Training Manual

on HIV Prevention
for Community Health Volunteers

Published by the Philippine Red Cross with the support from the International Federation of Red Cross and Red Crescent Societies

The Training Manual on HIV Prevention for Community Health Volunteers is endorsed by;

Philippine Copyright 2011 By Philippine Red Cross ISBN

All rights reserved. Parts of the training manual can be reproduced, copied, or translated for teaching/training purposes. Written permission is required for all such uses.

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Facilitators Guide

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Table of Contents Overview Goal of the Training Package Brief Review of Principles of Adult Learning Training Methodology Participant Evaluation Training Content Prototype Schedule Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 Session 7 Session 8 Session 9 Session 10 Session 11 Session 12 Session 13 Session 14 Getting to Know Each Other Leveling of Expectations & Introduction to the Course Pre Test / Self Assessment Survey Introduction to Reproductive Health Defining HIV and AIDS HIV and AIDS in our Community HIV Transmission Preventing HIV Transmission HIV Testing and Counseling Stigma and Discrimination Community-Based HIV and AIDS Psychosocial Support Community-Based HIV and AIDS Dissemination Action Planning Post Test / Evaluation Annexes Glossary of Terms

Overview AIDS will kill more people in this decade alone than all the wars and disasters in the past 50 years. Since the HIV pandemic began, 25 million people have died and 40 million are now living with HIV. Combating this global disease is a major challenge to all of us. In the Philippines alone, by the year 2010, there would be an estimated of 12,000 people living with HIV and AIDS. At present, there is an average of 2 new cases a day, of these new cases 9 out of the ten new cases are males or men who have sex with men (MSM). In 2007, Philippine National Red Cross joined the Global Red Cross and Red Crescent HIV and AIDS Alliance. This alliance aims to strengthen and make better use of combined capabilities of National Societies and the International Federation to support community level action and resilience. Philippine Red Cross sincere in its desire to scale up its program framework manifested its commitment thru the NGO Code of Good Practice as a signatory to its cause. The NGO Code of Good Practice calls upon all humanitarian organization to keep track its activities towards the fight against HIV and AIDS spread. To seek additional funding support to materialize its HIV and AIDS initiative, PRC launched its Program Appeal for 2009 thru the International Federation focusing on the strengthening its programs for Youth, Overseas Filipino Workers and in the Community. The appeal was a success and was able to secure support from the Federation. Mid 2009, PNRC officially started the Federation supported project Strengthening PRC HIV Program for Youth, OFWs and in the Community. It aims to improve the activities being implemented by PNRC and to focus its attention to major population groups that are greatly affected by the disease. Main key players of its implementation are the health volunteers at the community level that is why a training program was developed for its purpose. This training will equip community health volunteers the right knowledge, skills and attitudes towards dealing with HIV and AIDS. Thru the community health volunteers, PRC will be able to take part in the fight against the spread of HIV and AIDS. Thru the community health volunteers, PRC will be able to mobilize the power of humanity to make the difference.

Goal of the Training The goal of the training will be to provide the community health volunteers with the relevant knowledge, attitude, and skills capabilities required to assist and support community based HIV prevention activities. Objectives of the Training Objectives of the training are to: 1. Increase knowledge of the community health volunteers surrounding HIV and AIDS and its prevention, care and support. 2. Enhance attitudes of the community health volunteers which they should exhibit at the community towards dealing with HIV and AIDS. 3. Promote the transfer of skills to the community health volunteers regarding important information, skills and practical knowledge required for community based HIV prevention, care and support. Targets of the Training The targets of the training are the trainees, or participants and the facilitators of the training which will use their training manual. The term Community Health Volunteer or CHV, is used throughout the training manual in reference to the trainee. Community health volunteers do not require any previous experience in community-based HIV management. This training has been designed to suit the lowest level of education of the training audience. Facilitators are also expected to adapt content to match the particular skills and knowledge levels of the training audience, and meet the requirements of the working environment of the CHVs in the community.

Brief Review of Principles of Adult Learning Key Characteristics of Adult Learners It is important for facilitators to understand the needs and characteristics of adult learners. While the intended facilitators for this training package will have previous experience in training adults, a brief review of important concepts related to the methodology of the training are explored in this section. Malcolm Knowles, a pioneer in the field of adult learning, identified several key characteristics which influence adult learning. Key Characteristics of Adult Learners Autonomous and Adults will direct their own learning Self Directed based on their objectives and final goal. In addition to providing course content, facilitators need to help create an environment where trainees are encouraged to be involved in the learning process. Adult learners will draw from their current and previous life experiences, such as education level, past training, work experience and family and social history while learning. Learning is more relevant when trainees can draw on their own life experiences and knowledge and relate them to the course content. Adults undertake training for a specific reason and goal which they want to achieve. Facilitators need to find out goals, or expectations, of trainees prior to training and explain the course contents, objectives and show how the course will meet these goals.

Accumulated life experience and knowledge

Goal-Oriented

RelevanceOriented

Adult learners need to see the value of learning something new and how training will help them meet their needs. An important part of finding out the goals and expectations of trainees prior to training is to tailor training activities to meet the needs of trainees. Adults want to learn new information or gain skills that have a practical application for their jobs or daily lives. Facilitators should help trainees to apply the knowledge gained through training in practically useful ways. As all individuals participating in the course (both facilitators and trainers) are adults, each participant has skills and experience to contribute to the training. Facilitators should treat trainees as equals and provide ample opportunity for participants to excess their thoughts freely in an open and productive learning environment.

1.

Motivation

Once a trainee has decided to learn, facilitators must assist each trainee to remain motivated throughout the training course in order to keep learning. Ways Facilitators Can Help Trainees Stay Motivated Friendly and An open and friendly learning Supportive environment will encourage trainees to Learning participate in activities and share Environment information and experiences. Correct Level of Facilitators must adapt course contents Course Difficulty to the right level of difficulty to be challenging, but capable of being understood by trainees For example, to remain challenging, facilitators should ensure course content does not involve a needless repetition of skills and knowledge trainees already have. If the content is too easy, trainees will not be stimulated to learn. If the course content is too difficult and involves training on knowledge or skills that are not of practical use to participants, trainees are likely to become frustrated and lose interest. Facilitators should provide participants with feedback on their performance throughout the course. The evaluation tools such as pre-and post tests and demonstration of skills at the end of each module are designed to assist facilitators in providing participants with constructive feedback on their performance.

Practical

Require Respect

How Facilitators can be Effective Teachers In order for training to be successful, facilitators must create a stimulating environment and present materials in an interesting way. Four elements which influence adult trainees to learn are:

Feedback

2.

Reinforcement

90% of what they see, hear, say and do

Reinforcement or feedback is an important technique for facilitators when teaching trainees new knowledge and skills. Positive reinforcement improves learning. For example, asking questions, praising participation, being warm and friendly, and only providing criticism of performance in a constructive way. Examples of positive feedback statements include good work, that is a good question or excellent example. If providing negative feedback, it is best for facilitators to start with what has been done correctly. Facilitators should provide specific information on why a trainee is not doing something correctly, and ways in which they can improve. If giving negative feedback, try not to do this in front of the rest of the group as this may discourage the trainee and make them resistant to learning. For example, if providing negative feedback to a trainee who has incorrectly demonstrated how to move a bedridden client, take them aside and say something like, Good. The way in which you helped the person to roll over is done very well, but you have not provided the client with enough support while in the sitting position. In order to help them maintain balance and avoid falling over, you should stand in front of the client and hold both of their shoulders while in the sitting position.

For this reason, the Training Manual for HIV and AIDS for Community Health Volunteers have been designed for facilitators to give short, mini-lectures (hear) with visual aids and handouts (see) followed by activities that allow participants to discuss the topic (say) and practice the new skill (do).

4.

Transference

Transference is when trainees have the ability to apply or practice what they have learnt in a new setting. Successful transference occurs when participants have successfully retained the knowledge and skills they have been trained on. Training Methodology As briefly reviewed in the previous section, the training methodology of the training package has been designed to support adult learning. Session Outlines Each of the modules in the training package is structured in sessions, during which important information under the session topic discussed. At the beginning of each session, facilitators are provided with a session outline that covers: The purpose of the session. The objectives for trainees following session training. The approximate duration of the session. Any required materials for conducting session activities; and The body of discussion that facilitators should focus their session.

3.

Retention

One of the most important roles for facilitators is to ensure that trainees learn and retain the knowledge and skills taught. Trainees retain information through: - 20% of what they hear - 30% of what they see - 50% of what they see and hear - 70% of what they see, hear and say

Session Content Session content provides facilitators a guide of the lecture content and activities to be used in the training environment.

1. Topic Headings Topic headings are provided to give facilitators a guide of the topic of discussion and the approximate time that should be taken to complete the mini-lecture and any activity related to that topic. 2. Mini Lectures Each topic heading is followed by information that should be provided to participate during mini-lectures. This information is not designed to be read directly from the manual, but to provide a guide of key information to be imparted by facilitators. 3. Important Terms Each session contains a number of important terms that facilitators should know prior to training. The important terms in each session are indicated in bold font within the content. A glossary of all important terms is provided at the end of this guide. Facilitators should review the glossary and refer to it during training if a review of important term is necessary. 4. Tools Tools in each session represent activities designed to engage participants in group discussions, activities, games, demonstrations or role-plays related to the topic of discussion.

Participant Evaluation Following the completion of the training, participants will have the opportunity to be evaluated. Criteria for Evaluation The criterion for evaluation for the training involves a combination of two types of assessment. 1. Post-Test Knowledge 2. Demonstration of Core Skills In order to pass evaluation, participants must achieve a minimum of 50% pass on the post-test and a minimum level of performance to enter practice in core skill assessment. Participants failing to achieve a 50% pass on either or both of the criteria for evaluation should be provided with 3 opportunities to pass evaluation exercises for each module. For example, a participant unable to answer more than 50%, or more than half, of the questions on a post-test correctly should be allowed to re-take the same test three times in order to achieve a passing mark. In the case of core skill assessment, if a participant is unable to demonstrate a minimum level of performance on a skill, facilitators should provide specific feedback for improvement and the participant should be given three opportunities to demonstrate. The intention of training for participants is to develop the knowledge and skills required to assist with HIV management at the community level, and NOT to exclude or discourage participants from continuing their good work. Facilitators should provide participants with any support or additional instruction required in order to pass evaluations. For example, facilitators should provide participants displaying difficulty in achieving a pass on the post-test evaluation with additional instruction areas of knowledge that have not been fully

comprehended. In the case of core skills, facilitators should provide participants with additional coaching and demonstration so that they may successfully demonstrate any competency they are having difficulty mastering. Pre and Post Test Administration A Pre- and Post-Test has been designed for this training. Preand Post-Tests are not intended to measure individual skills, but to capture the individual learning success of participants on important concepts in this training. To achieve a 50% pass in post-test evaluation, participants must provide correct answers to a minimum of 50% of questions asked. Core Skill Evaluation Facilitators should remember that varying degrees of skill are observed at different points in time in a CHVs work. Usually, successful skills demonstration occurs when an individual enters practice at a novice level. Therefore, evaluation of core skills for the training represents a facilitators judgment that the participant has achieved the minimum level of performance to enter practice of each core skill. However, it is expected that participants will continue to develop and improve upon these skills over time. The activities used to assess core skills are provided in this training. Facilitators can recognize a core skill activity within the module content by the formatting of the tool. As the intention of training is to provide participants with the relevant knowledge, attitude, problem solving and skills transfer capabilities required to assist and support community-based HIV management: Facilitators should review the core skills required for evaluation at the beginning of training for each module

Participants will have the opportunity to practice the core skill during training by completing the activity as it is covered in the session content. Facilitators should remind participants that these activities are core skills and provide participants with constructive feedback on how their performance can be improved during training, to help ensure a satisfactory demonstration of this skill in assessment at the end of the training.

Training Content Session Session 1 : Getting to Know each Other Session 2 : Leveling of Expectations & Introduction to the Course Session 3 : Pre Test / Self Assessment Survey Session 4: Introduction to Reproductive Health Session 5 : Defining HIV and AIDS Session 6 : HIV and AIDS in our Community Session 7 : HIV Transmission Session 8 : Preventing HIV Transmission Session 9 : HIV Testing and Counseling Session 10 : Stigma and Discrimination Session 11 : Community Based HIV and AIDS Psychosocial Support Session 12 : Community Based HIV and AIDS Dissemination Session 13 : Action Planning Session 14 : Post Test / Evaluation Session Length

Session 1: Getting to Know each Other Purpose: The purpose of Session One is to provide opportunity to facilitators and participants to get to know each other. Objectives: By the end of this session, CHVs should be able to: 1. Familiarize itself to other participants 2. Build rapport to work with each other Duration: 1 hour Required Materials: Depends on the selected activity by the facilitator ------------------------------Discussion-----------------------------Suggested Activity: Facilitator will prepare cut outs (e.g. pictures or shapes cut into two) and distributed to the participants, The facilitator then provide instruction to participants to find their partner among the group. The participants is given 10 minutes to ask each other about their partners respective background. Facilitator then provides opportunity to all partners to introduce one another to the group. This session will still depend on the kind of activity the trainer will select to implement. It is very important that all participants will be able to meet each other and introduce themselves to one another.

Session 2: Leveling of Expectations & Introduction to the Course Purpose: The purpose of Session Two is to identify expectations of participants and to provide them with the overview of the course. Objectives: By the end of this session, CHVs should be able to: 1. Relate their expectations of the training with what the training can provide them Duration: 1 hour Required Materials: Metacards, Pentel Pen ------------------------------Discussion-----------------------------Suggested Activity: Divide the group into 2-3 groups, provide them with 4 colors of meta cards. Ask them to think of keywords that will best represent their expectations regarding the following category: Training, CoParticipants, Facilitators & House Rules. Facilitators can give 10 minutes for the group to brainstorm, each group can provide 2-3 terms for each category. Each group should assign a reporter to discuss the groups key expectations After all the groups sharing, the facilitator now review the key expectations by running through all the key terms. The facilitator then relates it to the training by addressing some of the concern especially by re enforcing expectations towards the participants and facilitator. The facilitator should also clearly relate the expectations to the training to what will be its scope. This session could end by explaining the goal and key objectives of the training.

Session 3: Pre Test / Self Assessment Survey Purpose: The purpose of Session Three is to assess the baseline knowledge and prevailing attitudes of the participants regarding the focus of the training. Objectives: By the end of this session, CHVs should be able to: 1. Assess their baseline knowledge regarding HIV and AIDS 2. Identify their prevailing attitudes towards HIV and AIDS Duration: 30 minutes Required Materials: Pre Test Sheet ------------------------------Discussion-----------------------------Conducting a pre test survey allows the facilitator to gauge the level of knowledge and prevailing attitudes to HIV and AIDS of the participants of the training. This information can guide the facilitators on how the training sessions can be modified or adapted so as to maximize the participants opportunities for learning. Provide a copy of the pre test to all participants, provide them with 10-15 minutes to answer the questions being asked. Facilitator will need to check the pre test during free time to determine the status of all participants. There is no need to discuss the answers at this point because a post test shall be given towards the end of the training. See Annexes for answers.

Session 4: Introduction to Reproductive Health Purpose: The purpose of Session Four is to provide an overview on Reproductive Health. Objectives: By the end of this session, CHVs should be able to: 1. Know about the reproductive health, its definition and scope. 2. Differentiate gender from sexuality. 3. Identify the parts & functions of the male and female reproductive organs. 4. Demonstrate ease in using words to describe sexual reproductive parts. Duration: 1hr Required Materials: Manila Paper, Pentel Pen, Crayons ------------------------------Discussion-----------------------------Facilitator shall start by asking participants about their understanding by the term Reproductive Health. After gathering reactions from the group, he/she then defines it using prescribed definition. Facilitator will also ask participants about their understanding on Sexuality and Gender. After gathering reactions from the group, he/ she then defines the two terms using the prescribed definition. A group activity can be organized after the discussion by dividing the group into two. Ask them to draw and label the male and female reproductive system. Ask them to assign a group member to report their output by identifying also the functions of major parts of the reproductive system. Finalize their output by reviewing their drawings and labels, try to reinforce the functions of all major parts of the reproductive system in the discussion.

Session 5: Defining HIV and AIDS Purpose: The purpose of Session Five is to define HIV and AIDS and understand the progression of HIV infection to AIDS. Objectives: By the end of this session, CHVs should be able to: 1. Understand and define HIV and AIDS for clients in a simple way. 2. Explain to clients how HIV and AIDS affect the body, in an easily understood manner. 3. Explain the progression of HIV into AIDS. Duration: 1 hour and 30 mins Required Materials: Flipchart, markers

------------------------------Discussion-----------------------------Defining HIV and AIDS a) Broad Definition: Human Immunodeficiency Virus HIV is the virus that causes AIDS. It attacks the immune system - the body's defense against disease. HIV is found in blood, breast milk, semen and vaginal fluids. HIV is a virus that attacks the body and makes it weak. When the body is weak, it is easier to get coughs, diarrhea, fever and other health problems. The immune system is the body's defense system against diseases. White blood cells called lymphocytes play an important role in helping the body's immune system. CD4 cells are a special type of lymphocyte. In HIV infection, the virus attacks the immune system. HIV destroys the special CD4 cells, and it is the loss of CD4 cells that leads to the weakening of the immune system. b) Broad Definition: Acquired Immune Deficiency Syndrome

AIDS is the name given to a group of illnesses in HIV positive people. These are illnesses that arise when PLWHA are no longer able to fight off infection because of lowered immunity. Understanding the Acronym: Acquired means a disease you get during life rather than one you are born with. Immune Deficiency means a weakness in the body's immune system. Syndrome means a group of particular health problems that make up a disease. The Progression of HIV Infection to AIDS The progression of HIV to AIDS refers to the time from HIV infection to the time when PLWHA develop AIDS. The progression of HIV to AIDS depends on individual circumstances and environment and is never the same in every person. The progression of HIV to AIDS consists of six major phases: 1. HIV Infection 2. Window Period 3. Seroconversion 4. Asymptomatic Stage 5. HIV related illness 6. AIDS Stage Description Characteristic 1. HIV Infection The time when HIV is introduced into the body and starts to multiply and spread 2. Window Period The time from HIV infection to the time when the body begins to make detectable antibodies. It lasts approximately 3 to 6 months after HIV infection. During the window phase, HIV infected individuals are infectious. If an individual takes an HIV test during this time, it will come out negative although he or she is HIV positive (called a false negative)

3. Seroconversion The time when a persons blood starts developing antibodies to help fight HIV infection. Seroconversion occurs approximately 6 -12 weeks after HIV infection (when the window period ends. Individual will now test positive for HIV. 30 - 50% of people suffer from a flulike illness during this time (fever, swollen lymph nodes, night sweats, skin rash, headache or cough) 4. Asymptomatic phase Asymptomatic HIV is the period during which a person will test positive for HIV, but does not have any signs or symptoms of the disease. PLWHA can remain asymptomatic for 10-15 years or more. Generally no signs or symptoms, but may be accompanied by swollen glands for a long time without any other symptoms of disease (called persistent generalized lymphadenopathy or PGL by doctors. It is during the asymptomatic phase that people are at greatest risk of transmitting HIV. Because they may look and feel healthy, they may not know that they are HIV positive and may be passing on the virus 5. HIV-Related illness During an HIV-related illness, PLWHA begin to show signs and symptoms of disease. This occurs after the asymptomatic phase and can last from months to years, depending on treatment of Opportunistic Infections and availability of ARVs. HIVrelated symptoms increase due to an increase in the amount of HIV virus in the body and the destruction of CD4 cells and other important immune system functions. During this period people will begin to develop increasing opportunistic infections (weight loss, chronic diarrhea, prolonged fever, thrush and/or pulmonary tuberculosis (TB)) 6. AIDS Acquired Immune Deficiency Syndrome (AIDS) is the life threatening or terminal stage of HIV infection. The immune system is severely weakened in PLWA, and cannot cope with infection. This creates a life threatening condition. Once a person has AIDS, he or she can be expected to live for one to two years if no treatment is available. HIV Wasting Syndrome unexplained weight loss greater than 10%, chronic diarrhea for longer than one month and chronic fever for longer than one month. A CD4 count of less than 200 Life threatening infections and cancers develop such as:

 Severe lung infection Severe infection of the eyes. Fungal infections that cause thrush in the mouth, or infections As time progresses, the hearts (CD4) decrease and the circles (HIV) increase. When the hearts go down and the number of circles goes up, more problems arise. When more circles exist, infections become more serious and last long.

Session 6: HIV and AIDS in our Community Purpose: The purpose of Session Six is to understand the magnitude of the epidemic in our country. Objectives: By the end of this session, CHVs should be able to: 1. Impart information to their clients about the magnitude of HIV and AIDS in their own country and community Duration: 2 hours Required Materials: Manila Papers, Markers

------------------------------Discussion-----------------------------Origin of HIV and AIDS in the Community Suggested Activity: Role Play Before you begin to address HIV and AIDS in others, participants need to be aware of their own attitudes about the origins of HIV and AIDS. Ask participants to reflect upon the following for a few minutes: What attitudes does your community have about: 1. The origins of HIV and AIDS 2. People who are HIV positive Now that you have addressed myths and misconceptions about the origins of HIV and AIDS, it is important that participants tell the story of HIV and AIDS in your community. Divide participants into 2 to 3 groups. Provide each group with 15 minutes to develop a presentation that tells the story of HIV and AIDS in your community.

Participants can choose their own method of presentation (through drama, flipchart information), but be sure to address each of the following points in their presentations: 1. When did people in your community first become aware of HIV and AIDS? 2. How did the effects of HIV and AIDS first show themselves in your community? 3. How did people react? HIV and AIDS in our Country Facilitator should present statistics on national and local data including: 1. Estimated national prevalence of HIV infection 2. Breakdown of prevalence in different regions of your country 3. Breakdown of prevalence in different populations (women, youth, level of income) 4. Major mode of transmission and any special factors identified in that country contributing to the spread of HIV (migration patterns, conflictetc.) Facilitators Note: Facilitators should emphasize that HIV and AIDS affect people all over the world. To demonstrate this, facilitators should present current global and national statistics on HIV and AIDS. After reviewing national prevalence of HIV and AIDS in our country, ask participants the following questions: 1. What is the most important thing that clients should know about statistics about HIV and AIDS? 2. How can this information be provided to clients in a way they will understand?

Facilitators Note: Allow participants to explore the following questions, ensuring that they acknowledge the importance of discussing the major mode of transmission, most vulnerable groups for new HIV infection and special factors that are contributing to the spread of HIV in our country. Skills Transfer Activity Suggested Activity: Divide CHVs in 3 groups and contemplate on the 3 core topics below and ask them to make a poster which will best represent the topics. It is important that CHVs are able to explain the information provided in this session to their clients in a manner that will be easily understood. Divide participants into pairs and have each pair take turns explaining the information topics below; 1. Defining HIV and AIDS 2. Addressing rumors and myths about the origin of HIV and AIDS in your Community. 3. HIV and AIDS in your Community and Nation Facilitators Note: To ensure that CHVs are providing accurate information, core skill evaluation should ensure participants address the following points: How HIV Attacks Our Health How your body fights illness HIV is a virus that attacks the bodys immune system (shield) Special white blood cells called CD4 cells are important in helping the immune system shield stay strong AIDS is the condition that results from HIV infection when the bodys shield is so weak that it is no longer able to fight off illness

Rumors and Myths about the Origin of HIV and AIDS Correct any identified rumors and myths about the origin of HIV and AIDS in our community. Discuss with clients and their families how rumours and myth can lead to stigma and discrimination against PLWHA. HIV and AIDS in our Community and Country Major mode of transmission in our country/community. Group with the highest rate of new infection and why they are vulnerable or at risk. Special factors in your community that contribute to the spread of HIV.

Session 7: HIV Transmission Purpose: The purpose of Session Seven is to develop skills and knowledge required to educate community on how HIV is transmitted. Objectives: By the end of this session, CHVs should be able to: 1. Accurately describe the three modes of transmissions to clients and their families. 2. Dispel any myths or misconceptions held by clients about how HIV is transmitted. Duration: 2 hours Required Materials: Manila paper, Markers and Pens ------------------------------Discussion-----------------------------HIV Transmission a) What is the difference between 'transmission' and 'infection'? The transmission of HIV is the process of spreading or contracting HIV through one of the three main modes of transmission (sexual contact, blood transmission, parent-to-child transmission). HIV infection is the result of HIV transmission, where HIV is introduced into the body and starts to multiply and spread. b) How HIV is transmitted Main Modes of Transmission Activity Ask the group to name ways in which they think HIV can be transmitted. Write down each answer provided on several cards (one mode per card) and place them on the wall in a large group. Review these cards after discussing the three modes. Facilitator should write each main mode as headings and cluster each mode provided by

participants into the appropriate category they fall under (e.g., sharing needles into 'Blood Transmission' category). Correct any misconceptions about how HIV is transmitted through answers provided that do not fall into one of the three main modes of transmission. At the end of this activity, facilitators should ask participants how they feel about the information on transmission provided. 1. Unprotected Sexual Contact Is the most common means of transmitting HIV. HIV can be transmitted during unprotected sexual intercourse or through contact with infected blood, semen, cervical or vaginal fluids of the infected person HIV can be transmitted sexually through vaginal sex, oral sex and anal sex The presence of other Sexually Transmitted Infections (STIs) increases the chance of contracting or transmitting HIV. 2. Blood Transmission HIV infected blood gaining entrance to the body through: A transfusion Sharing of contaminated needles, syringes, razors or other sharp objects. Infected blood entering the body through open wounds 3. Mother-to-Child Transmission Mothers can pass HIV to their babies during pregnancy, during delivery, or after birth through breastfeeding. If a pregnant mother is HIV positive there is approximately a 1 in 3 chance her baby will become infected. However, there are ways to decrease this possibility. There are drugs called ARVs that HIV positive mothers can take, and special feeding practices that will help reduce the chance of a mother passing HIV to her child.

Ways in which HIV is NOT transmitted Social Contact Hugging Kissing Shaking hands Breathing the same air, coughs, sneezes Sweat, contact through sport Tears, consoling someone who is crying Sharing Toilet seats Food utensils or drinking cups Clothes Public baths or swimming pools

Insects

Mosquito bites Bed bugs Any other biting insect or animal

Despite all of the fear surrounding HIV and AIDS, HIV is actually a fairly weak virus that is easily destroyed once outside the human body or body fluids. There is no evidence that daily social contact can spread HIV. Because people can contract malaria from mosquitoes, a common myth is that HIV can be transmitted through mosquitoes or other bloodsucking insects. When a female mosquito bites a person, the blood containing HIV is stored in the insect's digestive tract where it is digested and killed. Unlike the malaria parasite, which moves from the digestive tract of a mosquito back into the salivary duct, HIV does not do this. HIV cannot be transmitted through bug bites of any kind, or through flies landing on an open wound and then landing on food or another open wound.

Main Modes and Myths of Transmission Game Read out each of the modes and myths listed below. Ask participants to move to one side of the room on items with which they agree and to the other side with those they disagree. If they are unsure, they can remain in the centre of the room. After all participants have moved to either side for each item, the facilitator asks a member of each group why they chose that side. Read the following aloud without indicating whether they are a 'mode or a myth': Modes of Transmission: Unprotected sexual contact Pregnancy, Delivery, Breast feeding Sharing contaminated needles Myths of Transmission: Kissing Sharing bath water Drinking from the same cup Mosquito Bites Facilitator's Note: At the end of the activity, facilitators should make sure to address any additional myths of transmission. Myths should be corrected through the provision of factual information and a review of the three modes. Factors Affecting Transmission Factors that Increase Risk Risk can be thought of as things that you do tha t might increase the chances of transmitting or contracting HIV. Unprotected Sexual Contact All unprotected sexual contact (oral, anal and vaginal sex) will enhance ones risk for HIV infection The swelling or rupture of wounds on genitals caused by STIs increases risk of infection during unprotected sexual contact

Drug Abuse and Alcohol Consumption Drug use and alcohol consumption increases risky behaviors that can lead to HIV transmission Sharing contaminated needles increases the risk of HIV transmission. Multiple Sexual Partners and/or Casual Sex Not knowing your HIV status or that of your partner places you at risk for HIV infection Individuals who have multiple sexual partners or engage in casual sex frequently are at greater risk of HIV infection When one or both partners are not faithful the risk of HIV infection increases for the individual and their sexual partners. Factors that Increase Vulnerability Vulnerability can be thought of as the environmental aspects influencing who you are that may impact your risk of transmitting or contracting HIV. The concept of vulnerability recognizes that due to their situation, some people may have limited choice about whether or not they can reduce behaviors that might put them at risk for HIV infection. For example, certain groups of people such as sex workers, men who have sex with men (MSM), and injecting drug users (IDUs) have long been regarded as being particularly exposed to "high risk" and, therefore, more vulnerable to HIV infection. Other factors that can increase vulnerability include: 1. Social Mobility HIV and AIDS often follow routes of trade and commerce (trucking routes, cross border trading). Mobile populations can be at greater risk to HIV infection because they may not have a regular sexual partner. Sex work can also follow routes of trade and commerce, increasing risk of HIV infection among both sex workers and their clients. 2. Stigma and Denial Because of stigma and denial, people may not make use of HIV Testing and Counseling services to become aware of their status, or know the status of their partner.

3. Conflict HIV spreads more easily in times of war or conflict Rape, use of sex workers and inadequate health care are situations worsened through war, which contribute to the spread of HIV. 4. Culture Culture includes traditions, beliefs and practices that can influence the way people think and behave Cultural traditions such as wife inheritance, polygamy, rites of passage and genital mutilation can increase risk if people are not well informed on how to reduce transmission of HIV through safe practices. Culture can promote denial or stigma of PLWHA. 5. Gender Gender inequalities increase the vulnerability of women to HIV infection (a woman's ability to negotiate for safer sex or refuse sex, women forced to engage in transactional/intergenerational/commercial sex). Abuse of young girls or boys. 6. Poverty Poverty reduces people's ability to access accurate information on HIV/AIDS and how to protect themselves Poverty can force women into transactional sex to meet basic needs, increasing their vulnerability to HIV People living in poverty cannot always access medical care that reduces the risk of transmission. Understanding HIV Transmission in Our Community Knowledge: Not everyone knows about HIV; myths circulate around communities that are not correct, people learn about HIV not just from accurate sources but from many different sources Belief about personal risk: Some people think that HIV only affects sex workers, injecting drug users (IDUs) or men who have sex with men (MSM); people do not like to think that they might be at risk from their husband, so they deny it; people invent convenient stories to

believe that they are safe 'I only have a few local girlfriends, I don't visit sex workers' Means to protect themselves: Some people cannot access condoms. They might be too young and shops won't sell condoms to them. They might be poor, or they do not want to carry condoms around in case someone sees them. Clean needles might not be available in their area, or they are scared to go and get them. Skills: They might not know how to use a condom properly might be using two or three for added protection, they might not be able to ask for safe sex, assert themselves, and they might only have sex after they have been drinking alcohol. Power: Not everyone is in a situation where they are in control of whether they have safe sex or not. Wives may not be able to insist that their husband uses a condom when he returns for a work assignment; condom use in sex work might be dictated by the owner of the brothel or by the client, not by the sex worker; people who drink too much alcohol might lose their ability to make a good safe decision; a sex worker who needs money to buy food for her children may not be in a position to refuse unsafe sex

Session 8: Preventing HIV Transmission Purpose: The purpose of Session Eight is to develop the skills and knowledge required to educate clients on how HIV infection can be prevented. Objectives: By the end of this session, CHVs should be able to: 1. Explain to clients how they can make use of the 4 methods of preventing HIV transmission discussed in this session. Duration: 2 hours Required Materials: ------------------------------Discussion-----------------------------Methods of Preventing HIV Transmission The following are factors that decrease the risk of HIV transmission: 1. Safer Sex Abstinence (not having sex at all). Correct and consistent use of condoms - male and female condoms. Delaying sex is important in young people who may not be prepared or able to negotiate safer sex Having sex in a faithful monogamous (one partner only) relationship protects partners from contracting or transmitting HIV if they are not exposed to HIV through drugs or other activities. Avoid having multiple partners and/or casual sex Being aware of your partner's HIV status and taking necessary precautions 2. Prevention of Mother to Child Transmission (PMTCT) PMTCT involves methods that help prevent a mother passing HIV on to her baby during pregnancy, child birth or breastfeeding

3. Harm Reduction Harm Reduction is a term used to describe activities aimed at preventing or reducing negative health consequences associated with certain behaviors. It is important for CHVs to understand that harm reduction does not involve either supporting or opposing behaviors that increase risk, but focuses on reducing harm among those who may be either unwilling or unable to stop risk behaviors, even if it is illegal in your country. 4. Precautions against Infections CHVs need to take steps to ensure no contact with blood and body fluids. Keeping sterile medical equipment and taking all possible measures to avoid disease transmission and for self protection are called 'Universal Precautions' and should be used in every caring situation, whether you know your client's HIV status or not. Universal precautions not only help prevent the spread of HIV, but other infectious illness Do not share needles, toothbrushes, razor blades or other sharp objects. Cover any open cuts or sores on clients, partners or caregivers. Clean up any blood or body fluid with mild disinfectant (diluted bleach), and protect hands with gloves or plastic bags. Wash clothes or linen with blood or body fluid on them separately. Dispose of waste contaminated with body fluids safely. If Caregivers Feel They Have Been Exposed to HIV Infection They Should: Immediately wash skin or wound entry point with soap and water, then wash the area out with saline or mild disinfectant Report to their local health facility immediately if PEP is available. Post Exposure Prophylaxis (PEP) is antiretroviral drugs (ARVs) that are taken after exposure to HIV transmission by blood or body fluid contact with an infected person. These drugs should be taken within 72 hours from the time of exposure to HIV infection.

Session 9: HIV Testing and Counseling Purpose: The purpose of Session Nine is to provide knowledge and skills required to give clients an overview of the purpose and process of HIV Testing and Counseling. Objectives: By the end of this session, CHVs should be able to: 1. Identify ways that CHVs can help reduce barriers to HIV testing and counseling in the community. 2. Provide clients with accurate information about confidentiality 3. Impart accurate information to clients regarding special considerations for HIV Testing and Counseling Duration: 2 hours Required Materials: ------------------------------Discussion-----------------------------What is HIV Testing and Counseling What is a HIV test? A HIV test is a test that reveals whether HIV is present in the body. Commonly-used HIV tests detect the antibodies produced by the immune system in response to HIV, as it is much easier (and cheaper) to detect antibodies than the virus itself. Antibodies are produced by the immune system in response to an infection. For most people, it takes three months for these antibodies to develop. In rare cases, it can take up to six months. During this window period of early infection a person is at their most infectious.

How long after possible exposure should I wait to be tested for HIV? Generally, it is recommended that you wait three months after possible exposure before being tested for HIV. Although HIV antibody tests are very sensitive, there is a 'window period' of 3 to 12 weeks, which is the period between infection with HIV and the appearance of detectable antibodies to the virus. In the case of the most sensitive anti-HIV tests currently recommended, the window period is about three weeks. This period may be longer if less sensitive tests are used. During the window period, people infected with HIV have no antibodies in their blood that can be detected by an HIV test. However, the person may already have high levels of HIV in their body fluids such as blood, semen, vaginal fluids and breast milk. HIV can be passed on to another person during the window period even though an HIV test may not show that you are infected with HIV. Why should I get a HIV test? Knowing your HIV status has two vital benefits. Firstly, if you are HIV positive, you can take necessary steps before symptoms appear to access treatment, care and support services, thereby potentially prolonging your life for many years. Secondly, if you know you are infected, you can take all the necessary precautions to prevent the spread of HIV to others. Thirdly, your health care provider may recommend it, for example if you are pregnant and want to protect your unborn child. It may also be recommended by your health care provider if you are unwell, in order to obtain a more accurate medical assessment.

Where can I get tested? Thru the VCT sites. There are many places where you can be tested for HIV: in the offices of a private doctor, a local health department, hospitals, family planning clinics and sites specifically set up for HIV testing. Always try to find testing at a place where counselling is provided. Are my test results confidential? The results of the HIV test must be kept absolutely confidential. Consent Before you take a HIV test you must give informed consent prior to being tested. Ideally it is given individually, in private, in the presence of a health care provider. This means your health care provider should provide certain pre-test information to you and give you the opportunity for your questions to be answered. Confidentiality There are different types of testing available: Confidential HIV test: the medical professionals handling the HIV test keep the result of the test confidential within the medical records. Results cannot be shared with another individual unless written permission is provided by the person tested. Shared confidentiality is encouraged and refers to confidentiality that is shared with others that might include family members, loved ones, caregivers, and trusted friends. However, care should be taken when revealing the results as it can lead to discrimination in healthcare, professional and social settings. Shared confidentiality is therefore at the discretion of the person who will be tested. Although the result of the HIV test should be kept confidential, other professionals such as counsellors and health and social service workers might also need to be aware of the person's HIV-positive status in order to provide appropriate care.

Counselling Every person who takes a HIV test must receive counselling when their test results are given, regardless of the test result. You should have access to post test counselling regardless of the result of the HIV test. Pre test counselling was a core component of the original voluntary counselling and testing which was designed to assist clients to assess other personal risks and to identify practical strategies to cope with their test results. This model sees counselling and testing as both a primary and secondary prevention strategy (reducing risk of HIV exposure and onward transmission). However, in many settings pretest group information now replaces individualized pre-test counselling. What does it mean if I test negative for HIV? A negative test result means that no HIV antibodies were found in your blood at the time of testing. If you are negative, make sure you stay that way: learn the facts about HIV transmission and prevention avoid engaging in unsafe behaviour. However, there is still a possibility of being infected, since it can take up to three months for your immune system to produce enough antibodies to show infection in a blood test. It is advisable to be re-tested at a later date, and to take appropriate precautions in the meantime. During the window period, a person is highly infectious, and should therefore take measures to prevent any possible transmission.

Session 10: Stigma and Discrimination Purpose: The purpose of Session Ten is to provide knowledge required for CHVs to understand Stigma and Discrimination. Objectives: By the end of this session, CHVs should be able to: 1. Acquire relevant knowledge to understand stigma and avoid discrimination Duration: 2 hours Required Materials: Depends on the facilitator

Session 11: Psychosocial Support Purpose: The purpose of Session Twelve is to develop an understanding of what psychosocial support means and the role of CHVs in psychosocial support for HIV and AIDS . Objectives: By the end of this session, CHVs should be able to: 1. Describe what psychosocial support is and is not and why it is important for PLWHA in their community 2. Discuss issues of confidentiality CHVs may face in their community and how they can be dealt with 3. Refer clients and families to appropriate services to meet psychosocial needs. 4. Demonstrate an understanding of the role of CHVs in psychosocial support for HIV and AIDS. Duration: 2 hours Required Materials: Flipcharts, Manila Papers, Markers ------------------------------Discussion-----------------------------This session will be highlighted with specific lectures combined with activities using the prescribed presentations. Role plays on specific scenarios in the field is also encouraged.

------------------------------Discussion-----------------------------Facilitator can choose to invite a resource speaker that can effectively share information & personal experiences regarding stigma & discrimination. Facilitator can choose also to discuss this topic using the prescribed presentation and using a video presentation with a combined activity.

Session 12: Community Based HIV and AIDS Dissemination Purpose: The purpose of Session Eleven is to develop skills of CHVs in the conduct of awareness dissemination in the community. Objectives: By the end of this session, CHVs should be able to: 1. Conduct an organized/mock dissemination activity Duration: 3 hours Required Materials: Manila Papers, Pentel Pen, Crayons ------------------------------Discussion-----------------------------Facilitators are expected to organize an activity wherein CHVs will return demonstration their knowledge & skills on HIV. It could be in the training or in an arrange activity outside.

Session 13: Action Planning Purpose: The purpose of Session Thirteen is to develop necessary plans in carrying out the HIV and AIDS disseminations in the Community Objectives: By the end of this session, CHVs should be able to: 1. Identify appropriate and realistic activities in carrying out awareness dissemination thru an action plan. Duration: 1 hour Required Materials: Manila Papers, Pentel Pen ------------------------------Discussion------------------------------

Workplan Chapter: Objective: Strategies/Activi ties Resource Requireme nt Time Fram e Person Responsib le Partner Organizatio ns

Session 14: Post Test / Evaluation Purpose: The purpose of Session Fourteen is to assess the level of acquired knowledge & attitudes in the training and to evaluate the conduct of training according to the participants perspectives. Objectives: By the end of this session, CHVs should be able to: 1. Assess their acquired knowledge regarding HIV and AIDS 2. Improve their prevailing attitudes towards HIV and AIDS 3. Evaluate the conduct of the training Duration: 1hr mins Required Materials: Post Test Sheet, Evaluation Sheet ------------------------------Discussion-----------------------------Towards the end of the training the facilitator needs to conduct a post test survey which will allow facilitators to gauge the level of acquired knowledge and attitudes to HIV and AIDS of the participants of the training. The results of the post test can guide the facilitators on how the training was effectively carried out and give points to him/her who among the CHVs did learn or not. Provide a copy of the post test to all participants, provide them with 10-15 minutes to answer the questions being asked. Facilitator needs to check the post test right after they have passed their sheet. Facilitator needs to discuss the answers at this point to clarify all the questions that were given. An evaluation of the training shall be also be done, using the evaluation form (see annex). Allow participants to accomplish the form 10-15 minutes. This will provide feedback on the conduct of the training, on the participants perspectives. Evaluation forms shall be collated after the training.

Suggested Activity A simple feedback can be initiated, wherein the participants can share their insights on the training, venue, facilitators, food etc. Using a ball of yarn, the facilitator passes it to the first participant to share insights, the participants then passes it to another participants until everybody has given their insights.

Annexes

Self-Assessment Survey KNOWLEDGE ON HIV AND AIDS Questions 1. 2. 3. HIV attacks the immune system of a person. You can tell if a person has HIV infection by simply looking at him/her. The following body fluids are possible medium of HIV infection. a. Blood b. Urine c. Saliva d. Semen e. Sweat f. Tears g. breast milk The following are the modes of transmission of HIV: a. Blood transfusion b. Mosquito bites c. Pregnancy d. Kissing e. Hugging f. sexual intercourse g. sneezing and coughing h. sharing eating utensils and glasses i. sharing of needles and syringes among injecting drug user Abstinence from sex is the only way of preventing HIV transmission. A person who has only one sexual partner is free from risk of HIV infection. True False Dont Know

4.

5. 6.

7. 8. 9.

Taking antibiotics before having sex can prevent HIV infection. There is a cure for HIV infection and AIDS The HIV antibody test can tell if a person has HIV infection a month after the person has acquired this infection.

10. A negative result in an HIV antibody test is possible even in persons with HIV infection

ATTITUDES ABOUT HIV AND AIDS 1. 2. 3. 4. 5. 6. 7. 8. Questions HIV Human Transmission is more related to things that people do than to which group they belong. HIV transmission is rooted in individual behavior alone. HIV transmission is rooted in social condition alone. HIV transmission is rooted in both individual behaviors and social conditions. HIV affects only those who engage in promiscuous behaviors. It is not necessary to agree with peoples behavior in order to be of service to them. I would feel uncomfortable giving service to people living with HIV and AIDS regardless of how she/he became infected. It is necessary to give people correct and accurate information about all the ways to prevent transmission of HIV. Agree Disagree

Training Course Evaluation To help us improve the conduct of future trainings, please answer the following questions. We would appreciate your honest response. 1. How do you find the following sessions? Please check the corresponding column of your answer. Least Useful Session 1: Introduction/Getting to Know each Other Session 2: Leveling of Expectations Session 3: Pre Test/Self Assessment Survey Session 4: Introduction to Reproductive Health Session 5: Defining HIV and AIDS Session 6: HIV and AIDS in our Community Session 7: HIV Transmission Session 8: Preventing HIV Transmission Session 9: HIV testing and Counseling Session 10: Stigma and Discrimination Session 11: Community Based HIV and AIDS Psychosocial Support Session 12: Community Based HIV and AIDS Dissemination Session 13: Action Planning Session 14: Post Test and Evaluation 2. Do you think the course was: Too long Too short Useful Most Useful

3.

Were there topics that you have wanted the speakers to discuss in greater depth? Yes No If YES, please specify.

4.

Where there topics that you think should have been omitted? Yes No If YES, please specify.

5.

Did you find the learning methods helpful? Yes No If YES, in what way? (Please provide further comments below.)

Just right

6.

Was there a logical sequencing of the sessions? Yes No If NO, please provide suggestions on how to improve it.

9.

Please rate the training course in terms of its over-all conduct. Needs Very Fair Good Excellent Improvement Good

Other Comments:

7.

Were the trainers well prepared? Yes No If YES, please provide further comments below Thank you very much!

8.

Were the trainers easy to understand? Yes If NO, please elaborate.

No

Glossary of Terms Acquired Immunodeficiency Syndrome (AIDS): the name given to a group of illnesses in HIV positive people. These are illnesses that arise when people living with HIV are no longer able to fight off infection because of lowered immunity. Active listening: a counseling skill that involves paying close attention to what a client is telling you and showing the client that you are paying attention. Adherence: means sticking to or being devoted to something. In ART, adherence involves taking medications in the correct amount, at the correct time and in the way they are prescribed. Analgesics: the broad name given to medications used to treat physical pain. Analgesic Ladder: a tool developed by the World Health Organization (WHO) to help people determine when to increase and decrease pain medication and what kind of pain medication to give. Anticipatory Grief: grieving of both clients and their families once they realise he or she has an incurable illness. Anti Retroviral (ARV): drugs used to treat HIV. Anti Retroviral Therapy (ART): a term used to describe giving ARV drugs in the correct way, with adherence support Asymptomatic: not showing any symptoms of an illness or disease. Bedsores: the name of wounds of the skin that result from lying in one position for too long. Also called pressure sores, bedsores result from constant pressure on a particular part of the body. Bereavement: a term used to describe the loss of something of value and grief associated with that loss.

Biological Markers: methods of measuring adherence that involve testing levels of viral load (called a viral load assay) or the amount of drugs in a person's blood (called Therapeutic Drug Monitoring, or TDM). By the Clock: a method of treating chronic pain that involves giving pain medications in the appropriate doses at the appropriate times in an attempt to provide continuous relief of pain. By the individual: a step in treating pain that involves giving each client's pain medication according to their needs and ensuring that both PLWHA and their families understand when and how pain medications should be taken. By the Mouth: a recommendation for treating pain that encourages clients to take analgesics by the mouth whenever possible. Caregiver Burnout: a term used to describe the state resulting from stress that is built up over time until a caregiver is no longer able to cope. Caring for Carers: a term used to describe recognizing that caring can produce stresses and strains on caregivers. Caring for carers involves ensuring the mental and physical well-being of people who provide care in the community and helping caregivers to relieve stress and lead a healthy lifestyle. CD4: a common name for a type of white blood cell that fights infection that is destroyed by HIV. The more CD4 cells a person has, the healthier he or she is. CD4 Count: The amount of CD4 cells in a person's blood is used to test for AIDS, and often used to determine when to start ART. The CD4 count can be used as a clinical marker to follow the progression of the disease over time.

Checking Questions: questions which allow counselors to find out how much a client has understood and what topics need further information or explanation. Client Initiated (HIV Tests): when people seek out a facility through which they can take an HIV test, is often referred to as voluntary counseling and testing. Closed Question: a type of question which requires a one-word, often 'yes' or 'no', answer only. Co-infected: a term used to describe being infected with two things at once. In terms of HIV and AIDS, 'co-infected' is a common way to describe people who are infected with HIV and Tuberculosis (TB) at the same time. Combined Therapy (also called Fixed-Dose Combination): a combination of more than one ARV in a single tablet. Combined therapy is aimed at helping PLWHA on ART take fewer pills in a single day. Community Mobilization: involves ensuring a supportive environment for PLWHA before they start ART. Community Preparedness: a term used to describe providing support and breaking down barriers for successful interventions in a community (such as ART roll out). Confidentiality: the obligation owed by one person to another, not to disclose information given by or about another or the obligation to disclose it only in limited circumstances. Confidentiality means any information shared between two people is not revealed to anyone else without consent. Continuity of Care: one of the general principles of good care for PLWHA which involves ensuring that care for PLWHA remains consistent over time Continuum of Care: all aspects of caring for clients linked to different levels of care. Palliative care is thought of as a continuum of care.

Coping Mechanisms: a term used to describe thoughts or activities that people use to deal with stress. Coping Strategies: methods of reducing stress and preventing burnout that involve 'acting' on a person's stress by gathering and using information, planning and taking real steps to help that person cope. Cotrimoxazole or CTX: a commonly prescribed prophylaxis for people living with HIV and AIDS. Counseling: a confidential dialogue that involves an interpersonal relationship between a person or group of people seeking help on a problem(s), and someone to assist in solving the problem. Counseling process: steps that CBVs can take to prepare, begin, conduct and end a successful counseling session. Counseling skills: techniques used by counselors to communicate well with clients and develop a good counselor/client relationship. These skills include listening, questioning, being non-judgmental and empathetic. Counselor: a term to describe a person who has developed special skills and experience in helping people work through their problems. Culture: the beliefs, practices or values of a group of people. Cyclical relationship: a type of relationship where one problem causes or improves/worsens the other. The relationship between poor nutrition and HIV is cyclical. Dehydrated: a term used to describe the result of losing water from the body through sweating, fever, diarrhea or vomiting. Denial: when someone chooses to ignore or disbelieve the facts. People often go through denial when they do not want to accept the reality of a difficult situation.

Depression: a common term to describe feeling very sad or discouraged. Diagnostic Testing (for HIV): when an HIV test is conducted by health professionals when trying to determine the cause of an illness. Diarrhea: a condition in which watery stools are passed three or more times a day. Dietary management of symptoms: using food and nutritional practices to help manage HIV and AIDS related illness. Dietary management involves adjusting food intake to help people cope with the complications of HIV and opportunistic infections. Directly Observed Therapy (DOT): a method for measuring and enhancing ART adherence that involves doctors or other medical staff being with a client when they take their medication. Disclosure: the process a person living with HIV goes through to tell others about their HIV status. Discordant Couple: when one partner tests HIV positive and the other HIV negative. Discrimination: a term used to describe treating other people differently or unfairly because they are different from others. Dual Method: when a second method of contraception is used along with condoms for added protection against pregnancy. Dual Protection: use of condoms to protect from STIs, re-infection by HIV and to avoid transmission to sexual partners and undesired pregnancies. ELISA: a type of HIV test Empathy: a term used to describe trying to understand a situation from another person's point of view and showing that you care.

End of Life Care: helping a dying client with the physical, emotional, social and spiritual support and comfort they need during the end stages of life. Exclusive breastfeeding: when a mother ONLY breastfeeds her child breast milk for the first few months of life. Exclusive replacement feeding: when a mother only feeds her baby alternative feeds such as formula but no breast milk from birth. First-line regimen: the name given to a combination of three ARV drugs used 'first' to treat HIV. Food safety: a term used to describe keeping food safe from contamination or spoiling so that it is healthy to eat rather than a source of infection. Food security: the ability of people to access and afford enough food to meet their nutritional needs and live a healthy and productive life. Grief: a term used to describe the feelings of pain and loss during bereavement. Grief affects people physically, mentally and spiritually Harm Reduction: a term used to describe activities aimed at preventing or reducing negative health consequences associated with certain behaviors. Highly Active Antiretroviral Therapy (HAART): a combination of three antiretroviral drugs used to treat HIV and AIDS. Human Immunodeficiency Virus (HIV): the virus that causes AIDS by weakening the body's immune system. HIV Related Illnesses: illnesses that PLWHA contract as a result of lowered immunity. HIV infection: the result of HIV transmission, where HIV is introduced into the body and starts to multiply and spread.

HIV Testing and Counseling: a broad umbrella term that indicates the different ways of being tested for HIV. HIV Transmission: the process of spreading or contracting HIV through one of the three modes of transmission (sexual contact, blood transmission, mother-to-child transmission). Informed Consent: means that an individual has been given important information, has fully understood what has been discussed, and based on this agrees to undergo a medical procedure (such as an HIV test). Interdisciplinary Approach: a term used to describe the combined efforts of professional and community resources. Palliative care is thought to use an interdisciplinary approach involving hospitals, clinics, social workers, nurses, doctors, community members (like CBVs), PLWHA and the family of PLWHA. Immune System: the body's defense against diseases. Injecting Drug User (IDU): term preferable to drug addicts, which is seen as derogatory, often resulting in alienation rather than creating the trust and respect required when dealing with those who inject drugs. Leading Questions: a type of question in which a counselor guides (or leads) the client to give an answer that he/she wants to hear. Legumes: foods such as beans, peas, lentils or nuts that provide the body with proteins needed to build and repair the body and build strong muscles. Life cycle: a term used to describe different times in a person's life. People at different stages in their life cycle will have different needs, concerns and ways of coping with problems. Lymphocytes: white blood cells that play an important role in helping the body's immune system.

Mal-absorption: a term used to describe the inability of the stomach to take up nutrients from foods that are eaten. Malnutrition: a term used to describe a condition where the body either does not get enough of the right foods, or process foods properly to remain healthy. Meaningful Involvement of People Living with or Affected by HIV and AIDS (MIPA): one of the general principles of good care for PLWHA which recognizes the important contribution PLWHA can make in response to the fight against HIV and AIDS and creating a space within society for the involvement and active participation of PLWHA in such responses (like ART intervention). Medication Diaries: booklets in which clients can write down the time and date each time they take their medications (such as ARVs), record when and why they have missed doses and write down any side effects experienced, or questions or concerns they may have about their ART regimen. Medication Events Monitoring System (MEMS): an electronic method of measuring adherence to ART that uses an electronic chip in the lid of a medication bottle that measures the opening and closing of the bottle. A computer programme records information from the electronic chip and provides a report on how many times a bottle has been opened, the time it was opened and intervals between doses. Memory Books/Boxes: treasure chest of family photographs, letters, stories or documents that help describe the history of a family. Micronutrients: vitamins and minerals in food that play a special role in keeping people healthy. Mixed Feeding: when a mother gives breast milk in addition to water, formula or dairy milk during the first few months of life. Mixed feeding increases the chance of transmission of HIV to infants.

Mother-to-Child Transmission (of HIV): when an HIV infected mother passes HIV to her baby through pregnancy, during childbirth, or after delivery through breastfeeding. Mourning: a term used to describe the way in which grief is expressed. Mourning is the external activities or behavior following a death. Mouth care: ensuring the proper cleaning of the mouth (teeth and gums) to prevent infection and decay. Non-adherence: not taking ARV medications as they are prescribed. Nutrients: the substances we absorb from food that we need for growth, energy, to build our bodies and to stay strong. Nutritional goals: specific ways in which PLWHA can prevent malnutrition and promote a healthy and active lifestyle with food. Open Question: a type of question that requires more than a one-word answer and encourages people to explore their situation or feelings. Opportunistic Infections or OIs: diseases that attack the body when it is weak. Opt-Out: the choice of individuals to say 'no' to having an HIV test conducted during provider-initiated, or routine offer HIV testing and counseling. Oral Rehydration Solution (ORS): a drink used to help prevent or treat dehydration. Palliative Care: symptom management during both acute and chronic illness and at the end of life. Peer Support: Support for people by people in the same situation. Personal Hygiene: In terms of food safety, involves ensuring that people who are touching and handling food take proper care to ensure that they do not pass on bacteria or viruses.

Pharmacy Re-fill Tracking: a method of measuring adherence that involves recording if PLWHA are re-filling their ARV prescriptions at the appropriate time. Pill boxes: containers for storing medication with dividers for each day and each dose during the day. Pill burden: a term used to describe ART regimens that involve many doses of pills each day with specific food and fluid instructions. High pill burden is associated with decreased levels of adherence. Pill charts: a visual display of medications and the dosages required in their treatment regimen. For example, pill charts use different colors and shapes to differentiate with different types of ARV drugs in a treatment regimen. Pill count: counting the number of pills remaining in a prescription during a scheduled visit. If the number of pills remaining is greater or less than it should be, problems with adherence are revealed. Positive Living: a term used to describe steps taken by people living with HIV or AIDS that enhance their lives and increase their health. Positive Prevention: term used to describe activities aimed at increasing the self-esteem and confidence of HIV positive individuals to protect their own health and avoid passing the infection to others. Post-Exposure Prophylaxis (PEP): ARVs intended to prevent the uptake of HIV after exposure to infection by blood or body fluid contact with an HIV infected person. Prevalence: measure of how common or widespread a disease or infection is in the community or population group at a given period of time. This measure includes existing and new cases. Prevention of Mother to Child Transmission (PPTCT): methods that help prevent an HIV positive mother passing HIV onto her baby during pregnancy, child birth or breast feeding.

Preventive Care: a term used to describe caring efforts intended to prevent discomfort before it begins in PLWHA. Mouth care, prevention of bed sores, proper bathing, prevention of pain and stiffness in muscles and joints and moving bedridden clients comfortably are all methods of preventive care for PLWHA. Primary Caregivers: the friends, family or neighbors that do most of the day-to-day home caring for sick clients. Prophylaxis: a therapy or treatment taken to prevent infections. Provider Initiated HIV Testing: when an HIV test is conducted by health professionals when trying to determine the cause of an illness, or when HIV tests are offered to all sexually active people seeking medical care. Provider Judgement: health care professionals involved in the care and treatment of PLWHA making an estimation of how well a person is adhering to ART based on observation. Psychosocial support: a term used to describe caring for the emotional, psychological, social and spiritual well-being of others. Questioning: counseling skill that helps the counselor to understand the client's situation, and can determine the quality of information a counselor receives from the client Range of Motion (ROM): a term used to describe the ability of people to move their joints (wrists, knees, elbows, ankles, shoulders, hips and neck) freely and without pain. Rapid Tests: commonly used HIV tests that give quick results and do not require special equipment Relaxation techniques: methods of reducing stress and preventing burnout that involves engaging in activities or thought processes that help a person to relax and let built up stress be released.

Resistance: the ability of HIV to change its structure in ways that make drugs, such as ARVs, less effective. Respite care: a term used to describe arranging for another caregiver to provide care to client while you take a holiday or break from caring. Retrovirus: a class of viruses, which includes HIV. Retroviruses are characterized by their ability to convert RNA to DNA in the host cell. Routine Offer (HIV testing): when HIV tests are offered to all sexually active people seeking medical care. Secondary Caregivers: people often thought of as 'specialists' of certain types of care who are trained for the care they provide. Sexually Transmitted Infections (STIs): infections that are spread by the transfer of organisms from person to person during sexual contact. Shared confidentiality: means that information about a client can not be shared with anyone other than the HIV care team staff without the client's consent. Staple foods: types of foods eaten commonly/routinely by a given community which are in most cases grains or tubers that provide lots of energy and some protein. Stigma: negative attitudes toward people who belong to a particular group or who have different characteristics than others. Stress: a term used to describe feelings of being emotionally, physically or mentally overwhelmed when faced with a certain situation, event or person Supplement: something you eat, often as a pill or tablet, in addition to food to improve diet and health. Support Network: a term used to describe people in your life with whom you can talk openly and honestly about things that trouble you. A support network often includes people who you feel understand you and what you are going through.

Symptom: any perceptible, subjective change in the body or its functions that indicates disease or phases of disease, as reported by the client. Therapeutic Drug Monitoring (TDM): a method of measuring adherence by testing the levels of ARV drugs in a person's blood. Treatment Failure: a condition in which drugs (such as ARVs) stop being effective. Treatment Preparedness: the process of preparing PLWHA and their surrounding community to initiate, or start, ART. Treatment Literacy: providing individuals with the skills and knowledge necessary to manage HIV infection through ART. Treatment Supporter: a person, usually a family ember or friend and preferably someone who lives with the client and can help with day to day adherences to ART Tuberculosis (TB): an illness caused by a germ that is breather into the lungs. There are two types of TB, pulmonary TB (affecting the lungs) and extra-pulmonary (affecting organs of the body other than the lungs. Universal Precautions: simple infection control procedures that reduce the risk of transmitting infectious agents through exposure to blood body fluids, or contaminated medical or other types of equipment among family members and health care workers. Viral load: a term used to describe the amount of HIV in a persons body. The more HIV, the higher a persons vial load is. Viral load assay: test conducted to measure viral copies (such as HIV) in a persons blood. Virus: Infectious organism that can only reproduce inside the cell of another plant or animal.

Voluntary Counseling and Testing (VCT): the common term for the process of seeking out and taking an HIV test. Western Blot: a type of HIV test Window period: time from infection with HIV until detectable seroconversion. A person will test negative for HIV during the window period but can still transmit the virus to others during this time.