Hiv, Aids ,And Stis Notes Book

MODULE 1: BASIC CONCEPTS AND
EPIDEMIOLOGY OF HIV & AIDS

Module Goal
• Impart knowledge on basic concepts of HIV and AIDS.
Module Objectives
1. Describe the basic concepts of HIV and AIDS
2. Appreciate the global and national HIV statistics and epidemiology
3. Explain HIV combination prevention intervention
4. Describe HIV positive living
5. Discuss myths and misconceptions of HIV

HIV & AIDS General information
• HIV- the acronym for Human Immunodeficiency Virus
• It’s the virus that’s causes HIV infection and AIDS
• Weakens immune system by destroying cells that fight disease/ infection
• Is preventable & manageable but is NOT curable
• Transmission by exchange of body fluids (blood, breast milk, semen and vaginal
secretions)
• Not transmitted kissing, hugging, shaking hands, sharing personal objects, food or
water
General information
• HIV invades the helper T cells (CD4+ cells) in the body of the host (defense
mechanism of a person)
- No signs or symptoms of illness but are still infectious to others during the initial
stages of infection
- The body can’t fight off infections.
- HIV takes advantage the weak immune system causing AIDS

What is AIDS?
• AIDS - The acronym for Acquired Immune Deficiency Syndrome
• AIDS is a disease which has the following elements:
• A confirmed positive test for HIV/AIDS
• Patients predisposed to multiple opportunistic infections leading to death

Risk factors of HIV infection
Behaviours and conditions that put individuals at greater risk of contracting HIV
include:
• Having unprotected sex (anal or vaginal)
• Having STI e.g. syphilis, herpes, Chlamydia, gonorrhea, bacterial vaginosis
• Sharing injecting needles
• Receiving unsafe injections, tissue transplantation, medical procedures that involve

unsterile cutting or piercing
• Health Care workers- accidental needle stick injuries
• HIV positive mother to child at pregnancy, birth, breastfeeding

HIV prevention Key approaches
• Individuals can reduce the risk of HIV infection by limiting exposure to risk factors
• Combination prevention used as HIV prevention approaches:
✓Combination HIV prevention interventions are defined as a combination of

mutually reinforcing biomedical, behavioural, and social/structural interventions
Biomedical prevention
• Condom use promotion and distribution
• Elimination of mother to child transmission (EMTCT)
• VMMC
• Methadone replacement therapy
• STI treatment
• Blood safety
Behavioral interventions
• HIV testing
• Behavior change communication

Structural interventions
• Social Protection - Cash Transfers for Orphans and Vulnerable Children (CT-OVC)
• Building the resilience of women and Girls
• Girls enrolled in secondary school

HIV Positive Living
• Antiretroviral (ARV) drugs controls virus, prevent transmission for healthy, long
and productive lives
✓antiretroviral therapy(ART) taken daily and right way
✓reduce the amount of virus (viral load) in blood and body fluids thus reduce
chances of transmitting
• Visit health care provider as directed when taking medicines to treat HIV (ART)
• Use condoms the right way every time you have sex
HIV Positive Living
• Choose less risky sexual behaviors
✓Anal sex -highest-risk
✓Oral sex- less risky than anal or vaginal sex
✓Sexual activities that don’t involve contact with body fluids (semen, vaginal fluid, or
blood) carry no risk of HIV transmission
• Not sharing needles for injecting drug users
• Pre-exposure prophylaxis (PrEP)
• Adherence to treatment
• Get tested and treated for other STIs
• Encourage your partners to get tested for HIV

Statistics of HIV
Global HIV Statistics – 2016
• globally living with HIV: 36.7 million
• accessing antiretroviral therapy : 19.5 million people
• newly infected with HIV :1.8 million people - 1 million people- died from AIDS -
related illnesses
• people infected since epidemic: 76.1 million people
• Deaths by AIDS: 35.0 million people
(According to the UNAIDS Fact sheet 2017)

Statistics of HIV
People living with HIV : 36.7 million
• adults: 34.5 million ; women (15+ years): 17.8 million; children (<15 years): 2.1
million
People living with HIV accessing antiretroviral therapy-19.5 million , up from 17.1
million (2015) and 7.7 million (2010)
• people living with HIV with access to treatment- 53%
• 15 years and older living with HIV with access to treatment- 54%
• children aged 0 – 14 years with access to treatment - 43%
• pregnant women living with HIV - 76%

Statistics of HIV
New HIV infections
Worldwide newly infected-1.8 million
• estimated 11% decline, new HIV infections among adults (1.9 million in 2010 to 1.7
million in 2016)
• 47% decline HIV infections among children since 2010 (300 000 in 2010 to 160 000
in 2016)
AIDS - related deaths
• AIDS - related deaths have fallen by 48% since the peak in 2005.
• In 2016, 1 million people died from AIDS-related illnesses worldwide, compared to

1.9 million in 2005 and 1.5 million in 2010.
Statistics of HIV
HIV/tuberculosis(TB)
• leading cause of death among people living with HIV, accounting for around one in
three AIDS-related deaths.
• global TB cases in 2015-10.4 million; 1.2 million [11%] among people living with
HIV.
• TB related deaths among people living with HIV fell by 33% between 2005 and 2015.
• 60% of TB cases among people living with HIV were not diagnosed or treated,
resulting in 390 000 tuberculosis-related deaths among people living with HIV in
2015
•.
unit 3: Myths and misconceptions of HIV and
AIDS
Objectives
• Discuss myths and misconceptions on HIV and AIDS in our various communities
Transmission of HIV
HIV is not transmitted by:
• Touching/hugging
• Mutual masturbation, Kissing, Oral sex
• Insect bites
• Water, food, air
• Sharing toilet seats, tables, door handles, cutlery, towels

Group exercise on myths and misconceptions of
HIV and AIDS
• If I get infected fluid from an HIV-positive person into my body will I

definitely get HIV?
• Isn’t HIV only a risk for certain groups of people?
• I’m HIV-positive and so is my partner, so we don’t have to worry about HIV,

do we?
• It’s easy to tell the symptoms of HIV
MODULE 2
INTRODUCTION AND BACKGROUND TO HIV TESTING

SERVICES (HTS)
Module goal and description
Module goal
• To provide a general overview of the main concepts in HIV testing services

provision
Module description
• HIV testing service delivery must be informed by evidence, policy, guidelines and
standard operating procedures that ensure standardization of services provide
• In Kenya, we have numerous policies and guidelines that provide both justifications
and directions on how best to implement HIV and especially HTS
Specific Objectives
By the end of the session, the participants should be able to:-
1. Understand the general overview of the HTS training
2. Define the various international and national policy frameworks and guidelines that
are critical to quality and comprehensive delivery of HTS in Kenya
3. Describe the various Kenyan HIV and HTS related guidelines and standards
Global Policy Documents
There are three global policy documents
1. 100-95-90 Targets
• 100% of all people living with HIV will know their HIV status
• 95% of all people with diagnosed HIV infection will receive sustained antiretroviral
therapy
• 90% of all people receiving antiretroviral therapy will have viral suppression
Approaches and Settings of HIV Testing Services
• Client Initiated HTS (CITS); where the client seeks HTS either in the community
or health facility settings based on own volition clients
• Provider initiated HTS (PITS) where a health worker offers HIV testing to clients
within a facility, regardless of the reason for the visit
Populations Targeted for HTS
-General Population - Youth and adolescents Infants and children
-Couples and sex partners - Persons with disabilities (PWDs)
-Key populations -Survivors of sexual and gender base violence
- Vulnerable populations
Core principles of HIV testing and counseling
• Consent
• Confidentiality
• Counseling
• Correct test results
• Connection (Referral and linkage to care)

HTC protocol
The five primary components of HTS package include:
• Pre-test session
• HIV test
• Post-test session
• Assessment of other health related conditions
• Referral and linkage to other appropriate health services

Disclosure in HTS
• Disclosure in HTS is the process through which a client shares information about
their HIV test result with significant others or a third party
• HTS service providers should encourage their clients to disclose their HIV test
results to significant others
• In some situations, a health care provider may disclose patient HIV results to
another provider for purposes of further care/management
Integration of Services
• The aim of integrating services is to ensure that clients get the services they need,
when they need them, in ways that are user friendly, achieve the desired results and
provide value for money
• Due to the potential benefits of integration, it is highly recommended that all health
service delivery points integrate HTS
• Integrated services can be offered by one service provider during the same
consultation or by more than one provider within the facility during the same visit
Human Resource
Who should provide HTS?
• All qualified medical personnel from health care training institutions should be able
to provide quality HIV testing services, having undergone training based on any of
the NASCOP approved curricular
• Non-medical (Lay) HTS providers who have undergone the HTS training using
approved curricular and certified by NASCOP
• They can be engaged to work in the community settings or in the health facility
settings where task shifting is applied to supplement the health workers and
undertake tasks such as HTS, linkage to care, adherence counseling and support
group management
HTC Commodities Management:
• Uninterrupted supply of HTS commodities is critical for the success of HTS
• An effective commodity managements system must be in place to ensure the

accessibility and effective use, both at the service delivery level and the referral
services
• Commodity management for HTS should follow well established principles but must
be flexible and responsive to varied settings and services offered
Quality Assurance
• Quality is a critical dimension of social justice and human rights principles and forms
one of the pillars of a viable and sustainable healthcare system
• QA should be an integral part of all the HTS and should be implemented during
testing, counseling, commodity, human resource and data management
• All stakeholders should have a systematic and planned approach to monitor QA on a

continuous basis
Promotional Activities
• Promotional activities are an essential component and are necessary for increasing
awareness, acceptability, demand and utilization of HTS
• Additionally, they aim at advocating for increased resource allocation, formulation of

policy and mainstreaming HTS in broader health service delivery
• Promotional activities for HTS include communication, advocacy, capacity building

and HTS campaigns
Coordination, Monitoring & Evaluation
HTS program requires effective coordination, coupled with robust monitoring and
evaluation systems at all levels of the health system
• Coordination: The coordination of HTS is multi-faceted and multi-level, with

responsibilities spanning national, county and lower level structures
• Monitoring and evaluation: It is essential for the effective management and

improvement of HTS.It answer specific management and epidemiologic questions
that will guide future actions, planning, and decision making regarding HTS
Module 3: HTS Populations Targets,
Approaches, Setting and Strategies
Module Goal
• At the completion of this module, participants shall be able to
describe:
othe populations targeted by HTS
othe different implementation strategies and approaches in
respect to setting
oHow to provide services to clients/patients as per the
National HTS guidelines.
Specific Objectives
1. Describe the various population categories that are targeted for HTS
2. Know and apply specific HTS strategies to enable those with unknown
status know their statuses
3. Describe the HTS testing approaches, settings and strategies that apply in
each category
4. Define the roles HTS provider in scaling up and sustaining HTS services
within the communities
Unit 1: Population targeted for HTS
• General population
• Key populations
• Priority populations
• Vulnerable populations
HTS population targets
General population:
Children & • This is a person who is below the age of 15 years.
Infants • Children and adolescents up to the age of 14 years should be tested with the consent of a parent
or guardian.
• However those from 7 years to 14 years need to assent after the parent or guardian consents
(permits).
• HIV-exposed infants below 18 months should be tested within 4–6 weeks of birth so that those
presumptively diagnosed with HIV can start ART.
• HIV-exposed infants with non-detectable NAT at 4–6 weeks should undergo HIV serological
testing at around nine months of age (or at the time of the last immunization visit) to rule out
HIV infection. Infants whose serological assays are reactive at nine months should undergo
testing to rule in HIV infection.
• Children of school age (6–12) should be told their HIV positive status; younger children should
be told their status incrementally to accommodate their cognitive skills and abilities.
Adolescents & • Adolescents are defined as persons aged between 10 to 19 years.
Youths • Youth are persons aged 20 to 24 years.
• Adolescents aged 15 years and above can consent for HTS
• Mature or emancipated minors can provide consent HTS: those sexually active, pregnant
or already parents or with an STI but below 15 years.
• Special consideration should be made for key populations and vulnerable adolescents
and youths: men who have sex with men, transgender people, those who inject drugs,
sex workers, youth who belong in multiple group’s e.g transgender youth who inject
drugs).
• Youth who are HIV positive should be:
o Encouraged to disclose their status to their parents/guardians
o If challenged, health provider provides support to disclose, to facilitate access to
treatment and other services.
• HIV negative youths should be linked to other supportive HIV prevention services as
appropriate.
Adults • These are all individuals above the age of 24 that are not identified in any of the
other categories and want to access HTS
Couples/ sex • This constitutes 2 or more individuals either already involved in sex or are planning to have
partners (SP) sex.
• It is recommended that individual testers are encouraged to test together with their sexual
partners as couples, whether heterosexual or same sex.
• Couple/partner HTS should facilitate disclosure and adequate referrals to prevent HIV
transmission/acquisition as well as facilitate linkage to care and treatment and other
psycho-social support.
• Couples/SP should be supported to disclose their results to other family members.
• The HTS service provider should screen for potential intimate partner violence (IPV) risks
and make appropriate referrals.
• Information about prevention of mother-to-child transmission (PMTCT) and family
planning (FP) services should be provided where appropriate.
Key populations (KP)
• KP are those groups who, due to specific higher-risk behaviours, are at increased
risk of HIV irrespective of the epidemic type or local context.
• They often have legal and social issues related to their behaviours that increase their
vulnerability to HIV
• HTS should be routinely offered to all key populations (every 3 months).
• Retesting at least annually is recommended for all clients of key populations.
• More frequent voluntary retesting may be beneficial, depending on risk behaviours
Men who have • Refers to all men who engage in sexual and/or romantic relations
sex with other with other men.
men (MSM), • It’s believed that the HIV prevalence for MSM is at 18.2 %
Sex workers • Sex workers include female, male and transgender adults (18 years
(SW) of age and above) who receive money or goods in exchange for
sexual services, either regularly or occasionally
• Female sex workers HIV prevalence rates stands at 29.3%.
Person Who • Refers to people who inject psychotropic (or psychoactive)

inject drugs substances for non-medical purposes.
(PWIDs). • It’s believed that the HIV prevalence for PWIDs is at 18.3 %
Vulnerable populations:
• These are persons who due to situation or circumstances beyond their control, they are at high risk
of getting infected or transmitting, accessing vital HIV services etc.
• Where applicable these persons should also be encouraged to be tested with their sex partners.
These include;
• Widows and widowers
• Orphans and vulnerable Children (OVCs)
• Families and children living on the streets
• Young women aged 15-24 years
• Service men and women, and their families
• Refugees, displaced persons and migrants
• People who abuse alcohol
Survivors of sexual and gender based violence
• Clients who report sexual violence should receive HTS at the first contact.
• They should immediately be referred for clinical evaluation, documentation
and treatment, trauma counselling and initiation of post exposure prophylaxis
(PEP).
• Survivors who test negative should be re-tested after 4 weeks and if still
negative or in a discordant relationship, retesting should be done at 12 weeks.
Unit 2: HTS Approaches, Setting and Strategies
• National HTS approaches
• HTS Settings
• HTS strategies
HTS Approaches
HTS Approaches
Approach Descriptions
Client • Client initiates or seeks HTS on their own volition,

Initiated HTS either at the community or at a health facility.
• CIHTS emphasis on individualized risk reduction
counselling to help the client identify a plan for the
prevention of HIV transmission or acquisition.
• This category may also be referred to as ‘Opt In’.
HTS Approaches
HTS Approaches
Approach Descriptions
Provider • HIV or other Health service provider offers an HIV test to a client or
Initiated HTS patient regardless of their reason for attending the facility.
• PITS seeks to;
o Increase HTS coverage,
o To provide diagnosis earlier for those attending health facilities and
normalize HIV testing.
• PITC service offered with an “OPT-OUT” option based on informed
choice.
• Provider-initiated HTS is considered the standard of care in health
facilities in Kenya, failure to offer HTS in the following situations is
unacceptable and will be considered negligent:
HTS Approaches
PITS standard of care

• Children and mothers attending antenatal, childbirth and postnatal health services
• Adult and pediatric inpatient facilities
• Persons attending tuberculosis (TB) clinics
• Persons attending sexually transmitted infection (STI) clinics
• Persons who may have been exposed to HIV either through rape or in their workplace
(i.e. health care workers)
• Persons receiving health promotion services (i.e. FP services)
• Persons attending other outpatient departments as necessary, according to
the determination of the health care provider or patient, including persons attending
specialist clinics
HTS Approaches
CITS versus PITS

Client Initiated HTS Provider Initiated HTS
Clients Clients
a.Clients own initiative hence maybe a.Clients not taken own initiative hence may not be
receptive to providers key messages as receptive to providers Key messages
b.Clients highly motivated hence issues i.e. b.Motivation levels maybe low hence disclosure,
disclosure, adherence, referral and linkages adherence, referral and linkages etc maybe
maybe easier challenging
c.Disclosure navigation may be easy c.Disclosure navigation may be difficult
d.However, above is dependent on reasons for d.However, the above is dependent on the initial
seeking HTS, driving force for seeking HTS,
e.If one is coerced/forced against their will to e.If one is coerced/forced against their will to seek
seek HTS services, they may have the HTS services, the negative effects maybe
opposite effects increased.
HTS Approaches
CITS versus PITS

Client Initiated HTS Provider Initiated HTS
Providers Providers
a.The role of mobilization is passive a.The provider plays an active in mobilizing
than active for HTS and hence the agenda maybe more
b.The efforts expended towards HTS provider oriented than client oriented
provision to the clients may not be b.The efforts expended towards HTS
as much as in PITS provision to the clients is high
c.The programmatic results/outcomes may not
be as high as in CITS
HTS Approaches
HTS Settings
• The HTS are delivered in the two broad settings i.e. community and facility based
HTS.
Facility Based HTS Community Based HTS

These are all HTS provided These are those HTS services
within a designated health that are provided outside a
facility either private or designated health facility. This
public i.e. a health clinic, strategy is meant to strengthen
dispensary, health center or integration of community and
hospital. the health systems.
HTS Approaches
HTS Approaches, Settings & Strategy

Unit 3: Counselling concepts, skills and
techniques
Counselling
• Counselling is a ‘professional’ relationship (safe, client-centered, dynamic) between a
trained counsellor and a client.
• Two forms; one on one and group therapy.
• Helps clients to reach self-determined goals through meaningful well informed
choices.
• Helps client explore, discover, & clarify ways of living more satisfyingly and
resourcefully.
• A range of skills and techniques used to facilitate positive change from:
• Dissatisfaction to satisfaction
• Pain to comfort
• Low esteem to high esteem
• Low social skill to high social skills
Qualities of a good counsellor
• Good communicator • Competent – (multicultural).
• Non judgmental • Tactful
• Acceptance • Committed & persistent
• Empathy/compassion • Knowledgeable
• Good Problem-Solver • Flexibility
• Rapport-Builder • In control
• Recognizes the boundaries of their • Be concrete/firm
competence • Etc.
• Possess high level of Self-Awareness
Counselling Skills
What is a skill?
• An acquired ability practiced, mastered and perfected for a specific purpose.
• Counselling skills are divided in to two categories;
• Supportive skills – these skills communicate warmth, unconditional positive
regard and concern for clients.
• Challenging skills - offer clients a view or perspective which is different from
theirs and which stimulates them to reconsider their current position or view.
Supportive Skills
• Attending: Providers ability to demonstrate presence during a session.
• Involves; being kind and polite, demonstrating availability, tuning yourself into the client
world, minimizing distraction etc.
• Uses S.O.L.E.R.
• Sit squarely- to communicate presence and availability
• Open posture- signify that you are open to the client and to what the client is saying.
• Lean forward (slightly) - towards the client is a natural sign of involvement
• Eye contact- maintaining it without staring
• Relax- Be relaxed and remain natural when doing all the above..
• The Purpose of SOLER is to demonstrate interest and attention by using body language.
Skills
• Listening skill: Ability to actually hear client to; detect common themes in the client
issues/story, reveal omissions and facilitate knowing of clients experience/behaviour/
feelings.
• Questioning skills: Two types of question; Open ended and close ended questions.
a. Open end questions: Gives opportunity to the client to express him/herself freely
and can help the counsellor to identify the client’s needs and priorities.
b. Close end questions: Questions where answers are measured i.e. with a one word or
short answer (“yes, “no”, “20 years”, “3 kids” etc). They are good for gathering basic
information at the start of a counselling session.
• Paraphrasing: Re-states or repeats the client’s words in own words in order to convey own
understanding of client’s issues, demonstrate attentiveness/presence in the session both
physical and psychologically and is listening actively.
Skills
• Empathy: Tuning into client world/“to get into client’s shoe”. Conveys in depth caring of the
client’s thoughts/feelings and to communicate/ reflect that back to the client.
• Summarizing: Helps in threading together all the themes covered during a session in order to;
ensure understanding of each other correctly or identify the key points and highlight decisions
that need to be acted upon at the end of each session.
• Focusing: Done with a view of enabling a client understand their issues at greater depth. It
helps the client to be clear and bring out priority issues. It gives direction to the session. It helps
move from;
• Talking about others to talking about self,
• Being general to being specific,
• Talking about the past to talking about the present & future and
• Talking about facts to talking about feelings, thoughts & wishes
Skills
• Minimal prompts/ encouragers: Encouraging client to continue talking about issues and
also demonstrates attentiveness and concern of the provider. They are both;
• Non-verbal prompts;- nodding, raising eyebrows etc and
• Verbal prompts include;- mmh, yes, yah, go on, etc
• Working silence: No verbal communication is taking place while provider is there for the
client: Helps the client to have dialogue with him/herself, Allows the client to communicate a
strong feeling or emotion to self.
• Affirmation: this encourages the provider to praise, appreciate the client for the efforts they
have put in place already in their lives.
• Structuring/contracting: This entails establishing with the client what the session will
cover and the boundaries of the service. Ensure both parties have a clear understanding
about the session and what roles and responsibilities each plays.
Challenging Skills
• Confrontation: Helps the client reflect on contradiction and incongruence’s that they express during
the session. It also helps the client to identify his/her blind spots. However, if the client responds with
persistent denial, the provider must let go.
• Self disclosure: Provider appropriately discloses/shares personal experiences, emotions, attitudes
with client to facilitate client growth and exploration.
• Only share what you have successfully dealt with the issue they want to disclose and
• What is going to help the client make a therapeutic movement i.e. move from one level to the
next.
• Immediacy: This includes protecting oneself from exploitation by the client by ensuring that
constant reflection on the current state of the relationship is undertaken especially by the provider.
This helps in ensuring that professionalism is maintained during the entire time.
• Concreteness/firmness: This means that the provider is specific, definite, and vivid rather than
vague and general. Provider uses specific facts and figures, is resolute in making some unpopular
decisions especially with a client and demonstrates that they are well grounded in their profession.
Unit 5: Professional Issues and Ethics
in Counselling
Paul’s Case Scenario
Paul is a trained HTS provider with a degree in counselling psychology but has no background in medical services. He
works at an integrated HTS site in one of the busy Health Centre in Nairobi. Paul is a very hard working provider who
usually sees many clients in a day (on average, he sees more clients than other providers since he spends less time with
clients than other providers). In some cases, he has been overheard instructing some of his HTS clients to adopt his views
even though they may not be practical to clients own unique needs. Paul is known to skip supervision and continuous
capacity building sessions with very flimsy excuses and hence the supervisor at the HTS site is concerned about the quality
if the services that Paul provides to clients. An analysis was done last quarter that sowed that his linkage of HIV positive
client was on average, about 25% lower than the rest of HTS providers. Paul is known to carry the HTS registers home to
get some assistance from his family members in preparing the monthly reports.
Recently, a female HTS client reported to one of Paul’s colleagues that he made some sexual advances to her after she tested
HIV positive claiming that there wont be any issues since even he is not ‘clean’. The colleague wasn’t surprised because it
has always been known that he does this. In fact, it is common knowledge that Paul receives gifts from his clients who are
very happy with the services that he provides them. It further emerged recently that Paul once undertook a physical
examination of a female client who suspected that she may have had a sexually transmitted infection before he referred her
to a clinician for further management.
Paul usually prefers to attend to young clients especially female ones and sometimes keeps other clients waiting for long or
misses appointments that he has made with some of his clients.
Ethical Issues in Counselling for HTS
• Counsellors and especially HTS providers must uphold the basic values of integrity,
impartiality and respect.
• They must also apply the principles of confidentiality, autonomy, beneficence,
avoidance of harm, justice and fidelity to specific situations while endeavoring to
fortify their self-care.
• They have a responsibility to the clients, to themselves, their colleagues, the
profession, members of other caring professions, the wider community and the law.
• They appropriately address issues of confidentiality, advertising, public statements,
research and ethical decision-making.
Ethical Principles in Counselling
• Confidentiality and Privileged Communication: HTS providers must assure clients
privacy and preserve the confidentiality of information acquired in the course of
their work:
a. Consultation with other health providers or managers may breach
confidentiality except when serious physical harm to themselves and others is
involved.
b. Record keeping of client information.
c. Confidentiality is defined as an ethical responsibility and professional duty that
demands that information learned in private interaction with a client not be
revealed to others.
d. Professional ethical standards mandate this behaviour except when the
counsellor’s commitment to uphold client confidences must be set aside due to
special and compelling circumstances or legal mandate.
• Autonomy: Make every effort to foster self-determination and individual
responsibility on the part of clients. It’s a respect for the client right to be self-
governing. It prohibits the counsellor from manipulation of the client against their
will may be for socially beneficial ends.
• Beneficence: To act in the best interest of your client. A commitment to solely
benefit the client (to foster psychological and physical wellbeing of the client and to
maximizing the utility they achieve from the service).
• Non-maleficence (“Do No Harm”): A commitment to avoiding harm to the
client. This principle is to avoid sexual, social, financial and emotional or any form of
exploitation.
• Justice: Fair, impartial and adequate service, just and equal opportunity, disregarding
their personal and social characteristics, values and biases which might give rise to
discrimination/ oppression. Respect for human rights and dignity.
• Fidelity: involves the notions of loyalty, faithfulness, and honoring commitments.
Enhancing trust and have faith in the therapeutic relationship for growth is to occur.
Provider must take care not to threaten the therapeutic relationship nor to leave
obligations unfulfilled.
• Self-Respect/care: Fostering the practitioners self-knowledge and care for self.
Seeking counselling for appropriate personal, professional support and development.
To keep updated on training, active encouragement in life enhancing activities and
relationships.
Counselling: personal moral qualities
• Empathy: ‘Standing in the client’s shoes’. what is required.
• Sincerity: commitment to consistency between • Fairness: The consistent application of
what is professed and what is done. appropriate criteria to inform discussions and
• Integrity: Straight forwardness, honesty and actions.
coherence. • Wisdom: Possession of sound judgment.
• Resilience: Strength to work for the client • Courage: To act despite fears, risks and
without getting stressed. uncertainty.
• Respect: Showing appropriate esteem to others • Commitment: To keep up appointments and
and their understanding of themselves. respect the individual.
• Humility: The ability to assess accurately and • Concern: To be all concerned and give
acknowledge one’s own strengths and adequate time/attention to the client.
weaknesses.
• Competence: Using skills and knowledge to do
PSYCHOSOCIAL,CONTEXTUAL AND
EMERGING ISSUES IN HIV
Module 5
Specific objectives
1.Discuss HIV and the psychosocial issues that affect
different populations.
2.Demonstrate the ability to apply a brief Intervention
to clients using substance and alcohol
3.Discuss Gender based violence in context of HIV
4.Demonstrate ability to provide HIV disclosure support
services and loss and grief Counselling.
Unit 1: Families, Couples, Youth, Children in HIV
settings
Unit 2: Drugs and substance abuse within HIV/AIDS
context
Definition of terms
• Drug: A drug is a substance that influences the normal functioning of
the central nervous system and results in both physical and mental
effects.
• Drug Use: Drug use is a broad term to cover the taking of all
psychoactive substances within which there are stages: drug-free (i.e.
non-use), experimental use, recreational use and harmful use, which
is further sub-divided into misuse and dependence.
Definition of Terms cont….
• Drug or substance dependence: Drug or substance

dependence is described as a: ‘maladaptive pattern of
substance use leading to clinically significant
impairment or distress, as manifested by three (or
more) of the following within a 12 month period:
How does Drug dependence Occur
• Tolerance: a need for increased amounts of a substance

to achieve the desired effect or a diminished effect with
ongoing use of the same amount of substance
• Withdrawal
• The substance taken in larger amounts over longer
periods than was intended
How does Drug dependence Occur cont….
• Persistent desire or unsuccessful efforts to cut down

or control use
• A great deal of time spent in activities relating to
obtaining the substance, using the substance or
recovering from use
How does drug dependence occur cont…
• Significant social, occupational or recreational

activities are given up or reduced because of use
• Continued use despite knowledge of having a
persistent or recurrent physical or psychological
problem that is likely to have been caused by the
substance
How are Drugs/substances administered?
• Smoked or inhaled:
• Snorted/sniffed:
• Ingested
• Injected:
• Applied Topically (on skin, mouth, vagina, anus etc)
• Some people transit from one route of use to others (from
smoking to injecting heroin)
• Some use multiple drugs and multiple routes
Risk factors in substance abuse and alcohol
• Peer Pressure
• Curiosity and the drive to experiment or find out
• The need to cope with problems
• The belief that one feels good after drug use or
alcohol consumption
• Idleness – the desire to kill boredom and time
(employment)
Risk factors in substance abuse and alcohol
cont….
• The desire to belong
• The desire to gain strength and courage
• The desire to remain awake
• The belief that drug use can help one cope with
certain odd conditions e.g. when one is for example, a
mortuary attendant
• Encroachment of foreign values
• Advertisements
Categories of drugs
• Stimulants –Increase the activity of the central nervous system e.g.
Tobacco,Cocaine,Miraa
• Depressants –Decrease the activity of the central nervous system e.g

Heroine,Alcohol,valium
• Hallucinogens-. Cause pronounced alteration of perception, a state of fantasy
or illusion, a feeling of being lost in the world of dreams e.g cannabis and
hashish
• Opiate and Opioids-, Examples of opioids are: Painkillers such as; morphine,
methadone, Buprenorphine, hydrocodone, and oxycodone.
Categories of drugs
Stimulant-Tobacco Chemicals in Tobacco

Stimulants cont….
• Miraa Cocaine
Depressants
• Changaa Alcohol
Depressants cont…..
• Heroine
Hallucinogens
Bhang Leaf Hashish
Opiates and Opioids
• Oxycodone
Signs and Symptoms of Drug Use
Physical Behavioral Psychological
• Red eyes or dilated or pinpoint • Drop in attendance and lack of • Unexplained change in personality,
pupils interest in work or school attitude, and behavior
• Changes in appetite • Unexplained need for money that • Mood swings, irritability, angry
• Changes in sleep patterns leads to borrowing and stealing outbursts, or unexplained
• Sudden weight loss or gain • Engaging in secretive or suspicious excitement

behavior • Periods of unusual hyperactivity,
• Deterioration of physical
• Sudden changes in friends, favorite agitation, or giddiness
• appearance
hang outs, and hobbies • Lack of motivation and ambition
• Skin manifestations such as
• Frequently getting into trouble • Appears lethargic or spaced out
abscesses or ulcers
(fights, accidents, illegal activities) • Appears fearful, anxious or
• Needle marks or puncture
• Possession of drug gear or paranoid
wounds on skin from injecting
paraphernalia
Unit 3: Gender Based Violence in the context of HIV
• Definition of terms
• Gender based Violence (GBV) Gender based
violence – it is any act that causes physical, sexual, or
psychological harm to both men and women, including
threats of coercion or arbitrary deprivation of liberty,
whether occurring in private or public life
Definition of Terms
• Intimate Partner Violence (IPV) is a pattern of

abusive behaviour in any intimate relationship that is
directed towards a current or former spouse, boyfriend
or girlfriend in heterosexual or homosexual
relationships. The perpetrators can be either men or
women, however, most commonly women are victims
of male perpetrated IPV.
Definition of Terms
• Population-based studies in East Africa estimate that

rates of Intimate Partner Violence in the region are
among the highest in the world with Kenya having one
of the highest rates of IPV at 39 %.
Forms of GBV/IPV
• Physical
• Sexual
• Emotional
• Psychosocial
• Economical/Financial
Unit 4: Disclosure, Loss & Grief in HIV
Definition of Terms
• Disclosure of HIV status
• Disclosure in HTS is the process through which a
client shares information about their HIV test result
with significant others or a third party. The goal of
HIV disclosure is to share one’s challenges and get
support that enhances access to care.
Disclosure to a child about their HIV status
HIV test results for children upto14 years will be given

to the parents / guardians whose consent is needed for
testing them. Parents, guardians, and caretakers should
be guided on disclosing to children their HIV status
using age appropriate language.
Disclosure to a child about their HIV status
WHO recommends that the decision on who to disclose

to the child be guided by the intent to improve/promote
the child’s welfare and minimize the risk to his or her
wellbeing and to the quality of the relationship between
child and parent/caregiver.
Disclosure involving youth and adolescents
• Adolescents and youth should be counseled about the

potential health benefits of disclosing their HIV status
to Significant others, including their parents/guardians
and supported to determine, when, how and to whom
to disclose. Parents / guardians, who find it difficult to
disclose the HIV status of their children, should be
supported by the HTC providers to disclosure.
Disclosure to a third party
• In line with the HIV Prevention and Control Act
(2006), no person should disclose any information
concerning the result of an HIV test or any related
assessments to any other person except with the
consent of that person.
Disclosure to other health care workers
• A health care worker who provides an HIV test or

other related assessments for a client is permitted to
disclose information concerning the results of those
tests to other health care workers who are directly
involved in the management of the client.
Disclosure to a sex partner or other person at risk
HTS providers should make every effort to encourage and support

clients and patients to disclose their HIV status to their sex partner(s).
Disclosure of an infectious disease is necessary for public health and is
enshrined in the laws and policies of the country, such as the Public
Health Act (1986) and the HIV and AIDS Prevention and Control Act
(2006)..
• In this regard refusal to notify a sex partner(s) that

one is HIV positive is an infringement of the right to
health and wellbeing of the sex partner(s) at the risk of
infection
cont….
• In line with the Kenya HIV Prevention and Control

Act 14 of 2006, if efforts to encourage the client or
patient to disclose their HIV status fail, and if the client
or patient is placing a sex partner(s) or other persons at
risk, a medical practitioner may disclose that person’s
HIV status to their sex partner(s) or other person at risk.
• However, persons must be given a reasonable

opportunity to disclose their HIV status to the sex
partner(s) on their own, before a medical practitioner
intervenes. In order to respond to high risks of HIV
acquisition and transmission among steady sex partners,
contact tracing and partner notification is
recommended.
Disclosure on death certificates
• The law requires proper completion of death

certificates with accurate reporting of reason for death.
AIDS related deaths should be truthfully and accurately
reported in these statutory documents
Loss and Grief
• Definition of Terms
• Loss is the experience of separation from something of
personal importance. Loss is anything that is perceived
as such by the individual
Definition of Terms
• Mourning is “the psychological process (or stages)

through which the individual passes on the way to
successful adaptation to the loss of a valued object.
Definition of Terms Cont…
• Grief is defined as “the subjective states that

accompany mourning, or the emotional work involved
in the mourning process. Grief work and the process of
mourning can collectively be referred to as the grief
response.
Stages of Mourning
• Denial
• Anger
• Bargaining
• Depression
• Acceptance
Signs of Grief
Emotional Symptoms of Grieving Physical Symptoms of Grieving
A person who is dealing with grief will most likely It may come as a surprise that grief is
display some of the emotional symptoms associated not entirely emotional. There are very
with grieving. While these emotional symptoms are
real effects that grief can have on the
normal in the days and weeks after a traumatic event,
they can be indicators of a more serious disorder if body. Some of the physical symptoms
they do not fade over time. These can include: of grieving are:
• Increased irritability • Digestive problems
• Numbness • Fatigue
• Bitterness
• Detachment
• Headaches
• Preoccupation with loss • Chest pain
• Inability to show or experience joy • Sore muscles
Counseling principles and procedures
• Help the survivor identify and express feelings
• Assist living without the deceased
• Facilitate emotional relocation of the deceased
• Provide time to grieve
Counseling principles and procedures
• Interpret ‘normal behavior’
• Allow for individual differences
• Provide continuing support
• Examine defenses and coping styles
• Identify pathology and refer
Techniques for handling a grieving person
• Evocative language “Your son died’ instead of ‘you lost your
son’
• Use of symbols Photos, clothing, letters
• Writing - Keeping a journal of ones grief experience or poetry
• Drawing
• Role playing e. g. of situations that they fear or feel awkward
about.
• Cognitive restructuring Help the counselee lessen feelings
triggered by certain irrational thoughts such as no one will
ever love me.
Techniques for handling a grieving person
• Memory book
• Direct imagery - Client could close eyes and imagine
the deceased is sitting in front of them and then talk
‘to’ him rather than talk about him. Sometimes
medication can be used for example antidepressants
but only for short duration. Grief counseling can also
be done in groups. Funerals rituals are very effective in
facilitating grief because they help in bringing home
the reality and finality of death.
Key Message
• HIV infection affects all dimensions of a person’s life:

physical, psychological, social and spiritual
• Counselling and social support can help people and their
carers cope more effectively with each stage of the infection
and enhance quality of life
• PLWHA are more likely to be able to respond adequately to
the stress of being infected and are less likely to develop
serious mental health problems with adequate support
HTS SERVICE PACKAGE AND
PROTOCOLS
MODULE 6
Goal
• The goal of this module is to impact participants with knowledge, skills and attitude
to implement the HTS service package and Protocols effectively.
Module description
This module outlines the HTS service package
Unit one:
▪ Describes HTS core principles (5Cs); Consent, Confidentiality, Counselling, Correct results and
Connection-linkage to care and other appropriate post-test services.
▪ These core principles guide should be adhered to when providing HTS.
Unit two:
Outlines the minimum HIV Testing Services package; Pre-test counselling, HIV testing, Post-test
counselling, assessment of other health related conditions and effective referral and linkage to
care.
The package is aimed at enabling the clients to understand their HIV risk, take the HIV test, come up
with a risk reduction plan, take up appropriate referrals and be linked to care.
Module description …Cont
• Unit three :
• Guides the participants through all the HTS protocols.
• This protocol is mainly guided by the Egan’s counselling theory (Ref Counselling
theories).
• The protocols are structured to incorporate HTS core principles and the HTS
Package as outlined in unit 1 and 2 of this module
Specific Objectives
• 1. Describe the core principles in HTS
• 2. Outline the 5 elements in HIV Testing Package
• 3. Demonstrate ability to facilitate a HTS counselling protocol session through

the utilization of appropriate communication skills and techniques
• 4. Demonstrate ability on how to apply appropriate counselling theories concepts

in the delivery of quality HTS.
INTRODUCTION
• HTS in Kenya should be conducted in accordance with best interest of the client.
• HIV testing should never be coercive or mandatory, except in a situation such as

court orders.
• HTS services are guided by the 5 core principals(5Cs)

Unit 1: HTS Core Principles (5Cs);
1.Consent
• Consent in the context of HTS is a process of giving adequate information to clients

to facilitate proper decision making prior to obtaining permission for conducting
HTS.
• Should be written or verbal, voluntary and not coerced.
• HTS Provider should provide adequate information to clients for proper decision
making in regard to HIV testing.
Unit 1: HTS Core Principles (5Cs)…cont
.Consent
• The HIV and AIDS Prevention and Control Act (2006), states that “no person shall
be tested without their consent” The Act stipulates that “Under no circumstances
should a person be required to have HIV test for the purpose of employment,
marriage, education, travel, or provision of health care insurance cover or any other
service”.
• The only circumstances where the client/patient may not be required to give consent
for an HIV test are:
• When a person is required to be tested for HIV under the provisions of a

written law
• When a person is unconscious and unable to give consent, and the test is
medically necessary for a clinical diagnosis for the benefit of the client
Consent
• It is recommended that adolescents and youth of 15 years and above can give their
own consent for testing without the parent/guardian consent.
• Children and youth under the age of 15 years should be tested with the consent of a
parent or guardian, those from 7 years and above need to give assent after the
parents give consent.
• An emancipated minor may not require parental permission for medical or surgical
care irrespective of age and can give their own consent.
• A person with an impairment that prevents them from giving consent may be tested
with the consent of their caregiver.
2.Confidentiality
• Confidentiality in the context of HTS, refers to the privacy of the interaction

between the client and the HTC provider.
• Confidentiality must be maintained when conducting all types of HIV testing.

Confidentiality shall be upheld except where consent has been expressly given or
disclosure is allowed by law in the interest of public health.
• HTS provider may disclose patient/client HIV results to another provider for
purposes of further care/management (shared confidentiality)
2.Confidentiality
• Policy guidelines, training and institutional infrastructure needed to uphold patient

confidentiality and to protect patient privacy must be in place and adhered to.
• Confidentiality shall be maintained even after the patient’s death.
• HTS records and information, should be kept confidential in all circumstances and
stored in lockable cabinets accessible only by authorized personnel.
3.Counselling
• HTS counselling is a confidential interaction between the HTS provider and the
client aimed at allowing for informed decisions and benefit from the HIV service
package by the clients.
• The length and scope of the counselling session will depend on the specific settings,
approches and needs of the client (maximum one hour).
• Everyone who wishes to have an HIV test is entitled to adequate information before
and after the test. For couples, children, adolescent and groups the specific
counselling protocol/s should be followed.
4.Correct results
• HTS providers should strive to provide quality testing services. Quality assurance
mechanisms (both Internal and External) should be in place to ensure the provision
of correct test results to clients (Refer to Module 7).
• Providers should adhere to the national HIV testing algorithm as part of the effort to
achieve acceptable standards in test results given to clients. If the testing algorithm
recommended tests kits are not in place HTS should not be offered.
5.Connection
• Connection, in the context of HTS, is the process of ensuring appropriate referral

and linkage to prevention care and support services.
• HTS should be accompanied by appropriate, comprehensive and effective referral

and linkage to post-test services.
• Clients who need post-test services, including HIV care and treatment will be issued
with a standard referral form which should be filled in triplicate. The client should
receive the original referral form. The duplicate copy should be left at the point of
receiving referral services and the triplicate copy left at the HTS center/health
facility/point of testing for reference.
5.Connection
• HTS providers should;
• ensure follow up of the clients to determine if they accessed the services

referred for. (Linkage to Care).
• document client linkage in appropriate tools (HTS referral and linkage

register). HTS service providers should ensure that HIV positive clients are
linked to care and support services.
Unit 2: HTS Service package
There are five primary components of HTS service package which include;
• 1. Pre-test session
• 2. HIV test
• 3 Post-test session
• 4. Assessment of other health related conditions such as Tuberculosis
• 5. Referral and linkage to other appropriate health services
These five components make up the minimum service package of HTS

Client initiated HTS (CITS)
1.Pre-test counselling
•Introduction and Orientation to the Session
•Assess Risk
•Explore Options for Reducing Risk
•HIV Test Preparation
2.HIV Test
Perform Rapid Test – As per module 7

Unit 2: HTS Service package…Client initiated HTS
(CITS)….cont
3.Post- test counselling
• If negative results:
• Provide HIV negative result
• Negotiate risk reduction plan
• Identify support for risk reduction
• Disclosure and partner referral
• Assess for other health related conditions and refer appropriately

cont
Post- test counselling
• If positive Result
• Provide HIV Positive Result.
• Discuss positive living.
• Identify Sources of Support
• Negotiate disclosure and partner referral
• Address Risk Reduction Issues.
• Asses for other conditions.
• Refer and link for care and treatment.

Provider intiated HTS (PITS
• 1.Pre-test counselling
Introduction and orientation to the session
• Welcome and self introduction
• Role of counselor and health center services
• Explain shared confidentiality
• Explain reasons for referral

Provider intiated HTS (PITS)
cont
2.HIV Test
• Perform test if client/patient consents,
• Terminate session if client declines and promise to revisit next time
• Perform Rapid Test – As per module 7

Unit 2: HTS Service package…
Provider intiated HTS (PITS)…. cont
3.Post test counseling
• If negative,
• Confirm the Negative results
• Discuss the need for partner testing
• Refer client appropriately
• Assess other conditions
• Ongoing counseling.
• Terminate session
Unit 2: HTS Service package…Provider intiated
HTS (PITS)…. cont
3.Post test counseling cont
Provider initiated HTS (PITS) in health facility settings
• If positive
• Confirm the Positive results
• Discuss implication of being HIV Positive
• Review the services available for someone testing HIV Positive
• Refer for Care and treatment
• Ensure linkage.
• Initiate partner notification and family testing.

Unit 2:
Group Counseling in HTS
• Introduction and Contracting for group Session
• Group information on HIV
• Separation (Remind group that next session will be individual and agree on sequence,
e.g following the client numbers )
• Individual testing and counselling
• Personal Risk Assessment and Reduction and Test preparation Undertaken

Individually
• Post Test Intervention. Undertaken Individually

Unit 2:
Child Counseling in HTS
Categories of children in HTS
• Infant: below 18 months
• Younger child: 7 years to 14 years
• Adolescences : 15 years to 19 years
However, there are children with different experiences e.g.:
• Emancipated minors
• Sexually abused
• Mentally and physically handicapped

Unit 2:
Child Counseling in HTS …cont
Consenting Procedures for Children and Adolescents
• For infants: The guardian/parent consents and sign the consent form for the
child.(Verbal/Written)
• For younger children: The parent/guardian consents and children give assents.
However, the child may be allowed to participate in the counseling session.
• In some situations, the child can be allowed to access counseling alone, however
involve the parent/guardian during the test for easy discloser and support.
• The adolescence : give consent on they own. The parent/guardian can be involved
in the counseling and testing session if she/he assents.
Child/ Adolescent Counseling in HTS
• Introduction and orientation to test decision session for parent/guardian
• Pre-test and risk assessment session.
• Negative result counseling/
• Positive result counseling of child and consenting parent/guardian.
• Negative result counseling of consenting parent/guardian alone.
• Positive result counseling of consenting parent/ guardian alone.

Individual Counseling for adolescent (15 to
under 19 years)
• Note:. These category of the children will be offered an individual counselling
session as per CITS protocol.
• Nevertheless, with their assistance, counselors should encourage them to disclose

their results to the guardians.
• For adolescents who are not sexually active and opt to have their consenting
parents/guardians participate in the counselling session, the counsellor should use
the child protocol to guide the session.
Unit 2:…cont
• The client’s uptake of post-test referral and adoption of safe sex behavior is
dependent on the quality of the post-test session.
• The post-test counselling session should be tailored to the test results

Guide for referral and linkage.
Below is a guide for referral and linkage.
Unit 3: HTS Protocols: Demonstrate
implementation of HTS protocol
• Refer trainees to appendix on cue card in participant's manual
Unit 1
HIV AND IMMUNE RESPONSE TO HIV
INFECTION
Broad Objective
By the end of this unit, participants will be able to describe the HIV
structure and immune responses in relation to HIV testing

Enabling Objectives
Describe structure and types of HIV
Understand HIV replication cycle
Explain target sites for ARVs
Describe how immune system works
Describe progression of HIV disease
Introduction to HIV structure
Introduction
Infectious diseases,[e.g. AIDS] are caused by organisms. These organisms

include Viruses[e.g. HIV]
In this session the causal agent of AIDS is discussed
Classification, structure, replication and modes of transmission of HIV will be the

main focus.
This session is useful for understanding viral transmission, control and

management.
The virus HIV belongs to a family of slow growing viruses of the genus-
Lentiviruses ;Family-Retroviridae
These viruses store their genetic information as RNA, unlike most

viruses which store their genetic information as (DNA)
Note: Viruses, unlike other organisms are categorized into RNA OR DNA
but not both
• The virus HIV belongs to a family of slow growing viruses of the genus-
Lentiviruses ;Family-Retroviridae
• These viruses store their genetic information as RNA, unlike most viruses
which store their genetic information as (DNA)
• Note: Viruses, unlike other organisms are categorized into RNA OR DNA but not
both
• A retrovirus is an RNA virus that utilizes the enzyme RT to make cDNA from its
RNA genome
• They cause long-duration illnesses and long incubation period
• Identify some of the structural components of HIV[see next slide and note their
significance in transmission and IPC ]
HIV Structure
Core
RT
Envelope
HIV TYPES
There are two types of HIV namely HIV-1 and 2
Both HIV 1&2 cause AIDS
HIV-1 IS responsible for most of HIV infections globally
HIV-2 is less transmittable and infection slowly progress to AIDS

HIV Groups and Subtypes
HIV has groups and subtypes
Subtypes Sub-
HIV classification (Clades) subtypes
A
A1 to A5
B
Type 2
Group M
C
HIV
Type 1 Group O D
F F1
Group N
G F2
Group P H
J
HIV-1 subtypes recombine to generate intersubtype recombinants
154
K
HIV Groups and Subtypes
The four sub-groups of HIV are based on slight sequence difference in their
genome
Group M (majority); O (outliers); N (non-M/non O) and P[next letter in the

alphabetical order]
Group M is the most prevalent and is responsible for the majority of the
global HIV epidemic
HIV LIFE CYCLE
HIV Replication
HIV LIFE CYCLE
There are seven stages in the HIV life cycle:
1.Binding: This process is initiated when gp120 attaches to receptors on
the surface of a CD4+ T lymphocyte
2.Fusion: This involves interaction of host cell and viral membranes
3.Reverse transcription: The viral reverse transcriptase changes the viral

genome into a complementary DNA (cDNA)
HIV LIFE CYCLE
4. Integration: Viral integrase enzyme insert the viral genome into the host’s
DNA
The resulting integrated virus DNA (also called a provirus]
5. Replication: this step involves the uses host enzymes .eg RNA
polymerase to create viral proteins
HIV LIFE CYCLE
6. Assembly: The HIV proteins together with copies of HIV's RNA genetic
material are assembled into new viruses
The newly assembled virus "buds“ out from the host
7 Maturation: The new virus budding out mature into viruses that can now
infect nearby CD4 cells
Summary of HIV Replication
Take home messages
The virus Its enzyme, New viruses

It uses cells
enters cells reverse are
machinery to
by gp120 transcriptase, assembled
replicate the
attaching to turns viral and bud out
newly made
CD4 RNA into of the CD4
DNA
receptors DNA cell.
HIV LIFE CYCLE AND ARVs [see target sites of ARV]
ARV treatment involves inhibitions at the viral replication process:

Inhibition at the entry at the entry stage drugs are referred to as fusion
inhibitors[FIs]
Inhibition at the reverse transcription stage- Reverse transcriptase inhibitors
[NRTIs and NNRTIs]
Inhibitors at the protein cleavage stage- Protease inhibitors (PIs).
Inhibitors at integration stage-Integration Inhibitors[IIs]
Target sites of ARVs
NNRTIs
and NRTIs
act here
PIs
act here
Fusion
Inhibitors
IMMUNE SYSTEM AND AIDS
Objectives
Discus the organization of the immune system
Define terms commonly used in immune responses
Describe how immune system works
Describe progression of HIV disease

Definition of terms
The immune system: a system of special cells (lymphocytes, monocytes),

proteins (antibodies), tissues and organs that defend the body against foreign
substances (antigens= germs, microorganisms, HIV)
Definition of terms
Antigen
❖A foreign substance which when introduced into the body will
stimulate the immune system to respond by producing antibodies
Antibody
❖A protein substance produced by lymphocytes, and deposited in
blood, and they bind to specific antigens
Introduction to Immune system
This is the body’s protective mechanisms and response to infections
Organisation:Immune system responses is organized into Innate, cellular

and humoral
Further:
• The immune system is organized into organs, tissues and cells
• The organs involved in the immune system are categorized into;
1. Primary and 2. secondary organs
Introduction to Immune system
Primary and secondary organs of the immune system
1. Primary Lymphoid Organs:
▪ Thymus and
▪ bone marrow
2. Secondary Lymphoid Organs:
▪ Lymph nodes and
▪ spleen
The Lymphoid System
Primary Lymphoid Organs Secondary Lymphoid Organs
Waldeyer’s lymph nodes,

ring tonsils, and
adenoids
thymus
lymph nodes
bone marrow
spleen
mesenteric
lymph nodes
lymph nodes Peyer’s patch

1. Primary Lymphoid Organs:
Primary (central) lymphoid tissues
Serve to generate mature lymphocytes from immature cells
provide a place of ‘training’ for lymphocytes

2.Secondary Lymphoid Organs:
• Secondary (peripheral) lymphoid tissues
Lymphocytes interaction with antigen
Expansion/production of more cells
Its also provide a home for lymphocytes, where they can be available when
they are needed
1. Cellular Responses to HIV infection
Once HIV enters the body, anti-HIV antibodies and cytotoxic T cell
production is initiated
Macrophages and dendritic cells bind virus and present it to the CD4
cells
T-cells are the prime target for HIV attack due to CD4 receptor.
Other cells with CD4 receptor are macrophages, glial cells, langerhans
cells, chromaffin cells.
[see the slide on Cells involved in the Immune responses

Cells Involved in the Immune Response
platelets Haemopoietic T-dth
eosinophil T-cytotoxic
stem cell
Attack worms Destroy
(and allergies) megakaryocyte antigen
T-helper
communication
neutrophil
Attack
bacteria common T-supressor
common
myeloid lymphoid
progenitor progenitor
basophil
B cell
Make
sentries antibodies
mast cell plasma cell
monocyte third population cells

macrophage
Cellular Responses to HIV infection
The other very important cell in HIV infection is CD8+ T cells
CD8+ cytotoxic cell lyse HIV infected cells and secrete cytokines, and
chemokines that inhibit virus replication and block viral entry into CD4+ T
cells.
Development of CD8+ T cells is crucial for control of HIV replication.

Why are CD4+ T cells depleted by HIV?
CD4 T Lymphocyte is the main target of HIV
HIV infection leads to low levels of CD4+ T cells through three main
mechanisms:
Direct viral killing of infected cells
Increased rates of apoptosis (self programmed death) in infected cells
Killing of infected CD4+ T cells by CD8 cytotoxic lymphocytes that recognize
infected cells.
2.Humoral response to HIV
The humoral immune response involves production of specific antibodies in
response in HIV infection
Non-neutralising antibodies to HIV structural proteins (i.e. P17 and P24) and
neutralizing antibodies specific to proteins are produced target:
The variable region of gp120
CD4 binding sites and chemokine receptors
The transmembrane protein gp41
3.Cellular and Humoral response
In HIV infection both cellular and humoral immune responses combined
play important role
Initially cellular responses are initiated followed by Antibody responses
four to eight weeks after infection
B Cells play the major role in production of antibodies
Mutations within the HIV glycoproteins render antibodies ineffective
See the Central Role of CD4+ Lymphocyte figure& Immune response figure below
for more clarity [Figure 1&2]
Fig 1. Central Role of CD4+ Lymphocyte
Immune Stimulus
Looking at this figure, explain how

CD4+ helper/inducer lymphocyte
opportunistic infection occurs ????
(Prime target for HIV attack)
Production of cytokines leading to

Macrophage
........ .
activation CD8 cytotoxic
T-cell maturation
(Kill virally infected cells
and tumour cells)
(Kill intracellular bacteria B-cell
and tumour cells) proliferation
T-Cell memory clone
CD8 T-Cell
Plasma cell antibody production memory clone
(Clear infecting organisms)
(Memory clones are primed to
provide a rapid response
B-Cell memory clone against re-infection)
Fig 2.Immune Response to HIV
Take home messages
How HIV 1. CD4 cells that

Affects the are infected die and
Immune fewer are available
System to fight diseases.
2. Macrophages and T 3. The number of healthy

helper cells have the CD4 cells remaining can
CD4 receptor and can be estimated in the
therefore be infected by laboratory using a CD4
HIV count machine.
Virological makers of HIV infection
1. Viral Load
Viral load (no. of viral particles is an indicator of disease progression.
During the window period the viral load can be very high.
CD4 declines correlates with viral load increase.

See figure on correlation of Viral load and disease progression
Correlation of Viral Load and
HIV Disease Progression
Window period
Window period is the phase between infection and seroconversion

Soon after infection with HIV, antibody levels are not detectable.
One may test false-negative for HIV antibodies, and can still pass the virus to
others during this period.
Seroconversion occurs generally 2-8 weeks after the initial infection
Serological makers of HIV infection
Testing of HIV infections is commonly based on serological markers –
antigens and/or antibodies.
Correct use of appropriate tests gives reliable results
Some of the markers used for HIV testing include:
P24 antigen
Antibodies with detectable quantities 2-8 weeks after infection,
AIDS staging/phase of the disease.
IgM class of antibodies which are the first to be released by the body.
Virological and serological markers during the first weeks following infection
of HIV
IgG class of antibodies (against gp41), are able to be detected in all stages of
the disease.
Note fluctuations in the markers over time period

UNIT 2
INFECTION, PREVENTION AND CONTROL
Objective
By the end of this module the participants should be able to;
•This Unit will provide you with the basics of safety
•Infection control and prevention
• Practices necessary during provision of HIV and AIDS services
• Understand how to prevent infection in health facilities
• Understand on fundamentals of safety practices in HTS
• Good clinical and laboratory practice (GCLP)

Introduction
• Percutaneous exposure incidents (PEIs)
needle stick, sharp injuries, splashes are a potential mode of exposure to and
transmission of blood-borne infectious diseases among healthcare workers
• Blood borne pathogens have been associated with sharps injuries - hepatitis B virus
(HBV), hepatitis C virus (HCV), and HIV . This problem therefore, requires
infection control prevention and practices
Fundamentals of safety practice in regards HTS
• Staff education and continuous education- Formal training and specialized HTC
training and continuous support supervision
• Provision of safe building and equipment-Laboratory room – adequate
Laboratory floor – non polished/carpeted, Proper lighting and ventilation, Benches –

standard height and depth, Sink – free flowing water, Drawers and cupboards
Good Laboratory Practice (GLP)

Good analytical practice
• HIV testing services require a specific organizational structure and procedures to
perform and document HTS work for quality of data, traceability and integrity of
data. Documentation can help find out;
• Who has done what
• How the experiment was carried out
• Which procedures have been used
• Whether there has been any problem and if so
• How it has been solved

Hazards and occupational exposure
Objectives
By the end of this lesson the participants should be able to;
• Defining what are hazards and occupational
• Describe on sources of hazards and their classifications

Hazards and Occupational Exposures
• Knowledge of the potential hazards and proper management of Infection control
practices is required for the HTS service providers
• Biological
• Chemical
• Electrical
• Physical/Mechanical
• Radiation
Laboratory Hazards and Sources
Classification of Hazard Type of Hazard Proper Disposal / Correction of
Hazard
Biological Blood/ body fluids, Used needles Sharps Container/ Sharps Container if needles;
Any Materials contaminated with blood or Incinerate and dispose of according to Safety
Body fluids Guidelines
Chemical Reagents, chemicals, strong bleach (Jik) Use Spill kit / sand to soak up spill, use absorbent
Alcohol material to clean up spill, disinfect area, and dispose
of waste in biohazard container
Physical/Mechanical Equipment or supplies on floor Make arrangement for removal of equipment or

Discarded equipment left on floor and not expired supplies; store equipment or supplies in
disposed of properly appropriate area or on shelves out of walkway
waste left on floor
Electrical Electrical cords placed across sinks, down Reorganize electrical equipment in room so cords do
hallways; cords frayed and not repaired; too not come in
many equipment plugs connected to one contact with water or cross floors;
outlet Either have frayed cords repaired or discard in regular
trash container
Sources of Biological Hazards
• Accidental pricks/cuts
• Contamination of open cuts
• Inhalation
• Ingestion
Infection, Prevention and Control procedures
Objectives
• Describe the chain of infection
• Brainstorm on various components of standard precautions
• demonstrate on proper use of various personal protective equipment (PPE)
• describe safe injections procedures and practices
• Describe significance of using PEP and scenarios where PEP is applicable
• Describe in detail how to segregate wastes and formulas used in preparing

disinfectants
Chain of infection
• Transmission of microorganisms and subsequent infection
• Transmission occurs when the agent in the reservoir exits the reservoir through a
portal of exit, travels via a mode of transmission and gains entry through a portal of
entry to a susceptible host
• Assess the risk of exposure to blood, body fluids and non-intact skin and identify the
Strategies that will decrease exposure risk
Assessing the risk of exposure and identify the strategies that will decrease exposure
risk and prevent transmission of microorganisms is based on;
• Client/patient/resident infection status (including colonization)
• Characteristics of the client/patient/resident
• Type of care activities to be performed
• Resources available for control
• HCW’s immune status
• Risks are assessed for

Risks are assessed for
• Contamination of skin or clothing by microorganisms in the client/patient/resident

environment
• Exposure to blood, body fluids, secretions, excretions, tissues
• Exposure to non-intact skin
• Exposure to mucous membranes
• Exposure to contaminated equipment or surfaces

Rationale for Standard Precautions
• Standard Precautions are the minimum infection prevention practices that apply to all
patient care
• Protect healthcare personnel (HCPs) and prevent HCPs from spreading infections
among patients include hand hygiene use of PPE
• Safe injection practices, safe handling of potentially contaminated equipment or

surfaces in the patient environment, respiratory hygiene/cough etiquette etc
Components in Standard Precautions
Hand Hygiene : general term that applies to either handwashing or antiseptic hand
rubs
Perform hand hygiene:
• BEFORE: coming into direct contact with patients for health-care related
procedures; putting on gloves (first make sure hands are dry)
• AFTER: an injection session; any direct contact with patients; removing gloves.
Personal Protective Equipment (PPE)
They include gloves, gowns, facemasks, respirators, goggles and face shields
• Equipment that protect HCPs from exposure to or contact with infectious agents
• Selection of PPE is based on the nature of the patient interaction and potential for
exposure to blood, body fluids or infectious agents
Gloves
• Must always be worn when handing blood, body fluids, secretions, or equipment and
environmental surfaces contaminated with the above
• Gloves are task-specific and single-use for the task
• Hand hygiene should be done before wearing and after removing gloves
Gloves cont….
• Order to Put On & Remove
• ON – gown, mask, gloves
• OFF – gloves, mask, gown

Apron / Gowns
• worn as a protective clothing
• procedure generates splashes or sprays of blood, body fluids, secretions, or

excretions
• are removed immediately after use, followed by hand hygiene to avoid transfer of
micro-organisms to other patients or environment
• Hen contaminated decontaminate with appropriate disnfectant

PPEs
Biohazard Signs
BIOHAZARD
BIOHAZARD WASTE
HANDLE WITH CARE
ISOLATION
BIOHAZARD
ADMITTANCE TO AUTHORIZED PERSONNEL ONLY!!
CAT. NO. SBH-9
HAZARD IDENTITY_______________________
______________________________________
______________________________________
______________________________________
CAT. NO. SBH-W2 CAT. NO. SBH-3
BIOHAZARD BIOHAZARD
HAZARD IDENTITY BIOHAZARD
HAZARD IDENTITY
BIOHAZARD
CAT. NO. SBH-4
CAT. NO. SBH-5
Safe injection practices
• A sharps injury prevention program must be in place in all settings and include
follow-up for exposure to blood-borne pathogens
• prevent injuries when handling needles, scalpels and other sharp instruments, devices
during procedures, cleaning process and disposal
• Treat all specimens as potentially infectious
• Dispose specimens in appropriate containers to prevent potential spillage and

transmission of pathogens
In event of blood or body fluid spills:
• Pour chlorine based disinfectant (e.g. sodium hypochlorite (jik) granules or solution)
over blood or body fluid spills. It should achieve 10,000ppm chlorine.
• Wear gloves and use paper towels to clean up blood and body fluids spills
• Dispose them into a biohazard bag and mop the area with institution recommended
disinfectant
Post-HIV Exposure Prophylaxis (PEP)
In case of an accidental prick :
• Do not panic
• Inform the supervisor immediately
• Wash site with plenty of soap and water. DO NOT squeeze to promote bleeding as
this will damage the site further, increases the surface area
• Perform basic first aid (arrest bleeding)
• Record in incident/accident log book

PEP cont…..
In case of splashes:
• Do not panic
• Flood the surface with water
• Record in incident/accident log book
• Access HTS
• Assess risk of exposure (use the details recorded)
• Initiate ARV prophylaxis immediately and take for 4 weeks
Note: an initial 3 day dose of ARVs may be given before accessing HTS
PEP cont….
• The risk of HIV transmission from a single needle stick is 0.3%
• This can be further reduced by 80% by taking antiretroviral (post-HIV exposure
prophylaxis)
• The recipient must be HIV negative to benefit from PEP

Waste segregation and disposal
• In the process of providing HTS, waste is generated since re-use of the materials is
not recommended. Some of these wastes are contaminated and pose potential
hazards to service providers
• proper waste management should be practiced in order to further ensure safety of
the practitioners
• Procedure required include; waste segregation, disinfection and disposal

Waste Management
Waste is segregated into the following categories:
• Non contaminated solids- burn or incinerate
• Sharps- Put in sharps container. Sharps container must not be more than ¾ full
• Contaminated solids- place in color coded biohazard bag, burn in a designated pit or
incinerate
• Contaminated liquids- add neat bleach to the waste in the ratio 1 in 10 and leave for
at least 30min, pour down the sink and flush with plenty of water
Sharps Containers
Disposal of Waste
Never Place Needles or Sharps in Office Waste
Containers
Disinfection
These are chemical solutions used to decontaminate or sterilize working surfaces,
equipment, etc.
Choice of disinfectants is based on:
• Mode of action (Cidal, Static)
• Rate of action (sensitivity to light, working concentration etc.)
• Side effects (Corrosiveness, Irritant vapors, Staining properties)
• Keeping qualities. (bleach should be prepared on a daily basis)

Making a 0.5% Hypochlorite Solution
Example: Jik at 3.5% Hypochlorite

To make 0.5% Hypochlotire solution, then
Stock concentration / required concentration – 1 = (3.5/0.5) – 1 = 6
Therefore 1 part Jik and 6 parts water
Water Label Container

Fill Line
0.5% Initials
= Hypochlorite
solution Exp. Date
+
1 Part 6 Parts Health Warnings
Water Bleach
Bleach
Fill Line
219
HIV testing services safety standards
• Strictly observe universal precautions
• Do not break, bend, re-sheath or reuse lancets, syringes or needles
• Never shake sharps containers to create space because this leads to formation of
aerosols
• Eating, drinking, smoking and applying cosmetics is prohibited
• Mouth pipetting is prohibited
• Staff must behave in a safe and responsible manner at all times

safety standards cont….
• Appropriate PPE must be worn at all times
• The HTS provision area must be kept clean, tidy and should contain items necessary
for the work carried out
• decontaminate all working surfaces at the end of each working day and after any
spillages
• wash hands when leaving the service provision area
• Avoid the formation of aerosols or the splashing of materials

Safety standards cont….
• Appropriately decontaminate all contaminated waste or reusable materials before
disposal or reuse
• Report and take appropriate action all incidents and/or accidents
• All staff must be adequately trained
• Gowns should be worn and removed immediately after the task in a manner that
prevents contamination of clothing/skin and prevents agitation of the gown
Ethical issues in HIV testing
Objective
By the end of this lesson,
The participants will observe laboratory code of ethics during HIV testing services
Goal
By the end of this unit, the participants will observe laboratory code of ethics during
HIV testing services
Content Overview
• What are ethics?
• Why are ethics important?
• Who is responsible for ethics?
• How are ethics applied to HIV rapid testing?
• Maintaining confidentiality
• Code of conduct
Introduction
• Voluntary testing, requires confidentiality and privacy of clients prior and informed
consent for those being tested with pre and post-test counseling
• Negligent testing that will resulting in misdiagnosis would invite legal actions for
damages against the person and institution
• In population surveillance there should be anonymous and unlinked testing of

populations or groups necessary for epidemiological purposes
What Are Ethics?
“Set of principles of right conduct”
“Doing the right thing”

Why are Ethics Important?
• Clients will not have confidence in your HTC site if they perceive their
confidentiality won’t be protected
✓Clients may not choose to get tested to determine their HIV Status,
which may jeopardize their health or their children’s or family’s health
• Other health care workers will not respect you or your HTC site if Ethics
are not followed
Who is Responsible for Ethics?
EVERYONE!
• Medical Laboratory Technologist
• Nurse Counselor
• Clinician/counselor
• Social Workers/other health workers
• Clerk
• Secretary
• Driver
How Do We Apply Ethics To HIV Rapid Testing?
• Using only kits approved for use in country
• Ensuring quality outputs – Following SOPs as written
• Keeping supplies and kits in safekeeping
• If you have questions, ASK
• DO NOT falsify results
• Ethics is also applied in your behavior. Always conduct yourself in a professional

manner
• Behavior of management – Management sets the example or expectations of how

staff should conduct themselves
• Maintaining client confidentiality at all times

Maintaining Confidentiality
It is important to:
• Keep all client/patient information private
• Secure all records / logbooks
• Restrict access to testing areas
People often violate ethics not

Warning because they mean to, but because
they are careless.
What is a Code of Ethics?
• A Code of Ethics is an expression of basic values - the principles and standards by
which a person should conduct him or herself in the workplace
• A number of laboratory professional organizations have code of ethics, with

common principles of conduct
Code of Ethics (IFBLS)
Excerpts from International Federation of Biomedical Laboratory Science (IFBLS)
• Maintain strict confidentiality of patient information and test

results
• Safeguard the dignity and privacy of patients
• Be accountable for the quality and integrity of laboratory

services
Code of Ethics (ASCP)
• Treat patients and colleagues with respect, care and thoughtfulness
• Perform duties in an accurate, precise, timely and responsible manner
• Safeguard patient information as confidential, within the limits of the law
• Use laboratory resources properly

Role-Play Ethical Decisions
In small groups read each of the following four scenarios and write down the groups’
responses to the following questions.
• What happened?
• What were the ethical issues involved?
• What were the implications?
• What would you do if you were in this situation?

Scenario I
A pregnant woman comes for HIV testing. Your test site has just run out of the 2nd
test in the algorithm. You tell her that she will have to come back in 2 days. She
becomes very emotional and explains that she has traveled a long distance after finally
deciding to get tested and won't be back in the area for a long time.
- What is the right thing to do?

Scenario II
At the HIV rapid testing site, you discover that you have just run out of the buffer for
Test 1 of the algorithm, however, you still have buffer from kits of Test 2.

Scenario III
Today is Monday. You discover that there are enough test devices to last through the
entire week, but they will expire on Wednesday.

Scenario IV
Rick, the tester, is excited about getting home at the end of his work day, because a
relative he hasn’t seen in quite some time is scheduled to arrive. Right before he is ready
to leave, he gets distracted by a phone call and forgets to lock up the lab register in the
cabinet.

Scenario V
• Nancy received a shipment of 500 Determine Tests and noticed 300 tests expired
four days ago. Nancy knows the HCT clinic scheduled a HCT Campaign in a week’s
time and is expecting 400-500 clients. What should Nancy do in this situation?
What Could Be the
Consequences of reporting…
• A false positive HIV result to a client?
• A false negative result to a client?

Key Messages
• Ethical issues are important. We must constantly remind ourselves of the code of
conduct and ensure we do the right thing
• People often violate ethics not because they mean to, but because they are careless
UNIT 3
SPECIMEN COLLECTION AND
MANAGEMENT
Objectives
• By the end of this Topic the participants should be able to;
• Describe how to collect a quality specimen from clients
• Describe various specimen collection sites and specimen types.
• Outline key safety precautions and specimen collection procedures
• Demonstrate finger prick specimen collection techniques
• Define DBS and list DBS collections requirements, drying processes
• Explain specimen rejection criteria

Specimen Collection
• It is extremely important that “the correct specimen is collected in order to give the right
results to the right client”
• The identification of client and labeling of test devices should therefore be done
properly
• Having a good test kit is not enough guarantees to obtaining reliable results
• Valid and reliable results depend on quality specimens
• Proper specimen collection techniques play a vital role in quality of results issued
Collection and preparation of blood specimen
Specimens and specimen types
Specimens can be collected from various sites
• Finger
• Toe
• Heel
Specimen types
• Whole blood, DBS, HIV Rapid Tests)
• Serum or plasma (HIV Rapid Tests)
• Oral fluids
• Urine
Preparation Requirements:
• Pen for labeling
• Rubber latex gloves/protective clothing
• Alcohol or spirit swabs
• Dry cotton wool
• Cotton gauze
• Sterile blood lancets
• Specimen collection devices – pipettes, filter papers etc.
• Disinfectants
• Tubes for CD4 (K3 EDTA Vacutainer)
• Tubes for CD4 (K3 EDTA vacutainer)
• Disposal receptacles for sharps, dry waste, etc

Client orientations
• Client should be identified with the Identification system in place
• Ensure that the client is Comfortable and settled
• Explain to the client the procedure you are about to undertake.
• Let client choose the finger to be pricked, remember human rights aspects of
your service provision
• Assess the finger for suitability of pricking check for;
➢ skin texture
➢ wounds, and cuts
➢swells, rashes
➢deformity and scars

Specimen collection procedure
• Label the test devices
• Sterilize site with an alcohol or spirit swab
• Allow alcohol to air dry
• Perform skin puncture (finger, heel, toe)
• Wipe out first drop of blood with dry cotton wool
• Collect sufficient amount of blood using appropriate device
• Stop the bleeding using dry cotton wool
• Dispose of all contaminated materials appropriately

Steps for Finger Prick
1. Position hand palm-side up. Choose finger
2. Apply intermittent pressure to the finger to help the blood to flow

Hold the finger and firmly place
Clean the fingertip with alcohol swap. a new sterile lancet at the center of the finger tip
Start in the middle and work outward
to prevent the area from
contamination and allow to air dry.
Wipe away the first drop of blood with a
Firmly press the lancet
sterile dry gauze pad or cotton ball
to puncture the side
of the finger
Apply a gauze pad or cotton ballto the puncture
Collect the specimen. Blood may site until the bleeding stops
flow best if the finger is held
lower than the elbow
What is a Dried Blood Spot (DBS)?
• Whole blood dried on filter paper, usually obtained through finger pricking not from
phlebotomy
• Requires only a small amount of blood
• Easy to store
• Easy to transport
• Such specimens may be collected in case of quality assurance requirements
• For infants HIV diagnosis by PCR, in case of discrepant results, discordant couples,
or indications for further testing in another laboratory
NAME:___________________
DATE: ___________________
Features of acceptable DBS
NAME: 10105/03/0057
DATE: 20/03/2018
008
Required Supplies for DBS DBS Specimen Collection
collection • Use skin puncture procedure
• Blood collection card (filter paper) • Label the filter paper taking care not
• Wax paper/glysine envelopes to touch the circles
• Sealable plastic bags • Place labeled filter paper on drying
• Humidity cards rack
• Desiccant packs • Apply two (2) drops of blood to
each circle
• Allow blood to dry overnight
DBS Drying and infant blood collection
DBS Drying Process Specimen collection from infants
• Avoid touching or smearing the blood • Specimens from infants may be required
spots for Early Infant Diagnosis (EID) and any
• Allow the specimen to fully air dry other testing. In such a case the service
horizontally over night at room provider will be required to collect such
temperature specimens and forward them to the
laboratory or any testing setting
• Keep away from direct sunlight
• Choosing where to prick
• Do not heat, stack or allow DBS to touch
other surfaces during the drying process • Infants age 1- 4 months or less than 6kg
heels work best
• Completely dry blood spots before
packaging • Infants age 5- 10 months or less than 10kg
toes work best
• Infants older than 10 months or above
10kg use finger
Prick at the position shown below (towards the sides but not at the sides), this applies to the toe
too
Heel Puncture Precautions
• Do not puncture deeper than 1.5 mm
• Do not puncture through previous punctures
• Do not puncture the area between imaginary boundaries
• Do not puncture the posterior curvature of heel
• Do not puncture in the arch
• Do not puncture areas of the foot other than the heel or toe
Packaging and storage of DBS
• Ensure the blood spots are completely chocolate brown
• Label the glacine storage bags
• Insert each filter paper into appropriately labeled
• Ziplock bag and add small desiccant
• Expel air and Seal the bag
• Insert glacine bag into a zip-lock bag (5 in 1)

Packaging and storage of DBS
• Add five pieces of desiccant
• Add one humidity indicator card
• Seal the zip-lock bag immediately and Store at RT and submit to the Reference
laboratory
• When DBS specimens are delivered to a reference

Rejection criteria
This criteria check for the following;
a) Proper labeling and identification
b) Over saturation
c) Insufficient blood
d) Scratched spots
e) Scattered spots
Rejection criteria conti…….
f) Two layer spots
g) Clotted blood
h) Serum rings – water, alcohol, horizontal plane
i) Improper drying
j) Spots that cannot elute/extraction
• Specimens that do not pass these criteria are unacceptable and further procedures on
the specimens are not undertaken
Unit 4:
HIV Testing Strategies and Algorithms
Objectives
By the end of this unit the participants should be able;
1. To explain key aspects of Rapid HIV testing
2. Understand different terminologies used in Rapid HIV testing
3. To explain various HIV testing strategies
4. To understand the national HIV Testing algorithm used in the country

Introduction
HIV test result can have life-altering and lifelong consequences
Correct test result (core principles of HTS) is important to ensure that the client
get the correct treatment
HIV testing service in Kenya is classified into two settings

➢ Facility
➢ Community
Approaches namely;
➢Client Initiated HIV Testing Services (CITS)
➢Provider Initiated HIV Testing Services (PITS) and Self testing

Rapid HIV testing in Kenya
• Rapid HIV testing is the recommended type in HIV Testing Services in Kenya, as
well as PCR and Antigen testing which are also available
• The Rapid test algorithm leads to a greater proportion of clients receiving their test
results, reduced wastage of test kits and increased efficiency
• Rapid tests are a simplified version of antibody ELISA tests
• They look for HIV antibodies in the blood
• The antigens for HIV are fixed on one particular strip along the rapid test stick
• Towards the end of the testing stick are control antigens to show that the test worked
properly
Rapid HIV testing in Kenya conti…..
• Specimen is placed at the end of the testing stick and a chemical called buffer is
added to facilitate the testing process
• The chemical causes the antibodies in the blood to flow along the test stick and
When they pass over the section with the antigens, if there are any antibodies for
HIV present then they will stick to these antigens and change color
• Once the test is complete, if there is one stripe it means it is a negative result
• If there are two stripes then it means it’s a positive result
• If there are no stripes it means the test did not work properly.
• Advances in technology have led to the development of a wide variety of rapid HIV
tests including;
➢ agglutination assays
➢ dipstick assays
➢ flow-through membrane assays
➢ Lateral flow membrane assays
• Many of these tests are presented as strips or cartridges incorporated with reagents
and not requiring additional equipment
• They are suitable for the performance of single tests and are easy to use and can be
carried out by any health care worker who has received appropriate training skills.
Benefits of rapid testing
• Sensitivity and specificity is comparable to that of ELISA
• Similar diagnostic performances
• Room temperature storage
• No electricity or machinery required
a) Easy to interpret results
b) Easy to store
Benefits of rapid testing conti….
• No highly skilled technical staff
• Whole blood, plasma, or serum
• Very small amounts of blood is suitable for testing
• Provision of same day/same hour results
a) increased in number of tests performed
b) Reduction of occupational exposure risk
• In-built controls
Definitions of terms
Performance of medical laboratory tests is often described in terms of sensitivity and
specificity
• Sensitivity – Ability of the test method to correctly detect that contain HIV
antibody expressed as a percentage
• Specificity – Ability of the test method to correctly detect a sample that do not
contain HIV antibody
• False Positives: results are when the test concludes HIV is present when, in fact, the
person is not infected
• False Negative: results are when the test concludes HIV is not present, when in fact
the person is infected
Definitions of terms conti…
• Antigen – A substance that elicits an immune response, e.g. protein, carbohydrate, nucleic acid
or other non-living material
• Antibody – A substance that is produced by the body in response to an immune stimulus (e.g.
–TB antibodies, Typhoid antibodies, HIV antibodies
• Whole blood – blood that has not been modified except for the addition of an anticoagulant
• Serum – amber, watery fluid, rich in proteins that separate out when blood clots
• Plasma – the pale yellow, liquid component of un-clotted blood, in which the blood cells and
other components have been suspended.
• The Window Period – is the time from infection until a test can detect any change.
• The average window period with HIV-1 antibody tests is 22 days. Antigen testing cuts the
window period to approximately 16 days and NAT (Nucleic Acid Testing) further reduces this
period to about 9 days.
National HIV testing algorithm
The HIV testing strategies
• These testing strategies differ for populations with high or low HIV prevalence
• This refers to testing approach (Serial or parallel testing)
• It involves use of appropriate algorithm and combination of appropriate tests
• Most of the screening tests used in Kenya are based on Antibody detection
• The purpose of the test can be either Screening or Confirmatory:
• Screening tests: are designed to identify all infected individuals hence they must
have high sensitivity values greater than 95%
• Confirmatory tests: are designed to identify individuals who have tested positive with a
screening test but are actually negative. They must have high specificity values greater than
95%
National HIV testing algorithm
• This describes the specific brands of assays used in a given HIV testing strategy
• These can be defined as the combination and sequence (sensitivity vs. specificity of rapid
vs. ELISA; antigen vs. antibody) of specific tests used in a given strategy to determine a
person’s HIV status
• Usually includes 2-3 tests, performed serially or in parallel
• Always follow the sequence of the tests in the algorithm and do not interchange them
Serial Testing
• Serial testing involves running the screening test first and the results obtained
will determine whether the confirmatory test is to be done or not
• When the screening test is non–reactive, the confirmatory test is not done, and the
final HIV result is negative
• When the screening test is reactive, the confirmatory test must be performed
• If the confirmatory test is reactive, then the final HIV result is positive
• If the confirmatory test is non–reactive, then the result is inconclusive
• In both cases a client has to be re-tested by a second tester using the same algorithm
Determine
Non Reactive Reactive

Report Negative
First Response
Non Reactive Reactive
Inconclusive Report Positive

Retesting in MCH, wards or settings without CCC:
To be done by a different service provider on a
different specimen Refer to the Comprehensive Clinic Centre
Screening Test Determine
Report Negative Non Reactive Reactive Non Reactive
First Response Inconclusive
Non Reactive Reactive Request for retest after 2

weeks at CCC
Collect DBS and send to lab for
DNA PCR Report Inconclusive Report Positive
If the result is still inconclusive,
collect DBS and send to lab for
Enrol to care and
DNA PCR
treatment
Interpreting Serial Testing Algorithm
• There are a variety of combinations of outcomes when following a serial testing
algorithm
TEST 1 TEST 2 DNA PCR HIV STATUS
(SCREENING) (CONFIRMATION)
Non-Reactive N/A N/A Negative
Reactive Reactive N/A Positive
Reactive Non-Reactive Non-reactive Negative**
Reactive Non-Reactive Reactive Positive
** - Client is required to be re-tested using the same algorithm after 2-4 weeks
Re-testing in different populations
Scenario/Population Recommendation for Re-testing
General population
Re-test annually (for children, re-testing is only required if there is a new exposure)
Key populations Re-test every 3 months in case of frequent instances of high risk exposure
Re-test at the initiation of ART for the HIV positive partner, and every 3 months until HIV-positive partner achieves viral suppression.
Once viral suppression is confirmed re-testing can be performed every 6 months. Other prevention services should still be
Negative partner in discordant union recommended, including consistent and correct use of condoms. Assess for eligibility and willingness for PrEP
Test in first trimester or first contact; re-test in the third trimester. All women who were not tested during the third trimester should be
Pregnant women tested during labour and delivery
Parallel Testing algorithm
• In a parallel testing algorithm, both the screening test and confirmatory
test are performed at the same time
• The two tests should be of different characteristics (sensitivity and

specificity)
• Concordant negative or positive results are reported as such
• In case of discrepant results, the tie-breaker must be performed

Interpreting Parallel Testing Algorithm
• There are a variety of combinations of outcomes when following a parallel testing
algorithm
TEST 1 TEST 2 DNA PCR HIV STATUS
(SCREENING) (CONFIRMATION)
Non-Reactive Non-Reactive Negative

Reactive Reactive Positive
Non-Reactive Reactive Non-reactive Negative**
Reactive Non-Reactive Non-Reactive Negative**
Non-Reactive Reactive Reactive Positive
Reactive Non-Reactive Reactive Positive
** - Client is required to be re-tested using the same algorithm after 2-4 weeks
DIFFERENT HIV TEST PROCEDURES
Alere DetermineTM HIV-1/2 Ag/Ab Test Procedure
Test Principle
• The Alere DetermineTM HIV-1/2 Ag/Ab is a single-use immunochromatographic

test for the detection of circulating, free HIV-1 p24 antigen and/or antibody to HIV-
1 or HIV-2 in finger stick whole blood
• This test system is intended for use as a point-of-care test to aid in the diagnosis of
infection with either HIV-1 or HIV-2
• This test is suitable for use in multi-test algorithms designed for the statistical
validation of rapid HIV test results
• When multiple rapid HIV tests are available, this test should be used in appropriate
multi-test algorithms
Specimen Collection Procedure
• Fingerstick whole blood.
1. Don personal protection clothing
2. Clean the finger of the person being tested with an antiseptic wipe
3. Allow the finger to dry thoroughly or wipe dry with a sterile gauze pad
4. Using a sterile lancet, puncture the skin just off the center of the selected fingertip
and wipe away the first drop with sterile gauze
5. Collect the sample from the second drop by touching the disposable Capillary
pipette (provided in the test kit) to the drop of blood until the pipette is filled to the
fill line (50uL). Avoid air bubbles
6. Test immediately following the test performance instructions

TEST PROCEDURE
• Bring the Alere Determine HIV-1/2 Test kit components to room temperature prior to
testing
• Remove the Test Device and place it on a flat, dry surface
• Label the test device with client ID number
• Take a 50 μl (2 drops) sample using a capillary tube provided
• Add two drops (50 μl) of Whole Blood to the sample pad using the capillary tube
Alere Determine™ HIV-1/2
Test Procedure conti…..
• Dispose of used capillary tube into biohazard waste container
• Add one drop (25 μl) (1 drop of chase buffer to the Sample pad
• Observe for development of colored bands in the Results Window
• Interpret Results After 15minutes and record results
• After recording the results, dispose of test device into appropriate biohazard waste
container
Read Results after 20 minutes
INTERPRETATION OF TEST RESULTS
• Antibody Reactive (Two Lines - Control and Antibody Line)
• A pink/red Control line appears in both Control Area and the Test line
• The intensity of the Antibody and Control lines may vary
• Any visible pink/red color in both the Control and Lower Test Areas, regardless of
intensity, is considered REACTIVE
• A Reactive Test Result means that HIV-1 and/or HIV-2 antibodies have been detected in
the specimen,The Test Result is interpreted as PRELIMINARY POSITIVE for HIV-1
and/or HIV-2 antibodies
Result Interpretation
First Response® rapid HIV Test Procedure
Test Principle : First Response® rapid HIV Test is based on
immmunochromatography nitrocellulose membrane pre-coated with HIV-1

and HIV-2 antigens sample (contains antibodies) reconstitutes with HIV
antigens coated with colloidal gold where they conjugated antigen-antibody
complex moves through the membrane and binds to the HIV antigens
applied on the T (Test) line leading to formation of colour band if HIV
antibodies are present
Test Procedures
• Bring the First Response® HIV 1-2.O Card Test kit components to room
temperature prior to testing
• Remove the Test Device and the sample pipette from the foil pouch and place it on a
flat, dry surface
• Label the test device with participant ID number
• Take a 20 μl sample pipette provided and gently squeeze the bulb end
• Immerse the open end in the blood tube and then release the pressure to draw blood
into the sample pipette
Test Procedures
• Slowly add two drops (20 μl) of Whole Blood to the sample well (S) using the Sample
Pipette. Dispose of used sample pipette as biohazard waste
• Add one drop (35 μl) of Assay Diluent to the Sample Well(s)
• Observe for development of colored bands in the Results Window
• Interpret test results at 15 minutes
• After recording the results, dispose of test device as a biohazard waste

Results for First Response
Results
Non-reactive Reactive to HIV-1 Reactive to HIV-2 Reactive to HIV-1&2

Invalid Results
• No Colour band appears at ‘C” at end of stipulated time
No colour line Appearance of one

Appearance of two colour
appears on any of colour band at the
bands and ‘1’ and ‘2’ only
the windows HIV-1 window only
Factors That Affect Test Results
• Kit storage
• Testing area temperature
• Test kit shelf-life
• Specimen collection
• Test performance
• Results interpretation
Dos of HIV testing
• Store test kits under recommended conditions
• Follow manufacturers testing instructions
• Use timing device while testing
• Observe test kit expiration dates before use
• Make sure that all requirements are available before commencing testing
• Observe bio-safety precaution during testing
• Use the appropriate pipettes/reagents for each test kit
• Use recommended sample/reagent volumes

Do not’s of HIV Testing
• Interchange test reagents from different kit types
• Contaminate the reagents
• Modify the incubation time
• Use visibly damaged test device
• Use clotted blood
• Use solutions/reagents not part of the kit e.g. normal saline
• Introduce air bubbles along with sample to testing device

Unit 5
Quality Assurance for HIV Testing
Objectives
By the end of this unit the participants should be able to;
• Explain the role of QA in relation HIV testing
• List the various QA terminologies used in QA in relation to HIV testing
• Understand why quality is important in HIV testing and the role of HTS service
provider
• Discuss key factors that may compromise the quality of HIV testing results
• List the quality control procedures involved in HIV- testing

Introduction
• The availability of excellent HIV tests does not automatically guarantee reliable results
• Adherence to Standard Operating Procedures (SOPs) is paramount to obtaining quality

and reliable results
• Critical analysis of each of the steps must be carried out to ensure achievement of
quality controlled ‘products’
• Provision of quality results translates into good reputation of the testing site and hence
an increase in the demand for the service
Definitions
• Quality Control: Comprises those measures that must be included during each run
to verify that the test is working properly
• Quality control is used to monitor both precision and accuracy of the assay in order
to provide reliable results
• Quality Assurance: This is the total process that guarantees that the final results
reported by a HTS provider are as accurate as possible
• Total Quality Management: quality controlling all levels of laboratory operations

Definitions Conti…..
• Quality Assessment: This is a means of determining the quality of results. It is
usually an external evaluation of a laboratory performance by a reference laboratory
• Validation: Verification of randomly selected specimens from a site, against

reference standards
• Proficiency Testing: testing of specimens sent by reference labs to different testing

sites to monitor performance and quality systems
Definitions Conti…
• Support Supervisory Visit: periodic lab visits conducted by staff from various
levels to provide guidance and support
• Precision: The degree of fluctuation on repeated measurements
• Accuracy: The closeness of measurements to the true value

Quality implementers
• Why is quality important in HIV rapid testing?
• Quality at a testing site will result in accurate and reliable test results, which are essential to
all aspects of patient health, including prevention, care and treatment
• Who is responsible for quality?
• Quality is everyone’s responsibility
• All test site personnel implementing the procedures
• Laboratory management and program staff who supervise the procedures

Factors that may compromise the quality of HIV testing
results
• No written procedures
• Written procedures not followed
• Training is not done or not completed
• Test kits not stored properly
• Using part of the reagent that is not part kit

Why do errors occur?
Before testing During testing After testing
Common Errors • Specimen/test device mislabeled or• Country algorithm not followed • Testing results not recorded
not labeled
• Incorrect volumes of specimen or• Recording error
• Specimen stored inappropriately reagent • Bad handwriting
before testing
• Wrong reagents used • Not following standards for
• Specimen transported recording test results
• Reagents used after expiration date
inappropriately
• Incorrect waiting time before• Report sent to the wrong
• Test kits stored inappropriately location
reading test (too short or too long)
• Reporting invalid test results
How to prevent/• Check storage and room• Conduct test according to written• Re-check patient/client
detect errors temperature procedures identifier
• Maintain appropriate testing • Write clearly

workspace
• Record all test results
• Check inventory and expiration
following standards
dates
• Review testing procedures
• Record pertinent information, and

label test device
Do’s and Don’ts
• Never use expired HIV test kits
• Avoid modification of procedures
• Do not
• Add more or less blood
• Mix parts of different tests
• Add more or less buffer
• Exchange buffers
Do’s and Don’ts
Do not
Do’s
▪ Add more or less blood
▪ Mix parts of different tests
• Never use expired HIV test kits ▪ Add more or less buffer
▪ Exchange buffers
▪ Contaminate the buffers
• Avoid modification of ▪ Modify the incubation time
▪ Avoid use of clotted blood.
▪ Avoid use of ‘dirty’ blood (skin flakes, powder, sweat etc.)
procedures
▪ Avoid introducing air bubbles into the devices when adding the
specimen
Key messages
• ALWAYS use the government approved testing algorithms
• The simplest Rapid Test is not fool-proof
• Errors can occur throughout the testing process
• Always follow SOPs for each test performed
• If problems or errors occur, you must immediately take corrective actions before you
give results to clients and/or patients
Key messages
• If an invalid result is obtained at any point, repeat testing should be done prior to
reporting test results.
• For every positive result, a retest must be done by a different service provider before
enrollment to care and treatment
• In case of inconclusive results, a retest must be done by a different service provider

and if results still inconclusive, a DBS will be taken for PCR at a Ref Lab but if
positive then the client is forthwith enrolled to care and treatment
Methodologies of QA and significance of
External Quality Assessments (EQA
• Methodologies of EQA
• Validation
• Proficiency testing
• Support supervisory visits

Validation
• Specimens transported from testing sites (PMTC, HTS, PITC, Laboratories, HBTC,
Mobile units, etc.) to the Reference Lab for verification of results.
Proficiency testing
• Well prepared specimen panels are distributed by the National Reference lab to testing sites
at the service delivery points and Laboratories to monitor quality and competence
PT steps
Steps What to do
Receive PT panels (specimens) Enter site details in results submission form:
• Name, code, date, panel ID

Panel testing and data entry in the PT Enter test name, kit info and results against corresponding panel ID
results submission form
For ELISA, record pos and neg control means
Sending results to NHRL • Results to be relayed to NHRL by SMS or E- mail for timeliness.
• Results submission form to be sent to NHRL.
• Delivery courier services can be used.
• Filled forms MUST bear name and sign of person performing test.
• Site I/C to countersign and write their name.
• Dates of signing must be indicated
• Original form to be sent to NHRL by recommended means
Record keeping Duplicate forms filed at site for reference

Feedback Participating sites to receive feedback from NHRL in one month.
• For PASS, wait for next PT round.

Roles of Participating Sites
• To receive the panels or collect panels from the courier centers
• Check the panel package to be sure it is complete
• Properly reconstitute the panel
• Fill up all the required information in the results submission forms
• Test the panel and record the results properly
• Once sure no.4 is done, give the site in charge to countercheck the information and
sign
• SMS the results to the phone no. provided and then send the results form via the
available means to NHRL immediately
Support supervisory visits
These are visits conducted by staff from various levels, for the purpose of:
• Providing updated information on HIV testing and related topics
• Evaluating and monitoring adherence to SOP’s
• Stimulating information exchange and networking amongst HTS sites
• Re-training where the need for this is indicated
• Offering refresher courses

Benefits of participating in EQAS
• Provides tools for personal improvement, staff confidence and competence
• Early recognition of reagent/kit/instrument damage
• Improves quality of Laboratory by encouraging GLP
• Cost reduction by reducing number of repeated runs
• Quick identification of poor methods and their replacement with reliable ones, thus
providing updates on new technologies
Unit 6
HIV Testing documentation and records
Objectives
By the end of this unit the participants should be able to;
• Demonstrate the significance of testing documentation and records
• Understand the use of MOH 362, MOH 731 registers
• Highlight key testing indicators in the registers MOH 362, MOH 731 registers
Introduction
• To ensure quality documentation of testing records, appropriate tools should be utilized
by all the service providers
• Measures should be put in place to ensure accurate and timely recording and reporting
of HTS
• The tools used should capture data and information related to HTS: HIV testing,
commodities management and QA/QC

The service providers should use nationally approved tools to;
• Record client data
• Consumption
• Ordering
• Quality assurance and control
• This should be reported using the standard MOH reporting tools through DHIS2
and LIMS
The following are the approved MOH tools
• HTS Lab & Linkage Register (MOH 362)
• Monthly summary reporting tool (MOH 731)
• These tools and records should be safely stored, reviewed and destroyed as per the
government regulations of 10 years
• To increase access of HIV testing services in testing facilities, verification of HTS

recording & reporting tools (MOH 362 Registers, Referral & Linkage Registers, MOH
731should be adhered to
Quality Indicators Captured By The Register
o Potential kit or service providers specific quality issues against set of explicit
standards
o Adherence to recommended rapid HIV testing algorithm
o Test result interpretation
o Test concordance/discordance levels
o Test invalidity levels as well as assessing the suitability of the testing algorithm
o Identifies sites with poor performance and monitor performance over time
o Useful in tracking inventory
oIdentifies potential kit or service providers specific quality issues against set
of explicit standards
oAdherence to recommended rapid HIV testing algorithm
oTest result interpretation
oTest 1 and Test 2 agreement/disagreement levels
oTest invalidity levels as well as assessing the suitability of the testing

algorithm
oReal-time monitoring of the quality of HIV testing services at the point of
delivery
➢Can help identify sites with poor performance and monitor performance over time
➢Helps identify problem and source
➢Signifies where improvement efforts should be focused
oUseful in tracking inventory

oAn important part of the HIV testing QI program
HIV Test 2
HIV Test 1
Quality control DBS collected
TB screening/Refer to
Names of the HIV rapid Kit Name:
Final Results given
Couple Discordant
Age, Sex, etc………
Kit Name:
HTC Provider
test kits used
Final Results
Client Name
DBS Result
Serial No
Remarks
Date
Lot No.
Lot No.
Lot #s of kits used

Expiry Expiry
/ /
a b c d-n o p r s t u v w-x y z
Expiry dates of kits used

N:Negative N:Negative N:Negative
P: Positive P: Positive P: Positive
I:Invalid I:Invalid ID: Indeterminate

HIV Test 1 HIV Test 2
Quality control DBS

Final Results given
Couple Discordant
Kit Name:
HTC Provider
Final Results
Client Name
Kit Name:
DBS Result
collected
Serial No
Remarks
Determine FR
Date
Lot No. Lot No.
4569765O 1245879
Expiry Expiry
12 / 12 / 2020 1/12/2020
aIn case of
b invalid c d-n o p r s t u v w-x y z
results, repeat test and N:Negative N:Negative N:Negative
record results on next P: Positive P: Positive P: Positive
row I:Invalid I:Invalid ID: Indeterminate
100 21/08/12 J . Kamau N - N Y N N NA J. Mugo

101 21/08/12 R. Patel P P P Y N N NA CCC, TB J. Mugo
Lot-569765KO
Exp-28/12/16
102 23/08/12 P. Otieno P N N

If lotY Test
number
N
changes,
Kits Consumption
N NA
skip one J.row and
Mugo DBS Collected
record new
HIV Test 1 numberHIVon
Testnext
2 row
103 24/08/12 J. Kasuku I
N: 10 N: 2
103 24/08/12 J. Kasuku N - N Y P: 5Y Y NP: 3 M. Oloo
104 29/08/12 L. Kalo Monitoring
P inventory
N ID N I: 1 N NAI: 0 M. Oloo DBS Collected
Wastage: 2 Wastage: 0
Total: 18 Total: 5
Quality control DBS

Final Results given
Couple Discordant
Kit Name:
HTC Provider
Kit Name:
Final Results
Client Name
DBS Result
collected
Serial No
Remarks
Test sequencing Determine FR
Date
Lot No. Lot No.
4569765 1245879
Expiry Expiry
12 / 12 / 2020 1/12/2020
100 21/08/12 J . Kamau N - N Y N N NA J. Mugo

101 Test strategy
21/08/12 R. Patel P P P Y N N NA CCC, TB J. Mugo
Lot-569765KO
Exp-28/12/16
102 23/08/12 P. Otieno P N N Y N N NA J. Mugo DBS Collected
103 24/08/12 J. Kasuku I M. Oloo
103 24/08/12 J. Kasuku N - N Y Y Y N M. Oloo
104 27/08/12 K. Funzo N P N Y N N NA L. Mita

105 29/08/12 L. Kalo P N ID N N NA M. Oloo DBS Collected
Test Kits Consumption
Supervisor / In-charge
N: 10 N: 2
Name: Mary Makena
P: 5 P: 3
Sign: MM Date:29/08/12
I: 1 I: 0
Total: 18 Total: 5
Quality contro
DBS collected
TB screening/Re
Final Results giv
HTC Provider
Final Results
Client Name
Kit Name:
Couple Discord
Age, Sex, etc…
Kit Name:
DBS Result
Serial No
Remarks
Determine FR
Date
to
Lot No. Lot No.
4569765KO 1245879
Expiry Expiry
12 / 12 / 2020 1/12/2020
100 21/08/12 J . Kamau N N N Y N N NA J. Mugo

101 21/08/12 R. Patel P P P Y N N NA CCC, TB J. Mugo
Lot-569765KO
Exp-28/12/16
102 23/08/12 P. Otieno P N N Y N N NA J. Mugo DBS Collected
103 24/08/12 J. Kasuku I M. Oloo
103 24/08/12 J. Kasuku N N N Y Y Y N M. Oloo
104 27/08/12 K. Funzo P P N Y N N NA L. Mita

105 29/08/12 L. Kalo P N ID N N NA
Is
M. Oloo
site supervision
DBS Collected
carried out?
Test Kits Consumption
From Page summaries, is
N: 2 N: 4 Supervisor / In-charge
algorithm adhered to? Name:
P: 4 P: 2
Sign: Date:
I: 1 I: 0
Stock Management and Inventory
Having enough unexpired test kits and supplies to ensure uninterrupted
service
334
Supplies are kept at …
Store Room
Testing area
335
Stock Management Leads to
High Quality Testing
Stock management:
• Ensures availability of materials and kits, when needed
• Ensures expired kits are not used
• Minimizes waste
336
Stock Management Tasks
Perform a “stock count” and maintain proper inventory records
Ensure proper storage and cycling of stock
Check quality of stored supplies periodically
Decide when and how much to re-order
Inspect incoming orders
Submit list of needs to management for procurement

337
Inspect Delivery of New Orders
Store kits according

Record date Check to make sure Inspect test kits are
to expiration dates –
received and who you have received not open, damaged,
“First Expiry, First
received it the right order or expired
Used”
338
How to Store Kits with Different Lot Numbers & Expiry Dates
339
Ensure Proper Storage of Supplies
• Keep in a clean, organized, and locked shelf or cabinet
• Store according to manufacturer’s instructions
First Expiry, First Used

• Place in well ventilated room
• Store away from direct sunlight
• Organize supplies by expiration dates so that older supplies are used first
340
Questions?
MODULE 8
INTRODUCTION TO HIV CARE

AND TREATMENT
MODULE GOAL
The overall goal of this module is to provide

information on care and treatment of HIV/AIDS
from a comprehensive perspective.
Specific objectives
By the end of this module the participant should be able to: -
• Demonstrate understanding of holistic approach in comprehensive care.
• Describe various elements of comprehensive care
• Describe ARV classification of ARV drugs and patient management.
• Describe basic care package.
• Discuss Positive Health, Dignity and Prevention (PHDP)
• Demonstrate knowledge of referral for care and support.

Unit 1:
Components in Holistic HIV care & treatment

Holistic care components
spiritual emotional
• the person
physical social
Unit 2
Elements of Comprehensive Care
• The comprehensive care concept refers to the holistic approach towards the
management of a person infected with HIV.
• The comprehensive care team managing the patient requires a multidisciplinary team,
adequate staff and good coordination to provide full range of care services.
Providing ongoing clinical care to people with HIV does not need to wait for a full
CCC to be established. However, the team below is important for ideal set ups;
nurses, clinicians, laboratory, pharmacy, administrators, community health
workers/home support givers, social worker, physiotherapist, occupational therapist,
nutritionist, counsellor, record clerk, spiritual care giver and volunteers
• This team addresses the person’s wholesomeness in terms of body, mind and spirit.
Cont:
• The care and support options available include:
1)Psychological support
• A HIV diagnosis provides many challenges. Counselling helps PLWHIV live

positively with the disease. Counselling encourages people with HIV and AIDS to
avoid on going transmission to others and leads to reduction in risky behavior.
Types of counseling for HIV Positive Clients
• Supportive counseling - General counselling to assess how the client is coping with
HIV
• Preventive counseling - Focuses on sexual prevention of transmission of HIV to

other partners and encouraging disclosure
• Ongoing counseling - Counselling of clients with issues which have been identified
as challenges to coping with the HIV diagnosis
• Adherence counseling - Counselling the clients to be adherent to the whole

management of HIV
• Crisis counselling- its aimed at decreasing emotional pain providing emotional

support, ensuring that the person in crisis is safe and help develop a plan for coping
with the situation
2)Treatment of opportunistic infections and
prophylaxis
Patients who have HIV infection may contract many other infections as a result of
their weakened immune system. Many of these infections are preventable and many are
treatable with easily available and relatively cheap medication. Treatment involves
nursing care, physiotherapy, laboratory and pharmacological support. One may also
access prophylactic medication for opportunistic infections. Treatment may also
involve nutritional support. Proper nutrition in HIV has been demonstrated to have
tremendous effect on HIV patients and it is important that patients receive proper
nutritional counseling and support.
3)Anti-Retroviral Therapy
• Comprehensive care cannot be complete without the provision of antiretroviral for

those who qualify. ART is available at comprehensive care centers at subsidized costs.
The goals of ART can only be achieved if health care workers work as a team and
provide the right information. This information should include adherence to the
regimen, issues of possibilities of HIV transmission even during treatment, use of
protection during sexual intercourse.
4.Nutritional counselling
Counseling for optimal nutritional status is a critical component of care for PLWHIV,
who often lose weight progressively and have poor nutritional status. Their reduced
appetite cannot accommodate their increased energy needs caused by HIV and
opportunistic infections. They also have impaired gastrointestinal function and increased
metabolic rate. Poor nutritional status can have a negative effect on treatment outcomes
and further depress immunity. Dietary counseling, along with treatment of malnutrition,
may prevent wasting and alleviate some symptoms of the disease. Food-insecure people
living with HIV may have difficulty adhering to treatment and require economic
strengthening or food security support.
Cont:
Below are general nutrition counseling messages for people living with HIV.
• Eat a variety of foods from all food groups every day.
• Increase energy intake to meet the extra energy needs caused by HIV and
opportunistic infections.
5)PMTCT
• This is prevention of mother to child transmission of HIV during pregnancy,

delivery and breastfeeding. Without intervention up to 40 percent of HIV positive
mothers can transmit the virus to their children. The benefits of PMTCT include
decreased number of HIV infected children, and improved child health and survival.
Comprehensive care centers help patients access these services which are offered in
majority of hospitals country wide.
6)Home (based) care
• Home based care is that care given to the sick in their own homes. It includes care
extended from the health facilities through family participation and community
involvement. HBC also includes strengthening of the pts individual responsibility for
their health - positive living. HBC integrates care with HIV education which
promotes healthy lifestyles
7). Palliative care
• Palliative care is patient and family care that anticipates, prevents and treats suffering
of the patient. Palliative care optimizes quality of life as it provides pain and
symptomatic management. It addresses physical, emotional social and spiritual needs
of the patient.
8). Support groups (social support)
• Support groups which may include Post Test clubs, are formal or informal gathering
for people who have tested positive or negative. Here members share their
experiences and learn from one another promote AIDS awareness and support each
other in maintaining behavior change, and share other support activities e.g. IGAs.
PTCs are like social clubs where people who are HIV negative can interact with and
support those who are HIV positive.
9. Comprehensive care services for children
• All children born to HIV positive mothers should be given prophylactic treatment and
have access to HIV testing to confirm HIV status
• If the child is HIV positive they should get treatment for HIV
• The child's psychological needs as they grow up should be well addressed especially in
adolescence
Other services
• These may include: Legal support, Orphan care, Financial assistance among others
10)Other services
• These may include: Legal support, Orphan care, Financial assistance among others
a)Legal support
• The legal issues that may face someone with HIV may include discrimination or termination of
employment, succession and inheritance matters, divorce etc. It is important that those who are
helping these patients know where to refer these patients in case they need legal assistance. This
may call for health workers to involve other PLWHIV organizations, assist in such matters such
as will writing and community education on the legal issues surrounding HIV.
b)Orphan and vulnerable peoples care
• To achieve this, there is a need for strengthening protection and care of orphans
within extended families and communities. Strengthen economic coping capacity of
families and communities
• Enhance capacity of families and communities to respond to the psychological needs

of OVC and caregivers. Ensure involvement of children/youth in HIV programs
and access to education.
• Reduce stigma and discrimination, build partnerships and ensure that external
support strengthens community initiatives and motivation
c)Financial support
• PLWHA’s should be encouraged to engage themselves in income generating activities

supported by various agencies. Policies should be in place to favor orphans and
vulnerable children to access the educational bursary funds.
Unit 3
Anti-retroviral drugs, initiation and

monitoring of ART
HIV REPLICATION CYCLE
Classification of ARVs
• Entry inhibitors/ CCR5 receptor antagonist- not currently in the Kenyan market,
only one has been approved by the US Food and Drug Administration
• Fusion Inhibitors (not currently in the Kenyan market, only one has been
approved by the US Food and Drug Administration [FDA]).
• NRTIs – Nucleoside/Nucleotide Reverse transcriptase Inhibitors
• NNRTIs – Non-Nucleoside Reverse transcriptase Inhibitors
• Integrase inhibitors- Dolutegravir
• PIs – Protease Inhibitors

The table below gives a summary of antiretroviral drugs used in HIV therapy.
NRTIs Non-nucleoside Protease inhibitors Intergrase
Nucleoside Nucleotide
Reverse transcriptase (PIs) inhibitors
reverse reverse
inhibitors (NNRTIs)
transcriptase transcriptase
inhibitors (NsRTIs) inhibitor (NtRTI)
• Zidovudine • Tenofovir • Nevirapine (NVP) • Ritonavir (RTV) • Dolutegravir

(ZDV/AZT) Disoproxil • Efavirenz (EFV) (pharmacoenhancer) (DTG)
• Lamivudine (3TC) Fumarate (TDF) • Atazanavir (ATVr)
• Raltegravir (RAL)
• Abacavir (ABC) • Lopinavir/ritonavir
(LPV/r)
Five Goals of ART
Initiating Treatment
i. When to Start ART in Children, adolescents and Adults
ALL patients are eligible for ART initiation irrespective of CD4 count or percentage, WHO
staging, age, sex, and pregnancy status, for as long as the patient is prepared and ready to start
care and treatment preferably 2weeks after testing HIV positive. (TEST & TREAT)
i. Pregnancy and ART

• Not a contraindication to ART, START immediately after HIV diagnosis.
• ART greatly decreases vertical transmission
• Also allows mother to remain well to care for her child
Preferred First line ART Regimens for Children,
Adolescents and adults
population Preferred 1st line ART
Age/weight Preferred First line regimen
<2weeks AZT/3TC/NVP
>2 weeks and < 35 kg ABC/3TC+LPV/r
< 15 years and >35 kg ABC/3TC+DTG
> 15 years and >35 kg TDF/3TC+DTG
Post Exposure Prophylaxis (PEP)
Adults TDF/3TC/ ATV/r
Children ABC/3TC/ LPV/r
PrEP TDF/FTC
Some side effects of ARVs
Below are side effects linked to a specific drug
• Bone marrow suppression leading to Anaemia—AZT
• Hepatotoxicity—especially NVP
• CNS Manifestation-EFV
• Lipodystrophy and metabolic derangements especially PIs
• Impaired Renal function- TDF

Drug Interactions
There are many interactions with other drugs which may limit the way in which these
drugs can be given when someone is on ARVs, because ARVs have interactions with
other drugs. This may determine the combination of ARVs that one is put on and what
medications a person will not be given concurrent with ARVs. It is therefore critical for
the clinician/pharmacist to warn patients about potential interactions e.g. alcohol, over
the counter pills, rifampicin. Patients should also be encouraged to consult whenever
they take other medications. The clinician/pharmacist should be well versed with the
major drug interactions, so as to be able to discuss this subject with their clients.
Adherence to ART
• This is the cornerstone of anti-retroviral therapy. Adherence enhancing strategies

should be implemented beginning at the point of HIV diagnosis (as part of post-
test counselling and linkage) and continued during initial evaluation and follow up
for ART. To avoid treatment failure and need to switch to 2nd line or 3rd line ART, it
is key to have an adherence support strategy in place before ART initiation,
anticipating common and individual barriers to good adherence
HTS Post -test counselling: Key treatment preparation messages for all
patients who test positive
• Treatment is available and recommended for everyone with HIV
• Starting treatment early reduces one’s chances of becalming ill or infecting your
sexual partner(s)
• With good adherence one can live a long and productive life
•
• Reasons for regimen fail
• Poor adherence
• Consider who administers
• How drug is administered
• Storage of medications
• Is drug appropriate, taste, vomiting, food
• Has the dose been adjusted according to weight?
• Missed pills, forgetfulness etc.

• Resistance:
• 3 or more drugs are needed to provide adequate genetic barrier to resistance
• Sub-therapeutic levels provide selective pressure for resistance
• Within days, resistance may develop to NVP, EFV, 3TC if not taken appropriately
Key messages about ART
• All individuals with confirmed HIV infections are eligible for ART
• With test and treat post-test counselling should include 3 key messages
• Treatment is available and recommended for everyone with HIV
• Starting treatment early reduces one’s chances of becalming ill or infecting your
sexual partner(s)
• With good adherence one can live a long and productive life
• Psychosocial support for PLHIV and their families is essential their well being and
good health outcomes
Unit 4: Basic Care Package
• The basic care package for clients in care and treatment consists of a set of
commodities for use within the home. The package is given once and consumables
replaced on a monthly basis. The package is for distribution at the facility level by
health care workers including HTS providers or at community level by Community
Health Volunteers (CHVs).
Components
• Safe water sanitation and hygiene
• Malaria prevention
• Immunization
• IEC materials
• OI’s Prophylaxis –one month’s supply issued by health care workers
• Cotrimoxazole
• Isoniazid
• Multivitamins
• The basic care package has been a useful tool where it has been implemented by
• Increasing enrolment into care and treatment
• Increase defaulter return rate

Unit 5: Positive Health Dignity & Prevention
(PHDP)
Prevention strategies and messages for people living with HIV including;
Knowledge of status TB prevention in the community
Disclosure Adherence
Discordance Alcohol and substance abuse
Risk reduction Sexually Transmitted Infections
Child testing PMTCT
Partner and family testing Family planning and pregnancy intentions
Condom use
Key prevention messages
• With the aid of a scripted, illustrated flip chart, the provider assesses the patient’s risk and
then delivers targeted prevention messages:
• Encourage sex partners to get tested
• Disclose HIV status to sex partners – self disclosure and provider assisted disclosure
strongly advocated.
• Abstain from having sex or
• Be faithful to one partner and use condoms during each sex act
Cont:
• Seek family planning services, if needed
• Explore potential consequences of having sex without a condom
• Transmission of HIV to sex partners
• Reinfection with resistant strains of HIV
• Acquisition of sexually transmitted infections
• Mother-to-child-transmission, if an HIV-positive woman becomes pregnant

Unit 6: Concept of Referral for Care & Support
Promotional Activities for
HTS
Module 9
Objectives of the module
By the end of this module, the participants should be able to:-
• Define health communication, health literacy health advocacy, social
marketing and social mobilisation.
• Outline some health promotion theories
• Outline the communication channels and modes of communication.
• Discuss the importance of health advocacy in HTS
• Discuss the role of social marketing and social mobilisation in HTS.
• Demonstrate ability to promote HTS activities in workplace, community
and health facility
Definitions of HP components
• Health communication(HC) - study and use of communication
strategies to inform and influence individuals and community decision
making that enhance uptake of HTS. Planned HC helps spread
knowledge, values, improve social norms, and initiate, accelerate and
reinforce change
• Health literacy - cognitive and social skill, it determines the motivation
and ability of individual to gain access to, use information and
understand HIV testing services (HTS) in ways which promote and
maintain good health
Definitions of HP components ct
• Health advocacy is the pursuit of influencing outcomes(HTS) which
includes public health policy, resource allocation decision within political,
economic, social systems and institutions that directly affects people’s
health.
• Social mobilization - process that engages and motivates a wide range of
partners and allies at all levels of care to raise awareness of and demand
for HTS through dialogue
• Social marketing- application of commercial marketing technologies to
the analysis, planning, execution and evaluation of HTS designed to
influence the voluntary behaviour of target audience in order to improve
uptake of HTS
Health promotion theories
• A theory is a major factor that influence the phenomena of interest - why do some
people seek HTS and others do not. It explains relationships between factors such as
knowledge beliefs, social norms and behaviours.
• Theories in explaining health promotion phenomena are:-

Approach Theory or Model
Theories and models that explain health a) Health belief model
behaviour and health behaviour change b) Transtheoretical model
by focusing on the individual. c) Social cognitive theory
Theory that explain change in terms of a. Community mobilisation (planning
community and communal action for action and development) theory.
HTS b. Diffusion of innovation theory
Theory that guide the use of communication strategy to bring a. Health literacy
b. Communication – behaviour change
about behaviour change to promote HTS theory
c. Social marketing
Theories and models that explain how to implement change a. Organisational change theory
b. Intersectoral action model
within organization and create HTS supportive organizational
practice
Theories and models that explain the development and the a. A framework for making healthy public
policy
implementation of health public policy b. Evidence based policy making to
promote health.
c. Health Impact assessment
Channels and modes of Health communication
Choice on the channels and mode of H communication used dependent on
• target audience and
• environment where we are promoting HTS.
• Budget
• promotional activities
• stakeholders
Channel media
Interpersonal Individual: Patient education/counselling, Instruction, Informal discussion,
Telephone hotline
Group didactic: Lecture, Seminar, Conference
Group experiential: Skills training, Behaviour modification,
Sensitivity/encounter, Inquiry learning, Peer group discussion, Simulation/Role
play, Self-help
Organisation Town hall meetings, Organisational meetings, Workplace campaigns, men,
& community women, and youth groups
Channel media
Low technology ‘folk’ or Story-telling, song, dance, drama and pictures.

‘popular’ media
Limited reach media Focussed information transmission: Pamphlets/leaflets/brochures/
information sheets Newsletters Videos & Audio-cassettes (CDs, tapes,
flash disks)
Agenda setting & create public awareness and interest: Posters, T-
shirts, Stickers, badges, drink coasters
channel media
Mass reach Television: Advertising (Paid or public service placement), News, Public affairs/talk
media shows, Documentary, Drama (entertainment education), panel discussions
Radio: Advertising (Paid or public service placement), News, Public affairs,

Talkback (call in shows), Drama (entertainment education)
Newspapers: Advertising, Inserted section (paid), News, Feature stories, Letters to

the editor
Magazines: Organisational news letter
Internet|: Websites, Email lists, Chat rooms, Newsgroups, Advertising (paid or
unpaid)
Social media: Facebook, twitter, Instagram blogs, WhatsApp, messenger
Health Advocacy
• Health advocacy is the pursuit of influencing outcomes.
• Act on factors which directly affects people’s health such as public health
policy, resource allocation, decision within political, economic, social
systems and institutions
• Health advocacy is
❖Actions that lead to selected goals.
❖One of the strategies to approach a problem.
❖Used as a part of a community initiative and nested in with other components.
Health Advocacy CT
❖Advocacy is not a direct service.
❖Does not involve confrontation or conflicts.
❖Not giving people or groups information about HTS, they should be knowledgeable
about it.
❖Has no prescribed or clearly determined method
❖Involve working against established or entrenched values, structures and customs
❖ Has powerful results to enable health advocates gain access and voice in HTS
decision making
Advocacy tools and strategies
Tools strategies
❖ Television interviews Working with government and politicians
❖ Letters to editor Creating and generating debates
❖ petitions working with media (media campaign)
❖ Radio grab E-advocacy
❖ Interviews Community education
❖ Meetings with politicians Developing partnerships
❖ Action alert Opinion poling
❖ Media release Mobilizing groups
❖ Community awareness
❖ Influencing policy (inside and out), letter writing, framing your
issue
Group Exercise
1. Divide the participants into three groups where the groups are asked to take 15 minutes
to discuss the following and report to plenary
a. Group one: Comes up with a song on importance of HIV Testing services where
the chorus emphasizes key messages.
b. Group two: Perform a short skit mimicking a HTS awareness campaign in a certain
town or village
c. Group three: Panel discussion involving policy makers and HTS providers.
2.Instruct each group to present their work in 5 minutes and allow discussion after each
presentation.
Promotional activities
Community level workplaces Health facility
Community mobilization seminars client education –

outpatient clinic
Information sharing in Update meetings CME for staff

barazas e.g. chiefs
Education for organized Information learning on TV Information on notice board

groups e.g. youth group screens about HTS or wall charts
Education in churches, Information on notice board Information learning on TV

mosque or schools or wall charts screens about HTS
Promotional activities
Community level workplaces Health facility
Education during Organized events -electing Giving clients and

organized events like booth for information relatives print materials or
show, football matches by sharing CD to watch and read at
election booths home
Sharing information Exchange programs patient education in the
during school/ institution inpatient
open days
Road shows and walks Trips and tours to learn
about HIV
Module 10
COMMODITY MANAGEMENT FOR
HTS
Introduction
Uninterrupted supply of commodity is critical for the success of HTS. Commodity
Availability entails.
• Forecasting and Quantification.
• Procurement.
• Warehousing and distribution.
• Commodity reporting, ordering, resupply and distribution planning.
• Storage.
• Quality logistics management.

Commodity forecasting and Quantification (
F&Q)
F&Q is an estimation of required quantities for a specified time a process which depends
on data collected from facilities.
• Facilities should capture consumption data accurately on a daily basis in the

recommended tools for use in F&Q.
• Counties should quantify, budget, print and supply the tools to the facilities. Counties
are also required to conduct trainings with support from partners to ensure facility staff
use the tools correctly.
• NASCOP Lab quantification team works with HTS TWG to undertake annual
quantification based on targets and consumption data from facilities
Commodity Procurement
• All commodities procured fot HTS are approved and registered by MoH.
• KEMSA is the authority mandated to procure HIV test kits in Kenya,other private
institutions can procure tests kits for their use as long are approved for use in the
national algorithm.
• Procurement is based on funding from various entities ( GF,GoK counties,PEPFAR

etc.).
• NASCOP & KEMSA maintain a procurement plan showing items under

procurement ,funding sources and additional stocks to ensure country adequate
stocks.
Commodity storage
• Test Kits can be affected by exposure to hightemperatures, freezing and moisture.
• Temperatures should not fall below 2 ºC or rise above 20−30 ºC,
• Always check product-specific instructions on temperature restrictions for storage. Transport, storage
and in-country distribution of HIV Diagnostic Test Kits should be performed in temperature-
controlled environment to ensure that the temperatures remain within the manufacturer’s specified
limits at any time
• Temperature logs should be maintained to ensure commodities are stored at the required temperature.
Commodity inventory management
Expiry of commodities should be tracked to ensure First Expiry First Out (FEFO) or
First in First Out ( FIFO) is adhered to, to prevent commodity wastage and stock outs.
Cost efficiency is achieved when commodity expiry is minimized.
Quality logistics management (QLM)
QLM aims at ensuring commodity security; where commodities are in the right
quantities, conditions and available at the testing points when needed. Measures to
ensure QLM include:
• Utilization of “pull” system-Supplies are based on orders from facilities.
• Timely and accurate reporting at all levels.
• Commodity audits-Comparison od service data and commodity data should be
done by SCMLTs on a monthly basis to evaluate utilization & reporting of HTC
commodities.
• Use of standardized national inventory management & commodity tools to
ensure data is collected and reported routinely.
• CMLCS & SCMLCs should conduct regular facility support supervision to check
on data quality and improve data use.
• Inventory management SOPs should be adhered to.
Commodity data collection tools
Facilities must on a daily basis update HTS tools every day to avoid data losses. The
tools include:
• Daily activity register ( DAR)
• Stock cards.
• Lab top up forms.
• Expiry tracking chart.
• Facility Consumption Data Report & Request ( F-CDRR).

Commodity Facility ordering-Step 1
• Using the data collection tools, Facility enter data into (F-CDRR) MOH 643 and sends to SCMLC by
5th of every month
• Quantities for resupply is calculated by multiply quantity used by 3 plus 1 and subtracting the end of
month physical stock.
Data source tools-Top up forms
Data source tools-Stock cards
Data source tools-Daily activity Register
Exercise-Identify any data errors
COMMON DATA QUALITY ERRORS
FCDRR Completion procedure
• Facilities should regularly update the DARs, stock cards

and top up forms.
• The tools act as data sources in filling in the F-CDRR.
• Refer to the F-CDRR for correct reporting
Step two: SCMLC reporting
• SCMLC enter MOH 643 into DHIS 2/HCMP by 15th of every month, They update
the list of facilities in the system by adding new sites and removing the closed down
facilities. Each SCMLC is given log in credentials by CHAI.
Step three: RTK allocations
• County allocation teams determine facility need and allocate accordingly
Resupply is based on the following criteria:
• Resupply is done only to facilities with <4 MOS
• Outreaches should be well planned for to avoid stocks outs.
Zero supply of kits to facilities is based on the following criteria:
• No report, no supplies.
• No consumption ,data no supplies,
• > 6 MOS, no supplies-CLMTS are advised to do redistribution from over stocked

facilities to low stocked facilities
• 4-6 MOS, no supplies :SCMLCs should monitor stocks & ensure no stock outs
Step four: RTK distribution & Receiving
• Allocation is done on HCMP and is received by KEMSA through the LIS
• Picking, packing & distribution is done by KEMSA by zones in (2 weeks)
• Refer to Receiving Job aids

Commodity Re-distribution
Re- distribution is the movement of commodities from one facility to another:
Reasons for Redistribution
• Excess stock- >6 months of stock
• Short expiries-commodities with less that 3 months to expiry.
• As may be requested by the SCLMCs to avoid stock outs elsewhere.
• Refer to Job aids on redistribution.

Laboratory commodity and information flow – {HIV Rapid
test kits}
KEMSA NASCOP
Sub-County County
SDP SDP SDP SDP SDP SDP
Key:
Commodity flow
Information flow
Feedback
6,000 RTK sites countywide
Thank you

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MODULE 1: BASIC CONCEPTS AND

EPIDEMIOLOGY OF HIV & AIDS

• Impart knowledge on basic concepts of HIV and AIDS.

1. Describe the basic concepts of HIV and AIDS

2. Appreciate the global and national HIV statistics and epidemiology

3. Explain HIV combination prevention intervention

4. Describe HIV positive living

5. Discuss myths and misconceptions of HIV

• It’s the virus that’s causes HIV infection and AIDS

• Weakens immune system by destroying cells that fight disease/ infection

• Is preventable & manageable but is NOT curable

- The body can’t fight off infections.

- HIV takes advantage the weak immune system causing AIDS

• AIDS is a disease which has the following elements:

• A confirmed positive test for HIV/AIDS

• Patients predisposed to multiple opportunistic infections leading to death

• Having unprotected sex (anal or vaginal)

• Having STI e.g. syphilis, herpes, Chlamydia, gonorrhea, bacterial vaginosis

• Sharing injecting needles

• Receiving unsafe injections, tissue transplantation, medical procedures that involve

• Health Care workers- accidental needle stick injuries

• HIV positive mother to child at pregnancy, birth, breastfeeding

• Combination prevention used as HIV prevention approaches:

✓Combination HIV prevention interventions are defined as a combination of

• Elimination of mother to child transmission (EMTCT)

• Methadone replacement therapy

• Behavior change communication

• Building the resilience of women and Girls

• Girls enrolled in secondary school

✓antiretroviral therapy(ART) taken daily and right way

• Not sharing needles for injecting drug users

• Pre-exposure prophylaxis (PrEP)

• Get tested and treated for other STIs

• Encourage your partners to get tested for HIV

• globally living with HIV: 36.7 million

• accessing antiretroviral therapy : 19.5 million people

• people infected since epidemic: 76.1 million people

• Deaths by AIDS: 35.0 million people

(According to the UNAIDS Fact sheet 2017)

• people living with HIV with access to treatment- 53%

• children aged 0 – 14 years with access to treatment - 43%

• pregnant women living with HIV - 76%

Worldwide newly infected-1.8 million

AIDS - related deaths

• In 2016, 1 million people died from AIDS-related illnesses worldwide, compared to

• Mutual masturbation, Kissing, Oral sex

• Water, food, air

• Sharing toilet seats, tables, door handles, cutlery, towels

• If I get infected fluid from an HIV-positive person into my body will I

• I’m HIV-positive and so is my partner, so we don’t have to worry about HIV,

INTRODUCTION AND BACKGROUND TO HIV TESTING

• To provide a general overview of the main concepts in HIV testing services

1. Understand the general overview of the HTS training

Populations Targeted for HTS

-General Population - Youth and adolescents Infants and children

-Couples and sex partners - Persons with disabilities (PWDs)

-Key populations -Survivors of sexual and gender base violence

• Correct test results

• Connection (Referral and linkage to care)

• Assessment of other health related conditions

• Referral and linkage to other appropriate health services

• Uninterrupted supply of HTS commodities is critical for the success of HTS

• An effective commodity managements system must be in place to ensure the

• All stakeholders should have a systematic and planned approach to monitor QA on a