say if they are experiencing a difficulty. There is a response which
communicates empathy and one of sympathy.
Patient A: I have been told I It sounds as if you are Oh, you poor thing. Yes, it is
am HIV+ and I don’t know having a hard time. It is terrible to be HIV+. I don’t
what to do. good you have come know what you should do but
here because maybe at least I am here for you
talking it through will help.
(empathetic) (sympathetic)
Patient B: My husband is Oooh, that’s frightening! That sounds hard. A lot of
going to be so angry with You must feel awful. I’m people find telling their
me. I don’t think I can tell him so sorry. It is probably partner difficult. Is there
my results. better not to tell him. anything you think might
help?
(sympathetic) (empathetic)
Patient C: I’ve been feeling How awful for you. Being That doesn’t sound good. It
sick all week and have sick is so terrible. might be connected to your
vomited several times. I drugs or it might not be but it
think it might be connected (sympathetic) is worth checking it out with
to my drugs. the nurse.
(empathetic)
8. Explain what is being non judgemental, using the information in the participant
manual, OR ask a participant to read the section.
9. Say few words on values and attitudes OR ask a participant to read the section
in the manual.
Ask them to record their answer on a blank flipchart, and after 10 minutes ask to
one representative of each group to present the result of their group work.
Comment and complete the information as needed; and ask to the participants to
take notes on the two tables in their manual.
12. Review the objectives at the beginning of this chapter and confirm that they have been
met. If you suspect that an objective has not been well understood by all, answer questions
and provide further explanation as needed.
Duration: Purpose: The participant will understand the concept of stigma and
95 minutes discrimination and appreciate the need for addressing these issues in
HIV care and treatment
Learning objectives:
Materials: Introspect on one’s attitudes towards PLHAs
Cartoon cards Define meaning of stigma and discrimination
Blank List the different types of stigma
flipchart/markers; Identify with personal experiences of being stigmatised or
discriminated
1. Read the learning objectives aloud and the introduction of the chapter
2. Exercise 3.1:
Divide participants in to small groups of 3-4 each. Make sets of cards labelled ‘Agree’
‘Unsure’ ‘Disagree’. Read out a statement and then ask participants to discuss in their
groups for 1 minute what they feel about the statement. After a minute clap you hands to
signal to the groups to lift up the respective card that suits their response to the statement.
Ask groups to share their views of the statement.
Statements: CHOOSE 4 to 6 of the following statements that you think the most
relevant to discuss with your group of participants
People with AIDS are to blame for bringing this disease on themselves
Health Care Providers (HCP) should be able to refuse to care for a patient
with AIDS
The HIV epidemic could be stopped if laws against prostitution/homosexual
behavior are stronger
People with HIV have the same rights as all other patients
Free condoms when distributed will encourage immoral behavior always
The govt. is wasting money on PLHAs by giving free treatment
HIV is a just punishment for immoral behavior
All HCPs should be tested for HIV
All HCPs who are positive must not be allowed to work in any hospital
All patients should be tested for HIV whether they consent or not
People with HIV who continue to have sex must be put in prison
HCPs should have no fear of looking after people with HIV/AIDS
Then give them the definition of stigma and discrimination by either just stating it or
writing it in on the flip chart (pre prepared)
Other definition that you can use to complete, to comment with participants:
Stigma: the shame or disgrace attached to something regarded as socially unacceptable (2)
Stigma is found in the thoughts of people and communities, when people believe that a
particular illness, or something a person has done or feels, is shameful and brings disgrace
on themselves, their family or their community. They believe that the person is bad and
should be despised and avoided by the community
Divide participants to sit in groups of 3-4 members. Distribute cartoon drawings of the
following scenarios. Ask the participants to discuss the following in their group ‘What do you
see in the picture?’ and ‘how does this picture show stigma’
Make cartoon drawings of the following
o Parents pushing pregnant daughter out of the house: May be an unwanted
pregnancy. Do not know her HIV status. What could happen to her
o Man sitting all alone on the bed: No one seems to be caring for him.
Utensils under bed – shows that people are not sharing utensils with him.
He seems to have lost all hope
o Child going out to buy chicken and vegetables while rest of the children (2
others) including the father and mother are eating chicken in the house.
May be the child is HIV positive. So the child is treated differently from
other children in the family.
o Woman sitting all alone and crying: May be she has just discovered she is
HIV +. She is depressed, frightened of rejection, anxious and hopeless
o Man being told to leave the job and the community: Man just discovered to
be HIV positive. He reveals it to a friend and the next day he is being
thrown out of his job. The leaders of the community also tell him to leave
the village (picture shows luggage and furniture out of the house)
Write the responses on the flip chart / board and comment them with the participants
Emphasize on the lack of education and information as a major causes (which are the cause
of fears, misbelieves, myths…)
6. Ask to the participants what are the results-effects of stigma and discrimination, and list
them on a blank flipchart. Comment
o Explain how stigma blocks both prevention and treatment of HIV and AIDS:
o Stigma keeps people from learning their HIV status through testing and
discourages them from telling their partners and as a result they infect them.
o Stigma keeps people who suspect they are positive from accessing treatment
and counselling services. For example, a TB patient hides his diagnosis
o Stigma discourages people from using other services (pregnant woman from
taking ARVs)
o Stigma prevents people from caring for people living with HIV and AIDS.
7. Brainstorm with participants ‘what are the ways to address stigma in the community and
health care setting
Then explain the points that are given in the participant manual
11. Review the objectives at the beginning of this chapter and confirm that they have been
met. If you suspect that an objective has not been well understood by all, answer questions
and provide further explanation as needed.
Learning objectives:
Understand and describe the natural history of HIV/AIDS and the
Materials: difference between HIV and AIDS
Blank Describe the impact of HIV on the immune system
flipchart/markers; recognise the common opportunistic infections required for clinical
HIV Chronic Care staging and for initiation of ART
photos Understand the clinical stages of HIV/AIDS and be able to classify
patients into the appropriate clinical stage
understand the correlation between HIV and tuberculosis
understand and recognise atypical presentations of TB in HIV
infected persons
Wallcharts:
HIV clinical
staging Content Methods Duration
How HIV attacks our Discussion, Reading 10 minutes
health
2. Ask a volunteer to read the HIV/CD4 story. Explain that this simple story with simple
pictures can be used to explain the process to the patients.
3. Using the blank flipchart, have them define these terms: CD4, opportunistic infection,
immune system.
4. Ask the group: How long does it take for a person who becomes infected with HIV to
become severly symptomatic (AIDS) without ART? 7-10 years
5. Comment with the group the diagram of the HIV/AIDS progress and explain that this
illustration can be used to explain it to the patients.
Facilitator needs the HIV Chronic Care photos for this exercise and the HIV clinical stage
wallchart.
6. Ask the particpants to name and describe signs and symptoms that they have seen on
HIV+ patients. Record on a blank flipchart.
7. Ask a volunteer to read the section on the most common Ois. Comment with the group
8. Refre the participants to the section 3.6 from the Chronic HIV Care guideline on the
WHO Clinical Stages,
Important !! Emphasise that: the past history of the patient is determinant to identify the
clinical staging. E.g.: a patient is coming today with no signs, but he had a pulmonary TB last
year…..He will not be classified at stage 1 but he is already on stage 3
10. EXERCISE 4.1: Hand out individual clinical staging photos A through N to different
participants. One at a time, describe the cases below, and have the participant with the
photo that matches the description stick the photo on poster by the correct stage. If
necessary, ask others to help with the diagnosis, or supply the diagnosis
11.
The answers are actually in the participant manual in the staging table which you can
mention after the exercise—also, this wallchart with the photos should remain on the wall
until the end of the course so participants can refer to them).
Tell the participants that the letters in the clinical staging table in the manual correspond to
the pictures (at the end of the exercise).
8. EXERCISE 4.2: Now tell the participants to do the additional written exercise in the
manual. Then go over individually to make sure that each understands.
10. Tell the participants that tomorrow (day 2) will be the start of the skill stations where they
get to practise the skills they learned today with the expert patient-trainer. The clinical
staging will be one of the exercises that they do as a card sort, so it would be a good idea
to review this at home tonight.
Then, have them read this section, Correlation Between HIV and Tuberculosis in the
manual.
12. Have the participants look at the cases at the end of the chapter. Explain that they will
meet 3 patients who will be seen throughout the manual. Introduce Sushma, Manish, and
businessman Kumar. Have 3 volunteers (1 female, 2 male) to read aloud the cases
(suggestion: as we will follow the stories of these 3 patients in different chapters, try to
have the same participants reading the cases for each chapter). Go through the clinical
stage together for each case.
13. Review the objectives at the beginning of this chapter and confirm that they have been
met. If you suspect that an objective has not been well understood by all, answer
questions and provide further explanation as needed.
2. Ask for volunteers to read aloud up to Antiretroviral Drugs OR show a video on the
process of introduction of the virus in the cell and its replication (if available).
3. Have the participants do the EXERCISE 5.1 at the end of the chapter, individually then
discuss in group.
7. Ask: What are the benefits of ART? Write them on the flipchart.
8. Now have the participants read have a look to the Figure: showing impact of ART on
CD4 and viral load in the participant manual. (that illustration can be used to explain to
the patients.
10. Then, have the participants do EXERCISE 5.4. You can address the questions to the
whole group, as a drill.
10. Review the objectives at the beginning of this chapter and confirm that they have been
met. If you suspect that an objective has not been well understood by all, answer
questions and provide further explanation as needed.
2. Ask for volunteers to read aloud the chapter and comment each section with the group.
3. Do EXERCISE 6.1 and discuss as a group how to best explain resistance and the
negative impact on both the individual and the community in your community.
Read each statement and tell participants: If you agree with the statement, put your
green YES card in the air. If you do not agree, put your red NO card in the air (Right
Answers in parenthesis).
2. HIV can make variations of itself, by accident, even in patients who are YES
not taking ART.
3. Resistance is a change in the virus that makes the antiretroviral drugs YES
ineffective.
4. When a patient is not adherent, the patient will develop failure of therapy YES
and become sick again.
5. Review the objectives at the beginning of this chapter and confirm that they have been
met. If you suspect that an objective has not been well understood by all, answer
questions and provide further explanation as needed.
Duration: Purpose: To learn to assess the patient and provide clinical care
70 minutes
Learning objectives:
Explain why doing the complete assessment is crucial in HIV/AIDS
Materials: patients
Clinical review Do the complete assessment (including clinical review section 3.1
form (Annex A); and 3.2, pregnancy and contraception status, TB status section 5 of
Patient Chronic HIV Care guideline module)
Treatment Understand meaning of clinical signs and symptoms in HIV patients
Record (Annex not yet on ART
B) Determine what clinical care patient needs
2. Ask for volunteers to read 3.1 through 3.5 of the Chronic HIV Care guideline module
while reading the explanations in the manual. Have them read up to 2: Assess family
status. Explain that we will go over how to ask about adherence later.
Tell the participants that they have an example of the Clinical Review form in the back of
their manual (Annex A). Give a photocopy/sample of the form to each participant.
Facilitator should meet with the EPT/co-facilitator outside of the class while the
participants are reading to discuss the role-play. Tell the EPT/co-facilitator to say that
s/he has diarrhoea and history of pulmonary TB. The EPT/co-facilitator may expand
accordingly in the case as well as for the rest of the review.
Have the participants use the form as you do the demonstration of the clinical review with
the expert patient-trainer/or co-facilitator of a clinical review of signs and symptoms (NOT
including adherence to medications). Tell them to circle the positives i.e. when the patient
says "yes" to diarrhoea or another symptom. Have them decide what clinical stage the
patient is in at the end of the role-play and fill it in the form.
Ask: What status did the patient had in the role-play? Tell them to circle it in the form.
5. Drill: Facilitator should give the following examples and ask participants to determine the
patient’s functional status:
6. Assess family status: pregnancy, family planning, and the child’s HIV status.
Ask a volunteer to read section 4 in the guideline module on how to assess pregnancy
status, last menstrual period, use of contraception.
Explain that they should also ask questions to explore whether the woman is considering
having a child.
Explain that they should ask the woman if she does have children, and if so, ask about
whether or not her child has been tested yet.
7. Drill: What is the status and what is the plan? This drill is about how to respond to
woman who is:
pregnant,
not pregnant and on contraception,
not pregnant and not on contraception,
breastfeeding
9. TB Drill: Where does the patient belong on the TB dial? Point to the segment of the dial.
TB Drill: Part 1
Case Answers
HIV + man with cough for 4 weeks Suspect TB: Sputums: refer to
and no other symptoms. RNTCP/DOTS centre fro TB screening
HIV+ man with fever and weight loss Suspect TB: Refer to RNTCP/DOTS
for weeks, denies cough. No nodes, centre for TB screening
not producing sputums.
HIV+ woman with cough who has Record results and insure adherence
returned for the results of the sputum to ATT
test: sputum test is positive; started
on ATT
HIV+ woman with cough who has In Acute Care guideline p. 67—Since
returned for the results of the sputum still coughing, refer to clinician if
test: sputum test is negative and available, or treat with non-specific
patient is still coughing. antibiotic such as cotrimoxazole or
ampicillin. If cough persists, repeat
sputums.
13. Help participants review the assessment including the clinical review, functional status,
family status, and TB status. Explain that they will be using these skills in the following
day skill station.
14. Read section 6.1 in Chronic HIV Care guideline module and provide explanation.
15. Explain why we do specific treatment and symptomatic management. Explain why these
items are here (e.g. depression, drug and alcohol use interfere with adherence).
Sushma answers:
1/ Stage 2,
2/ Stage 2
3/ The doctor looks section 6.1 of the Chronic HIV Care guideline module. There it is
indicated to go to the Acute Care guideline module in case of new symptoms. She finds
the treatment for herpes zoster on p. 43 of the Acute Care guideline module.
The doctor gives Sushma painkillers and some amitriptyline at night. She also gives a
local disinfectant to put on the blisters.
The doctor asks about Sushma 's new partner. He is also HIV-positive.
Manish answers:
She should refer Manish to the higher level centre for further assessment for TB and
other causes of persistent fever.
Kumar answers:
The nurse advises Kumar on nutrition, to keep his weight up. She finds the information
she needs in the Chronic HIV Care guideline module section 11.4 and the Palliative Care
guideline module p. 23. She was referred to those pages when reading section 6.1 in the
Chronic HIV Care guideline module. The nurse also explains the treatment for the itching
rash (chlorpheniramine tablets, and calamine lotion).
14. Review the objectives at the beginning of this chapter and confirm that they have been
met. If you suspect that an objective has not been well understood by all, answer
questions and provide further explanation as needed.
Let participants know that this is a lot of information but that they are doing a good job.
Remind them that for the skill station, they should review the clinical staging and the clinical
assessment.
1. Read learning objectives aloud and emphasize the need of a good patient monitoring
system
3. Go through the sections 1 to 3 of the summary Page together, and explain that these
sections are those that can be filled and completed by the nurse and/or the counsellor.
Note that in the section 5, the weight, height and functional status can also be filled by
the nurse.
4. Do EXERCISE 8.1 using a blank record. This exercise can be done individually (with
debriefing in group) or as a group. Ask to the participants to fill the Patient Treatment
Record according to the information provided.
5. Instruct participants to use the Patient Treatment Record at the skill stations.
6. Review the objectives at the beginning of this chapter and confirm that they have been
met. If you suspect that an objective has not been well understood by all, answer
questions and provide further explanation as needed.
Preparation
None Content Methods Duration
Advantages of CTX Reading, Photobooklet 30 minutes
prophylaxis discussion.
2. Ask for a volunteer to read about prevention of opportunistic infections in the chapter
up to “Cotrimoxazole side effects”.
3. Ask for a volunteer to read page Section 7.1 in the Chronic HIV Care guideline module
and then the chapter together using the photobooklet.
5. Ask for a volunteer to read “Monitoring” in the chapter. Explain when cotrimoxazole can
be stopped.
6. Have the participants do EXERCISE 9.1, then go over each answer individually.
7. Ask participants if they see patients on fluconazole prophylaxis. Look briefly at guidelines
in Section 7.2.
The doctor tells all she knows about prophylaxis. He agrees to take it, and she gives him
a 32-day supply.
The doctor arranges a follow-up date in one month, to see if Kumar tolerates the drug
and is adherent.
9. Review the objectives at the beginning of this chapter and confirm that they have been
met. If you suspect that an objective has not been well understood by all, answer
questions and provide further explanation as needed.
2. Ask for a volunteer to read Section 8.9 in the Chronic HIV Care guideline module.
Explain that the chapter provides additional explanation and examples but what they will
rely on is in the guideline module. The guideline module text is highlighted in bold in the
participant manual chapter.
3. Read chapter and comment (note: the facilitator will have to evaluate how she/he would
like to proceed: ask volunteers to read aloud and comment, or comment and ask
questions to the participants…)
4. EXERCISE 10.1: Divide the participants in small groups and distribute equally the
questions (different questions to each group), and ask each group to report the answers
to the whole group.
5. Refer the participants to the Flipchart for Patient Education and explain how to use it.
Refer them to the Basic ART part—they should not just be reading from the back. They
need to learn to use it as a communication aid.
6. Ask: “What are conditions that can be a problem for adhering to ART?”
Write suggestions of the class on a blank flipchart. Explain what is relevant and what is not.
7. Do the following demonstration: Explain that 2 facilitators, or one facilitator and one
EPT, will do a role play (taking into consideration the examples selected).
Role-play:
32 year-old patient, who tested HIV+ three years ago. The patient has been followed at
the clinic in the past year. The patient completed TB treatment for pulmonary TB one
month ago, and he has had chronic diarrhoea for more than one month which has been
helped somewhat by antibiotics. Latest CD4 count is 180 cells. You decide he is
medically eligible for ART and you need to assess if he is ready for it. The patient has
been on cotrimoxazole in the past but had some problems with adhering to it and
sometimes had problems with the TB medications as well.
Use this case to demonstrate 5 A's using the examples of problems of adherence that
are generated in class.
Ask the class to write down at least one example of each of the 5 A's discussed during
the role play.
What was skipped? How would they have used the 5 A's differently?
10. Review the objectives at the beginning of this chapter and confirm that they have been
met. If you suspect that an objective has not been well understood by all, answer
questions and provide further explanation as needed.
Preparation
Prepared flipchart
with Sun/Moon
chart for all
regimens
2. Ask for a volunteer to read, or explain yourself, the Section 8.5, in the Chronic HIV
Care guideline module, to understand the 4 first line regimens.
3. Briefly introduce the Patient Education Card (Annex D of the participant manual) for
each first-line regimen.
Ask: In the first 14 days of treatment, how many FDC tabs and separate tablets are given
for the regimen d4T-3TC-NVP?
5. Show the examples of sun/moon pill chart for all the regimens that you have drawn on
blank flipchart.
6. Dosing Drill: Give a regimen for a patient. Ask a participant to explain the dose for the
patient for one day. Have the participant write the prescription on a sun/moon pill chart for
the patient, using a blank sheet from the flipchart.
7. Refer the participants to the Patient Treatment Record and explain them how and
where the regimen would be filled = in the section 6 on summary/front page of the
Patient Treatment Record and in column 10 of the follow-upvisit record, section 9
8. Participants should do EXERCISES 11.1 and 11.2 at the end of the chapter. Discuss
answers in the group as needed.
EXERCISE 11.2:
Show bottles of the drugs. Have the participant arrange and explain the first 2 weeks
dose of d4T-3TC-NVP using the pills and including the number of tablets dispensed. If
you have other drug regimens available in pill bottles, have participants practise
arranging those regimens as well.
9. Have the participants read Section 10.2 in the Chronic HIV Care Guideline module Avoid
first-line ARV drug interactions.
10. Have participants read the corresponding section Identify first-line drug interactions in
the Participant Manual to the end of the chapter.
11. Ask to the participants to do the EXERCISE 11.3, individually and comment the answers
with the group
2. If the patient is a woman who is taking Avoid a regimen containing NVP or use
an oral contraceptive, what advice would additional protection or switch to
you give? another form of contraception as the
efficacy of the estrogen-based OCP is
decreased with NVP.
3. If a patient is being treated for Nevirapine
tuberculosis with rifampicin, which ARV
drug should he avoid? Both drugs work on the liver. Rifampicin
will cause the blood levels of nevirapine
For what reason? to be lower which can cause HIV
resistance. Also, both drugs together
can be toxic to the liver.
12. Ask to the participants to read the continuation of the 3 stories at the end of the
chapter
Learning objectives:
Materials: Explain the 3 different categories of side effects
Blank Describe the most common side effects for each ARV drug used in
flipchart/markers; the first-line ARV regimens
Give an adequate explanation of the most important side effects to
Side effect colour patients
cards Explain to patients what to do if side effects occur
Understand the possible explanations when new signs and
symptoms develop in a patient taking ART
Identify and manage simple side effects
Preparation: List which side effects need advice or referral
None
2. Ask those who have been around patients on ART—what are the most common side
effects you have seen? List them on the flip chart.
3. Read the clinical cases at the beginning of the chapter and discuss the cases.
4. Explain the 3 types of side effects, using the information in the participant manual
5. Do EXERCISE 12.1 Side Effects Write the name of each first line drug on a separate
piece of paper and stick to the wall. Distribute a side effect card to each participant and
have the participants match them to the drugs.
6. Read section 8.7 in the Chronic HIV Care guideline module. The Patient Education Cards
are in Annex D. Point out the sections which talk about what to do with side effects
pertaining to the regimen. Also point out the prevention side of the card which is also
important for the patient to see.
7. Discuss what you should warn patient about; how to cope and when to seek care. Give
simple instructions.
8. Ask participants:
What is the general difference between what the patient with HIV and
immunosuppression can have versus a patient without HIV?
What about the HIV+ patient on ART versus before ART?
Refer the participants to the table “possible causes for signs and symptoms”, in this section
of their participant manual. For better understanding, you can write that table, step by step,
and commenting each of the three situations, on a blank flipchart
9. Ask for volunteers to read from Immune reconstitution syndrome to the end of the
chapter and comment.
10. Then look at the table in section 8.12 in the Chronic HIV Care guideline module and
discuss some of the signs or symptoms
11. Have participants do the role-plays in EXERCISE 12.2 and tell them to use the
Patient Education Card to explain the regimens and side effects to the patient during the
role-play. Note: if you have some time constrains, do it as a drill by addressing questions
to the group
12. Review the objectives at the beginning of this chapter and confirm that they have been
met. If you suspect that an objective has not been well understood by all, answer
questions and provide further explanation as needed.
2. Refer the participants to the Section 8.9, in the Chronic HIV Care guideline module:
Support ART initiation”
=> comment the information with the participants (use also the information of the
participant manual) . Make the discussion interactive by asking to the participants,
some examples, stories, experiences of their professional practice or personal life
3. Refer the participants to the Section 8.9, in the Chronic HIV Care guideline module:
“Monitor and support adherence”
Assess
Barriers of adherence
4. Ask participants what factors might interfere with adherence for their patients and list
these on a blank flipchart. Make sure that all factors listed in their manuals are on the list.
5. Have the participants doing the EXERCISE 13.1. Then discuss what they have written
6. Ask participants to list ways to remember taking ART at the right time. Write this on the
blank flipchart.
Count pills
7. Explain how to assess adherence. calculating the adherence percentage Read section,
Count pills in the participant manual, together with the participants.
8. Use a blank flipchart to write examples on how to calculate the examples and creat
examples to practise with the participants (e.g. patient misses 5 pills, no pills, 10 pills, etc).
Show where adherence is recorded on the Patient Treatment Record.
9. Go through the other 5 A’s of ‘Monitor and support adherence” = Advise, Agree, Assist
and Arrange
10. Ask an Expert Patient Trainer to share his/her experience on adherence to the ART
(15 minutes)
How was the preparation to ART?
Did she/she face difficulties?
What are the solutions that she/he found?
Does she/he have any support from other people?
11. Have the participants read the clinical cases at the beginning of the chapter and then
discuss them.
2. Ask for volunteers to read through the clinical cases at the beginning of the chapter
and discuss the questions.
3. Ask to the participant “why it is important to continue to talk about prevention when
the patients are on ART?”.
to comment, use the information in the section “Linking ART with increased
prevention” in the participant manual
4. Have them read the story of Priya and Ramseh and answer the questions at the end of
the story. Then go through the answers together.
5. Have participants list all the ways of getting infected with HIV and record using the
blank flipchart.
6. Do EXERCISE 14.2.
7. Have them look at the Flipchart for Patient Education and review the prevention part.
Tell them to practise giving advice about prevention with each other using the Flipchart
and not reading it.
8. Remind them about the back side of the Patient Education Card (Annex D) and the
prevention messages on it.
9. Read with them the section on “Ways to prevent infection with HIV”
11. Read the box on the “Safer sex for high risk individuals/settings” and comment it with
the participants
Note: To illustrate and discuss these issues, you can ask one of the EPTs and a facilitator to
demonstrate one of the cases on CWS or MSM (available for skill stations)
12. Review the objectives at the beginning of this chapter and confirm that they have been
met. If you suspect that an objective has not been well understood by all, answer questions
and provide further explanation as needed.
Preparation:
Prepare Content Methods Duration
wallchart: Introduction to Universal Discussion and explanation 10 minutes
Body fluid to precautions
which universal
10 minutes
precaution apply,
Body fluids and universal Exercise 15.1
Components of
precautions
Universal
precaution and Components of universal Discussion 45 minutes
PEP precautions Exercise 15.2
Occupational exposure Discussion 15 minutes
protocol
Reflective exercise, 10 minutes
Indications of PEP Explanation, discussion
4. Exercise 15.1: Distribute small chits of paper with the name of body fluid in it. Ask
participant to identify the body fluids which are at risk of HIV transmission and to classify
them on the table that you had prepared on a flipchart. Tell to the participants to take note on
the same table in their manual.
Body fluids considered at risk of HIV Body fluids NOT considered at risk
transmission of HIV transmission
Explain, comment them, one by one (use information in the participant manual).
6. Ask to the participants what the methods of disposal are needed for each type of waste
and what it is done at their health facility
The purpose of this exercise is to help participants become aware of the steps to be taken in
the following situation. Divide the group into three and give each group one topic to
discuss. After 10 minutes, ask to the groups to report: the groups can present a role play, or
a flipchart….
Group 1: As you are, collecting blood for lab tests, blood spilled on the floor. How will
you clear the blood spill from the floor?
Group 2: While starting an IV line for a patient blood stain is found on the bed linen.
How is the linen with blood stain cleaned?
Group 3: A 39year old lady, HIV+, died at your health centre. How will you handle the
body after death?
8. Case study: Ms Sheela gets a needle stick injury while collecting blood from a restless
patient..
- what should Ms Sheela do immediately
- to whom and when should Ms Sheela report after the incident?
- How high is the risk of infection to Ms Sheela?
- What tests to be carried out for Ms Sheela and what counseling has to be
given?
- For how long should she take PEP medication?
9. Ask to the participants which is the protocol to follow after an occupational exposure
•Crisis management
•Immediate care
•Recording and reporting
•Risk assessment
•Testing and counseling
•PEP medication
•Follow- up
10. Explain, comment them, one by one (use information in the participant manual).
10. Ask to the participant the definition of the Post exposure Prophylaxis and the
indications for PEP
Small volume Few drops of blood / body fluids / other potentially Basic Regimen
infectious materials (OPIM) AZT + 3TC twice daily
Short duration
Less severe Solid needle (no bore in it) for 4 weeks (28 days)
Superficial scratch
Large volume Several drops of blood / body fluids / OPIM Advanced Regimen
Long duration (several minutes or more) AZT + 3TC twice daily
More severe Large bore hollow needle + Indinavir every 8 hours
Deep puncture
Visible blood or needle used in persons artery /vein for 4 weeks (28 days)
12. Review the objectives at the beginning of this chapter and confirm that they have been
met. If you suspect that an objective has not been well understood by all, answer questions
and provide further explanation as needed.
3. Explain the eligibility criteria for ART in pregnant women: refer the participants to the
table in their manual. .
Emphasize: Highest priority for CD4 testing should be given to pregnant women
Step 1: Ask participants to briefly describe what they do in their clinics to prevent
mother to child transmission of HIV. Record on flipchart. Note if they have PPTCT
program.
Step 2: Ask PPTCT program staff to list the key points of their PPTCT program.
Record on flipchart.
Step 3: Summarize the exercise by highlighting the PPTCT interventions they are
currently providing.
Step 4: Conclude exercise by stressing PPTCT gaps in existing services.
(Please note that we are not trying to quickly teach PPTCT interventions for safer labour and
delivery or counselling on infant feeding choice. We do want to relate what we are teaching in this
course to what they may be practising in providing PPTCT interventions, to make them realize ART
is a PPTCT intervention, and to be sure pregnant women receive the other PPTCT interventions
which are available).
5. Lead the following discussion on ART and ARV prophylaxis for pregnant women
ART is the provision of a combination of 3 ARV drugs that are prescribed for the life
of the patient. It is only appropriate for pregnant women with advanced disease.
ARV prophylaxis is the short-term use of one drug, Nevirapine (200mg) at onset of
labour. The infant should also receive ARV prophylaxis (nevirapine) as soon as
possible after birth, within the first 72 hours.
ARV prophylaxis is appropriate for all pregnant women who are not on ART in
order to PPTCT of HIV
Step 2: Stress the need to provide the other PPTCT interventions even if a woman is on
ART.
Prepare a flipchart with the headings below.
Conduct a group brainstorm and ask the group to fill in the correct responses that
are listed in bold.
6. Now have the participants do EXERCISES 16.1 & 16.2 at the end of the chapter.
All the regimens without EFV are safe to start in pregnancy in a woman without anaemia.
EFV should not be given during the first trimester of pregnancy.
Refer for CD4 testing. Explain, advise PPTCT interventions: If she is not eligible for
ARTshe will receive ARV prophylaxis: nevirapine 200mg single dose at the onset of
labour, her baby also need ARV prophylaxis.
Arrange for counselling on infant feeding options (if you have not been trained to do
these)
2. A 25-year-old woman is pregnant. You think she must be no further than 2 months.
She is thin and she had just started TB treatment for smear-negative pulmonary TB. She
also had oral thrush 2 weeks ago. Her CD4 count is 260.What will you do?
This woman needs ART for her own health. The doctor may advise to start AZT-
3TC-EFV two weeks after the intensive phase finished. She should still be informed
on PPTCT interventions, and counselling on institutional delivery and infant feeding
options. Give CTX prophylaxis starting from 2nd trimester. She does not need ARV
prophylaxis as she is on ART. Her baby needs ARV prophylaxis.
You decide she is HIV clinical stage 2. Refer for CD4 testing. Do CD4. If her CD4
count is > 200 she is not eligible for ART. Counsel on institutional delivery, arrange
for counselling on infant feeding options. Give CTX prophylaxis starting from 2nd
trimester. She will be receiving ARV prophylaxis nevirapine 200mg single dose at the
onset of labour, her baby also need ARV prophylaxis.
4. A 24-year-old woman has been taking ART for 2 years. She tolerates the therapy,
and is adherent. Her weight has increased and she did not have any serious OIs
within the last 2 years. She was in stage 4 when she started ART. Her regimen is
d4T-3TC-NVP. She is now pregnant in her first trimester. What will you do?
Inform on the risk of PPTCT. Discuss the advantages of ART in reducing the risk of
HIV transmission; explain the risks and benefits of ART during the first trimester. She
should still be referred to someone trained in the PPTCT interventions (if health
worker is not trained), for counselling on institutional delivery and infant feeding
options. She does not need ARV prophylaxis as she is on ART. Her baby needs ARV
prophylaxis.
This case should be referred. She needs ART for her own health. She needs to
interrupt the EFV containing regimen, but cannot use NVP anymore. The doctor can
put her on NFV or may need to stop all the drugs and then restart. She still needs
PPTCT interventions. Her baby needs ARV prophylaxis.
As a recap, have participants read the about Sushma and discuss how to manage
Sushma:
The nurse informs Sushma that she should continue the drug. This regimen is not
harmful for the baby. Sushma needs the drug to stay healthy, but the drug will also
reduce strongly the risk that the baby acquires HIV infection. Sushma is happy about
this because it is very important to her that the baby is born negative.
The doctor and/or nurse advises Sushma to go to the PPTCT program, to get advice
on safe delivery and infant feeding options.
The doctor advises Sushma to continue the cotrimoxazole
8. Review the objectives at the beginning of this chapter and confirm that they have been
met. If you suspect that an objective has not been well understood by all, answer
questions and provide further explanation as needed.
1. Group discussion: Ask participants to discuss the possible differences between adults
and children as regards HIV infection and its treatment. List the differences mentioned by
them on a flipchart.
3. Explain to the participant how to identify HIV infected children (information is on page
H82, H83, H86 in the Chronic HIV care guideline module and the participant manual)
4. Discuss the differences in the clinical staging between adults and children. Hold the two
wallcharts and point out the similarities:
5. Ask participants to do EXERCISE 17.1 at the end of the chapter in Participant Manual.
Make sure everyone understands the correct answers.
1. Stage I
2. Stage III
3. Stage III
4. Stage III
5. Stage I
Child's ability to follow the above depends on family and environmental factors
including the way s/he is brought up, educational and the psychosocial support
from parents, siblings and other guardians. The health worker should be guided by
parents as well as his or her maturity (i.e. the child's ability to interact and grasp
and understand issues) as to when to involve the child for adherence.
The health worker needs to work with the caregiver and the child to develop a
treatment plan.
Children, who need ART, particularly when they are very young, face multiple
challenges. The health worker should follow the same principles, and use the 5
A's. Involvement of other people and carers (e.g. school nurses, or staff of
orphanage) in the dispensing of drugs when away from home for long periods or
when attending school is important. There is also the challenge of sustaining
confidentiality as caregivers change. There is also fear and related stress from
repeated painful procedures on the child. Timing of disclosure of HIV sero status
and counselling for the chronic medication needs careful and frequent close and
intimate adherence sessions.
7. Ask participants why and how children are different in terms of adherence and record
answers on the flipchart.
9. Ask them to read sections 8.9 and 12.8 in the Chronic HIV Care with ARV Therapy and
Prevention guideline module.
10. Have them discuss the following questions on Case study on Ramya , in Participant
Manual.
Q: What questions does the health worker need to ask about the situation?
A: Should include questions such as:
Where is grandmother?
Has there been a problem getting Ramya. to take her medicines?
What is the nature of the problem?
How often were doses missed?
Has the family been able to obtain the medicines?
Have there been side effects from the medicines?
What is the situation at home?
How many children are at home and who is caring for them?
Is there enough food at home?
What does Ramya understand about her need to take medicines every day?
Is stigma an issue?
Are there other problems at home?
11. Ask participants to read section on stabilizing the child before initiation of ART.
12. Discuss medical eligibility for ART for children younger and older than 18 months using
national guidelines and the clinical staging table in Participant Manual.
13. Explain to the participants t the nationally recommended paediatric first line regimens.
- clinical monitoring,
- managing side effects and chronic problems,
15. Discuss with the participants the management of nutrition for HIV+ children and
the specific (information are in the participant manual and in the Chronic HIV care
guideline moduleH94).
As children living with HIV benefit from ART, they will live longer and in better
health. Many of them will reach adolescence and adulthood and their full
integration into society will become a necessity, not only for themselves but
for society in general.
Ask to the participants to read the section on good communication with children, in their
participant manual, discuss and comment with the participants
17. Ask to the participants how it is possible to disclose his/her status to the child.
18. Refer the participants to the section on disclosure in the Chronic HIV care guideline
module (page H95) .
Answers to EXERCISE17. 2:
1. Assess John further using "the HIV component of IMCI" box. As John has two
conditions: Low weight for age and pneumonia, he has possibly symptomatic HIV
infection.
Do pre-test session for John's mum and himself
Monitor his growth
Begin cotrimoxazole prophylaxis if HIV result is positive
4. High grade fever, headache and neck stiffness are ominous signs of meningitis.
Consider cryptococcal meningitis.
Use follow up schedule. To be seen at least 3-monthly by clinician.
Continue ART and fluconzole as secondary prophylaxis
Follow for side effects of d4T, 3TC and NVP
6. Aruna developed the abscesses on 3rd week. Difficult to assess response to ART so
soon. However, it could be due to immune reconstitution syndrome. Drain abscess
and treat with potent antibiotics and continue the ART.
Review the objectives at the beginning of this chapter and confirm that they have been met.
If you suspect that an objective has not been well understood by all, answer questions and
provide further explanation as needed.
2. Ask for volunteers to read through the cases at the beginning of the chapter and then
discuss them.
=> the end of the stories of Sushma, Manish and Kumar will permit to the facilitator
and the participants to recap some issues discussed in the previous chapters
5. Review the objectives at the beginning of this chapter and confirm that they have been
met. If you suspect that an objective has not been well understood by all, answer
questions and provide further explanation as needed.
The facilitator for the first skill station of the day should make sure that the card sort
exercises are ready for the skill station. Facilitator should also make sure to have enough
copies of clinical review forms, Patient Treatment Records, and case-specific checklists at
each skill station.
Starting on Day 2 of the course to the Day 5, the skill stations are 2 hours each day and 1
hour on the last day. Cases that will be practised today are numbers 1-10.
The skill station is a way for the health worker to practise the skills that they have learned in
class with expert patient-trainers who are PLHA and have been trained to role-play HIV
cases with them. At the end of the role-play they will give the health worker feedback.
As facilitators, you are responsible for setting up the skill station, so whoever is the first group
to go should be the ones to set it up that day. In order to facilitate setting up and facilitating
the skill station it would be helpful to look at ''Section H: Skill Station Procedures'' from the
Facilitator Guide for the WHO Basic ART Expert Patient-Trainer Course. This guide also has
the facilitator's guide to each case and set up needs of each case. Each case also has a
case-specific checklist (found in the Handouts for the Expert Patient-Trainer) and enough
copies should be made of each case's checklist for the skill stations.
As part of the skill station, there are also card-sorts exercises which are exercises similar to
the exercises which are done in the class. As seen in the table below, each day there are
different card sorts where cases on the cards or drug abbreviations need to be matched to
the appropriate answers. All the cards for the card-sorts are available in the reusable kit. The
explanation for each card-sorts exercise is at the back of this facilitator guide in Annex B of
the Basic ART section and contains the set up needs for each exercise.
Prior to the start of the skill station, the facilitator should introduce the skill station and the
skills/materials to be used which will be important to be practised. The facilitator can use the
''Introduction to the health worker,'' Annex 7 of the Facilitator Guide for the WHO Basic ART
Expert Patient-Trainer Course to help with the first day introduction. Tell the health worker to
bring their manual which has the health worker case book in Annex C of the Participant
Manual as well as their guideline module. Explain to the participants that they should be
trying to use the materials which are at the skill station even if they have not completed that
chapter in class yet (i.e. the first day of the skill station introduces the Patient Treatment
Record and the first group will likely not have done that chapter yet. They can, however, fill
out the clinical stage, family status, functional status, and TB status in the card as they
learned from the previous day). The participants should practise using the 5 A's during the
skill station and use the clinical review forms (available at the skill station).
Explain to the participants that they should use the skill stations as an opportunity to put what
has been learned into practise. Remind them that this is not a test. It is an exercise of which
they should take advantage. The feedback given by the EPT is meant to be non-judgemental
and should be taken in a positive manner. The skill stations should be used as a tool to
improve their learning.
1 No skill stations
Clinical review
2
HIV Clinical Stages (link HIV clinical staging
(1 hour
1-10 the symptoms/signs to Functional status
for each
the stage) TB status
group)
Prevention
Prophylaxis
When facilitating the card sorts, remind the participants that it is more important to practise
their skills with the EPTs. If an EPT becomes available, they should be working with them
over the card sorts exercise.
Materials needed: HIV clinical staging wallchart, HIV clinical staging cards.
Set up: Place clinical staging wallchart on table and have all the cards in a pile next to
wallchart. The cards have an A side and a B side. The A side lists the initial presentation; the
B side lists the presentation on the next visit. You will have to tape the two sides together (or
laminate them together) to make the cards.
Participants should sort cards and group into correct clinical stage on the wallchart.
Facilitator should provide feedback.
Turn all cards over to look at the B side—decide if stays in same clinical stage or goes up
(re-sort).
Identify what medical care (participants can refer to stages in chart) should be provided
appropriate to the stage of infection.
Another option is to use a blank clinical staging table and then try matching the photos/cases
to the appropriate stage through practise.
Materials needed: Blank flipchart paper, Drug name/abbreviation cards, TB/HIV cards, tape.
Set up: Tape blank flipchart paper to wall (or table) and write the following directions on it:
"Link the drug abbreviation to the corresponding drug name". Tape the drug
abbreviation cards to this blank paper in a row. Then put tape on the back of the drug name
cards, so participants can place the card next to the proper abbreviation.
To make the exercise more interactive and interesting, you can ask the participants to put the
abbreviations and the names in the correct first-line regimens once they finish the first part of
the exercise.
Set up: Tape blank flipchart paper to the wall (or table) and write the following directions on
it: "TB/HIV Cases: Match the clinical cases to the correct management plan". Tape the
cases to the blank flipchart and put tape on the back of the management plan cards so
participants can tape them up on the flipchart next to the correct case.
Have the participants refer to section 8.4, p. H25 of their Chronic HIV Care guideline module
to do this exercise.
Go through each case together and have them decide what is the correct management.
Major and minor side effects on ART and treatment of side effects (Day 4)
This skill station includes card sorts of the side effects of the first-line drugs. Here the
participants should practise matching the major/minor side effects with the appropriate
regimen.
Materials needed: Side effects and drug regimen cards, blank flipchart paper and tape.
Set up: Tape blank flipchart paper to wall with the following directions on it: "Major/Minor
Side Effects of the 1st-line Drug Regimen: Match the side effect to the correct
regimen."
Tape each regimen to the flipchart and put tape on the back of the side effects cards, so
participants can tape the cards next to the appropriate drug.
Have the participants practise matching the side effects to the individual drugs and the
regimen.
Materials needed: Treatment of side effects cards, blank flipchart paper and tape.
Set up: Tape a blank flipchart paper to wall with the following directions on it: "Management
of Side Effects — Match the appropriate treatment plan to the clinical case."
Tape the cases to the blank paper and put tape on the back of the management cards, so
the participants can tape it on the wall next to the correct case.