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The key takeaways are that this document provides an overview of HIV/AIDS including its definition, epidemiology, etiology, clinical features, diagnosis, case management, prevention and control. It is intended as an educational resource for various health workers in Ethiopia.

The purpose of this document is to provide teaching materials about HIV/AIDS to students and faculty in health care fields in Ethiopia. The intended audience includes health officers, public health nurses, environmental health technicians, medical laboratory technicians, and community health workers.

Some of the core topics covered in Unit Two include the significance and brief description of HIV/AIDS, learning objectives, an epidemiological case study, definitions, epidemiology, etiology, clinical features, diagnosis, case management, and prevention/control. It also includes exercises to reinforce the content.

MODULE

HIV/AIDS
For the Ethiopian Health Center Team

Shabbir Ismail
Getnet MItike
Damen Hailemariam

Addis Ababa University

In collaboration with the Ethiopia Public Health Training Initiative, The Carter Center,
the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education

2002
Funded under USAID Cooperative Agreement No. 663-A-00-00-0358-00.

Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter
Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education.

Important Guidelines for Printing and Photocopying


Limited permission is granted free of charge to print or photocopy all pages of this
publication for educational, not-for-profit use by health care workers, students or
faculty. All copies must retain all author credits and copyright notices included in the
original document. Under no circumstances is it permissible to sell or distribute on a
commercial basis, or to claim authorship of, copies of material reproduced from this
publication.

©2002 by Shabbir Ismail, Getnet MItike, and Damen Hailemariam

All rights reserved. Except as expressly provided above, no part of this publication may
be reproduced or transmitted in any form or by any means, electronic or mechanical,
including photocopying, recording, or by any information storage and retrieval system,
without written permission of the author or authors.

This material is intended for educational use only by practicing health care workers or
students and faculty in a health care field.
TABLE OF CONTENTS
TOPIC PAGE
Table of Contents i
Preface iii
Acknowledgments v
List of Abbreviations vi

UNIT ONE Introduction 1


1.1 Purpose and Uses of the Module 2
1.2 Directions for Using the Module 3
UNIT TWO Core Module 4
2.1 Pre-Test 5
2.2 Significance and Brief Description Of HIV/AIDS 11
2.3 Learning Objectives 12
2.4 Epidemiological Case Study: Learning Activity 1 12
2.5 Definition 13
2.6 Epidfemiology 13
2.7 Etiology 16
2.8 Clinical Features 16
2.9 Diagnosis 16
2.10 Case Management 17
2.11 Prevention and Control 17
2.12 Group Exercise: Learning Activity 18
UNIT THREE Satellite Modules 21
3.1 Health Officers 22
3.2 Public Health Nurses 42
3.3 Environmental Health Technicians 66
3.4 Medical Laboratory Technicians 74
3.5 Community Health Worker 79
3.6 Take Home Message for Caregivers 84

i
UNIT FOUR Roles and Task Analysis 88
UNIT FIVE Glossary 103
UNIT SIX References 107
UNIT Seven Annexes 110
7.1 The' HIV-Spread Like the Fire'' Game 111
7.2 Key to Pre and Post Test Questions 113
7.3 List of Antiretroviral Drugs Used In the Case 116
Management of AIDS Patients
7.4 Live Case Studies 128
7.5 The authors 121

ii
Preface

HIV/AIDS has become a major public health problem worldwide. The pandemic has
brought about overwhelming threats to economically Poor countries, especially the sub-
Saharan Africa. In Ethiopia HIV/AIDS has spread very fast in the last fifteen years and it
has produced devastating effects.
Teaching students about HIV/AIDS is extremely vital, Although almost all textbooks of
recent editions talk, about HIV/AIDS in one way or another, The preparation of this
module has been realized with the following intentions:1/ text books are scarce ; and the
ones that are available in the shelves of libraries of the training institutions are in most
instances out of date;
2/ current and basic knowledge, especially about the Ethiopian situation is not widely
available; 3/ at this stage provision of facts is not adequate, students should be able to
teach patients, families, pupils, healthy individuals and communities; and 5/ the
knowledge and skills are not organized in such a way that it passes directly and clearly
to the caretaker which is essential in the case of HIV/AIDS control and prevention.

Therefore, this module is prepared to bridge those gaps mentioned above. it is


particularly designed for the health center team that will be working at the primary health
care unit PHCU as the first level of care in the referral system. Its spectrum extends to
the community health workers and caretakers. The module is organized in such a way
that each category knows the specific tasks and roles.

The module has the characteristics of lect6ure notes (factual based) as well as module
(interactive learning). This is because, there is a sho9rtage of reference materials of all
kinds and provision of essential information is important in these case in the form of
short notes.

The health center team training includes the following students (public health nurses,
environmental health technicians, and medical laboratory technicians). The module has
a Core Module; four satellite Modules and a Take home message for the caretaker. The
core Module is intended to provide the minimum essentials for all core Module. Specific

iii
areas of each category that were not possible to cover in the core module are
addressed in the satellite modules. However, the basis for the development of the
satellite modules is the core module and the tasks/roles analyses are presented in
tabular form.

Readers should understand that this modules is not prepared to replace any teaching-
learning about HIV/AIDS in the training years It is rather designed to supplement and
strengthen the teaching process through the interactive methods of the modular
teaching-learning process that enable students to take active roles in teachings
concerning HIV/AIDS.

iv
Acknowledgments

We are greatly indebted to The Carter for supporting the preparation and development
of this module as part of the Ethiopian Public health Training Initiative. The development
of the module as part of the Ethiopian public Health Training Initiative . The development
of the module has gone through series of workshops, meetings and individual as well as
group works both within the institution and groups of experts from other sister
institutions. There were critical comments and relevant suggestions Gondar College of
Medical Sciences, Dilla College of Teachers Education and Health Sciences (Debub
University), Almaya University and the Department of Community Health, Faculty of
Medicine (Addis Ababa University). We also greatly acknowledge internal medicine,
Faculty of Medicine, Addis Ababa University) and Dr Taddesse Wuhib (CDC - Ethiopia)
for their Valuable comments and critiques. We would like to pass our gratitude to Prof.
Dennid G.Carlson, Senior Consultant at The Carter Center for reviewing this module
and also for his effort in identifying additional expertise, and finally realizing the initiative,
which was extremely demanding Exhausting the names of those who helped to improve
this module is not possible Therefore, We acknowledge those who have helped us in
one-way or the other.

v
List Of Abbreviations

AAU - Addis Ababa University


AIDS - Acquired Immunodeficiency Syndrome
ARC - AIDS related complex
AZT - Azidothymidine
CBRHA - Community based reproductive health agent
CDC - Centers for Disease Control and Prevention
CHW - community Health Worker
CMV - Cytomegalovirus
CT - Care Taker
DCH - Department of Community Health
DNA - Deoxyribonucleic acid
EHT - Environmental Health Technician
ELISA - Enzyme Linked Immunosorbent Assay
FOM - Faculty of Medicine
HBC - Home based care
HIV - Human Immunodeficiency Virus
HO - Health Officer
IEC - Information Education Communication
INH - Isoniazid
MLT - Medical Laboratory Technician.
MPSC - Multipartner Sexual Comtact
NB - Note Back
NGO - Non - governmental organization.
NVP - Nevirapin.
OI - Opportunistic Infections
OSSA - Organization for Social Services for AIDS
PCP - Pneumocystic carinii pneumonia
PGL - Persistent Generalized Lymp0hadenopathy
PHCU - Primary Health care unit

vi
PHN - Public Health Nurse
PLWHA - People living with HIV/AIDS
RNA - Ribonucleic acid
STD - Sexually Transmitted Diseases
SYGA - Save Your Generation Association
TB - Tuberculosis
TT - Tetanus toxoid
UNAIDS - United Nations Joint Program on HIV/AIDS
VDRL - Venereal Diseases Research Laboratory
WHO - World Health Organization

vii
UNIT ONE
INTRODUCTION
1.1 Purpose and Uses of the Module

Module is a form of educational material comprising of a set of inter- related


instructional booklets that have the basic information to be learned. The different
parts of a module deal with materials that will enable participants to develops skills
on specific issues.

Modules enable Participants to be actively involved in the learning process by asking


questions and interacting in group discussions. There are, currently, modules
prepared for conducting in-service training for mid- level health workers in the
various health care programs. Modules are also increasingly becoming popular in the
preserves training; through which problem- based and student centered learning can
be facilitated.

This module was prepared with the aim of strengthening the health center team
training in Ethiopia. Besides its usefulness in basic training that is being given in the
training institutions, it is possible that the educators in the institutions be involved in
conducting continuing education for the various categories of health workers that
have been already deployed in the various health institutions in the country.

The module consists of the core Module as well as Satellite Modules. The
information and facts stated in the core module is the minimum set of information
that shold be known by all categories of health workers. Satellite modules
emphatically deal with the specific knowledge, attitude and skills that are required by
the respective category of the health center team members. Hence, each student
should know what is stated in the core module as well as in the respective satellite
modules. It is advisable that each student reads the satellite modules of other
categories, too. This will enable the team member to know the tasks of other
members of the health center team.

2
1.2 Directions for Using the Module

• Read this section on Directions for using the module both in the Core as will as in
each Satellite module carefully.
• First read the Introduction and understand the purpose and uses of the module.
• Then attempt to answer all the questions on the pretest questions (both designed
for all categories of the students [2.1.1] as well as those specific to the respective
professionals [2.1.2-2.1.5]).
• The instructor should conduct the game described in Annex 7.1 with the students.
• Answer the questions following the game. Then read and study the contents in
the Core Module.
• Read the Epidemiological Case study described in Learning Activity2 (section
2.12) Answer the questions that follow after the case study.
• Then each category of students should read their respective satellite modules.
After having read the satellite module thoroughly, the student should attempt to
answer all the post-test questions given in the core module. Compare your
answers to those shown in the key to pre- and post-test questions in section 7.2.
• Study and discuss the specific learning objectives, activities, and tasks of each
category of students and community health workers shown in the Tables (Unit
four).
• All categories of students should study carefully annex 7.4 and then discuss the
issues among yourself and with your instructors.
• All instructors using this module should formulate questions for discussion from
the case studies in annex 7.4.

3
UNIT TWO
CORE MODULE
2.1 Pre-test
2.1.1 Questions for all categories

1. Define the abbreviation AIDS:


2. Define the abbreviation HIV:
3. List the three main routes of transmission of HIV
a. ____________________________________________________________
b. ____________________________________________________________
c. ____________________________________________________________
4. What is the main mode of HIV transmission in developing counters like
Ethiopia? _______________________________________________________
5. List the three population groups which are at most risk for contracting HIV in
Ethiopia
a. ____________________________________________________________
b. ____________________________________________________________
c. ____________________________________________________________
6. Which one of the following is not a laboratory diagnostic test for HIV?
a. ELISA
b. Western blot
c. VDRL
d. Spot test
7. List the three main methods of preventing the transmission of HIV.
a. ____________________________________________________________
b ____________________________________________________________
c ____________________________________________________________
8. List the three most common manifestations of AIDS.
a. ____________________________________________________________
b. ____________________________________________________________
c. ____________________________________________________________

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9. Since January 2000, there is an effective treatment for curing HIV/AIDS
True______________________ False________________________

10. Mention three important points that should be stressed in counseling PLWHA.
a. ________________________________________________________
b. ________________________________________________________
c. ________________________________________________________

2.1.2 Questions for Health Officers

1. To what group of viruses does HIV belong?


a. Adenoviruses
b. Rotaviruses
c. Retroviruses
d. Cytomegalovirus
2. List the immunological components of the body that are most affected by HIV
infection
________________________________________________________________
_________________________________________________________________
_________________________________________________________________
3. Describe the five stages of clinical manifestations of HIV/AIDS.
_____________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
4. List three behaviors putting persons at a higher risk of contracting HIV infection.
a. ____________________________________________________________
b ____________________________________________________________
c. ____________________________________________________________

6
5. I f a person tests positive for HIV, what does it not necessarily imply?
_______________________________________________________________
6. State the most common opportunistic infections in AIDS and state how they
should be managed.
a._____________________________________________________________
b._____________________________________________________________
c. _____________________________________________________________
7. List at least four of the anti-retroviral drugs that are currently available worldwide
for the treatment of AIDS.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
8. List two neoplastic conditions that have been related with HIV/AIDS.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
9. Describe ways of reducing mother-to-child transmission of HIV.
a. _____________________________________________________________
b. _____________________________________________________________
c. _____________________________________________________________
10. List the main impacts of HIV/AIDS at a national level.
a. _____________________________________________________________
b. _____________________________________________________________
c. _____________________________________________________________
d. ____________________________________________________________

7
2.1.3 Questions for public Health Nurses

1. HIV infection can be transmitted through


a. Breast feeding
b. Handling utensils of patients
c. During delivery
d. Touching the body of an AIDS patient
e. Only ''a'' and ''c''
2. It is essential to wear hand gloves when giving care to an AIDS patient.
True________________ False_______________________
3. Proper nutrition does not play any role in the prognosis of an AIDS patient
True________________ False_______________________
4. Family members cannot be trained in the principles off home-based care for
an AIDS
Patient.
True______________ False_______________________
5. List the three main types of counseling given to PLWHA.
a. ____________________________________________________________
b. _____________________________________________________________
c. _____________________________________________________________
6. Describe the six main principles (components) of nursing care for PLWHA.
a. ___________________________________________________________
b. ___________________________________________________________
c. ___________________________________________________________
d. ___________________________________________________________
e. ___________________________________________________________
f. ___________________________________________________________
7. Describe the steps in handling blood and body fluids from AIUDS patients.
_______________________________________________________________
_______________________________________________________________

8
8. Describe the phrase "safer sex".
_______________________________________________________________
_______________________________________________________________
9. What should the nurse teach about safer sex?
______________________________________________________________
______________________________________________________________
10. List the steps of providing post-mortem care to people who have died of AIDS
______________________________________________________________
______________________________________________________________

2.1.4 Questions for Environmental Health Technicians

1. The etiologic agent for AIDS is a:


a. Bacteria
b. Virus
c. Protozoa
d. Fungus
2. Maintaining personal hygiene and cleanliness won't affect the prognosis of HIV
disease.
True_________________________ False_______________________
3. Which of the following are the best places for disseminating health education?
message about HIV/AIDS?
a. Health institution
b. Schools
c. Working places
d. All
4. List the infectious wastes From AIDS patient?
______________________________________________________________
______________________________________________________________

9
5. Hypodermic needle, scalpels and IV sets in health care facilities should be
collected in special containers before disposal.
True___________________ False________________________
6. All body fluids from patients should be handled with special attention in waste
Management.
True___________________ False_________________________
7. _______________ is necessary before reusing waste containers in health
care facilities and in home based care for PLWHA.
a. Washing
b. Disinfecting
c. Covering
d. None of the above
8. Disinfections is a process mainly used as a barrier between the patients and the
people about him/ her.
True___________________ False_________________________
9. List the methods of treatment and disposal of infectious wastes from AIDS
Patients.

2.1.5 Questions for Laboratory Technicians

1. Mention the principles behind laboratory screening methods for HIV?


_______________________________________________________________
_______________________________________________________________
2. What is specificity of a screening test?
_______________________________________________________________
_______________________________________________________________
3. What is specificity of a screening test?
_______________________________________________________________
_______________________________________________________________

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4. Mention the comparative advantage of Western blot test over ELISA?
_____________________________________________________
5. Mention the comparative advantage of ELISA over Western blot?
______________________________________________________
6. List the main serotypes of HIV
a. _____________________________________________________
b ______________________________________________________
7. Mention the tests required before administering Progress of patients on anti-
retroviral therapy for a patient?
______________________________________________________________
______________________________________________________________
______________________________________________________________
8. Mention the tests that are required for monitoring the progress of patients on anti-
retroviral therapy.
________________________________________________________________

________________________________________________________________
________________________________________________________________

2.2 Significance and Brief Description of HIV/AIDS

Infection due to Human Immunodeficiency Virus (HIV) and resulting Acquired


Immunodeficiency Syndrome (AIDS) has been occurring in the world as the major
pandemic since the last two decades of the past century. HIV/AIDS has affected all
parts of the world, but sub-Saharan Africa is the hardest hit. Ethiopia currently has one
of the highest numbers of people affected by the problem. In Ethiopia there are
indications that the epidemic has affected a large proportion of the society and that no
region or zone in the country is spared. To date no prophylactic vaccine is available.
However, there are anti-retroviral drugs used to prolong the life of AIDS patients in
developing countries and the respective governments fail to insure their supply. The
best intervention available is prevention of the acquisition of the

11
infection. As a result HIV/AIDS has caused an immense social, economic, cultural and
political burden in addition to the pressure on the health care system. HIV/AIDS has
stated to influence the demographic trends in many countries by increasing mortality
rates and lowering life expectancy. it has mainly affected the reproductive segments of
the population and hence, has become the most important development concern across
the world.

In this module major emphasis is placed on the Epidemiology as well as the prevention
and control of the problem.

2.3. Learning objectives

After going through this module all categories of students should at least be able to:
1. Define what HIV/AIDS is.
2. Describe the difference between HIV and AIDS.
3. Describe the risk factors and population groups at higher risk.
4. Discuss the routes of transmission.
5. Describe the clinical manifestations of HIV/AIDS.
6. List diagnostic tests.
7. Discuss the methods of prevention and control of HIV/AIDS.

2.4 ''HIV-Spread Like the Fire" Game-Learning Activity 1

Refer to Annex 7.1 for the detailed instructions as how to play the game. The instructor
should guide this game.

Questions

1. What did you learn from this game?


2. Discuss the reactions observed in the rest of the participants.
3. What were your feelings about the reactions?
4. Discuss the possible reasons about the reactions.
5. How do you relate the game with the real life situation?

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2.5 Definition
HIV infection is caused by one or two related viruses (HIV-1 and HIV-2) resulting in a
wide range of clinical manifestations varying from asymptomatic carrier states to
severely debilitating and fatal disorders related to defective cell mediated immunity.
Acquired immunodeficiency syndrome (AIDS) is a secondary immunodeficiency
syndrome due to HIV infection and characterized by opportunistic infections,
malignancies, neurologic dysfunction, and a variety of other syndromes.

2.6 Epidemiology -Transmission and Risk Factors


HIV is transmitted through the following main routes: 1) sexual intercourse- accounts to
70-80% of the global transmission of HIV infection; 2) perinatal (mother-to-baby) -5-
10%; 3) through blood and blood products -3-5%, and4) from unsafe injections. HIV is
not transmitted by casual contact or even by close non-sexual contact that normally
occurs at work, in schools or at home. in developing countries including Ethiopia, the
main route of HIV-1 infection is through heterosexual transmission.

Extent of the Magnitude of the Epidemic


The magnitude of HIV infection is estimated using "sentinel surveillance systems" They
provide important information for planners and decision makers. Sero-surveys
conducted among pregnant women attending antenatal (ANC) clinics and blood donors
are often used to describe the magnitude of HIV infection in developing countries, as
they are more likely to represent the general population. They are feasible to undertake
and are within the resource means of the countries.

Accordingly, sero-surveys conducted on pregnant women attending ANC in 1998, 1999


and 2000 in various parts of the country showed that the prevalence of HIV infection
ranged from 0.8%-4.0% in Atat Hospital (1998/00), 13.0%-20.8% in Bahir Dar (1992/93-
1999/00). in Gambella, Dilla, Awasa, Dire Dawa and Addis Ababa prevalence rates
between 13.6% and 19% were reported in the year 1999/00

13
In summary, HIV prevalence among the general population is estimated to be 7.3%
(ranging between 6%to9%) in Ethiopia. The prevalence in Addis Ababa is estimated at
16.8%, in other urban areas 13.4% and 5% in rural areas.

Among blood donors lower rates i.e. ranging between 3.8% and 7.9% were found. in
semi-urban and rural communities such as the Atat and Hosanna prevalence rates of
0.8% and 3.6%, respectively, have been reported (in 1998)

Among commercial sex workers, surveys conducted in several cities during the mid
1990s have documented HIV levels of 69.4% and 65.0% in Bahir Dar and Nazareth,
respectively, among sex workers in Addis Ababa; a prevalence rate of 73.4% was
reported in 1999.

The level of HIV infection and its progression specifically among adolescents and young
adults is not well known. This is because the ANC sentinel surveillance estimates for the
age group 15-49. in towns such as Dire Dawa, the prevalence of HIV among young
women attending ANC (15-24 years) was 14%. In Gambella the prevalence was 12.1%.
Data from blood donors also indicated that this group accounted for a large proportion of
infections among the general population.

Accurate information concerning AIDS related deaths is limited in Ethiopia. However,


AIDS has been identified as one of the most important cause of mortality in adults,
accounting for a large proportion of adult deaths in Ethiopia, and particularly in the cities.

Routes of Transmission
The major route of transmission in Ethiopia is reported to be heterosexual; the practice
of multi-partner sexual contact is the biggest risk factor for HIV transmission. A number
of factors increase the risk of infection by a single act of intercourse. One of such
important factors is the presence of a sexually transmitted disease (STD), such as
syphilis or gonorrhea, in either of the partners.
Crude estimate of vertical transmission (mother to newborn) is between 29% and 47%.
It was estimated that about 250.000 children under the age of 5 were infected by 2000.

Transfusion with infected blood always transmits HIV. However, in Ethiopia most blood
is screened for HIV. Therefore, few new infections are due to blood transfusions.

14
HIV can be transmitted by injection if the same needle is used to inject many people,
without being sterillized after each use. Practices such as unsafe/ unsterile injections
can result in new HIV infections.

High Risk Groups and Behaviors]

The risk behaviors for contraction HIV/STDs:


9 Having unprotected sexual intercourse (not using condoms)
9 Having unprotected sexual contact with many different partners
9 Having Sexually transmitted disease(s)
9 Alcoholism
9 Drug abuse

Population Groups at Risk in Ethiopia and the Respective Risk Factors

Population at Risk Exhibiting Risk Factors


Youth in and out of school Lack of awareness, alcohol and substance abuse,
Helplessness associated with unemployment
Multiple partner sexual Poor economic status, early marriage and marital
contacts and Commercial discord, practicing unprotected sex, alcohol and
sex Substance abuse
workers
Truck drivers Low awareness, high mobility alcohol and substance
abuse, practicing unprotected sex
Merchants Low awareness, high mobility, alcohol abuse, luxurious
living
Women in child bearing age Harmful traditional practices, divorce and poor economic
status, gender inequality
Migrant workers Unprotected sexual contact, high mobility, poor
economical status, and lack of awareness

15
2.7 Etiology
The causative organism is a transmissible retrovirus- the Human immunodeficiency virus
(HIV) types 1 and2. Type 1 is the organism causing AIDS in Ethiopia. The virus causes
immuno-suppression. By doing so it substantially reduces the capacity of human body to
defend against many of the pathogenic viruses, bacteria, protozoa and fungus.

2.8 Clinical Features


The incubation period in adults ranges between 3 to 12 years whereas in children it
ranges between 1 to 3 years. After infection there is a period of asymptomatic carrier
sero- negative state, followed by flu -like stage, and then sero-conversion occurs. AIDS
Related Complex (ARC) may follow with chronic symptoms and signs of HIV infected
persons without opportunistic infection or tumors to define AIDS. Wasting syndrome
(massive weight loss) is also a common feature.

2.9 Diagnosis

2.9.1 Clinical Diagnosis-African Case Definition

Using the WHO Case Definition based on major and minor criteria makes diagnosis.
Major criteria include weight loss, chronic fever and chronic diarrhea. Minor ones being
chronic cough, lymphadenopathy, fungal infections of the mouth and genitalia,herpes
infections, neurological abnormalities, cryptococcal meningitis, and others. Presence of
one major and two minor or two major and one minor criteria is diagnosed clinically as
AIDS. The main limitation of this definition is in patients with tuberculosis. The definition
also lacks specificity or moderate to severe HIV disease. The WHO case definition does
not include any of the now well-described neurological manifestations associated with
HIV infection.
An adult would be classified as having AIDS if the CDC surveillance case definition for
AIDS was fulfilled or patients had a positive test for HIV infection plus one or more of the
following:

16
” Greater than 10% body weight loss or cachexia, with diarrhea and/or fever,
intermittent or constant cough for at least one month, not known to be due to a
condition unrelated to HIV infection.
” Tuberculosis with the features in #1; tuberculosis that is disseminated (involving
at least two organs) or miliary; or extra pulmonary tuberculosis (which may be
presumptively diagnosed.)
” Kaposi's sarcoma.
” Neurological impairment sufficient to prevent independent daily activities not
known to be due to a condition unrelated to HIV infection, such as trauma.

This modified case definition is simpler, more specific and sensitive, yet requires positive
serologic result.

2.9.2 Laboratory Diagnosis

Laboratory diagnosis is dependent on detection of either antigens or antibodies for HIV.


The former is not in use currently. Antibody detection is done using two known tests.
Enzyme Linked Immunosorbent Assay (ELISA) and Western Blot-an
immunoelectrophoretic test, which is, used as confirmatory test after performing ELISA.
Additionally, there are also other tests such as rapid tests and spot tests.

2.10 Case Management


All available drugs to date attempt to inhibit viral replication. Some of these drugs are
AZT (zudovidine) nevirapine, saquinavir, indinavir, nelfinavir and others. These drugs
can either be used in single or in combination. The later has proved to be more effective.
All the mentioned drugs are very expensive for widespread use. See the annex for
details.

2.11 Prevention and Control


To date there is no protective vaccine against HIV. Therefore, the control lies on
prevention of the infection, which can only be achieved through modification of behavior.

17
The following information, Education, Communication (IEC) activities should be carried
out to teach the public in general and the high risk groups in particular.

1. Avoid unsafe sexual practices by reducing the number and frequency of sexual
contacts, avoiding high-risk practices and using barrier protection such as
condoms
2. Interruption of mother to baby transmission by testing for antibody of HIV for
women at risk for infection, and HIV infected women should be advised to defer
pregnancy - (termination of pregnancy is a more acceptable alternative)
3. Reducing transmission through potential drug use (drug injectors) by
educating and counseling drug users with regard to risk of sharing needles.
4. Discourage harmful traditional practices such as female genital mutilation,
tooth - extraction, venotomy, skin incisions, etc.
5. Others
a. Testing for HIV should be offered on a confidential basis to requesting
individuals but only when per - and post - test counseling can be given.
b. Medical personnel should protect themselves from patient contamination.
c. Follow strict infection prevention rules (disinfections and sterilization) in
clinical settings as well as at home

2.12 An Epidemiological Case Study: Learning Activity 2 How


HIV/AIDS Spread in Ethiopia?
HIV infection is believed to have spread to Ethiopia in the early 1980's. The first HIV

testing of the Ethiopian population was carried out in 1982, and infection was revealed in
the urban population until 1984.

The first evidence of HIV infection was reported in 1984 when two HEV sero-positive
samples were detected while testing a collection of sera from 167 hospital patients in
Addis Ababa.

In 1986 four positives were found among 5,265 samples of sera taken from army
recruits. In the second groups of recruits, tested in 1987, 0.9% were positive.

18
Testing multi-partner sex contact (MPSC) females and males attending STD clinics in
Addis Ababa in 1986 showed an HIV-1 prevalence of 6.7% and 1.4%, respectively.
Another study on MPSC females in 1986 sowed prevalence of 2.7%.
In 1989, a sero-epidemiological survey including a representative sample of 6,234
female sex workers in 23 towns of the country aside from Addis Ababa showed a
prevalence that ranged from 1.3% in Massawa to 38.1% in Dessie, with an average for
all the towns being 17%. The highest prevalence rates (above20%) were found in large
towns situated along the roads leading from Addis Ababa to Asseb, Gondar and Mekele.

HIV prevalence estimated among the antenatal clinic attendants of Addis Ababa in 1996
was 16.4% The prevalence was higher (20.7) in the younger age group (15-24years)/
Various sero-epidemiologic studies conducted in 1998-1999 among antenatal care
attendees across the country showed varying prevalence rates: 14.1% in Addis Ababa,
19% in Gambella, 14.5% in Dilla, 14.4% in Awasa, 13.6% in DireDawa, 3.6% in Hosana
and 0.8% in Atat are among the few.

Currently (in 2000) it is estimated that there are about 2.6 million people infected with
HIV and 400,000 actual AIDS cases. By the end of 2000, the overall prevalence of HIV
infection in the general population was estimated to be 7.3% A total of 100,303 Aida
cases have been reported in Ethiopia (June 2001).

19
Questions
1. From the given information, what can you comment on the trend of prevalence
of HIV Infection in Ethiopia?

2. Which groups of the population seem to be more affected? Justify your


response.
3. Can you explain the difference in prevalence rate of HIV infection among the
various locations in Ethiopia, including urban-rural differences, if any?

20
UNIT THREE

SATELLITE MODULES
UNIT 3.1
SATELLITE MODULE FOR
HEALTH OFFICR STUDENTS
3.1Satelite Module for Health officer students
3.1.1 Introduction

Health officers (HO) are involved in the prevention of HIV/AIDS and managing PLWHA.
It is, therefore, necessary to equip this category of health workers with up to-date
knowledge in HIV/AIDS research. It is also vital that the HO develop a caring attitude
towards persons affected by HIV/ AIDS. They should be sufficiently skilled to diagnose,
manage and care for AIDS patients both n clinical setting and at home. At the same time
they should also be learning the various protective measures against acquisition of HIV
from their patients, this module, therefore, deals with equipping the HO with the
appropriate knowledge, attitudes and skills for preventing the spread of HIV through
implementing effective IEC strategies and handling people living with HIV/AAIDS
(PLWHA)

3.1.2 Instructions for Using the Satellite Module

Proceed through the modules as follows:

D Read the Directions for using the module in section 1.2 and follow the
instructions.
D After doing so read the core module, do the pre-tests, do the exercises and
then go through this satellite module.
D It is advisable that you read all other satellite modules.

3.1.3 Learning Objectives

At the end of the session the students should be able to:


1. Describe the etiology ad pathogenesis of AIDS.
2. Describe the routes of transmission of HIV and their relative importance.
3. List and describe the various clinical manifestations of AIDS.
4. List the most common opportunistic infections defining AIDS.
5. List and describe the various laboratory diagnostic methods.

23
6. Explain the case management of AIDS and list the available drugs used
worldwide in the treatment of AIDS patients.
7. List some of the complications of treatment with drugs.
8. Describe principles of counseling people living with HIV/AIDS.

3.1.4 “AIDS Spread like fire’ game: Learning Activity 1(Annex 7.2)

Questions

1. Which parts of the game address the magnitude of HIV/AIDS?


2. Which parts of the game indicate about human behavior related to HIV/AIDS?
3. What does the game show you about the spread and sped of HIV infection?
4. From the game is it possible to identify persons infected by HIV? Explain
your reason.
5. Relate the concept of ice-berg’ to the game.

3.1.5 Etiology And Pathogenesis

As already stated in the core module, HIV, one of the retroviruses, causes AIDS.HIV
causes both malignant and non-malignant diseases. HIV infects a major subset of T-
cells – the T4 or CD4 receptors are found on T-lymphocytes, macrophags, monocytes,
tissue cells (dendritic cells present in genital and anorectal area) certain brain cells (glial
cells) and some other cells as well. HIV also infects non- lymphoid cells in the lungs,
brain, skin and lymph nodes. Humoral immunity is also affected, leading to
lymphadenopathy. CD4 counts are used in monitoring the progression of the immune
suppression in the body.
The CD4 (T4) helper cells are very important in the regulation and control of the immune
response by:
Ä Directly, or indirectly, protecting the body from invasion by certain bacteria,
viruses, fungi and parasites
Ä Clearing away a number of cancer cells.
Ä Producing substances that are useful in the body’s defenses

24
They also influence the development and function of monocytes and macrophages,
which act as scavenger cell I the immune system.

How does the HIV multiply I the body and cause immune suppression?

After binding to the CD4 receptor, the viral genetic material enters the host’s cell (E.g., a
CD4 cell) with the reverse transcripts reaction, the virus’s DA copy becomes
incorporated into the host cell. Enter the blood stream and infect more cells. In this
process, the host cells (such as CD4 T lymphocytes) are damaged and destroyed.

It takes the HIV a umber of years to destroy enough of the immune system to cause
immune- deficiency ad immune-incompetence. It may take 3-7 or eve ore years, for a
person who is HIV-infected to develop immunodeficiency and HIV-related medical
conditions.

An untreated GIV infected person has an estimated chance of developing AIDS at a rate
of 1-2% per year in the first several years following infection. The it increases to 5% per
year. In the first ten years 50% develop AIDS. Eventually, all develop AIDS.

3.1.6 Clinical Features


Natural Course of infection

HIV infection may progress in the following stages. This is a general description and not
every HIV infected person will necessarily follow this pattern.
The Centers for Disease Control and Prevention (CDC) in the United States published a
classification system for the progression of HIV infection. This system delineates more
inclusive definition and classifications that can be used for patient care, health planning,
public health strategies, prevention and control activities, and epidemiological studies.
Classification into groups is not intended to have prognostic significance or severity of
illness designation.
From occurrence of HIV infection to onset of AIDS symptoms and disease in adults,

25
the time period can be long or short it can be as short as 1-2 years. In this case the
disease ay progress more rapidly, especially in persons with underlying problems, such
as chronic diseases, recurrent infections, anemia, malnutrition, closely spaced and
repeated pregnancies, malaria and tuberculosis.

Window period
Detectable antibodies usually develop within 2 weeks to 3 months of infection. Most
commonly, sero-conversion occurs in tow to four weeks. However, individuals exposed
to HIV risk should wait for three months following exposure to be tested for HIV
antibodies. Otherwise, a negative result may mean there has not been enough tie for
antibodies to develop.

The “Window Period” of delayed sero-conversion is an important concept for clinicians


who are assessing and counseling clients. Many HIV infected persons do tend to exhibit
some clinical signs of compromised immune system function months or years before
AIDS is evident. Clinical practitioners should maintain a high level of suspicion and
assess carefully (and test/repeat HIV testing, if available) those clients who present with
unexplained fatigue, recurrent oral or vaginal candidacies, persistent diarrhea, ad
persistent dermatitis or other skin conditions.

Signs and symptoms of AIDS are due to:


Ä New infections, especially opportunistic infections
Ä Reactivation of old, inactive or dormant infections, such as tuberculosis,
herpes or unusual cancers
Ä The HIV itself and its effects on various organs and tissues in the body

Stages of Clinical Manifestations

A person who becomes infected with HIV will usually go through various clinical
Stages that occur over a long period of time.

26
Early [primary] HIV Infection is defined as a flu- like syndrome, with or without aseptic
meningitis that is associated with sero-conversion of HIV antibody. This takes up to 3
months after exposure to HIV. Antibody. This takes up to 3 months after exposure to
HIV. Infection persons to develop recognizable sign and symptoms in the acute phase.
Antibodies ay appear three to six weeks and nearly always are present in three months.

The clinical signs and symptoms may typically include fever, sweating, headache,
migraine, rash, sore throat, muscle and joint pain. Most frequently this develops in the
second week of the illness. This ay be accompanied with generalized lymphadenopathy
involving axilliary, occipital, and cervical nodes.

Asymptomatic infection includes patients with no signs and symptoms of HIV infection.
HIV is persistent even if it is inactive or dormant; allowing for its transmission, even
when the person is asymptomatic. This can take variable number of years or months.

The asymptomatic phase is usually associated with CD4 cell counts between 500
and 800 cells/mm3 Or even less.

Persistent Generalized Lymphadenopathy [PGL] includes patients with persistent


palpable lympndodenophaty with lymph node enlargement of 1 cm or grater at two or
more extra sites that persist for more than three months in the absence of a concurrent
illness other than HIV that explains these findings. Up to 70% of HIV infected persons
show PGL. The pathologic finding in PGL is non-specific. PGL may persist for several
years, even in the absence of other symptoms PGL may be seen alone or in conjunction
with systemic complaints like fatigue, fever, and major swats. There may also be herpes
zoster, skin rashes, fungal nail infections, recurrent oral ulcerations, recurrent upper
respiratory tract infections and weight loss. In this phase the CD4 cell count is between
350 and 500 cells/mm3
HIV related diseases-previously known as “AIDS Related Complex” [ARC]
Includes patients with findings of GIV infection other than, or in addition to
lymphadenopathy.

27
The most common signs and symptoms of this stage are as follows:
Ä Oral or vaginal candidiasis (thrusa)
Ä Hairy leukoplakia on the tongue
Ä Recurrent herpes simplex infection-cold sore or genital herpes infection
Ä Herpes zoster (shingles) involving two rmore distinct episodes or more than one
dermatome
Ä Acne-like bacterial skin infections
Ä Persistent and unexplained fevers (greater than 38.5%) and night sweats
Ä Skin infections
Ä Generalized lymphadenopathy or shrinking of previously enlarged lymphnodes
Ä Persistent diarrhea (more than one month)
Ä Weight loss
Ä Reactivation of tuberculosis

The CD4 cell count is usually between 150- 350 cells/mm3.

Severe HIV- related disease- AIDS, the severe symptomatic phase

The presence of any serious opportunistic infection is a sign that the body is not coping
immunologically

Signs and symptoms of AIDS may differ from one patient to another and depending on
the infection, cancer or organ affected. Refer to the manifestations mentioned above.

AIDS is always associated with a high HIV viral load and severe immunodeficiency.
This usually corresponds to CD4 cell counts below 200 cekks/mm3 to a low lymphocyte
count.

28
The relation ship between the immune status, the CD4 counts, the lymphocyte
counts and the presence of symptomatic disease

Clinical Condition CD4 cell count Lymphocyte Count


Well with no symptoms More than 500-600 More than 2500
cells/mm3 cells.mm3
Minor symptoms 350-500 cell.mm3 1000-2500 cells.mm3
Major symptoms and 200-350 cells.mm3 500-1000 cells.mm3
opportunistic diseases
AIDS Less than 200 cells.mm3 500-1000 cells.mm3

Opportunistic infections
The most common opportunistic infections occurring in HIV infection
9 Tuberculosis
9 Pneumonia due to
{ Group B streptococcus (usually in children)
{ Heamophilus influenzae (usually in children)
9 Pneumocystic carinii pneumonia
9 Salmonellosis
9 Cryptococcosis
9 Candidiasis-oral and vaginal
9 Infection with atypical mycobacteria
9 Toxoplasmosis
9 Various viral infections-herpes, Cytomegalo (CMV), etc.
9 Cancers- kaposi's Sarcoma and lymphomas

Diagnostic Evaluation
Patients may present with known HIV serological status; alternatively, THEY MAY
present with complications of HIV infection without prior testing and without
readily evident risk factors. Ten common findings at the time if initial evaluations
are:

29
1. Persistent generalized lymphadenopathy (PGL)-enlarged lymph nodes involving
two noncontiguous sites other than inguinal nodes
2. Cytopenias(low blood cell count)
3. Pulmonary symptoms suggesting Pneumocystis carinii pneumonia (PCO)
4. Kaposi's sarcoma
5. Localized candida infections.
6. Constitutional symptoms-- Weight loss, night sweats, chronic fever (at least 30
days), and /or chronic dearrhea (at least 30 days), fatigue
8. Bacterialinfections-Pneumococcal pneumonia, Streptococcus
pnuemonea, Haemophilus
influenzea, Pseudomonas aeruginosa ,Staphylococcus aureus, clostridium
defficile, Nocardia astroides, Rhodococcus equi,Rochalimaea Quintana
9. Tuberculosis
10. Sexually transmitted deseases
11. Neurological syndromes-dementia, peripheral neuropathy.

Physical Examination

The physical examination in patients with HIV infection should include attention to those
anatomical sites that are likely to show significant changes and prove useful in
management, including staging. Especially important are:
$ The evaluation of lymph nodes
$ Fundoscopic examination-CMV retinitis
$ The oral cavity
$ Careful skin examination
$ Abdominal examination for hepato-splenomegaly
$ Genital examination for STDs, pelvic examination in women
$ Neuropsychological testing
$ Nutritional assessment

30
3.1.7 Laboratory Diagnosis

Initial or baseline Laboratory studies


(Most of the tests cannot be performed at the health center level, yet the health officer
should have basic knowledge of the tests.)
5 Complete blood count with differential and platelet count
5 Blood Chemistry
5 CD4 cell count
5 Purified Protein Derivative (PPD) with or without energy testing using two of the
following three skin tests reagents:candida albicanus, tetanus toxoid, mumps
5 Venereal Disease Research Laboratory (VDRL) test or alternatively Rapid
Plasma Regain (RPR) test
5 Chest X-ray
5 papanicolau (PAP) smear (repeatedly every 6-12 months)
5 Verify HIV serological status
An HIV test does not tell whether you have AIDS. It only determines whether you have
been infected with the virus.

Interpreting Test Results:

HIV Positive Test Result means

D There is definite HI?V infection if there are other obvious signs of


immunodeficiency.
D There is likely HIV infection and a confirmatory test should be dome.
D The person is able to spread the HIV during sex, through his/her blood, or during
pregnancy, childbirth and breast feeding.
The HIV positive test result does not mean:
D That the person has developed the AIDS stage of HIV disease

D That the person will definitely develop AIDS. However, most HIV positive
People (95%) will develop AIDS within 7-10 years from the time of the infection
(not from the time of the test!),

31
D It does not reveal the stage of the disease.
D it cannot determine when the person acquired the HIV infection.
HIV negative test result means
D The patient does not have HIV infection, unless the test is dome during the
"window period'
D It may be falsely negative if the test is dome within the first 6-12 weeks after
possible HIV exposure, then the test should be repeated after a total period of 12
weeks after the possible HIV exposure.
D Laboratory error
Who should be tested?

$ Persons who have sexually transmitted diseases


$ Persons considered to be in high risk categories:
• Commercial sex workers
• Hemophiliacs
• Persons who received unscreened transfusions
• Intravenous drug users
• Gay and bisexual men
$ Persons who consider themselves at risk or request the test (voluntary testing)
$ Women who are in child-bearing age or who are pregnant
$ Medical evaluation (diagnostic test) for patients with clinical or laboratory findings
suggesting HIV infection including:
• Generalized lymphadenopathy;
• Unexplained dementia;
• Chronic, unexplained fever or diarrhea;
• Unexplained weight loss;

32
• Diseases that commonly complicate HIV, such as chronic or generalized
herpes, thrush, oral hairy leukoplakia;
• Other opportunistic infections suggesting unexplained defective cell-mediated
immunity;
• Opportunistic tumors including Kaposi's sarcoma and B cell lymphoma;
• Unexplained cytopenias (anemia, leukopenia, lymphopenia,
thrombocytopenia);
• Unexplained neurological syndromes (Guillian-Barre syndrome, aseptic
meningitis, peripheral neuropathies)
$ patients with active tuberculosis
$ Recipient and source of blood or body fluid exposure:
• Body fluids considered source of infection (other than blood): semen,
Vaginal secretions, cerebrospinal fluids, synovial fluid, pleural fluid,
peritoneal fluid, peicardial fluid, amniotic fluid aned bloody body fluid;
• Body fluids not considered resk are feces, nasal secretions ,sputum,
saliva, sweat, tears, urine and vomitus unless they contain visible blood;
HIV testing must be carried out according to the proper and ethical standards. There
must be:
Ä Pre-and post-test counseling
Ä Informed consent
Ä Privacy, confidentiality and the right to refuse to have the test

3.1.8.1 Case Management

Drugs used in the case management of AIDS, the opportunistic infections and
their side/effects and complications

Antiretroviral therapy-currently the antiretroviral drugs are not included in the Essential
drug list for health centers. But for information, the list of the various drugs used for
treatment is annexed.
Management of the most common opotunistic infections
1. Peneumocystis carinii - tremethroprim or pentamidine, clindfamycine, atovaquone
2. Candida (thrush) - ,etoconazole, nystatin clotrimazole, fluconazole,

33
3. Candida (vaginitis) - Intravaginal miconazole suppositories, clotrimazole OR
ketoconazole, fluconazole
4. Cryptococcal meningitis - amphotericine B or fluconazole, itraconazole
5. Micobacterium tuberculosis - INH, rifampicine, pyrazinamide, ethambutol,
streptomycin
6. Herpes simples - acyclovir OR foscarnet, topical trifluridine solution
7. Herpes zoster (dermatomal) - acyclovir OR foscarmet
8. Staphillococcus Pneumonae - penicillin or erythromycin, cephalosporines
9. Heamophillus influenza - ampicllin/amoxicillin OR co-trmoxazole,
cefuroxime/cefamandole,
10. Salmonella(ac ute) - ampicillin then amoxicilline, ciprofloxacin OR co-trimoxazole
11. Staphillococcus aureus - nafcillin, oxacillin ± gentamycin , rifampine OR
cephalosporin ± gentamycin or rifampine, vancomycin

Advise the patients on:


Self - care to:

Ä Have balanced diet


Ä Consider nutritional supplements, such as vitamins and minerals
Ä Avoid smoking
Ä Avoid Alcohol intoxication
Ä Do physical exercise
Ä Avoid taking unnecessary drugs
Ä Have lots of rest and sleep
Ä Have a positive mental; attitude
Ä Alternative therapies (such as massages)
Ä Seed early treatment for medical problems

Safer sexual practices:


Ä Protection through condom use
Ä Alternative sexual methods -masturbation
Ä Avoid anal sex

34
Support, Counseling and Referral

Remember that there are three types of counseling for PLWHA, these are the pre-, post-
test and follow up counseling-for details refer to the satellite Module for public health
Nurses.
In counseling PLWHA, the following messages should be included:
1. The natural history of HIV infection:
a. Average time between infection and serious illness
b. Prospects and uses of administering anti-retroviral therapy and prophylaxis
2. Positive serology indicates viral carrier state and risk of transmission to others-
counsel on how to prevent the spread.
3. Pregnancy in a seropositive woman carries a 30-35% risk of HIV infection in the
infant.
4. Inform about their sexual and needle sharing partners
5. The need for early testing and early treatment
6. Psychological responses such as anxiety, depression, insomnia, somatic
concerns, and/or suicidal thoughts need support.
7. Medical care - treatment should include appropriaste attention to nutrition,
exercise, continued work, andf other facets of ''wellness.''
8. Available resources for patient services and financial assistance - organizations
such as organizations such as organization for social services for AIDS patients
(OSSA) save your generation Association (SYGA), Dawn of hope, etc.

Principles of home-based care

The health officer should advise the caretakers of AIDS patients to provide the following
home:(refer for details on the satellite module for public health Nurses)
1. General hygienic measures - personal hyugiene, house keeping (handling
contaminated soiled materials)
2. Nutrition of the patient - provide good nutrition (proper balanced diet)
3. Treatment of opportunistic infections
4. Physical therapy - physical exercises and massages

35
5. Various types of support to be provided - social, spiritual, emotional,
psychological and material support
6. Measures on the sexual behavior of the patients - information and education to
promote responsible or safe sexual behavior to prevent the spread

3.1.9 Prevention and control


HIV transmission mechanisms and interventions

Transmission Mechanisms Interventions


unsafe medial practices Ensure sterile conditions
Transfusion Eliminate unnecessary transfusions
Screen donors
Test blood supply
Prenatal (mother-to-child) Counseling
[During pregnancy, delivery and breast Testing
feeding] Nutrition
Family planning
AZT or Nevirapine (NVP)
sexual transmission Maintain faithful partnership
Delay onset of sexual activity
Use of condoms
Control STDs

Transmission through Blood Transfusions

Avoid unnecessary transfusion. Blood supply should be made as safe as possible.


Laboratory tests and screening potential blood donors through interviews should screen
blood in order to reject as donors or those that have a high probability of being infected.

Mother to child Transmission


$ Counseling and Testing of young women for HIV
$ Reducing number of pregnancies - counseling and testing to convince HIV
infected women not to get pregnant

36
$ Reduce transmission during childbirth - vaginal cleansing, delivery by
$ Anti-retroviral therapy - AZT or NVP during childbirth and postpartum period
$ Reduce transmission through breastfeeding -curtail breastfeeding

Transmission through Heterosexual Contact

$ Promoting abstinence before marriage and faithfulness to one partner


o Use mass media, counseling and educational programs
o Delaying in onset of sexual activity among adolescents
o Limiting sexual partners at any one time
o Reduction in the number of men who have contact with commercial sex
workers and bar girls
$ Promoting the use and availability of condoms, including female condoms,
$ Controlling other sexually transmitted diseases such as syphilis, gonorrhea and
cancroids
$ Combined interventions

3.1.10 Impacts of AIDS

5 Demographic Impacts

AIDS will have a big impact on population size, growth and life expectancy. With the
continued AIDS epidemic, the total population of Ethiopia would be 85 Million by 2014,
which is 7 Million smaller than the projection without AIDS. However, by that time the
population would still be growing at.2.3% per Year.

5 Health Care Impacts

Ä Costs of health care


AIDS is an expensive disease that will require a considerable amount of resources from
the health system. By 2014, expenditures for AIDS care could amount to one-third of the
entire budget of the ministry of Health. Clearly, this would place a tremendous burden on
the public health care system to provide adequate care for AIDS patients and still try
to meet all the other health needs of the population.

37
Today, as much as one fifth of all hospital in the country are occupied by AIDS patients.
As the epidemic grows, so will the hospital bed requirements? BY the year 2000 about
half of all hospital beds are projected to be occupied by AIDS patients.
Ä Childhood deaths
The number of children dying from AIDS is increasing and this negatively affects the
outcomes of child survival programs.
Ä HIV and Tuberculosis
TB/HIV relationship is already established in Ethiopia. With AIDS, a number of new
cases of tuberculosis will develop. In the absence of HIV, the number of new TB
infections would be limited to about 0.12% of the adult population. This would result in
35,000 55,000 new TB cases each year. If we assume that, among people with both HIV
and latent TB infection, 8 percent develop TB each year, and then the additional number
of TB cases due to HIV infection would be about 82,800 in 2000 and 13. 380 by 2014.
Even this is likely to be an under-estimate since these new cases may transmit the
disease to others. The impact of HIV on tuberculosis is a serious problem. Since TB can
be infectious through casual contact, the increased number of TB cases due to HIV can
also lead to additional TB cases among those who are not infected with HIV. Also drug-
resistant strains of TB are appearing, making it much more difficult and expensive to
treat tuberculosis.

5 Economic Impacts

AIDS has an impact on the economic development of Ethiopia in a number of ways. The
loss of young adults in their most productive years of life will certainly affect overall
economic output. If AIDS is more prevalent among the economically well to do, the best-
educated people and with the highest paying jobs, then the impact could be much
larger. The huge expenditures for care of AIDS patient will lead to reduction in
investment, which could lead to reduction in investment, which could lead to a significant
reduction in economic growth,
AIDS can also affect foreign exchange allocation. It has been estimated that the foreign
exchange requirements for imported drugs could require from 7 to 37 weeks of entire
foreign exchange quota if all AIDS patients received complete drug treatment.

38
Sectors highly affected:
• Health
• Education
• Military
• Transportation
• Extension services
• Banking
• Agriculture
• Industry
o Loss of workers
o Lost work days due to sickness
o Lost work days due to funeral leave
o Increased health care costs

5 Social Impacts

$ Grandparents will have to assume full responsibility for raising children when
parents die.
$ Children are more likely to be malnourished, and have fewer opportunities for
education
$ Increase in the number of orphans. The number of AIDS orphans could increase
to 750,000 by 2000 and to 2.1 million by 2014.
$ If the husband dies, the remaining wife and children can be particularly
vulnerable. Some women will be over worked with family affairs and some even
have to resort to commercial sex to cover costs for supporting the family.
$ A widow can also be forced to sell sex if she cannot maintain herself and her
children on the farm or with other occupations.
$ A woman may be at risk of getting HIV even though she is faithful to her husband,
because her husband could have extramarital affairs.
$ At family level -an increased burden and stress for the extended family.
$ At community level and national level there will be an increased burden on
society to provide services for the orphaned children.

39
3.1.11 Epidemiological Case Study: learning activity 2

(Refer to the Core Module Section2.12)


After reading the Case Study thoroughly, answer the following questions.

1. From the case study describe the rate of progression of the spread of HIV
infection.
2. Who do you think are at higher risk of acquiring infection? Why do you think these
groups are at higher risk?
3. How do you compare the prevalence of HIV infection between the various
population groups? To what do you attribute these differences?
4. Why do you comment on the prevalence of HIV infection among commercial sex
workers and its impact on the spread of HIV/AIDS?

40
UNIT 3.2
SATELLITE MODULE FOR PUBLIC
HEALTH NURSE STUDENTS

41
3.2 Satellite Module for public Health Nurse Students

3.2.1 Introduction

Public health Nurses (PHN) are involved in the management, and care of PLWHA.
Prevention and control of HIV/AIDS, is one of the major areas where PHNs will be
involved. Therefore, it is vital to equip this category of health workers with the up-to-
date and relevant Knowledge and skills that help them to give the maximum care/
support for HIV/AIDS patients including counseling and conduct promotive and
preventive activities. They should be sufficiently skilled to provide optimal care for AIDS
patients both in clinical setting and at home. It is also important that PHNs develop
caring attitude towards persons affected by HIV/AIDS and be taught on the various self-
protective measures during their practice.

3.2.2 Directions for Using the Module

Proceed through the modules as follows:


Î Read the Direction for using the module in section 1.2 and follow the instructions.
Î After doing so read the core module, do the pre-tests, do the exercises and then
go through this satellite module.
Î Afterwards, you may also read the satellite modules of other category of health
Professionals.
Î Read the clinical manifestations from the satellite module prepared for health
officers.

3.2.3 Learning objectives

At the end of the session the students should be able to:


1. List the various clinical manifestations of AIDS.
2. Describe in detail the nursing care for AIDS patients.

42
3. Describe the precautions while providing nursing care and handling body fluids.
4. Identify the potential sources of contamination from a patient with HIV/AIDS.
5. List the available drugs used in the treatment of AIDS patients.
6. List some of the common side effects of drugs used in the treatment of AIDS.
7. Describe the types and procedures of counseling PLWHA.
8. Explain the procedures of home based care for AIDS patients

3.2.4 Case Study: Learning Activity 1


Questions (based on "the HIV-Spread like a fire game ")(Annex 7.1)

1. What is the role of a public Health Nurse in the prevention and control of the
epidemic
2. How and where should PLWHA be managed?
3. In relation to the game played, what are the implications of the rapid spread of
HIV/AIDS?
4. What other methods should be used to teach the community?
5. Who is responsible to counsel and what is the importance of counseling (relate
the questions with laboratory services given in the game)?

3.2.4 Nursing Care of AIDS patients

Nursing care is one of the most important cares that need to be given to PLWHA. since
there is no cure for HIV/AIDS nursing care and support are the main-stay of help for
PLWHA.

The following are the general principles of providing care for PLWHA:

1. General hygienic measures


2. Nutrition services
3. Information and education for sexual behavior

43
4. Physical therapy
5. General support services
6. Treatment of opportunistic infections.

1. GENERAL HYGIENE SERVICES

The purpose of home-based care (HBC) services for PLWHA in the area of general
hygiene is to:

œ Establish state of cleanliness


œ Refresh PLWHA

œ Improve relationship between PLWHA and caregiver

œ Provide opportunity for care givers to observe PLWHA'S general condition

œ Improve quality of care

Other HBC activities in this category aim to keep the PLWHA'S surroundings clean and
to help prevent contamination and cross- infection.

a) Bed Baths
Definition

Abed bath is given to a bedridden patient in the bed. The patient is helped to bathe by
the caregiver. While giving bed baths the care giver should always be gloved.

Steps
1. Explain the procedure to the patient and offer a plastic container /urinal if
necessary.
2. Close the windows and draw the screen
3. Strip the bed and cover the patient with a blanket. NB: if bedding is soiled
(e.g., stool, urine, blood), follow steps below under" Handling Soiled Linen''.
4. Help the patient into a suitable position.
5. Protect the bed with a plastic sheet.
6. Place basin of Warm water on the stool/table; be sure the patient can easily
reach toilet articles.

44
7. Permit the patient to take bath by him (her) self as far as condition allows, even
leaving the room for a short time, if patient is able to manage alone.
8. When the patient has finished to the extent possible, return, change the water
and complete the procedure by
⇒ Washing the patient's back
⇒ Attending to the patient's feet
⇒ Taking care of pressure areas
⇒ Cutting finger-and toe nails
9. Help patient into clean clothes and make the bed.
10. Make sure that the patient's hair has been combed. Offer a mouthwash and help
clean the teeth, A male patient may wish to shave.
11. Leave the patient in a comfortable position.

b) Turning PLWH/A in Bed

Definition
This is care given to bed-ridden PLWHA to prevent them from developing pressure
sores caused by lying on one side of the body for long periods. Turning should be
done at least every 4 hours.

Steps
1. Explain the procedure to the patient.
2. Strip the bed leaving the top sheet loose so that the patient's limbs can be
easily moved.
3. Bring an arm and a leg across to the side the patient is to face.
4. One person brings over the shoulder while the other rolls the pelvis.
5. Now the 2 people join hands over the PLWHA hop joints and thighs and lift the
patient into the center of the bed.
6. Adjust the pillow under the PLWHA'S cheek.
7. Put the PLWHA'S hands in a comfortable position.
8. Bend the PLWHA'S legs slightly.
9. Remake the bed ad leave the patient comfortable.

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C) Handling Body Fluids

Definition
This is care taken to dispose of body fluids to prevent contamination.
Purpose

People living with HIV/AIDS are at greater risk of contracting various infections. Body
fluids are often a source of infection to both PLWHA and their families. They may
contain HIV and other harmful germs. PLWHA and their families need to handle body
fluids with care.

The following sections are about how to handle these body fluids:
⇒ Blood
⇒ Plus
⇒ Stool and urine
⇒ Sputum and vomits

Blood from Wounds and Bleeding

Steps

1. Put on gloves or plastic bags.


2. Stop the bleeding.
3. Cover the wound with clean cloth or bandage.
4. Soak clothes soiled with blood for 10 minutes in cold water/5% chlorine solution.
5. Wash clothes with hot water and soap; rinse well.
6. Dry clothes in the sun.

Menstrual Blood

Steps
1. Put on gloves/ plastic bags.
2. Change the pads or cloths.
3. Wrap the used pads or cloths in newspapers or plastic bag.
4. Burn the pads or throw them into a pit latrine.

46
Note: Wrap contaminated wastes in news, if available, for disposal in a pit latrine.
d) Stool, Urine, Vomits and Sputum

Stool and urine should be thrown down the pit latrine immediately.

Steps
1. Prepare plastic containers with 5% chlorine solution to decontaminate the body
waste.
2. Put the plastic containers by the PLWHA'S bedside or underneath for use.
3. Always cover containers used to collect body wastes.
4. Explain to the PLWHA how to use the containers.
5. Put on gloves/plastic bags to empty the containers preferably in apit latrine, or
bury the contents.
6. Soak the plastic containers for 10 minutes in soapy water with 5 % chlorine
solution.
7. Scrub containers using brush.
8. Rinse in clean water.
9. Prepare containers for re -use

Body Fluids on surfaces


If any body fluids spill on the floor, seats or objects, they should be cleaned up
immediately and the surfaces decontaminated.

2. NUTRITION SERVICES

The purpose of nutrition services to PLWHAS is to provide a diet that can compensate
the catabolic losses due the illness as well as for the patient to live a relatively
comfortable and ''healthy'' life. Such food should be able to:
D Provide energy to the body
D Repair worn out body cells
D protect the body against infections
D Stimulate the appetite
D Improve well-being of the body

47
Food preparation; Food preparation in this context means making nutritionally balanced
meals in a form that is appealing, appetizing (presentation, smell, taste) and culturally
acceptable.

Food Service: Food service involves presentation of food in an attractive way, to


stimulate the patient's appetite and encourage ingestion. PLWHA may be able to feed
them selves or they may need assistance.

Steps

1. Explain the procedure to the patient.


2. Help the patient into a comfortable position.
3. Place a protective cloth on the chest of the patient.
4. Feed the patient with small quantities of food, allowing time to swallow.
5. Give drinking water on demand.
6. Have patient rinse the mouth with water or mouthwash after eating.
7. Remove the protective cloth and eating utensils.
8. Settle the patient.

3. INFORMATION AND EDUCATION SERVICES FOR SEXUAL BEHAVIOR

The purpose of providing information and education (IE) about sexual behavior is to:
$ Prevent infection and re- infection
$ Improve and maintain sexual relationship
$ Raise awareness
$ Provide opportunities to make informed decisions

Information and Education for safer sex

Penetrative sex always carries some risk. This is why it is wise for PLWHA not to have
any penetrative sex at all. However, if PLWHA and their partners decide to have
penetrative sex, they should be sure to use protection. Condoms are effective in
preventing pregnancies and infections from HIV/AIDS and other STDs because they
help prevent contact with sexual body fluids (semen, vaginal fluids and blood).

48
What is "safer sex''?

Safer sex is any sexual practice that reduces the risk of passing (transmitting) HIV from
one person to another.
The best protection is obtained by choosing sexual activities that do not allow semen,
fluid from the vagina, or blood to enter the mouth, anus or vagina of the partner, or to
touch the skin of the partner where there is an open cut or sore.
Safer sex practices include:
$ Staying in a mutually faithful relationship where both partners are uninfected.
$ Avoiding certain practices that increase the possibility of HIV transmission, for
example ''Dry'' sex, which may lead to breaks in the skin.
$ Following the ABC Rules of sexual behavior:
A = Abstinence from sexual activity
B = Be faithful to one partner or
C = Condom use with all sexual partners
Copies should talk about sex and learn to please each other. This can allow for the
negotiation of safer sex and make the intercourse more pleasurable for both and less
likely to cause discomfort or minor damage to the genitals.

4. Support services

Support services are those given to PLWHA to help meet social, spiritual and emotional
needs. Support services help to:

$ Reduce anxiety
$ Provide sense of belonging
$ Assure quality of care
$ Improve relationship between PLWHA and care giver
People who have AIDS or people who are in contact with someone with AIDS are often
afraid that the negative feeling described about PLWHA will be too strong to bear. These
feelings cannot and should not be avoided. They are normal reactions to crisis. Family,
friends, neighbors, CBRHA (or anyone who cares) can help another person cope with
these feelings by listening and tailing to the person about these feelings.

49
Neighbors can help a family that is affected by AIDS. Women's clubs, youth and
religious groups can also be mobilized to assist. Similarly, local political and social
organizations can be involved.
Fear, Anxiety or Depression
What to Teach the Family:
$ Listen to the patient.
$ Let the patient know that their feelings are normal.
$ If they need or want professional help, help them to get it if possible.
$ Talk to some one; family members may also be depressed and need help and
counseling.
$ Get support from a helping organization in the community. Many health workers
and religious and spiritual organizations can counsel people living with HIV/AIDS
and their families.
Note: If people need help and do not accept it, or are so angry that they may hurt
themselves or another person, it is a good idea for the family to talk to someone
in a helping organization.

What to Teach the Person and the Family:

$ Keep the person as comfortable as possible.


$ For pain, provide ant pains at regular times.
$ Help the person relax: for example, give back rubs and body massages, serve
tea.
$ Keep the person clean and dry.
$ Help the person to be as independent as possible:
Accept decisions such as refusing to eat or get up
Respect requests such as having or not having certain visitors
$ Allow the person to give for the losses that are being experienced.
$ Let the person talk about how (s) he feels.
$ Accept the person's feelings; for example, anger or sorrow.

50
Confusion

What to Teach the Family:

$ Move loose or dangerous object out of the way.


$ Help the person to stand and walk, about.
$ Try no to leave the person alone and unattended.
$ Keep medicines out of the way if the person is forgetful and might take them
incorrectly.

Physical Therapy
Purpose

Physical therapy includes exercise or massage that helps to:

$ Improve blood circulation


$ Improve digestion
$ Prevent stiffness of joints
$ Prevent muscle wasting
$ Prevent secondary infection, e.g., Inhalation pneumonia
$ Relax the patient

Steps

1. Assess PLWHA for the need or exercises/massage.


2. Explain the exercise/massage to the PLWHA.
3. Perform the exercises/massage.
4. Ensure that the exercise/massage is not painful.
Teach PLWHA the routine of the exercise/massage, including timing and duration.

5. SERVICES FOR THE MANAGEMENT OF OPPORTUNISTIC


INFECTIONS.
The purpose of home-based care of opportunistic infections is:
$ To reduce suffering
$ To promote healing of these infections
$ To maintain continuity of services

51
$ To bring services close to the PLWHA

Home/Traditional Treatment
Steps
1. Identify PLWHA requiring home/traditional treatment.
2. Identify the conditions for which PLWHA require home/traditional treatment.
3. Decide on appropriate treatment if there is no medical treatment.
4. If medical treatment is prescribed ensure that any medications are taken
according to prescription.
5. If PLWHA is on home/traditional treatment ensure that the treatment is safe and
effective.
6. Refer PLWHA who need medical treatment.

Referral for Medical Treatment

PLWHA often have health problems that cannot be treated at home. In this case they
Must seek the advice and care of medical practitioners. The home-based caregiver
Needs to be able to recognize such conditions and provide referrals for medical
Treatment.

This service:
$ Maintains continuity of medical care
$ Provides linkage between clinics and PLWHA
$ Provides support for PLWHA
$ Allows follow-up
What should people do at home?
Hygiene

What to teach the person and the family:


$ Always wash hands before cooking or eating.
$ Always wash hands after defecating.
$ Wash dishes in hot water with soap.
$ Wash linens and clothes with soap and hot water.
$ Cover the mouth when coughing then wash hands.

52
$ Always spit into a container, not on the ground.
$ Always wash the hands after touching blood.
$ Dispose of garbage in covered containers, or bury or burn it.

Nutrition

What to teach the person and the family:


$ Eat small amounts often, including complete nutrition if possible: fruits,
vegetables, grains and beans, and if possible, eggs, milk, meat or fish.
$ Choose foods that the person likes.
What to teach the family:
$ Keep the person away from cooking smells.
$ Prepare small amounts of favorite food often.
$ Watch for dehydration. (See treatment for dehydration under Diarrhea.)

Skin problems

What to teach the person and the family:

$ If the patient has diarrhea:


$ Wash the skin with warm soap and water after each bowel movement and
$ Keep the skin clean and dry.
& For open sores:
$ Wash with soap and water
$ Keep the area dry, and apply 1% gentian violet solution
$ Dressings can be made of cloth strips that have been washed and dried in the
sun
$ Dressings soiled with pus or blood should be handled the way body fluids are
handled

& For rashes:


$ Apply local remedies or calamine lotion.
& Herpes zoster causes a large area of open sores on one side of the body; this
can be very painful. For adults, take paracetamol 1000 mg every 4 hours. Local
remedies and locally applied wet compresses may also be helpful. If the pain is
very bad or the sores become infected, encourage the person to go a health care

53
facility for stronger pain medicine and for dressings and medicines for the open
sores.

Sore Mouth and Throat

What to teach the person and the family:

& Rinse the mouth with warm water mixed with a pinch of salt.
& For white patches, suck a lemon to ease sores on the lips and mouth.
& Eat soft foods as much as possible.
& Apply gentian violet solution to sores on lips and mouth.
& Use any local remedies that are soothing.

Pain

What to teach the person and the family:

& For adults, take paracetamol 500mg tablets every 4 hours.


& Use any local remedies that ease the pain.
& If lying in bed, change positions frequently.
& For swelling, raise legs or swollen body parts on pillows.

What to teach the family:

$ Rub and gently massage sore muscles. Use oils.


$ Talk with the person. Provide distraction o help the person forget the pain.
$ Help the person to change positions and to raise the legs or swollen body parts.

Tiredness, Weakness
What to teach the person and the family;

$ Rest as needed. Learn to accept help from others


$ Find ways to make activities easier. For example, sit rather than stand to wash.

54
What to teach the family:

If needed, help the person with care such as washing, going to the toilet or latrine,
getting in and out of bed, eating .If the person cannot get out of bed at all, gently move
the arms and legs several times a day

Fever

What to teach the person and the family:

& Wash the body in cool water or wipe the skin with wet cloths.
& For adults, take paracetamol 500mg tablets every 4 hours.
& Drink more than usual: water, tea, broth or juice.
& Use any local remedies that reduce the fever.
Fevers may be caused by infections such as malaria and tuberculosis that can be
treated effectively by modern medicine. Encourage the person to go to health care
facility if a new or especially high fever develops.

What to teach the family:

& Offer water and other drinks frequently.


& If the person is weak, help him or her to turn from side to side in bed, or to sit up
and move about.
& Help keep the person clean and dry.
& Watch for dehydration. (see treatment for dehydration under Diarrhea.)

Chronic Diarrhea

People living with HIV/AIDS may have diarrhea that does not go away.

What to teach the person and the family

& Drink much more than usual: lots of water, tea, broth or juice.
& Continue eating solid foods, including porridge (admit) and fruit such as bananas:
& Wash and dry the skin around anus and buttocks after every bowel movement.
What to teach the family:
& Encourage and serve lots of water, soup and juice frequently.

55
& Watch for signs of dehydration: the tongue is dry, the eyes are sunken, and skin
goes back slowly when pinched. If the person is dehydrated, give oral re-
hydration solution.
Note; If the person cannot drink, and dehydration becomes worse, encourage the
family to quickly take the person to the nearest health facility.

Cough and Difficulty in Breathing

What to teach the person and the family:

& For adults, take paracetamol 500 mg tablets every 4 hours.


& Drink lots of fluids, especially if there is fever.
& Move about and turn in bed frequently.
& Sit up when possible.
& Cover the mouth when coughing. Spit into something that can be burned such as
a piece of paper, sputum cup, leaf or a p0aper box.
& Use any local remedies that are soothing.
Infections such as pneumonia and tuberculosis (TB) can be treated effectively. TB is
contagious to others if it is not treated. In courage the person to go to a health care
facility for any new cough or difficult breathing, especially if there is chest pain, bloody
sputum or a new fever.

What to teach the family:

& Elevate head and upper body on pillows or raise the head of the bed on blocks to
assist breathing.
& Sit with the person. Difficulty in breathing can be very frightening.

Care of the Person who is dying of Aids


Eventually, the person with AIDS will die. This is sometimes hard for the person and for
the family to accept. In this case, do not avoid discussion or deny that the patient is
dying. Otherwise this creates fear and anxiety. Patients and their family often want to,
and need to, talk about death. This serves to express feelings and fears and helps to
prevent anxiety and other problems. Being open about death can help the patient and

56
His/her loved ones get close and make the dying process smooth. it also helps to
prevent '' regret'' that later makes the grieving process more difficult for the relatives.
A different kind of care is needed for the person who is dying. This care can be provided
either in hospital or at home. In both places, the family is very important when a person
is dying. Any person who is handling the deceased should strictly follow hygienic
practices, i.e., the person should be fully gloved and protect him/herself from coming
into contact with any of the body fluids of the deceased.

Post-mortem care

Pay special attention to your personal protection, i.e., the caregiver should be properly
gloved and if possible gowned.
The following procedures should be followed:
5 Clean the body, bathe if necessary
5 Close eyes and mouth
5 Place the body parts in normal position(arms, legs,head,etc)
5 Pack cotton/pads in the rectum and vagina
5 Cover any draining wounds with clean dressing
5 Tie extremities loosely
5 Pad ankles and wrists
5 Wrap the body in clean shroud of discarded sheet or any other garment
depending on the culture.
3.2.7 Counseling for PLWHA
In counseling PLWHA. The following messages should be included:
1. The natural history of HIV infection.
2. Average time between infection and serious illness.
3. Prospects and uses of administering anti-retroviral therapy and prophylaxis
4. Pre and post test counseling.
5. Positive serology indicates viral carrier state and risk of transmission counsel on
how to prevent the spread.
6. Pregnancy in a sero-positive woman carries a 30-50% risk of HIV infection in
theinfant. Viral transmission may take place in-utero, during birth or with breast-

57
feeding. Condoms are not adequate for birth control and should be used in
conjunction with other methods such as oral contraceptive pills.
7. Inform about their sexual and needle sharing partners and the precautions
8. The need for early testing and treatment.
9. Psychological response - anxiety, depression insomnia, somatic concerns and/
orsuicidal thoughts.
10. Available resources for patient services and financial assistance - organizations
such as OSSA, SYFA, Dawn of Hope, etc.
11. Medical care - treatment should include appropriate attention to nutrition,
exercise, continued work, and other facets of "Wellness."
There are three types of counseling for PLWHA; these are the pre-, post-and follow up
counseling
Pre-test Counseling
Reasons:
Ä To ensure that the person understands the basic facts about HIV/AIDS
Ä To assist the patient in understanding the test and what the results mean and to
prepare him/her to receive this result
Ä To consider and explore what he/she might do if the test is positive or negative
Ä To explore potential support for loved ones, family, friends, etc
Ä To understand that if he/she is Hive positive, there is medical care/follow up
which can help to keep him/her healthier for longer
Ä To ensure that the person has confidence in the confidentiality of the test result,
I.e., that it will be kept private
Ä To advise on safer sexual practices
Ä To enable the person to make an informed decision whether to take the test or
not
Ä To make an assessment of risk of possible HIV infection
Some of the most important issues:
Ä Does the patient understand the basic information about HIV infection and AIDS?
Explain these and clear up any misunderstandings.

58
Ä Does the patient understand what the test is and what a positive or negative
result would mean? Remember it is an antibody test and does not tell whether
you have the AIDS phase of the disease
Ä Explore why he/she wants the test, or explain why you have suggested the test,
and what benefits there are in knowing one is HIV positive. Has he/she been at
risk for acquiring HIV infection?
Ä It is also important to discuss how the patient thinks he/she might feel and react if
the test is positive. How would he/she tell the news of the result to the sexual
partner? If the result is positive, the sexual partner may also need a test.
Ä It is best if he/she thinks carefully about who to tell the result to: employers,
friends, and even some family members may not keep the result to themselves.
Many people have lost their jobs, friends and lovers after telling them the positive
result.
Ä Explain when and how he/she can get the result. HIV results should be given to
patients in person and in privacy/ the result must be kept confidential.
Ä Let him/her know that you understand the difficulty and anxieties involved in
having an HIV test. Let him/her know that you, or another health worker, will be
available to give the result. Tell him/her that it will be, kept confidential and that
there will be ongoing support and advice if needed.
Ä Does he/she know how to prevent the spread of HIVinfection? Does he/sher
know how to have sex in a safer way? Can he / she get condoms or do you need
to provide them? Does he / she know how to use them correctly? you may need
to explain in detail about the Importance of practicing safer sex from now
onwards. Remember this may be the last time you will see the patient.
Ä After exploring the above issues, it is important finally to ask if he/she still wants
to undergo the test, or would he/she like to think about it a little longer? In this
way he /she will be able to give informed consent.

59
Post/test Counseling
Reasons:

Ä It is often difficult for a person to accept and believe that he/she has HIV infection
merely on the basis of an HIV positive test result. Counseling is often needed to
help convince the patient about reality of the situation.
Ä To ensure the person understands the meaning of the result.
Ä To help the person cope with the result, especially in the days or weeks to follow
(if the result is positive).
Ä To make a follow up plan for the ongoing care of the person if he/she is HIV
positive.
Ä To ensure that the person is aware of the dangers of spreading HIV (if the result
is positive) or of preventing infection (if the result is negative). Information on
safer sexual practices should also be given.
Ä To understand the need for careful consideration about having children, if HIV
positive.
Ä To explain the need for re-testing if he/she is considered to be in the['' Window
period''.
It is usually best to give the result as soon as possible with out any unnecessary delay.
Results must be given the result as soon as possible without any unnecessary delay.
Results must be given in a private and confidential manner. Remember the patient is
most likely to be very anxious and will be concerned about the result. Allow him/her time
to think about it. Whether it is positive or negative, you must check that he/she
understands the meaning of the result, and what the implications are. He/she may need
to return to clear up misunderstandings or to hear some of the details again.

If the HIV tests result is positive:

Ä Give the patient time to express his /her feelings and fears, and encourage
him/her to talk, He /she may experience many different feelings, such as anger,
guilt, sadness, anxiety, fear, confusion or disbelief. He/she may become
emotionally' shocked'' or be unclear or confused about what to do next. These are

60
all normal and expected responses. Give him/her the opportunity to feel them and
express them.
Ä Reassure that he/she will not be abandoned (left alone). Make it clear than
he/she will be supported and guided as to what to do next. Explain that coming
to terms with the result is a process that needs some time.
Ä Try not to overload him/her with information and advice all at once. He/she needs
to treat and manage an HIV positive person. Let him/her know that you, and/ or
other co-workers, are available to provide ongoing support and care.
Ä He/she should understand the importance of practicing safer sex. and the need to
protect sexual partners from infection. He/she may need a supply of condoms.
Ä He/she may need convincing that an HIV positive result really means that there is
HIV infection.
Ä In a woman it is even more important for her to approach her sexual partner very
carefully. The male partner may become aggressive and violent when he learns
that his wife or girlfriend is HIV positive. He may even walk out on her and leave
her destitute. The woman needs to think very carefully about what she should do.
Ä The patient must also be aware that he/she must not donate blood for transfusion
or share a syringe, needle or razor blade with anyone else.
Ä You will need to discuss to whom he/she should tell the result and when to do so.
You should do all possible to maintain confidentiality of information that may lead
to any stigmatization of PLWHA.
Ä Also discuss the possibility that the partner, family, neighbors and friends may
reject him. Such rejections, isolations and discriminations are called stigma.
Ä You may need to arrange another time to discuss this and other questions and
problems.
Ä Any health worker should do all in his/her capacity to protect PLWHA against the
effects of stigma.
If the HIV tests result is negative;

Ä Check with the patient whether he/she understands the meaning of a negative
result

61
Ä If you fell he/she has had risk of exposure to infection in the 12 weeks before
having the test, then you want to advise him/her to have another test in 6-12
months' time. Remember there is 'window' period where a person is HIV-infected
but the test is falsely negative.
Ä Discuss the importance of him/her remaining HIV negative. This means knowing
how he/she could become infected in the future. The necessary precautions to
prevent further infection will need to be taken.
Ä You may need to counsel him/her about safer sexual practices. He/she must
appreciate sex in a safer way. It might be useful to explore why it has been
difficult for him/her to practice safer sex.
Ä He/she also needs to understand the connection between other sexually
transmitted diseases (STDs) and AIDS; and the importance of having the STD
treated.

Follow up Counseling

Follow up counseling is offered to a person after pre and post test counseling to hilp the
person try to live positively with HIV infection and cope with any problems she/he may
face.

The aims of offering follow up counseling:


& Maintain hope
& Empower people with HIV to maintain control over their lives
& Develop healthy coping skills
Who should be offered with follow up counseling?

& To all clients who have undergone pre and post test counseling.
Where should it be offered?
& At office or clinic
& In hospital
& At the persons' home
& Counseling centers, or
& Any convenient place

62
Follow up counseling process:

1. Helping the person tell the story - issues from last counseling session any
concerns (Feelings, listening, understanding)
2. Helping the person consider options
3. Helping the person make plans

Issues in providing follow-up support and counseling:

1. Psychological adjustment (anxiety, stress, suicidal ideas, etc)


2. Counseling prior to death and bereavement counseling
3. practical support - coping mechanisms for self and family
4. Medical issues -- liaison with medical personnel, providing information,
promotion of healthy living
3.2.8 Drugs used in the Management of HIV/AIDS and their side effects -
Annex 7.3
3.2.9 Self-protective Measures

Precautions to avoid contracting HIV infection from patients

1. The handling of used needles

a. Re-sheathing needles - do not re-sheath or re-cover used needles


unless there is a special apparatus which will hold the sheath and give
the health worker protection. If a needle must be re-sheathed, then you
must not hold the needle cover with your hand.
b. Discarding needles - All needles must be discarded in to protected
containers. never discard a used needle or sharp instrument into a
dustbin or paper or plastic bag.

2. Procedures that involve blood and body fluids

a. Wear gloves when using sharp instruments, taking blood, putting up


drips, handling body fluids.
b. Take extra care to avoid blood splashing or spilling onto your skin.
Wash off any blood from your skin as soon as possible.

63
c. Keep obvious cuts and sores covered with waterproof plasters or tape.
d. Wear gloves when handling any blood-contaminated materials, such as
swabs, cotton wool, bandages, dressings and instruments, or for
handling any body fluids.
3. Surgical procedures: The health care worker must take extra care when doing
surgery, post-mortem and other invasive procedures. It is important to regard all
patients as possibly being HIV-infected and to take precautions on them all.

a. Take special care passing sharp instruments around during surgery.


b. Also extra care should be taken when inserting or removing a blade
from a scalpel. Workers doing post-mortam examinations should also
take extra care.
c. Use gloves and plastic apron if you are doing surgical procedures or
delivering babies (childbirth).
4. Washing hands
a. Always wash hands after examining or caring for a patient, after cleaning
up, or after doing a procedure
b. If possible use an antiseptic soap, such as iodine (Betadine), chlorhexidine
(Hibitane/Hibiscrub) and cetrimide (Cetavlon, Savlon).
5. Other protective measures
a. Eye and mouth protection -wear protective eye equipment (glasses or
goggles) when doing procedures where body fluids may e splashed.
b. Contaminated linen-wear gloves and plastic aprons for handling
contaminated linen, bed clothes, dressings, or for cleaning up any spills of
blood or body fluids
c. Mouth to mouth resuscitation- if possible place a thin cloth over the mouth,
to avoid any saliva or fluid exchange during mouth -to- mouth contact.

64
3.2.10 Case study: learning Activity 2

Refer to the Epidemiologic case study in the core module and attempt the
following questions:
1. considering the data given on the case study, what would you comment
on the effect of the epidemic on professional providing care to PLWH?
2. What precautions should be taken by professionals providing care to
PLWHA in light with the various prevalence rates of HIV infection among
the various population groups?

65
UNIT 3.3
SATELLITE MODULE FOR
ENVIRONMENTAL HEALTH
TECHNICIANS

66
3.3 Satellite Module for Environmental Health Technicians (EHT)

3.3.1 Introduction

Environmental health technicians like any other health workers, are involved in the
prevention and control of HIV infection. It is therefore necessary to equip this category of
health workers with the up to date knowledge on HIV/AIDS. it is also vital that EHT
develop favorable attitude towards PLWHA.EHT should also be sufficiently skilled to
educate the public in ways of preventing the acquisition and spread of the infection. EHT
should be effectively assisting other health workers in reducing contamination from
instruments used to give care for HIV/AIDS patients and hazardous excretion/discharge
from the patient by practicing optimal sanitary measures, particularly disinfections and
sterilization. This module, therefore, deals with equipping the EHT with the appropriate
knowledge and skills of handling HIV infected individuals and propagate sanitary
practices related to HIV/AIDS prevention.

3.3.2 Directions for Using the Module

Proceed through the module as follows:

B Read the directions for using the module in section 1.1 and follow the
instructions.
B After doing so read the core module, do the pre-tests, do the exercises and then
go through this satellite module.
B Afterwards, you may also read the satellite modules of other categories of health
professionals, too.

3.3.3 Learning Objectives and Activities

At the end of the session the students should be able to:

1. Describe the routes of transmission of HIV


2. Describe the ways of prevention and control of HIV/AIDS with focus on reduction
of contamination and IEC.
3. Explain to family members the principles, methods and hygienic measures to be
taken while providing home based care to AIDS patients.

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3.3.4 Prevention and Control (IEC Focus)

HIV transmission mechanisms and Interventions

Transmission Mechanisms Interventions


Unsafe medical practices Ensure sterile conditions
Transfusion Eliminate unnecessary transfusions
Screen donors
Test blood supply
Prenatal Counseling, Testing
(Mother-to-child) Nutrition
Family planning
Drug treatment
Sexual transmission Maintain faithful partnership
Delay onset of sexual activity
Use of condoms
Control STDs

3.3.5 How to Reduce Infection by contamination in Health Care


Facilities?

Disinfections and Sterilization Measures


Disinfections is mainly used as a barrier to contamination by discharges from the patient. It
should be applied, as closely as possible to the patient. It is frequently used to treat the
excretions and discharges of patients and also fomites and various objects with which the
sick person discharges come in contact.
Methods:
Ä Chemicals
Ä Heat
Ä Steam, boiling
Ä Large steam sterilizing

68
Ä Dry heat
Ä Light

Chemical Agents

Ä 5% chlorine solution to disinfect sputum and feces -effective if the chemical agent
is in solution form
Ä Alcohol (as antiseptic and germicide) -effective germicide in solution of 50-70%
Ä Iodine -2.5% solution in 70% alcohol
Attendants should disinfect their hands after handling patients and materials soiled with
patient's body fluids. This can be accompanied by wetting the hand with a 70%alcohol
solution.

Disinfecting Bed and Body Linen

Ä Steaming, boiling or soaking for one hour in a 5% carbolic solution, or


10%formaline before laundering
Ä During the period of illness cleaning rooms should be accomplished by scrubbing
and other dustless method (hot water and detergent) at least three times a day
(dampened cloth)
Ä For soiled walls -washing, painting or repapering may be advisable.
Ä Complete airing and sun lighting or rooms.

Management of Infectious Wastes and Sharps

„ Infectious wastes including wastes from laboratories are good media for growth of
infectious agents. These wastes have to be incinerated.
„ Sharp needles, blades and instruments could be encapsulated for disposal.
„ Blood should be disinfected before discharge into sewer or may be incinerated.

N.B: After incineration or any other disinfections process, residues may be land-filled.

69
Segregation and Packing
„ Careful segregation and separate collection of infectious waste may be tiresome for
health personnel but it is the key to safe and sound management of infectious
wastes.
„ Double packing i.e. using plastic bag inside a holder/container for easy cleaning
„ Containers for hazardous /infectious wastes should be disinfected (e.g., using
sodium hypo chlorite / bleach) before reuse.
„ Cleaning personnel should be informed about the potential risks posed by waste
handling. They should be trained in safe handling procedures and should wear
protective aprons and gloves. The waste should be collected daily.

Treatment and Disposal of infectious Wastes

Ä Thermal process
o Static - grate single chamber incinerator
o Drum or brick incinerator
o Open air burning
Ä Wet thermal disinfections
o Exposure of waste to increase temperature and increase pressure steam
Ä Autoclaving
Ä Chemical disinfections
o E.g., stool disinfections -in a bucket add chlorine
o Oxide powder or dehydrate- lime oxide (CaO)
General Remarks

B Infected dressings are put into clean, covered containers


B The lids of the containers must always be firmly covered.
B Contents should not be directly handled (free hand)
B The containers should be cleaned with disinfectants after emptying.
B Hands should be washed after disposal of contaminated wastes.
B Sharp needles, syringes, etc should be put into a special container before
disposal to avoid puncturing in collectors.

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What should the public be taught about the prevention and control of HIV
infection?

$ People should be convinced that abstinence before marriage and faithfulness to


one partner is the best way to prevent one from getting HIV infection. To do so
one can use mass media, interpersonal talks, IEC materials, and other
educational programs.
$ Adolescents and young people should be advised and convinced that they should
delay in onset of sexual activity; they should also limit their sexual partners to one
and abstain from having sexual contact with commercial sex workers.
$ In cases where the above recommendations are not feasible then all sexual
contacts must be protected by using condoms.
$ Persons having signs and symptoms or suspected of having any STD, should be
detected early and properly treated at health institutions.
$ Health professionals should be informed that any blood should be screened in the
laboratory before it is transfused. All samples testing positive should be
discarded.
$ In infected pregnant women reduce transmission through breastfeeding -curtail
breastfeeding if other options of feeding are available.
$ Reducing number of pregnancies - counseling and testing to convince HIV
infected women not to get pregnant.
$ All women (particularly young and pregnant ones) should be tested for HIV and
undergo proper counseling.
$ Proper handling of wastes and discharges from patients

3.3.7 Principles of hygiene in home based care (HBC) for PLWHA

HBC activities in this category teach families of the PLWHA to keep the surroundings clean
and to help -prevent contamination and cross-infection.

71
Handling Body Fluids
Purpose
People living with HIV/AIDS are at greater risk of contracting various other infections.
Body fluids are often a source of infection to both PLWHA and their families. They may
contain HIV and other harmful germs. PLWHA and their families need to handle body fluids
with care. Therefore, it is essential to teach caregivers of PLWHA about proper handling
and management of body fluids and soiled materials.

The following sections are about how to handle these body fluids:
⇒ Blood
⇒ Pus
⇒ Stool and urine
⇒ Sputum and vomits

Blood from Wounds and Bleeding

Steps
1. Put on gloves or plastic bags.
2. Stop the bleeding.
3. Cover the wound with clean cloth or bandage.
4. Soak clothes soiled with blood for 10 minutes in cold water/5% chlorine solution
5. Wash clothes with hot water and soap; rinse well.
6. Dry clothes in the sun.
Note: Wrap contaminated wastes in newspapers, if available, for disposal in a pit

Stool, Urine, Vomits and Sputum


Stool and urine should be thrown down into the pit latrine immediately.
Steps
1. Prepare plastic containers with 5% chlorine solution to decontaminate the body
Fluids.
2. Put the plastic containers by the PLWHA bedside or underneath for use.
3. Always cover containers used to collect body wastes.
4. Explain to the PLWHA how to use the containers.

72
5. Put on gloves/plastic bags to empty the containers preferably in a pit latrine, or
bury the contents.
6. Soak the plastic containers for 10 minutes in soapy water with 5% chlorine
solution.
7. Scrub containers using brush.
8. Rinse in clean water.
9. Prepare containers for re -use

Body Fluids on Surfaces

if any body fluids spill on the floor, seats or objects, it should be cleaned up immediately
and the surfaces decontaminated.

3.3.8 Epidemiological Case Study: Learning Activity 2


Answer the following questions related to the Epidemiological case study (2.12).

1. What can be the role of the Environmental Health? Technician in curbing the
spread of the HIV infection in Ethiopia?
2. Can you comment on the spread of HIV infection in the health care setting
through unsanitary environment?

73
UNIT 3.4
SATELLITE MODULE FOR
MEDICAL LABORATORY
TECHNICIANS

74
3.4 Satellite Module for Medical Laboratory Technician
Students
3.4.1 Introduction

Medical Laboratory Technicians (MLT) are involved in the diagnosis are management of
HIV/AIDS In individuals who are suspected to have the problem or who are apparently
healthy. They support the process of diagnosis by producing laboratory evidences. In
addition, as health professionals, they can contribute in the control and prevention of
HIV/AIDS. It is therefore, necessary to equip them with the up-to-date knowledge. It is
also vital that MLT develop favourable attitude towards persons affected by HIV/AIDS.
MLT should be sufficiently skilled to conduct the laboratory diagnosis of HIV. At the
same time they should also be taught on the various protective measures against
acquisition of HV from patient specimens during handling and processing. This module,
therefore, deals with equipping the MLT with the appropriate knowledge and skills of
handling HIV infected persons and AIDS patients and their specimen.

3.4.2 Directions for Using the Module

Proceed through the module as follows:

D Read the core module and ”the HIV-Spread like a fire” game (Annex 7.1)
D Perform the pre-test.
D Then go through the satellite module
D Conduct the post-test. If your score is not satisfactory, you may repeat the
Procedure

3.4.3 Learning Objectives

1. Describe the types of types of diagnostic tests available for diagnosing HIV
infection.
2. Describe the procedures of HIV testing.
3. Discuss on the sensitivity and specificity of each test.

75
4. Identify the types of supportive tests that could be conducted at a health center
level to diagnose opportunistic infections,
5. Discuss on the precautions I handling specimens for HIV testing.

3.4.4 Learning Activity 1 (Refer to the core module, Annex 7.1)


Questions (based on the observation of fire game)
1. Were the participants at ease for providing blood specimen for HIV testing?
2. What reaction did you observe when participants were shown the “instruments for
3. What is the role of diagnostic tests for the prevention and control of HIV/ AIDS?
HIV testing”?
4. What are the implications of being Test Positive and Test Negative? Explain by
assuming that you are the person who was tested.

3.4.5 Laboratory Diagnosis

Specific tests for HIV include antibody and antigen. Detection. Blood (serum) is
screened by enzyme linked immunosorbent assay (ELISA). Positive specimens are
then confirmed by a different method (e.g., Western Blot) or through repeated ELISA
testing. Nowadays rapid and spot tests are also used.

Nonspecific laboratory findings with HIV infection may include anemia, leukopenia
(Particularly lymphopenia) and thrombocytopenia in any combination polyclonal
hypergammaglobuliemia, and hypochoestrolemia.

For information on prognosis and guiding therapy decisions, the most important test is
CD4 lymphocyte count. As counts decrease, the risk of serious opportunistic infection
wvr the subsequent 3-5 years increases. The limitations of CD4 count include that
there is substantial diurnal variation (counts are generally lower in the morning), and
counts may be depressed by any intercurrent illness, Therefore trends is more
important than any single count.

The threshold CD4 count for initiation of therapy is 500-cills/ micro-liter of blood.
$ Those above the threshold count need counts every 6 month
$ Between 500 to 200- the counts are made every 3 months (below 200, one
needs to start prophylactic therapy for pneumocystis Carinii)

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Laboratory Tests Related to HIV Infection

The following Table illustrates the significance of the tests that need to be performed in
HIV/AIDS patients. It should be noted some of the hospitals. Yet, there will probably be
progress and chages in availability of testing. However, it is essential that MLT students
should have the basic knowledge of the various diagnostic tests and be able to conduct
the tests when the opportunity arises, only few special diagnostic centers can handle
tests such as Western blot, CD4 count, viral load determination and B Microglobulin
determination

Test Significance
Enzyme Linked Screening test for HIV infection.
Immunosorbent Sensitivity >99.9%
Assay (ELISA) To avoid false positive results, repeatedly reactive results must be
Confirmed with Western Blot

Western Blot Confirmatory test for HIV.


Specificity when combined with ELISA>99.9%.
Indeterminate results with early HIV infection, HIV2 infection,
autoimmune diseases, pregnancy, and recent tetanus toxoid(TT)
administration
Complete Blood Anemia, neutropenia, and thrombocytopenia common with advanced HIV
Count (CBC) infection
Absolute CD4 Most widely used predictor of HIV progression, Risk of progression to
Lymphocyte count
CD4 Lymphocyte Percentage may be more reliable than CD4 count.
Percentage Risk of progression to AIDS opportunistic infection or malignancy is high
With percentage<20%
Viral load tests These tests measure the amount of actively replicating HIV.
Correlates with disease progression and response to antiretroviral drugs.
Levels>5000-10,000 copies/ml indicate the need for treatment.
B Microglobulin Cell surface protein indicative of macrophage-monocyte stimulation,
Levels>3.5mg/dl associated with rapid progression to disease.
Not useful with intravenous drug users

.
Source: Tierney, LM, McPhee, SJ & Papadakis, MA. Current Medical diagnosis and
Treatment 2001. 40th edition, Lange Medical Books/McGraw-Hill, 2001.

77
3.4.6 Validity of Diagnostic Tests for HIV

The sensitivity of screening serologic tests is greater than 99.5 the specificity of
positive results with two different techniques approaches 100% even in low-risk
populations. In general, Western blot is more specific than ELISA.

False positive screening tests may occur as normal biologic variants or association with
recent influenza vaccination or other disease states such as connective tissue disease;
These are usually detected by negative confirmatory tests.

3.4.7 Precaution to be Taken During Specimen Handling and


Processing

The precautions needed for handling and processing blood specimens for HIV
testing are not different from those that are needed in handling and processing
other blood specimens. However, one should be aware of the moral as well as
legal consequences of mislabelling specimens and/or coming up with incorrect
or inconclusive results. In addition, the result of the test needs to be strictly
confidential. For these reason, the laboratory technician is, currently, the focal
person in HIV/AIDS diagnosis with implications for possible misconduct in
iterpretig and reporting of screening test results. Therefore, one needs to be
armed with the utmost ethics and professionalism in handling these issues.

78
UNIT 3.5

SATELLITE MODULE FOR

COMMUNITY HEALTH

WORKERS

79
3.5 Satellite Module for Community Health Worker

3.5.1 Introduction

The majority of people living with HIV/AIDS do not have the access to health services
either because health services are not sufficiently available or because they are not
organized in such a way that PLWHA would be served properly. It is therefore vital that
local resources from the community itself be utilized in order to motivate such people to
seek health services or provide local care to the sick at home level. In this regard, the
CHW and the family members of patients can play a significant role both in the
prevention of HIV transmission and home based care. Therefore, educating CHWS is
very important in the control of HIV/AIDS.

3.5.2 Learning Objective


The objectives of this Module are to;

1. Equip CHWS, with relevant knowledge about HIV/AIDS so that they will play
An active role in educating the people in their communities, and
2. Improve home based care for people living with HIV/AIDS.

3.5.3 Pre & Post Test

Answer the following questions in short Write your answers I the separate sheet
Provided.
1. What is HIV infection ad what is AIDS?
2. What is the cause of AIDS?
3. List the main modes of transmission of HIV.
4. List the high-risk behaviours and practices that enhance spread of HIV?
5. Describe the preventive measures against acquiring HIV infection.
6. Is it possible to give care to PLWHA at home? How would failies and the ommunity
care for PLWHA?
3.4.5 Definition
AIDS is caused by tiny organisms called HIV (virus) or germs. The virus weakens the
defense system and hence predisposes (weakens) the body to other killer diseases.

80
3.5.5 Epidemiology - Transmission and Risk Factors
HIV is transmitted by either of the three main routes namely:
Ä Sexual intercourse with person having HIV
Ä Through unclean injections and transfusion of unscreened blood
Ä From mother to the baby during birth and breast feeding
Ä Harmful traditional practices such as uvula cutting, tattooing, female genital
mutilation, tooth extraction, etc.

HIV/AIDS Not Transmitted by:


• Touching
• "Dry" kissing with no exchange of saliva
• Hugging
• Toilet seats
• Swimming together
• Sharing, eating utensils or food cooked by an HIV positive person
• Shaking hands
• Working together
• Studying or playing with HIV positive individuals or other casual contact
• Mosquitoes or insect bites.

Groups at risk of Contracting HIV Infection


B Persons with multiple sexual partners
B Those who take alcohol
B Bar girls
B Long distance truck/train drivers
B Drug abusers
B Youth experimenting sex
B Raped women and men
High Risk Behaviors
; Having sexual contact with many deferent partners, such as the commercial sex
workers
; Having sexually transmitted disease(s)

81
; Alcoholism
; Sexual intercourse with commercial sex workers
; In and out-of-school youth practicing unsafe sex
; Drug abusing

3.5.6 Clinical Features

The difference between HIV infection and AIDS is that, HIV infection is simply the presence
of the microorganism in the bo0dy. An HIV infected person may apparently be healthy with
our having any signs and symptoms. AIDS on the other hand is the stage where the HIV
infected individual develops signs and symptoms of disease. A person may remain without
sign and symptoms for about 3 to 7 years or even up to 10 years.

persons suffering from AIDS may show various signs and symptoms such as long lasting
diarrhea, significant weight loss, fever, chronic cough, skin eruptions, skin rashes, swelling
of lymph nodes and many others.

To date there is no drug to cure persons suffering from AIDS. Preventing the acquiring of
HIV is the only possible solution.

3.5.7 Prevention and Control

To date there is no protective vaccine against HIV. Therefore, the control lies on prevention
of the infection, which can only be achieved through modification of behavior. The following
activities should be carried out to teach the public in general and the high-risk groups in
particular. One should follow the ABC rule I.e. abstention, be faithful and condom use
1. Avoid unsafe sexual practices by reducing the number and frequency of sexual
contacts, avoiding high-risk practices and using barrier protection such as
condoms
2. Interruption of mother to baby transmission by testing for antibody of HIV for
women at risk for infection, and HIV infected women should be advised to defer
pregnancy - (termination of pregnancy is more an acceptable alternative).
3. Other measures
a. Testing for HIV should be offered on confidential basis to requesting
individuals but only when pre-and post-test counseling can be given

82
b. Health personnel should protect themselves from patient contamination.
c. Following strict infection prevention rules (disinfections and sterilization)

3.5.8 Keys to pre and post Test

1. HIV is a human Immunodeficiency virus which weakens natural immunity of a


person. AIDS -Acquired immunodeficiency syndrome is a secondary
Immunodeficiency syndrome from HIV infection.
2. HIV is caused by microorganism called Human Immunodeficiency virus (HIV)
3. Modest of HIV transmissions
a. Sexual -unprotected sexual intercourse
b. parenteral - injections, blood transfusions
c. Perrinatal - transplacental, breast feeding
d. Sharing of blade, needles, nail, pin ... especially in local practices of uvula
cutting, tooth extraction, circumcision, tattooing, eye-lid incision...
4. The high-risk behaviors are promiscuity, extramarital sexual intercourse and
excessive alcohol consumption, harmful traditional practices involving use pf
blades. Needles, nails, pins...
5. Prevention of HIV infection
a. Sexual -abstain sex before marriage and remain faithful after marriage,
safe sex (use condom), reduce number of partners,
b. Parenteral -avoid using un-sterile injections, transfuse screened blood,
avoid village injectors, avoid needle sharing
c. Prenatal -counsel HIV positive mothers on risk of passing it to the baby in
utero and as much as possible not be pregnant
d. Avoid sharing body-piercing objects such as blades, needles, pins...
6. Yes, it is possible. AIDS patients can be given the same care and shown concern
as is dome for other sickness. Besides, all types of discrimination and
stigmatization associated to being HIV positive must be avoided. Furthermore, it
should be recognized that PLWHA are able persons who can work, generate their
livelihood etc and such rights of theirs should be respected.

83
UNIT 3.6
TAKE HOME MESSAGE
FOR PERSONS PROVIDING
HOME CARE TO PLWHA

84
3.6 Take Home Message for Persons Giving Home Care to PLWHA
3.6.1 Introduction

Household members and other close contacts of AIDS patients should be the main
focus of the prevention and control program. In addition, they are also the vital parts of
the HIV/AIDS treatment, especially in countries like ours. This is because, at the
moment, health sector resources that can be devoted to this situation are so minimal
that home care of patients will continue to be the mainstay of treatment.
Therefore, there is a need for an easy and acceptable method of educating
contacts of AIDS patients and other lay care givers on the disease, its causes
and manifestations, transmission routes, control and treatment measures.

3.6.2 Learning objectives


By the end of the session, the potential caregiver will be able to:
1. Define and explain home care for PLWHA
2. Explain the importance of home care for PLWHA
3. Describe the various services that can be given at home for PLWHA
4. Practice safety precautions when providing care for PLWHA
5. Explain and practice the steps in caring for PLWHA

Specific Massages
1. About HIV and AIDS
• Fast spreading disease
• A disease that does not have cure
• A disease which stays in the body along time without any manifestation
• Does not discriminate in terms of age, sex, color level of wealth...
2. Cause of HIV
• HIV infection is caused by entrance of a virus into body. The virus weakens
the body's ability to protect from a disease
3. Modes of HIV transmission

85
• Unprotected sexual intercourse
• Blood transfusion, injections, receiving or donating infected blood
• From mother to child during pregnancy, delivery and breast feeding
• Harmful traditional practices (e.g Uvulectomy, tooth extraction, circumcision...)
which expose one to be in contact with blood
• Shared blades, needles and any other piercing objects
4. Risk Behaviors related to HIV/AIDS
• Promiscuity
• Extra-marital sexual practices
• Harmful traditional practices
• Alcoholism and drug use (Such as Khat chewing)
5. Prevention of HIV/AIDS
• Abstain from sexual intercourse before marriage
• Remain faithful to partner after marriage
• Use condoms in cases of extra-marital sexual intercourse
• Avoid sharing piercing objects (blades, needles...)
• Avoid harmful traditional practices such as uvula cutting, circumcision, tooth
extraction, tattooing...
6. Care for People living with HIV/AIDS
• PLWHA need attention from their family and the community at large
• PLWHA should not be isolated within the community
• Isolating them would:
⇒ Aggravate the problem
⇒ Lower their self esteem and purpose of living
⇒ Initiate them to revenge
Hence, they should be considered as able to work, generate livelihood, and given the
right to live relatively healthy life.

Post-mortem Care
Clean the body, bathe if necessary
Close eyes and mouth
Place the body parts in normal position(arms, legs, head, etc)

86
Pack cotton/pads in the rectum and vagina
Cover any draining wounds with clean dressing
Tie extremities loosely
Pad ankles and wrists
Wrap the body in clean shroud or discarded sheet or any other garment depending on
the culture.

87
UNIT FOUR
ROLE AND TASK ANALYSIS BASED ON
LEARNING OBJECTIVES AND ACTIVITIES
Table 1. Learning objectives and activities for Health Officers
1.1 Knowledge objectives
1.2 Attitude/practice objectives

Table 2. Learning objectives and activities for Public Health Nurses


2.1 Knowledge objectives
2.2 Attitude/practice objectives

Table 3. Learning objectives and activities for Environmental Health Technicians


3.1 Knowledge objectives
3.2 Attitude/practice objectives

Table 4. Learning objectives and activities for Medical Laboratory Technicians


4.1 Knowledge objectives
4.2 Attitude/practice objectives

Table 5. Learning objectives for Community Health Workers


5.1 Knowledge objectives
5.2 Attitude/practice objectives

Table 6. Learning objectives for caregivers


6.1 Knowledge objectives
6.2 Attitude/practice objectives

89
Table 1 - Learning Objectives and Activities for health Officers

1.1 Knowledge objectives


Learning Objectives Learning Activities
Define HIV and AIDS Study the definition of AIDS. Describe the difference between HIV and AIDS
Describe the most important features of the Study the commonest features of the causative agent What is the difference
causative agent between HIV and other types of common viruses?
Name the causative agents Identify the causative agent for AIDS and the pathogenesis
Describe the historical background of Study when and where HIV/AIDS was discovered globally and in Ethiopia?
HIV/AIDS Describe the pace of HIV/AIDS expansion globally and in Ethiopia
Explain the natural course of HIV infection Discuss on the natural course of HIV/AIDS
and AIDS Discuss on Window Period.
Describe the epidemiiology of HIV/AIDS Form 3 groups, each consisting of 5-6 students. Discuss and study on the
globally and following points:
Group 1: How commonly does HIV/AIDS affect the population.
Discuss in terms of prevalence and incidence rates. Also, discuss global,
regional and national figures.
Group1: How commonly does hIV/AIDS affect the population.
Group 3: Discuss on the economic, demographic, social and health impacts of
HIV/AIDS
In a panel present and discuss on the findings of each groups
Identify the modes of transmission Study the modes of transmission and routes of spread of infection.
Discuss the three main global patterns of HIV transmission
Explain the common misconceptions about HIV spread
List and describe the various clinical Discuss the main clinical manifestations of AIDS
manifestations of AIDS Discuss the clinical stages of AIDS
Describe the stages List the most common opportunistic infections
Describe the most common opportunistic Identify common manifestations of opportunistic infections
infections in AIDS
Describe the various preventive methods Discuss the preventive methods of HIV
against HIV/AIDS Discuss on health professionals risk of acquiring HIV and state the reasons.
Explain the role of IEC in prevention of Study the protective measures: e.g during patient handling, blood and blood
HIV/AIDS products' handling
Explain the role of family, community, and Discuss the role of health education (IEC) in the prevention and control of HIV
institutions in preventing HIV/AIDS spread.
Discuss on the roles of family, community, and institutions in prevention of
HIV spread

90
1.1 Knowledge Objectives (Continued)
Learning Objectives Learning Activities
List and describe the various Explain the most commonly used laboratory diagnostic methods
laboratory diagnostic methods used to diagnose HIV

Form 3 groups each having 6 students and each to discuss the


following and present in 5 minutes time:

Groups 1. What can i mean if HIV test turns out to be negative


among people of high-risk groups and in high prevalence areas?

Groups 2. What can it mean if HIV test turns out to be positive


among people of high-risk groups and in high prevalence areas?

Groups 3. What can it mean if HIV test turns out to be intermediate


among people of high-risk groups and in high prevalence areas?

Conduct a panel discussion on the findings of the group-works


Describe and discuss the most sensitive and specific test available
nowadays in Ethiopia for diagnosing HIV infection.
Explain the differences between the different tests available

Explain the case management of Study the main modes of treatment of AIDS patients in a clinical set
AIDS and list the available drugs up.
used in the treatment of PLWA Discuss the commonly used drugs in the management of AIDS, the
principles of treatment and mechanisms of actions of the drugs
Discuss the principles of home based care/treatment
List some of the complications of Explain the main complication of treatment with the available drugs
treatment with drugs

91
1.2 Attitude/Practice Objectives

Learning Objectives Learning Activities


Explain the methods of guiding family Study the principle of home-based care for AIDS patients. discuss on the
members on how to provide home attitudes and practices of community members
based care to PLWHA on people lining with HIV/AIDS
Explain the importance of care/attention for PLWA in the family and
community.
Discuss the social and psychological Discuss among yourselves or discuss with your instructor on:
impacts of HIV/AIDS in the community
How do people perceive AIDS or what are their opinions about AIDS/the
illness and the patients/?

What people feel when they discover that they have AIDS.
Why do you think this happens?

What are some of the ethical issues related to HIV testing?

How do you think health workers should handle such ethical concerns and
HIV and/or AIDS patients?

What people feel when they discover that they have AIDS?
Why do you think this happens?

What are some of the ethical issues related to HIV testing?

How do you think health workers should handle such ethical concerns and
HIV and/or AIDS patients?

The importance of care/attention for PLWHA

The right of PLWHA to live actively in the social system

Perform a role-play among two volunteer students dealing with issues


related to social and psychological aspects of HIV/AIDS (30 minutes -
including the discussions).

Perform a role-play on how PLWHA are stigmatized. (5 - 10 minutes).


Discuss ways of overcoming such stigma among your colleagues and with
your instructor.
Describe Stigma related to PLWHA

92
Tables 2 - Learning Objectives & Activities for Public Health Nurses

2.1 Knowledge Objectives


Learning Objectives Learning Activities
Define HIV and AIDS Study the definition of AIDS
Identify the difference between HIV and AIDS
Identify the causative agent Name the organism that is responsible to cause AIDS
List the most common opportunistic What types of opportunistic infections are common to HIV/AIDS patients
infections related to HIV/AIDS especially in Ethiopia and other countries
Describe the manifestations of some common opportunistic infections
Describe the Epidemiology of Form 4 groups, each consisting of 4 students and discuss on the following
HIV/AIDS in Ethiopia points:
Explain the impact of HIV/AIDS on Group 1: The various modes of transmission and routes of spread of
development infection.
Group 2: How commonly does HIV/AIDS affect the population. Discuss in
terms of prevalence and incidence rates. Discuss national figures.
Group 3: Identify the various high risk factors for HIV/AIDS and also the
high-risk groups in the population.
Continue discussion in panel
Describe the modes of transmission of Study the modes of transmission of HIV.
HIV globally and in Ethiopia Describe the three main global patterns of HIF transmission
Discuss on the misconceptions about modes of transmission.
Explain the role of harmful traditional Discuss on the traditional practices that contribute to spread of HIV
practices forthe spread of HIV infection infection.
List and describe the various clinical Describe the main clinical manifestation of AIDS.
manifestations of AIDS
Describe the preventive methods Discuss on the preventive methods
Explain and discuss on how to teach on condom use
List and describe the various laboratory Describe the laboratory tests
diagnostic methods available Explain the differences between ELISA, Western Blot and Rapid tests
Explain the case management of AIDS Discuss the currently advocated case management of AIDS
List the available drugs used in the List the drugs commonly used for the treatment of people with AIDS
treatment of AIDS Identify the importance and limitations of drugs for treatment AIDS
Describe the advantages and patients.
disadvantages or limitations of the
drugs

93
2.2 Attitude/Practice Objectives
Learning Objectives Learning Activities
Describe the psychological and Discuss on the following points:
social impacts of HIV/AIDS in How people perceive AIDS or what are the feelings of the
the community general public towards AIDS - the illness and the patients?
What do people feel when they discover that they have AIDS?
Why do you think this happens?
What are some of the ethical issues related to HIV testing?
Describe stigma related to
PLWHA Performa a role-play on how PLWHA are stigmatized. (5-10
minutes).
Discuss ways of overcoming such stigma among your
colleagues and with your instructor.
Explain and demonstrate the Discuss and demonstrate the principles of counseling
various counseling methods Discuss the various types of counseling carried out for people
used for PLWHA lining with PLWHA
Explain the roles of family Discuss the methods of guiding family members and the
members, community and community and institutions on how to provide home based
institution for PLWHA care to PLWA
Perform appropriate nursing Discuss the principles and procedures to perform an effective
care of AIDS patients nursing care of AIDS

94
Table 3 - Learning Objectives and Activities for Environmental Health
Technicians
3.1 Knowledge Objectives
Learning Objectives Learning Activities
Define HIV and AIDS Explain what HIV and AIDS are Describe the difference
between HIV and AIDS
Identify the causative agent Name the causative agent
List the common modes of Discuss the various modes of transmission and spread
transmission
Identify and describe the various Discuss the common misconception about the transmission of
mi8sconceptions about modes HIV
of transmission Describe the three transmission patterns of HIV
Describe the Epidemiology of How commonly does HIV/AIDS affect the population
HIV/AIDS - globally and in Discuss in terms of prevalence and incidence rates.
Ethiopia Also, discuss global, regional and national figures

Identify the various risk factors for AIDS and also the high-risk
groups in the population.
Describe the various preventive Discuss the preventive methods against acquisition and
methods against HIV spread of HIV? List them and explain each
transmission Discuss about the wastes/excretions from the PLWA and the
care needed.

95
3.2 Attitude/Practice Objectives
Learning Objectives Learning Activities
Describe the psychological and Discuss on the following questions:
ethical impacts of HIV/AIDS in
the community. How do people perceive AIDS or what are the feelings of the
general public towards AIDS - the illness and the patients?

What do people feel when they discover that they have AIDS?
Why do you think this happens?

How do you think health workers should handle such ethical


concerns and HIV and/or AIDS patients?

Perform role-play among two volunteering students dealing


with issues related to ethical concerns in 5 minutes.
Describe stigma related to
PLWHA Perform a role-play on how PLWHA are stigmatized. (5 - 10
minutes.
Discuss ways of overcoming such stigma among your
colleagues and with your instructor.
Explain the importance of home- Discuss the role of family, community and institution in caring
based care for PLWHA for PLWHA
Discuss on the importance of precautions in disposing
contaminated materials and body fluids
Discuss on the role of general hygienic measures.

96
Table 4 - Learning Objectives and Activities for Medical Laboratory
Technicians
4.1 Knowledge Objectives
Learning Objectives Learning Activities
Define AIDS Describe what AIDS is
Identify the causative agent Name the causative agent
Identify the characteristics of the virus Discuss on the characteristics of the virus in relation to other similar
viruses
Describe the difference between HIV Discuss on the difference between HIV and AIDS
and AIDS
List the most common opportunistic Discuss on the Commonest types of infections that affect people with
infections in AIDS HIV/AIDS
Identify the commonest manifestations
Describe the Epidemiology of Discuss the various modes of transmission and spread of infection globally
HIV/AIDS - in Ethiopia and in Ethiopia.
How commonly does HIV/AIDS affect the population? Discuss in terms of
prevalence and incidence rates.
Discuss national figures.
Identify the various high risk factors for HIV/AIDS and also the high-risk
groups in the population.
List and describe the various laboratory What are the most commonly used laboratory diagnostic methods.
diagnostic methods Name them.
Where do you get these of tests? Describe each of them in terms of
sensitivity and specificity.
Discuss on the meaning of a negative or positive test result? What is the
advantage of doing repeated or confirmatory test?
Describe the various preventive Discuss on the various preventive methods
methods against HIV/AIDS Demonstrate the ways of using protective measures -especially patient
specimen handling, wearing gloves, blood screening
Describe the meanings of test positive, Discuss what HIV positive test means, what HIV negative means and what
test negative and intermediates an intermediate result means
Describe the preventive measures for What are the preventive methods against acquisition of HIV? List them
HIV and explain each.

97
4.2 Attitude/Practice Objectives

Learning objectives Learning Activities


Identify the type of identify the type of specimens collected for the diagnosis of HIV
specimens collected for the Describe the procedures use to collect specimen in relation to
diagnosis of HIV and the the type of test
procedures Describe the how the test results are interpreted, kept and
reported
Explain the ethical issues Discuss on the ethical issues of HIV testing
related to HIV testing
Describe the psychological, Discuss on the following
social and ethical impacts of
HIV/AIDS in the community
How do people perceive AIDS or what are the feelings of the
general public towards AIDS-the illness and the patients?
what do people feel when they discover that somebody has
AIDS? Why do you think this happens?
How do you think health workers should handle such ethical
Concerns and HIV and/or AIDS patients?
Perform role-play among two volunteering students dealing with
Describe stigma related to HIV testing issues related to ethical concerns in 5 minutes.
PLWHA

Perform a role-play on how PLWHA are stigmatized. (5-10


minutes).
Discuss ways of overcoming such stigma among your colleagues
and with your instructor.

98
Table 5- Learning Objectives and Activities for CHWs

5.1 Knowledge objectives

Learning objectives Learning Activities


Describe in a simple and Describe what AIDS is using the local terms
locally sound way what HIV
and AIDS is
Identify the causative agent Discuss that HIV is caused by microorganism (gems)
Study the difference between HIV infection
and development of AIDS. is possible to identify a person with
HIV infection with out investigations (clinical, laboratory)?
List the common high risk Describe the behaviors that expose people to
behaviors for HIV/AIDS HIV/AIDS. Which group of people is at higher risk for acquiring
HIV/AIDS and why? What is the importance of identifying high-
risk groups?
Describe the modes of List the modes of transmission of HIV/AIDS. Which of these
transmission of HIV modes of transmission are commonest?
Explain the role of harmful traditional practices in the spread of
HIV/AIDS

Explain the importance of Discuss the principles of home based care for AIDS patients.
home based care of AIDS Describe the importance of providing care for PLWHA at home.
patients

99
5.2 Attitude/ Practice Objectives
Learning Objectives Learning Activities
Describe the various Explain the preventive methods of HIV/AIDS.
preventive methods against Explain about condoms and their use in the community.
HIV/AIDS Study the correct way of applying and using condoms
during sexual intercourse.
Describe the psychological, Explain what people feel when they discover that they have
social and economic AIDS?
impacts on the family and Discuss on the social and economic implications of
the community HIV/AIDS on
the family and community at large
Describe stigma related to
PLWHA Perform a role-play on how PLWHA are stigmatized by the
community
Discuss how the community will be able to avoid
stigmatizing
PLWHA.
Describe the safety Discuss safety precautions in handling body fluids and
precautions in handling soiled
body fluids/soiled materials materials

100
Table 6 -Learning objectives and Activities for Caregiver

6.1 Knowledge objectives

Learning Objectives Learning Activities


Describe AIDS in a simple Discuss what HIV/AIDS is using the local terms
and locally sound way Explain the difference between HIV and AIDS using locally
sound examples
Name the causative agent Describe that the causative agent is a microorganism (germ) that
for AIDS Cannot be seen with naked eye.
Identify the signs and Discuss on the symptoms of AIDS
symptoms of AIDS
List the common high risk Identify locally recognized risk behaviors for the spread of
behaviors for HIV HIV/AIDS
transmission Discuss how commonly HIV/AIDS affect the families and the
community.
Discuss the various high risk factors for HIV/AIDS and also the
high-risk groups in the community.
Describe the routes of Discuss the common routes of transmission of HIV
transmission of HIV Explain the role of harmful traditional practices in the spread of
HIV
Discuss on the misconceptions about modes of transmission of
HIV
Explain he importance of Discuss the principles of home based care for AIDS patients
home based care for Discuss on the attitudes of people towards helping PLWHA
PLWHA Explain the effect of giving due attention/ care for PLWHA
Describe the preventive Explain the various preventive methods against acquisition of
methods against HIV/AIDS HIV infection
Explain about condom use as a preventive method

101
6.2 Attitude/ Practice objectives

Learning Objectives Learning Activities


Describe the psychological, Discuss on what people feel when they discover that
social and economic somebody
impacts of HIV.AIDS on a has AIDS?
family and community level Why do you think this happens?

Describe stigma related to


PLWHA

Discuss on how PLWHA are stigmatized by the


community.
Discuss how community will be able to avoid stigmatizing
PLWHA.
Describe the safety Discuss safety precautions in handling body fluids and
precautions handling soiled
body fluids/soiled materials materials

102
UNIT FIVE

GLOSSARY
Glossary of Terms

Asymptomatic - A stage in a natural course of a disease, where the


symptomsand signs are not manifested.
Attitude - Reflects our likes and dislikes. It often comes from our
experiences or from those of people close to us.
Catabolism - Breaking down of complex chemical into simple chemicals.
CD4 cell - Major subset of T-lymphocytes functionally helper T-cells.
Their receptors regulate and control the aspects of
immune System.
Control - Control lies on prevention of the infection, which can only
be achieved through modification of behavior.
Counseling - Advising, educating, informing of all possible outcomes -as
Pre-and post-test counseling, also allowing persons
express Feelings and questions.
Cytopenias - Advising, educating, informing of all possible outcomes -as
Pre-and post-test counseling, also allowing persons
expressFeelings and questions.
Cytopenias - Deficiency of cellular elements in blood or tissue
Diagnosis - Statement of the nature of a disease condition made after
observing its signs, symptoms and other indications.
Diurnal - Happenings during the daytime.
Epidemic - Occurrence of a disease in an a excess of usual or normal
Prevalence
Epidemiology - The study of the distribution of diseases and related conditions
in terms of their distribution by time, place. and person.
Etiology - The main cause of disease conditions. Usually used for
microbial causative agents

104
Flu like syndrome - lllness looking like a bad cold and with fever
Hetero sexual - Having sex to the people of the opposite sex.
HIV-1 - Type 1 human immunodeficiency virus which is the
Predominant cause of AIDS throughout the world
HIV-2 - Type 2 human immunodeficiency virus, which is the
Predominant cause of AIDS in West Africa
Immunodeficiency - A weakening or deficiency in the immune system.
Immunosuppression - A process by which the immune system of the body is
not resposnsive to diseases.
Kaposi Sarcoma - Cancer which takes the form of many
hemor(bleeding) nodes affecting the skin, especially
on the extremities
Knowledge - information stored in the brain. Mainly facts, concepts
and ideas.
Leukopinia - Reduction in the number of leucocytes in the blood,
usually as a result of a disease
Leukoplakia - Condition where white patches form on mucous
membranes (Such as tongue or inside of the mouth)
Lymphadenitis - inflammation of the lymph nodes
Opportunistic infection - infections that occur when the defense mechanisms
of the body are weakened
Parenteral - Drugs and solutions administered through the
intravenous route during the management of patients.
Pathogenesis - The mechanism of causing damage to the tissue of
the body which result in clinical manifestations of a
disease.
Perinatal - The age of a newborn from birth to seven days

105
Practice - Way of doing things
Prevention - Avoiding or averting harmful conditions or diseases
from affecting individuals or communities by and large.
Sensitivity - Ability of a diagnostic test to detect a disease when
the disease is actually present
Sentinel surveillance - An epiemiologic methodology where there is
continuous Collection and analysis of data on a
certain health issue from a specified target
population. In case of HIV. the sent
inel population are usually pregnant women.
Sero-epidemiolgic survey - A monitoring mechanism for diseases and conditions
throug the use of continuous serological and
epidemiological
measurements.
Sero-prevalence - Presence of a condition in a certain population over
time as detected in the serum of the individuals
Specificity - Ability of a diagnostic test to declare negative when
the disease is absent
Stigma - A consequence or complication due to a disease
leading
to isolation, discrimination, labeling and prejudice.
Transmission - Mechanism/transferring power, in developing
countries,
the main route of HIV-1 infection is through
heterosexual
transmission
Thrombocytopenia - Condition where the patient has an abnormally low
number of platelets in the blood
Tumor - Abnormal swelling or growth of cells

106
UNIT SIX
REFERENCES
1. AIDS Action. Understanding HIV: Training exercise for Health Workers, issue
27 December 1994-February 1995. Published by AHRTAG (Adopted from Health
care Together/ TALC
2. Bedri A Impact of AIDS on the economy and health care services in
Ethiopia. Ethiop. J. Health Dev. 1998; 12:191-201.
3. Buve, A., & Rogers, MF. Overview: Epidemiology. AIDS 1998;12 (suppl A)S53-
S54.
4. Disease Prevention and Control Department Ministry of Health. AIDS in
Ethiopia. 3rd Edition, November 2000.
5. Essex Max, Mboup, Kanki P., Kalengayi M. Ed. AIDS in africa. Raven press Ltd.
New York, USA, 1994.
6. Evai C. primary AIDS Care; A practical guide for primary Health Care
personnel in the Clinical and supportive care of people with HIV/AIDS. 3rd
edition, January 2000.
7. Federal Democratic Republic of Ethiopia, policy on HIV/AIDS, August 1998.
8. Fontanet, AL., et al. Age-and sex-specific HIV prevalence in the urban
community setti ng of Addis Ababa, Ethiopia. AIDS 1998; 12:315-322
9. GElete A., Kebede D., Berhane Y. Tuberculosis and HIV infecton in southern
Ethiopia. Ethiop. J. Health Dev. 1997:11:51-59
10 Hearst, N, & Mendel, Js. A research agenda for AIDS prevention in
tdeveloping world. AIDS 1997; 11 (suppl): S1-S4
11. Kebede D. Sanders E, Aklilu M. The HIV epidemic and the state of its
surveillance in Ethiopia: Rport submitted to the Technical Working group
on HIV/AIDS in Ethiopia -. UNAIDS -Ethiopia, March 2000
12. Meers M.H., Berkow R. Ed. The merck Manual (1999): Centennial Edition, 17th
edition. Merck Research Laboratories, USA, pp 1312-1323.
13 Mekanna, SL. Rapid HIV testing and counseling for voluntary testing
centers in Africa. AIDS 1997;11 (suppl): S103-S110.
14. Ministry of Health. AIDS in Ethiopia: Background, projections, impacts and
interventions. second Edition, 1998.

108
15. Mitike G., Kebede D., Yeneneh H. HIV infection and ant tuberculosis drug
resisance among pulmonary tuberculosis patients in Harar
TuberculosisCenter Ethiopia. EAst Afr Med J 1997;74: 154-157
16. MOH, National AIDS Control program: strategic framework for the national
response to HIV/AIDS in Ethiopia for 2000-2004 Addis Ababa, Ethiopia.
17. Pantales, G, & Pernin, L.can HIV be eradicated? AIDS 1998;12 (suppl a) s175-
s180.
18. Rahway. Huuman Immunodeficiency Virus (HIv) Infection. The Merck Mannual.
15th edition, 1992.
19. Romano, G, Massi, D.,& Giordano,. The standpoint of AIDS research and therapy
programs. Anticancer Research 1998;18;2763-2778.
20. UNAIDs (Ethiopia), Overview of HIV/AIDS situation in Ethiopia. Notes, 1998.
21. Zewdie,d., & ko9dakovich,L/ HIV infection & AIDS in Ethiopia. The Ethiop J Health
Dev, Special Issue, 1990:4(2).
22. Is mail S. Mitilce CT rapid assessment of the Ethio-Djibouti Transportation corridor
in the context of STDS/HIV/ AIDS related high risk factors: CDC Ethiopia (Report),
September 2001.

109
UNIT SEVEN
ANNEXES
Annex 7.1 - The "HIV-Spread Like the Fire'' Game
Follow the instructions below to play the game.
A. Prepare the following; few needles and syringes, some instrument
which may mimic a testing kit, few pieces of paper marked on
them either positive or negative using a red marker. On the back
of the positives write" I'm Sorry!" and on the bake of the negatives,
write" congratulations!''
B. Gather the student and form a circle (not exceeding 25 in
number).
C. Instruct the students about the game in clear language. Tell them
that this game is about Having either protected or unprotected
sexual intercourse in form of hand shaking. If some one scratches
your hand while you shake with that person, it means that it was
unprotected sexual intercourse; whereas if not scratched then it
was a protected one. Also, tell them that someone who is going to
be patted on his/her shoulder also means being infected.
D. Begin the game them to close their eyes; and while doing wo you
will go around from their backs, and pat the shoulder of one of the
students playing the game. Afterward tell them to open their eyes
again.
E. Then, ask them whether they can recognize who was infected
(patted on the shoulder).
F. Then, tell them to mix up and shake hands with each other. The
initially infected person shall scratch hands of three other persons
and each scratched person in turn will scratch another three
persons. Scratching more than three persons is not allowed.
However, they can shake hands without scratching, too.
G. Then in between, after about 2-3 minutes, clap your hands and
halt the shaking process.

111
H. Call the first person who was infected to come into the center of
the circle. Then call all others scratched to come into the center of
the circle. Watch out for the reactions of the students. Especially
the hesitation from the side of those who were scratched.
I. Ask them about their feelings of potentially being infected. (Take
enough time.)
J. Then ask the potentially infected persons to volunteer to be tested
for HIV, with instant result of the test to be disclosed to them.
Again, watch the reaction and responses of the participants.
K. Among those who volunteer to be tested ,pretend that you tested
them using the prepared kit, and provide them with the sheet of
paper with result of the test. Watch their emotions and feeling.
Now tell them to go back and take their seats.
L. Afterwards discuss the implications of the game with the students.
(Take plenty of time.)

112
Annex 7.2 Key to Pre and Post test Questions
2.1.1 All Categories
1. Acquired immune-deficiency Syndrome
2. Human Immune-deficiency Virus
a. Sexual intercourse
b. Parenteral
c. Maternal-fetal
3. Sexual intercourse
4. Commercial sex workers, military personnel and distance truck drivers
5. C
6. Abstinence, being faithful to a single partner, proper use of condoms
7. Long lasting fever, wasting, chronic diarrhea
8. False
9. Natural history HIV infection, what HIV positive means and does not mean, and
HIV negative means and what it does not mean.

2.1.2 Health Officers

1. C
2. B-lymphocytes, CD4 helper cells, humeral immunity
3. Early primary infection, a symptomatic infection, PEL, HIV related diseases,
severe HIV related disease
4. Sex with CSW, MPSC, unscreened blood transfusion, having unprotected sex
(non-use of condoms)
5. a. The person has developed the clinical stage of AIDS
b. The person will definitely develop AIDS,
c. Stage of disease, (4) when the person was infected
7. AZT,NVP, DDL, DDC,etc
8. Kaposi sarcoma, lymjphomas
9. Abort pregnancy, use antiretrivirals, avoid breastfeeding, avo9id pregnancy
altogether
10. Demographic, socio-economic, political,health care

113
2.1.3 Public Health Nurses

1. E
2. True
3. False
4. False
5. Pre, post and follow up counseling
6. a) Hygiene, (2) nutrition, (3) treatment of opportunistic infections, (4) physical
therapy (5) care/support on social, spiritual, emotional and psychological and
material
7. Steps
a. Put on gloves or plastic bags.
b. Stop the bleeding.
c. Cover the wound with clean cloth or bandage.
d. Soak clothes soiled with blood for 10 minutes in cold water /5% chlorine
solution
e. Wash clothes with hot water and soap; rinse well.
f. Dry clothes in the sun
8. Safer sex-types of sexual intercourse in which the risk or transmission of HIV is
minimized by having non-penetrative sex, using condoms, etc.
9. Teaching about safer sex practices include:
ƒ Staying in mutually faithful relationship where both partners are uninfected
ƒ Avoiding certain practices that increase the possibility of HIV transmission,
for example" dry"' sex, which may lead to breaks in the skin
ƒ Avoiding sex when either partner has open sores or any sexually
transmitted diseases (STD)
ƒ Following the ABC Rule of sexual behavior
10. The following procedures should be followed:
; Clean the body, bathe if necessary
; Close eyes and mouth
; Place the body parts in normal position (arms, legs, head, etc)
; Pack cotton/pads in the rectum and vagina

114
; Cover any draining wounds with clean dressing
; Tie extremities loosely
; Pad ankles and wrists
; Wrap the body in clean shroud or discarded sheet or any other garment
depending on the culture.

2.1.4 Environmental Health technicians

1. B
2. False
3. D
4. Blood and blood products, excreta, sputum, used clothes, needles used on
AIDS patients, etc.
5. True
6. True
7. B
8. True
9. Treatment and disposal of infectious wastes
o Thermal process
ƒ Static-Grate single chamber incinerator
ƒ Drum or brick incinerator
ƒ Open air burning
o Wet thermal disinfections
ƒ Exposure of waste to increase temperature and increase pressure
steam
o Autoclaving
o Chemical disinfections
ƒ E.g.. Stool disinfections-in a bucket add chlorine
o Oxide powder or dehydrate-lime oxide (CaO)

2.1.5 Laboratory Technicians

1. Screening involves detection of HIV-antibodies in the blood

115
2. Ability of the test to declare negative when HIV/ antibody are not present

3. Ability of the test to detect antibodies When are actually present.

4. Has higher specificity

5. Relatively cheaper cost


6. HIV-1, HIV-
7. Lever function test, CD-4 count, viral load
8. CD-4 count
Annex 7.3 List of antiretroviral drugs used in the case
management of AIDS patients

Nucleoside Reverse Analogue Transcriptase inhibitors (RTIS)

; Zidovudine (Retovir, AZT) -indicated for symptomatic HIV infections with


CD4 cell count of less than 500/mm3 or asymptomatic HIV infection with a CD4
count less than 2000 mm3. The major side effect is marrow suppression with
anemia or granulocytopenia. The other side effect is macrocytosis. Side efects
include: nausia, headache, insomnia, fatigue, myalgias, malaise, vomiting, and
abdominal pain.
; ddi (Dideoxyinosin, Videx) -in patients who have advanced HIV infection and
Prolonged prior treatment with AZT. HIV strains resistant to AZT are sensitive to
ddi. The most serious side effect is pancreatitis and peripheral neuropathy.

; ddC (Dideoxycytidine, HIVID, Zalcitabine) - for use along or in combination with


AZT in patients wit CD4 cell counts or 50-500/mm3 plus progression while
receiving AZT failure. The major toxicity of ddC is peripheral neuropathy. The
other major side effect is aphthous ulcers of the oral cavity or stomatitis. Panc-
reatitis is also observed in some patients.
; Others- stavudin (d4T, Zerit), lamivudine (3TC, Epivir)
Non- nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
; Nevirapine - Viramune - side effects are skin rash, hepatitis, Stenven
Johnson Syndrome

116
; delaviridine

Protease Inhibitors (Pl)

; Saquinavir (invirase)
; Nelfinavir (Viracept)
; Indinavir (Crixivan)
; Ritonavir (Norvir)

117
Anne 7.4 Live Case Studies
Case 1

She was born and grown in the northern part of Ethiopia - Wollo specifically in the rural
area of Last. At the age of 8 years her families arranged a marriage for her and then she
married. But she did not have had sexual intercourse. However her fiancée went to the
war front and then he died. Her parents died too. She went to jimma (southwest Ethiopia)
and started to live with her uncle. Then she stayed there but did not go to school. She
quarreled with the wife of her uncle. and disappeared to Addis Ababa. In Addis Ababa she
contacted the brokers and was hired as a housemaid She worked for a family for about
one and half year. Then she was able to meet her fried in Addis Ababa. Her fried lived in
Nazareth. She advised and convinced her to go together to Nazareth. Then she decided
and went to Nazareth accompanying her friend. Her friend has rented a small house at the
periphery of the town. She lived there for a few days. However something happened. Her
friend received some money from a man and started to provoke her to have sex with him.
Many times she lift her alone with the man. She struggled and stayed for about two
months without having sexual intercourse. One day he invited her to drink but she refused
then, the next day he made her take some alcohol and then she allowed him to have sex
with her. This was her first experience. Then she moved to the bar, where we interviewed
her, and started commercial sex work. she worked for a year and want back to her original
area -wollo she stayed for one year and came back to Nazareth. She entered the same
bar and continued to work for two years. Since six month she entered the same bar and
continued to work for two years. Since six months she became sick and finally was not
able to continue her previous work. Now she is living with the help of her friends in the
same bar. Luckily the bar owner did not push her out. Her life has completely changed.
We were very much touched by what happened to this young lady of 20 years of age. We
gave her some money so that she will be able to get medial help and went out.

We went to a known nightclub in Diredawa. The key informant who was a taxi driver took
us there. The place is called Gojo pub. Gojo means a Small hat. When we entered the
gate it was a very big nightclub. Music was flowing and everybody was taken up by the
music. The girls and the males were dancing together. It was so crowded and you hardly
identify who is who. The lights had different color combinations however the red was
dominating. It was very difficult to count the people. However we estimated about 25-30
females and 40to50 males according to the information the number increases during the
weekends. Services are provided in the dancing room as will as out side the room in the
big space available outside. Males serve drinks. In the bar there was no place to stand. It
was crowded with dancing males and females. We went out side and chatted with the girls
who were dancing.

118
The first one was an 18 years old girl. She is a short and beautiful girl. She came from Addis
Ababa a year back. She stopped her school at grade 5 three to four years back. She came to
this place because her family is poor. Both do not have jobs and their living conditions have
deteriorated She decide to come to Diredawa after discussing with a friend who has stared the
same activity. Them she directly came to Diredawa. she worked for about 2 months on
another hotel called Thehay Hotel. Then she left the hotel and started to look for clients in Gojo
pub. Now she earns 100 to 150 birr per night from her clients. She lives alone renting a room
in Ginde Kore ara. Almost she gets clients every day Unlike the other bars they do not pay for
te bar owner and they can go with thir clients any time. She never takes her clients to her room
that she rented, Her clients are responsible to find their place for passing the night. The club
starts its work after 11"00 P.M. the girls also come to the club after 10:30 -11:00 P.M. The peak
is between 12:00 P.M midnight to 1:00 A.M. She takes alcohol but does not chew khat and she
does not smoke. This girl was willing to be tested and also wanted to go back home. She was
very happy with the informal interview that we had with her. We planned to talk with her the
next day afternoon at Ras Hotel. From our discussion somehow we were convinced that she
has decided to go back home. We agreed to do as much as we can. If she becomes willing to
tell us the address of her parents, we planned to contact them in Addis Ababa. The next day
we met at Ras Hotel. In fact she came with another girl whom we have not seen yesterday. The
first girl has still persisted in ger previous decisions to go back home. She gave the address of
her parents including their full names, kefitegna. kebele, specific location, and the house
number but there was no telephone number. Sae has forgotten the telephone numbers of her
neighbors. We then furter discussed on the possibilities such as about alternatives to support
herself or finding of any job that could help her to slip saway from prostitution. We made some
arrangements with the Dirdawa Council Health Burau, HIV/AIDS Coordinator if there is any real
possibility. They had planned a training workshop and planned them to be involved in the
training and to counsel them so that they can teach on HIV/AIDS. from later developments both
girls have participated in the training workshop arranged by the bureau. However, the frst one
disappeared after she agreed to have VCT. But the second girl did.

119
Case 3

The second one was a 17 years old girl. Her physique tells that she is very young. Even
She looked younger than her age. She came to us after discussing with her friend. This
young girl is from Diredawa town. She stopped her school at 10th grade. Her grand
mother initially brought her up until she was about 10 or 11 years old. After she died she
started to live with her parents. When her mother was about to die, She told her that her
real father is living in Addis Ababa and her husband was not. Her real father had denied
and refused to accept that she is his daughter. After telling this story her mother died.

She indulged in to commercial sex work tow years back at the age of 15 years. Her
stepfather has married another woman. She was not at good terms with her stepmother.
She frequently quarreled with her. The stepmother does not like to give her food and does
not treat her well. Surprisingly her stepfather supported what his new wife was doing. One
of the reasons for going into commercial sex was her family situation. She had a
boyfriend. Now he is living in the USA. He still writes to her. She has waited for him for
three years. However, she thinks that there is no hope.

She does not have any non-paying commercial partner.

According our latest information she has decided to stop commercial sex work she was
not going to that nightclub anymore. After participating in the training workshop arranged
by the Diredawa Council Health Bureau, she has volunteered to be tested and blood has
been taken. We have called and talked to her and we were communicating witht the
HIV/AIDS Coordinator, who is our friend. Until we wire writing this report she has
continued her relations with the health bureau and the bureau has committed to help the
young girl.

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Annex 7.5 - The Authors
Shabbier Ismail (MD, MPH) is an associate professor at the Department of community
Health (DCH), Faculty of Medicine (FOM), Addis Ababa University ( AAU). He has an
extensive experience in teaching public health and research. He was teaching at the
gondar College of Medical Sciences. Currently, he is working in the Behavioral Sciences
unit of the Department of Community Health and teaches Health Education for both he
undergraduate and postgraduate students. He is also doing his PHD in reproductive
health specifically on HIV/AIDS.

Getnet Mitike (MD, MPH) is an associate professor at the DCH, FoM AAU. He was
teaching public health at the gondar College of Medical Sciences. Currently, he is
working at the Department of Community Health, Policy and Health Services
Management Unit. He teacheds both the undergraduate and postgraduate students.

Damen H/Mariam (MD, MPH, and PHD) is a health economist. He is an assistant


professor and head of the DCH, FoM, and AAU. He has an extensive experience in
teaching public health and research. He teaches both undergraduate and postgraduate
students.

Contributors

Berhanu Demeke (MD, MPH) was faculty member of the DCH, AAU. Currently he is
working as a consultant at the UNAIDS - Working for the National AIDs Secretariat. He
has been teaching health services management for undergraduate as wellas
postgraduate students.

Bekele Kebede (MD) was teaching at Gondar College of Medical Sciences in the school
of Environmental Health. He has a long teaching experience. Currently, he works in the
Ethiopian Science and Technology commission and he is an honorary member of the
DCH, FoM, AAU.

Mirgissa Kaba (BA, MAS) is a medical anthropologist. He has been teaching at jimma
University and later on in the behavioral Sciences Unit of the DCH, FoM, AAU. Currently
he is working for UNICEF.

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