PMTCT-Trainer Manual

Module 1 Introduction to HIV/AIDS
Module 1 Introdution
Total Time: 120 minutes
SESSION 1 Scope of the HIV/AIDS Pandemic

Activity/Method Resources Needed Time
Exercise 1.1 Hope Summary of information on 30 minutes
exercise: group discussion local/national/regional
epidemiology of HIV/AIDS
If available, HIV prevalence

among women at local prenatal
clinics.
SESSION 2 Natural History and Transmission of HIV

Exercise 1.2 HIV 1, 2, 3 Prizes, such as sweets or 90 minutes
Knowledge interactive condoms (optional), for the
game winning team
Also have available the following:

! Overheads or PowerPoint slides for this Module (in Presentation Booklet)
! Overhead or LCD projector, extra extension cord/lead
! Flipchart or whiteboard and markers or blackboard and chalk
! Pencil or pen for each participant
PMTCT—Generic Training Package Trainer Manual Module 1–1

Relevant Policies for Inclusion in National Curriculum
Session 1
! Brief summary of local/national/regional epidemiology of HIV
! If available, a graph illustrating HIV prevalence among pregnant women at
antenatal clinics (a local variation on Figure 1.2)
Module 1–2 Introduction to HIV/AIDS

SESSION 1 Scope of the HIV/AIDS Pandemic
Advance Preparation
For the Hope Exercise (Exercise 1.1), prepare a list of positive responses
to HIV in your area.
Total Session Time: 30 minutes
Trainer Instructions
Slides 1 and 2
Begin by reviewing the module objectives listed below.
After completing the module, the participant will be able to:

! Describe the global and local impact of the epidemic.
! Answer basic questions about HIV/AIDS in women, children, and families.
! Discuss the natural history of HIV infection.
! Present information about HIV transmission.
Slides 3, 4 and 5
Discuss the scope of the global HIV/AIDS pandemic.
Make These Points
! More than 90% of people living with HIV/AIDS (PLWHA) are in the developing world.
! 95% of all HIV-related deaths have been in the developing world, largely among
young adults.

Figure 1.1 Worldwide epidemiology of HIV/AIDS
Explain the effects of HIV/AIDS on children.
HIV in children, 2003

UNAIDS estimates that at the end of 2003:
! 40 million people worldwide were living with HIV/AIDS.

! 2.5 million people with HIV/AIDS were children younger than 15 years old.
! 90% of the children living with HIV/AIDS were from sub-Saharan Africa.
! 700,000 children worldwide were newly infected in 2003.
! 500,000 child deaths are estimated to have occurred from HIV/AIDS during 2003.
Make These Points
! Emphasise the number of new infections using the most recently available data.

New infections, 2003
According to UNAIDS, about 14,000 new infections occurred each day in 2003. Of
these new infections
! About 6,000 each day were among persons 15 to 24 years old

! Almost 2,000 each day were in children younger than 15 years old
! Most of the infections in children younger than 15 years old occurred through mother-
to-child transmission (MTCT) of HIV.
Briefly highlight the regional HIV/AIDS data as detailed in Table 1.1. This table also
appears in the Participant Manual, so you need not discuss the information in detail.
Table 1.1 Regional HIV/AIDS statistics and features, through 2003

Adults and Adults and Adult and Child
Children Living Children Newly Prevalence In Deaths Due to
Region with HIV/AIDS Infected with HIV Adults* AIDS
Sub-Saharan Africa 25.0–28.2 million 3.0–3.4 million 7.5–8.5 2.2–2.4 million
North Africa and

470,000–730,000 43,000–67,000 0.2–0.4 35,000–50,000
Middle East
South and
4.6–8.2 million 610,000–1.1million 0.4–0.8 330,000–590,000
Southeast Asia
East Asia and
700,000–1.3 million 150,000–270,000 0.1–0.1 32,000–58,000
Pacific
Latin America 1.3–1.9 million 120,000–180,000 0.5–0.7 49,000–70,000
Caribbean 350,000–590,000 45,000–80,000 1.9–3.1 30,000–50,000
Eastern Europe
1.2–1.8 million 180,000–280,000 0.5–0.9 23,000–37,000
and Central Asia
Western Europe 520,000–680,000 30,000–40,000 0.3–0.3 2,600–3,400
North America 790,000–1.2 million 36,000–54,000 0.5–0.7 12,000–18,000
Australia and New

12,000–18,000 700–1,000 0.1–0.1 <100
Zealand
40 million 5 million 1.1 3 million
Total
(34–46 million) (4.2–5.8 million) (0.9–1.3) (2.5–3.5 million)
* Percentage of adults age 15 to 49 years living with HIV/AIDS in 2003, using 2003 population data
The ranges in this table are based on the best available information. These ranges are more precise than in previous
years, and work is under way to further improve the precision of the estimates to be published in mid-2004.

Explain that to estimate HIV prevalence in the general population, researchers often
measure HIV prevalence in antenatal clinics.
Figure 1.2 below is a good example of the results of a prevalence study among preg-
nant women, which shows the extent of the South African epidemic.
Figure 1.2 HIV prevalence: Pregnant women in South Africa, 1991–2002
HIV prevelance among pregnant women at antenatal

clinics in South Africa, by age group: 1991–2001
40
35
<20
20-24
HIV prevalance (%)
30
25-29
25 30-39
20
35-39
40+
15
10
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Year
Most of these estimates are based on surveillance systems that focus on pregnant women
who attend selected antenatal clinics. This method assumes that HIV prevalence among
pregnant women is a good approximation of prevalence among the adult population (aged
15–49 years). A direct comparison of HIV prevalence among pregnant women at antenatal
clinics and the adult population in the same community in a number of African communi-
ties has provided evidence for this method of estimating HIV prevalence.

Slide 6
Explain that the impacts of HIV occur at all levels of society from the individual to the family,
community and country level. The social and economic consequences are far reaching.
Make These Points
! HIV/AIDS affects every region of the world.

! Millions of people are infected with HIV or live in families affected by HIV.
! The number of new infections continues to grow.
! The HIV/AIDS pandemic contributes to:
! Childhood malnutrition
! Shortened life span with illness and suffering
! Economic loss, personal and countrywide
! Weakened family system
Begin a group discussion about some of the pandemic's global outcomes, based on the
following information:
Global impact of HIV

The global impact of the HIV/AIDS pandemic is especially severe in resource-
constrained settings and results in the following:
! Negative impact on countries’ economic development
! Overwhelmed healthcare systems
! Decreasing life expectancy in many countries
! Deteriorating child survival rates
! Increasing number of orphans
Effects of the HIV/AIDS pandemic on individuals include the following:

! Illness and suffering
! Shortened life span
! Loss of work and income
! Death of family members, grief, poverty, and despair
! Barriers to health care related to stigma and discrimination
! Deteriorating child health and survival
! Weakened integrity and support structure of the family unit

Slides 7, 8 and 9
Slides 7, 8 and 9 feature national epidemiologic data; review this data with participants.
Invite the participants to share individual and family outcomes they have witnessed related
to the HIV pandemic.
Lead an interactive discussion based on Exercise 1.1.
Exercise 1.1 Hope exercise: group discussion

Purpose To begin the PMTCT training with a feeling of hope and
optimism despite the devastation left by decades of HIV.
Duration 20 minutes
Introduction Explain to participants that this activity is intended to introduce

hope and optimism about the response to HIV/AIDS.
Activities Ask participants to share their ideas about positive responses

to the HIV/AIDS pandemic. Record their responses on the
flipchart or board. Typical responses include:
! Groups in the community that have never worked together
before have connected with each other to address
HIV/AIDS.
! Global community has allocated increased funding for
healthcare systems in the developing world, especially
HIV/AIDS care systems.
! The Ministry of Health in many countries has become a
stronger advocate for the healthcare needs of people in all
sectors of society.
! Global community has become more attentive to TB
because of its connection to HIV.
! There is increased awareness of safer sex practices that
protect people from other STIs and HIV.
If no one identifies PMTCT as a positive response, ask what
the participants know about preventing transmission from
mothers to babies.
Debriefing Summarise the session by noting the following points:

! Much of the progress in HIV treatment and care in
developed nations relates to HIV-positive people living
longer, healthier lives.
! Fewer infants are infected from their mothers.
! Participants can be part of the progress in PMTCT.
! Even though HIV has brought devastation, it also has
brought positive responses such as bringing together
many different kinds of people to fight for a common goal.
! This PMTCT course begins on a note of hope.

Make These Points
! Despite the devastation caused by HIV, there are reasons to be hopeful and optimistic.
Slides 10, 11 and 12
Use this part of the session to present an overview of HIV infection and AIDS. For some
participants, this may be a review.
Discuss the definitions of HIV and AIDS and highlight the differences. Allow time to respond
to questions.
Overview of HIV and AIDS
Refer to Pocket Guide
Definitions of HIV and AIDS

HIV stands for human immunodeficiency virus, the virus that causes AIDS.
H: Human
I: Immunodeficiency
V: Virus
! HIV breaks down the body's defence against infection and disease—the body's
immune system—by infecting specific white blood cells, leading to a weakened
immune system.
! When the immune system becomes weak or compromised, the body loses its protec-
tion against illness.
! As time passes, the immune system is unable to fight the HIV infection and the per-
son may develop serious and deadly diseases, including other infections and some
types of cancer.
When a person is infected with HIV, the person is known as “HIV-infected.”
“HIV-positive” is when person who is HIV-infected has tested positive for HIV.
AIDS is an acronym for acquired immunodeficiency syndrome and refers to the most
advanced stage of HIV infection.
A: Acquired, (not inherited) to differentiate from a genetic or inherited condition that

causes immune dysfunction
I: Immuno-, because it attacks the immune system and increases susceptibility to

infection
D: Deficiency of certain white blood cells in the immune system
S: Syndrome, meaning a group of symptoms or illnesses that result from the HIV
infection

Make These Points
! Emphasise the differences between HIV and AIDS.
Differences between HIV, HIV infection, and AIDS

! HIV is the virus that causes infection.
! The person who is HIV-infected may have no signs of illness but can still infect others.
! Most people who are HIV-infected will develop AIDS after a period of time, which may
be several months to more than 15 years.
! AIDS is a group of serious illnesses and opportunistic infections that develop after
being infected with HIV for a long period of time.
! A diagnosis of AIDS is based on specific clinical criteria and laboratory test results.
(See Appendix 1-A for information about the World Health Organization (WHO) staging
systems for HIV infection and Disease and Appendix 1-B for the U.S. Centers for
Disease Control and Prevention (CDC) AIDS Surveillance Case Definitions.)
Slides 13 and 14
Discuss HIV-1 and HIV-2, highlighting the similarities and differences between them.
Types of HIV
HIV-1 and HIV-2 are types of HIV. Both types are transmitted the same way, and both
are associated with similar opportunistic infections and AIDS. HIV-1 is more common
worldwide. HIV-2 is found predominantly in West Africa, Angola, and Mozambique.
Differences between HIV-1 and HIV-2

HIV-2 is less easily transmitted than is HIV-1, and it is less pathogenic, meaning that the
period between initial infection and illness is longer. In some areas, a person may be
infected with both HIV-1 and HIV-2. While HIV-2 can be transmitted from an infected
mother to her child, this appears to be rare (0% to 5% transmission rate in breastfed
infants in the absence of any interventions).
A discussion of preventing mother-to-child-transmission (PMTCT) from women who are

infected with HIV-2 to their infants is included in Module 2, Overview of HIV Prevention
in Mothers, Infants, and Young Children, Appendix 2-A. Women who are infected with
both HIV-1 and HIV-2 should follow all PMTCT recommendations for HIV-1-infected
women.
Make These Points
! Emphasise the differences between HIV-1 and HIV-2 and be sure that participants
understand the information.

SESSION 2 Natural History and Transmission of HIV
Advance Preparation
Review Exercise 1.2 HIV 1, 2, 3 Knowledge interactive game: although a
few easy questions and a few difficult ones help to make the game fun, re-
write any questions that are inappropriate for participants.
Before the session, draw on flipchart paper in the front of the room (or on a
blackboard or whiteboard) one circle for each team. Each circle should be
approximately 30 cm to 60 cm in diameter so that people in the back of the
room can see it clearly. Divide each circle into sixths.
Optional: Purchase sweets or condoms to be used for prizes for Exercise 1.2.
Review the basic information about the natural history of HIV infection using Figure 1.3.
Explain the "Natural Course of HIV Disease" graph, and describe the presentation of
HIV at each stage of infection.
Make These Points
! Emphasise that HIV is transmitted during each stage and that many people do not
know that they are infected until they become symptomatic.
! Examine the relation of viral load and increased risk of transmitting infection.
Slide 18
Discuss CD4 count and viral load and highlighting the relationship between them.

Make These Points
! CD4 count and viral load are difficult concepts. Spend adequate time on them and
ask participants for feedback to verify that they understand both concepts.
! Explain that although CD4 and viral load are both indicators of disease progression,
they measure different things—one measures the amount of suppression of the
immune system and the other measures the amount of virus in the blood.
! Participants may find it confusing that a low CD4 count is a bad sign and a low viral
load is a good sign. Take the time to clarify these measures to be sure the partici-
pants understand the concepts clearly.
! Emphasise that high maternal viral load increases the risk of mother-to-child trans-
mission of HIV.
Background information on CD4 count and viral load

Figure 1.3 Characteristic viral load and CD4 changes over time in HIV/AIDS
Infection Clinical Latency AIDS

1200 107
HIV RNA
CD4+ T lymphocyte count (cell/mm3)
CD4 T lymphocytes
100
HIV RNA copies per ml plasma

900
105
600
104
300 Primary
HIV
infection
103
with or
without
acute HIV
syndrome
102
0 3 6 1 3 5 7 9 11
Weeks Years

The CD4 count and viral load are two measures of the progression of HIV. When HIV
actively multiplies, it infects and kills CD4 T cells—a specific type of white blood cell—
that are the immune system's key infection fighters. The effects of HIV are measured by
the decline in the number of CD4 cells.
The CD4 count is the number of CD4 cells in the blood and reflects the state of the
immune system. The normal count in a healthy adult is between 600 and 1,200
cells/mm3. When the CD4 count of an adult falls below 200 cells/mm3, the risk of
opportunistic and serious infection is high.
Viral load is the amount of HIV virus in the blood. It can be measured by the HIV
ribonucleic acid polymerase chain reaction blood test (HIV-RNA PCR). The test is used
as a marker of response to antiretroviral (ARV) treatment.
The viral load is very high shortly after primary HIV infection. It falls steeply when the
body develops antibodies and rises again after a number of years as the CD4 count
drops. High viral load leads to higher transmission risk. Most often, after a number of
years, high viral load is also a sign of more severe disease as people develop AIDS
(Figure 1.3).
Natural history (or course) of HIV infection

Seroconversion
People infected with HIV usually develop antibodies 4 to 6 weeks after being infected,
but it may take as long as 3 months for antibodies to develop. The period of time
between when a person is infected with HIV and when the antibody test result is
positive is called the "window period."
Unlike for most diseases, having antibodies for HIV does not indicate protection but
indicates infection.
When a recently infected person develops antibodies that can be measured using a
laboratory test, seroconversion is occurring. Some people may experience a glandular
illness (fever, rash, joint pains, and enlarged lymph nodes) at the time of
seroconversion.
HIV testing detects antibodies or antigens associated with HIV in whole blood, saliva, or
urine.
A person whose blood test results show HIV infection is said to be seropositive or
HIV-positive.
A person whose blood test results do not show HIV infection is said to be seronegative
or HIV-negative.
A person who tests HIV-negative but who has engaged in behaviour within
the past 3 months that places him or her at risk for HIV should be tested
again in 3 months.

Asymptomatic HIV infection
A person who is HIV-infected but looks and feels healthy is asymptomatic. None of the
physical signs or symptoms that indicate HIV infection are present.
Whether they have symptoms or not, people who are HIV-positive can still pass the
virus to others.
The duration of the asymptomatic phase varies greatly from person to person. Some
adults may develop symptoms of HIV as quickly as a few months after primary infection;
others may take as long as 15 years or more to develop symptoms.
For children infected with HIV through MTCT, during pregnancy, labour and delivery,
and breastfeeding, the asymptomatic phase is shorter. A few infants who are
HIV-positive will become ill within the first weeks of life. Most children start to develop
symptoms before they are 2 years old; a few remain well for several years.
Symptomatic HIV infection

A person who has developed physical signs of HIV and reports symptoms related to
HIV is symptomatic.
The immune system weakens and CD4 count decreases during this phase.
The progression of HIV depends on the type of virus and specific host characteristics
including general health, nutritional, and immune status.
AIDS
Almost all people who are HIV-positive will ultimately develop HIV-related disease and
AIDS, the end stage of HIV infection. As HIV infection progresses, the CD4 count
continues to decrease and the infected person becomes susceptible to opportunistic
infections.
An opportunistic infection is an illness caused by a germ that might not cause illness in
a healthy person, but will cause illness in a person who has a weakened immune
system. For example, co-infection with tuberculosis (TB) is very common in people
infected with HIV.
People living with advanced HIV infection suffer from opportunistic infections of the
lung, brain, eyes, and other organs. Other common opportunistic infections in persons
diagnosed with AIDS are pneumocystis carinii pneumonia (PCP); cryptosporidiosis;
histoplasmosis; other parasitic, viral and fungal infections; and some types of cancers,
such as Kaposi's sarcoma.
ARV treatment and prophylaxis and treatment of opportunistic infections help preserve
the CD4 cells, lower viral load, and prolong the time it takes for HIV to progress to the
symptomatic phase and, ultimately, to AIDS.

Slides 19, 20, 21, and 22
Discuss and reinforce the concept of HIV disease progression.
Make These Points
! Point out that the transition from the stages of asymptomatic to symptomatic to AIDS
occurs when CD4 counts decrease and immune function deteriorates.
Note that HIV infects many organ systems and causes a range of symptoms and
!
opportunistic infections.
! Emphasise the role of high viral load and low CD4 counts in the development of clini-
cal symptoms.
Review the staging systems for HIV and their purpose so that the participants are
familiar with these topics.
Take a few moments to go over the tables in Appendix 1-A with the participants.
Make These Points
! Tell the participants that staging systems continue to be modified as we learn more
about the disease.
Staging systems for HIV

Staging systems for HIV can:
! Contribute to the care of individuals who are HIV-infected

! Provide a framework for follow-up and management
! Help define prognosis and guide patient counselling
! Be used to help evaluate new treatments
World Health Organization (WHO) staging system for HIV

The WHO staging system groups HIV progression into four clinically relevant stages—
Stages I to IV—that correspond to the natural history of HIV. (See Appendix 1-A.)
The staging system for HIV infection in children is scheduled to be revised by WHO in
consultation with paediatric experts in 2004. In the interim, using the WHO staging sys-
tem can help define parameters for initiating treatment in resource-constrained settings.
However, adapting the staging system at the country programme level may be
appropriate.

U.S. Centers for Disease Control and Prevention (CDC) surveillance case definition
The CDC AIDS Surveillance Case Definitions include clinical and immunologic
categories. (See Appendix 1-B.) This system uses a combination of symptoms and
CD4 count levels to establish criteria for AIDS.
Slide 23
Review the natural history summary slide slowly and carefully and take the opportunity
to invite additional questions.
Discuss transmission of HIV.
Make These Points
! The main source of HIV transmission is unprotected sex with a partner who is
HIV-positive.
! Myths and misinformation regarding the transmission of HIV infection exist and
require clarification.
! Condoms used consistently and correctly prevent HIV and other sexually transmitted
infections (STIs).
! Effective PMTCT programmes reduce the risk of perinatal transmission of HIV.
Routes of HIV transmission

HIV can be transmitted through blood, sexual contact, or injection drug use, and from
mother-to-child (also known as perinatal or vertical transmission).
The most common route of HIV transmission is through sexual contact,

especially heterosexual intercourse.
Blood-to-blood transmission
! Transfusion with HIV-infected blood
! Direct contact with HIV-infected blood
Sexual contact
! Unprotected sexual intercourse (vaginal, oral, or anal)
! Direct contact with HIV-infected body fluids such as semen, cervical and vaginal
secretions

Women of childbearing age are at particular risk for acquiring HIV.
The main behaviour that places them at risk is unprotected sex with an
infected male partner.
Drug use
! Injection of drugs with needles or syringes contaminated with HIV
Perinatal transmission (MTCT)
! From mothers who are HIV-positive to their infants during pregnancy, labour, delivery,
and breastfeeding
HIV CANNOT be transmitted by:
! Coughing or sneezing
! Insect bites
! Touching or hugging
! Kissing
! Public bath/pool
! Public toilet
! Shaking hands
! Working or going to school with a person who is HIV-infected
! Telephones
! Water or food
! Sharing cups, glasses, plates, or other utensils
Public health strategies to prevent HIV infection

Blood-to-blood transmission
! Screen all blood and blood products for HIV.
! Follow universal precautions which include:
! Use of protective equipment
! Safe use and disposal of sharps
! Sterilisation of equipment
! Safe disposal of contaminated waste products
Sexual contact
! Promote abstinence or being faithful to one uninfected partner.
! Provide instruction on the consistent and correct use of barrier methods.
! Male or female condoms for vaginal intercourse
! Non-lubricated condoms for oral intercourse on a male
! Dental dams, plastic wrap, or latex panties for oral intercourse on a female
! Condoms for anal intercourse

! Prevent, identify, and provide early treatment for sexually transmitted infections (STIs).
! Provide access to HIV testing and counselling.
Condoms provide protection from HIV transmission as well as other sexually
transmitted infections (STIs) when used correctly and consistently.
Drug use
! Educate about the risks of infection through drug use with contaminated needles and
syringes.
! Provide referral for treatment of drug dependence.
Drug use in any form may increase the risk of HIV infection by limiting judgment and
facilitating engagement in risky behaviours. Even occasional use of alcohol, marijuana,

and other “recreational” drugs may increase risk of HIV infection.
Perinatal transmission from mothers who are HIV-positive

! Provide ARV treatment when indicated and available.
! Provide ARV prophylaxis during labour and delivery.
! Provide ARV prophylaxis to the infant.
! Offer elective caesarean section when safe and feasible.
! Follow safer delivery practices.
! Provide linkages to treatment, care, and social support for mothers and families with
HIV infection.
! Provide infant-feeding counselling.
(Module 2, Overview of HIV Prevention in Mothers, Infants, and Young Children contains
detailed information on a comprehensive PMTCT approach.)

Slides 27 and 28
Summarise key points for Module 1.
Module 1: Key Points

! HIV is a global pandemic.
! The number of people living with HIV worldwide continues to increase.
! The HIV epidemic is especially severe in many resource-constrained countries.
! HIV is a virus that destroys the immune system, leading to opportunistic
infections.
! The progression from initial infection with HIV to end-stage AIDS varies from
person to person and can take more than 15 years.
! The most common route of HIV transmission worldwide is heterosexual
transmission.
! Women of childbearing age are at particular risk for acquiring HIV. The main
behaviour that places them at risk is unprotected sex with an infected male
partner.
! Pregnant women who are HIV-infected are at risk of passing HIV infection to
their newborn.
! Risk of HIV transmission from mother-to-child can be greatly reduced through
effective PMTCT programmes.
Close the module by facilitating Exercise 1.2, the HIV 1, 2, 3 Knowledge Game. Your
copy of the game (pages 1-22 to 1-29) includes the answers in the column on the right.
The participant copy of the HIV 1, 2, 3 Knowledge Game is on pages 1-13 of the
Participant Manual.

Exercise 1.2 HIV 1, 2, 3 Knowledge interactive game
Purpose To present basic and advanced HIV/AIDS information in an
easy and enjoyable way while allowing participants an
opportunity to demonstrate what they know. This game also
gives the participants a chance to get to know each other.
Duration 60 minutes
Introduction Set up round tables that will accommodate 4–6 participants at
each table. Divide the group into two to four teams of equal
size, depending on the size of the group and the amount of
time you have. The more teams there are, the longer the
game will take.

Distribute the groups somewhat evenly by discipline, so that
each group has the same number of nurses, doctors, and so
on. Number the teams 1, 2, 3, and 4 and ask the participants
to sit with their teams.
Start the exercise by explaining that the objective is to be
the first team to complete the circle. Each team can fill in
one-sixth of the circle each time the team gets a correct
answer in six of the following seven categories:
! HIV/AIDS transmission
! Prevention
! Infant feeding
! Testing
! Mother-to-child transmission
! Linkages to treatment, care, and support
! Prevention in healthcare settings
Distribute one question sheet to each participant. Use the
Wild Card category only in the event of a tie.
Activities Give the participants 15–20 minutes to answer the questions
working together in their teams.
Remind the teams to record their answers on the question sheet.
Suggest that they keep the answers simple and not linger on
any one question.
To begin play, the first team chooses a category and a
question, then reads the question aloud and gives the
answer. The team has 10 seconds to answer.
If correct, the team colours in one-sixth of its circle and
records next to the circle the name of the category from
which the question came.
A team may only answer one question per category.
If incorrect, the next team gets to answer that question or
another question of its choosing.
Once a question has been answered correctly, no other team
may use it.
The facilitator should clarify any misconceptions that may
have surfaced during the discussion once the question is
correctly answered.
The next team takes a turn.

Exercise 1.2 HIV 1, 2, 3 Knowledge interactive game (continued)
The first team to fill its circle by colouring in all six pieces
(representing six correct answers in six different categories)
is the winner and receives the prize.
Debriefing Point out that each participant knows more than they think
they know and that by working together, they are able to
respond correctly to many of the HIV/AIDS questions in the
Knowledge Game.

Answers to Exercise 1.2 HIV 1, 2, 3 Knowledge Game
Category 1: HIV/AIDS Transmission
Question Answer
List at least three ways in ! Unprotected sex with an infected person
which HIV infection is ! From an infected mother to her infant before birth,
transmitted. during birth, or during breastfeeding
! Blood transfusion in countries in which blood is not
routinely screened
! Blood-to-blood transmission, including any of the
following:
! Injection drug use or

! Accidental exposure to needles or sharps in a
healthcare setting—razors, scalpel blades,
lancets, or scissors—that were used by a person
who was HIV-infected and not cleaned
Name the two types of HIV. HIV-1 and HIV-2
What body fluids contain high ! Blood
concentrations of HIV? ! Semen
! Vaginal secretions
! Breastmilk
What is the major route of HIV Unprotected heterosexual sex

transmission worldwide?
What specific part of the HIV infects the immune system, specifically the
human body does HIV attack CD4 cells. Over time, the weakened immune system
and what does this cause? has a progressively more difficult time fighting
infections.

Category 2: Prevention
Question Answer
What are the ABCs of A. Abstain from sex completely.
prevention (on an individual B. Be faithful to one partner who is uninfected.
level)?
C. Use a new condom properly each time you have
sexual intercourse.
Note: There is also a “D”. Do not use drugs and do not share
injection equipment.
Universal precautions are a ! Wash hands after any direct contact with patients.
set of practices designed to ! Do not recap needles, whenever possible.
protect health workers and ! Dispose of needles (hypodermic and suture) and
patients from infection. Name
sharps (scalpel blades, lancets, razors and scis-
at least four interventions that
sors) safely, putting them into puncture- and leak-
are universal precautions.
proof safety boxes.
! Wear gloves to prevent contact with body fluids,
broken skin and mucous membranes.
! Wear a mask, eye protection, and gown (and some-
times a plastic apron) if blood or other body fluids
might splash.
! Cover cuts and abrasions with a waterproof dress-
ing.
! Promptly and carefully clean up spills of blood and
other body fluids.
! Use a safe system for hospital waste collection and
disposal.

Category 3: Infant Feeding
Question Answer
Exclusive breastfeeding is Drops or syrups consisting of vitamins, mineral
defined by WHO as giving an supplements, or medicines
infant only breastmilk
(including expressed
breastmilk), with the exception
of ______________________
(fill in the blank).
List two reasons why cup ! Cups are safer because they are easier to clean
feeding is preferred over bottle with soap and water than bottles.
feeding when the mother ! Cups are less likely than bottles to be carried
chooses replacement feeds around for a long time, giving bacteria the opportu-
(rather than breastfeeding). nity to multiply.
! Cup feeding requires the mother or other caregiver
to hold and have more contact with the infant, pro-
viding more psychosocial stimulation than bottle-
feeding.
! Cup feeding is better than feeding with a cup and
spoon because spoon feeding takes longer and the
mother may stop before the infant has had enough.
At what age does WHO 6 months
recommend starting a child on
complementary foods (food in
addition to milk)?
Name two reasons why a ! To avoid stigma

woman may choose to ! To avoid inadvertently disclosing her HIV status
breastfeed rather than give a ! To accommodate family pressure
breastmilk substitute to her
infant.
! To maintain denial of her HIV status
! To manage finances if she cannot afford a breast-
milk substitute (or if one is not available)
! To comfort the infant in an easy way
! To compensate for a feeling that she is missing out
on something

Category 4: Testing
Question Answer
What is specifically measured HIV antibodies
when an HIV screening test is
done? Note: In some settings infants who are HIV-exposed
may be “screened” using antigen tests.
With regard to HIV testing, This is the period between the initial infection and the
what does the "window time when the HIV test can detect the antibodies the
period" mean? body has generated in reaction to HIV. People infected
with HIV usually develop antibodies 4 to 6 weeks after
being infected, but it may take as long as 3 months for
antibodies to develop.
Name two advantages of the ! The result is ready on the same day, so a woman
HIV rapid test (compared with does not need to leave the clinic and then return for
the traditional ELISA test). the results.
! Rapid tests are cost-effective because they do not
need special laboratory equipment and can be con-
ducted in the clinic setting.
! There is less potential for specimen mix-up and
loss.
! Providers do not have to spend time tracking down
test results weeks after the test was done.
! Pregnant women with positive HIV test results can
immediately receive information on treatment for
themselves and interventions to protect their infants
from mother-to-child HIV transmission.

Category 5: Mother-to-Child Transmission
Question Answer
If 100 women who were During pregnancy ...............................................5–10
HIV-infected gave birth to
100 infants, how many of the
infants would typically become
infected during pregnancy?
During labour and delivery ...........................About 15

If 100 women who were
HIV-infected gave birth to

100 infants, how many of the
infected during labour and
delivery? During breastfeeding ..........................................5–15
If 100 women who were
HIV-positive gave birth to
100 infants, how many of these
infected during breastfeeding? Total ..................................................................25–40
Name two maternal factors ! New HIV infection during pregnancy
that may increase the risk of ! Viral, bacterial, and parasitic placental infection
HIV transmission during (especially malaria)
pregnancy. ! Maternal malnutrition
! STIs
! Advanced HIV or late-stage AIDS
Name two factors that may ! New maternal HIV infection during breastfeeding
increase the risk of HIV ! Duration of breastfeeding
transmission during ! Mixed feeding (breastmilk along with replacement
breastfeeding.
feeding such as foods and fluids other than breast-
milk)
! Breast abscesses, nipple fissures (cracked nipples),
and mastitis
! Advanced HIV or AIDS in the mother
! Maternal malnutrition
! Oral disease in the infant, such as thrush and
mouth sores

Category 6: Linkages to Treatment, Care, and Support
Question Answer
Name at least two activities ! Assessment of healing, which includes:
that should be included in the ! Wound healing
6-week postnatal visit for the ! Uterine involution
woman who is HIV-infected.
! Cessation of postnatal bleeding
! Infant feeding support
! Family planning and contraception
! Supporting the mother's choice of contraception
! Discussing importance of safer sex to prevent other
STIs and the further spread of HIV
! Providing advice about early treatment of STI
Name one test that will tell An HIV antibody test (typically ELISA or one of the
you if an infant is HIV-infected. rapid HIV tests), done at 18 months of age or older
An HIV antigen test, such as the DNA polymerase

chain reaction (PCR) test, done beginning in the first
month of life (Note: Definitive diagnosis requires
2 positive antigen tests done at least a month apart.)
Name one of the more ! Low weight and/or growth failure

common symptoms ! Pneumonia, including PCP
associated with HIV infection ! Oral candidiasis (thrush)
in the infant or child.
! Lymphadenopathy
! Diarrhoea
! TB

Category 7: Prevention in Healthcare Settings
Question Answer
Name one disinfectant that is ! Soap and water
capable of inactivating HIV. ! 10% chlorine bleach solution
! 70% alcohol
! Hydrogen peroxide
If a healthcare worker The risk of HIV transmission in situations in which the

accidentally got stuck with a skin is punctured by a needle stick or other sharp is
needle that had previously less than 1%. The risk of HIV transmission from
been used on a patient with exposure to infected fluids or tissues is believed to be
HIV (and not cleaned), what lower than from exposure to infected blood.
would be the chance that he
or she would become
HIV-infected?
A. 1%
B. 5%
C. 3%
D. 20%
What are two things that you ! Cover broken skin or open wounds with watertight
can do when attending to a dressings.
patient in obstetrics to reduce ! Wear gloves when expecting exposure to blood or
risk of occupational exposure body fluids.
to HIV? ! Wear an impermeable plastic apron for the birth.
! Pass all sharp instruments on to a receiver, rather
than hand-to-hand.
! Use long cuffed gloves for manual removal of a pla-
centa.
! Modify surgical practice to use needle holders and
avoid using your fingers in needle placement.
! When available, wear an eye shield for operating,
assisting a cesarean section, and suturing epi-
siotomies.
! If blood splashes on skin, immediately wash the
area with soap and water. If blood splashes in the
eye, wash the eye with water only.
! Dispose of solid waste, such as blood-soaked
dressings or placentas, safely and according to
local procedures.

Category 8: Wild Card
Question Answer
AIDS is the ________ (choose A. Number 1
number) cause
of death in Africa?
A. Number 1
B. Number 2
C. Number 3
D. Number 4
The HIV/AIDS pandemic is Eastern Europe and Central Asia
growing fastest in which
regions of the world?
In sub-Saharan Africa, women C. 58%
represent what percentage of
all people living with
HIV/AIDS?
A. 78%
B. 72%
C. 58%
D. 48%
What is the difference Stigma refers to attitudes and thoughts.

between stigma and
discrimination? Discrimination is a behaviour based on stigmatising
attitudes and thoughts.
What is the difference Monitoring is concerned primarily with describing the
between monitoring and costs of an intervention, for example, the number of
evaluation? staff, hours worked, schedules, and costs.
Evaluation relates to the benefits, such as how the

project's objectives were realised (eg what percentage
of ANC women were tested for HIV? What percentage
of women who are HIV-infected received NVP? Was
there a reduction in the number of infants who were
HIV-infected?).

APPENDIX 1-A WHO staging systems for HIV infection and
disease in adults, adolescents, and children
WHO staging system for HIV infection and disease in adults
Clinical stage I
! Asymptomatic
! Generalised lymphadenopathy
Performance Scale 1: asymptomatic, normal activity
Clinical Stage II
! Weight loss of less than 10% of body weight

! Minor mucocutaneous manifestations (seborrhoeic dermatitis, prurigo, fungal nail infections,
recurrent oral ulcerations, angular cheilitis)
! Herpes zoster within the last 5 years
! Recurrent upper respiratory tract infections (e.g., bacterial sinusitis)
And/or Performance Scale 2: symptomatic, normal activity
Clinical Stage III
! Weight loss of more than 10% of body weight
! Unexplained chronic diarrhoea lasting for more than 1 month
! Unexplained prolonged fever (intermittent or constant) lasting for more than 1 month
! Oral candidiasis (thrush)
! Oral hairy leukoplakia
! Pulmonary tuberculosis
! Severe bacterial infections (e.g., pneumonia, pyomyositis)
And/or Performance Scale 3: bedridden less than 50% of the day during the past month
Clinical Stage IV
! HIV wasting syndromea
! Pneumocystis carinii pneumonia leukoencephalopathy (PML)
! Toxoplasmosis of the brain ! Any disseminated endemic mycosis
! Cryptosporidiosis with diarrhoea lasting ! Candidiasis of the oesophagus, trachea,
more than 1 month bronchi
! Cryptococcosis, extrapulmonary ! Atypical mycobacteriosis, disseminated or
! Cytomegalovirus (CMV) disease of an pulmonary
organ other than liver, spleen or lymph ! Non-typhoid salmonella septicaemia
node (e.g., retinitis) ! Extrapulmonary tuberculosis
! Herpes simplex virus (HSV) infection, ! Lymphoma
mucocutaneous (lasting for more than 1 ! Kaposi's sarcoma (KS)
month), or visceral
! Progressive multifocal ! HIV encephalopathyb
And/or Performance Scale 4: bedridden more than 50% of the day during the last month
a
HIV wasting syndrome: weight loss of more than 10% body weight, plus either unexplained chronic diarrhoea (lasting
longer than 1 month) or chronic weakness and unexplained prolonged fever (lasting longer than 1 month)
b
HIV encephalopathy: clinical findings of disabling cognitive and/or motor dysfunction interfering with activities of daily
living progressing over weeks to months, in the absence of a concurrent illness or condition other than HIV infection
that could explain the findings
Source: World Health Organization (WHO). 2004. Scaling up antiretroviral therapy in resource-limited settings: Treatment
guidelines for a public health approach, 2003 Revision, Appendix D: WHO staging system for HIV infection and disease
in adults and adolescents, p. 42

APPENDIX 1-A WHO staging systems for HIV infection and
disease in adults, adolescents, and children
(continued)
WHO staging system for HIV infection and disease in children
Clinical Stage I
! Asymptomatic
! Generalised lymphadenopathy
Clinical Stage II
! Chronic diarrhoea lasting more than 30 days in the absence of known etiology
! Severe persistent or recurrent candidiasis outside the neonatal period
! Weight loss or failure to thrive in the absence of known etiology
! Persistent fever lasting longer than 30 days in the absence of known etiology
! Recurrent severe bacterial infections other than septicaemia or meningitis (eg, osteomyelitis,
bacterial (non-TB) pneumonia, abscesses)
Clinical Stage III

! AIDS-defining opportunistic infections
! Severe failure to thrive (wasting) in the absence of known etiology a
! Progressive encephalopathy
! Malignancy
! Recurrent septicaemia or meningitis
a
Persistent weight loss of more than 10% of baseline or less than 5th percentile on weight for height chart on 2
consecutive measurements more than 1 month apart in the absence of another etiology or concurrent illness.
Source: World Health Organization (WHO). 2004. Scaling up antiretroviral therapy in resource-limited settings: Treatment
guidelines for a public health approach, 2003 Revision, Appendix E: WHO staging system for HIV infection and disease
in children, p. 44

APPENDIX 1-B CDC AIDS surveillance case definitions for
adolescents, adults, and children
I. CDC AIDS surveillance case definition for adolescents and adults

Clinical Categories
CD4 Cell Categories A B C*
mm3(%) Asymptomatic, PGL Symptomatic** AIDS Indicator
or Acute HIV (not A or C) Condition (1987)
Infection
1 >500/mm3 A1 B1 C1
(>29%)
2 200 – 499/mm3 A2 B2 C2
(14–28%)
3 <200/mm3 A3 B3 C3
(<14%)
* All patients in categories A3, B3 and C1-3 are defined as having AIDS, based on the presence of an AIDS-indicator
condition (see the following table) and/or a CD4 cell count of less than 200/mm3.
** Symptomatic conditions not included in Category C that are: a) attributed to HIV infection or indicative of a defect in
cell-mediated immunity or b) considered to have a clinical course or management that is complicated by HIV
infection. Examples of B conditions include but are not limited to bacillary angiomatosis; thrush; vulvovaginal
candidiasis that is persistent, frequent or poorly responsive to therapy; cervical dysplasia (moderate or severe);
cervical carcinoma in situ; constitutional symptoms such as fever (38.5° C) or diarrhoea lasting longer than 1 month;
oral hairy leukoplakia; herpes zoster involving two episodes or more than 1 dermatome; idiopathic
thrombocytopoenic purpura (ITP); listeriosis; pelvic inflammatory disease (PID) (especially if complicated by a tubo-
ovarian abscess); and peripheral neuropathy.
Source: U.S. Centers for Disease Control and Prevention. 1992. 1993 Revised classification system for HIV infection
and expanded surveillance case definition for AIDS among adolescents and adults. MMWR 41(RR-17)
http://www.cdc.gov/mmwr/preview/mmwrhtml/00018179.htm
II. CDC AIDS case surveillance definition for infants and children
CDC immunologic categories based on age-specific CD4 counts and percent of
total lymphocytes
Immunologic category <12 mos 1–5 yrs 6–12 yrs
mm3 (%) mm3 (%) mm3 (%)
Category 1: No evidence of > 1,500 (> 25) >1,000 (> 25) > 500 (> 25)
suppression
Category 2: Evidence of 750–1,499 (15–24) 500–999 (15–24) 200–499 (15–24)
moderate suppression
Category 3: Severe < 750 (<15) < 500 (<15) < 200 (<15)
suppression

adolescents, adults, and children
Clinical categories for children with HIV

CATEGORY N: NOT SYMPTOMATIC
Children who have no signs or symptoms considered to be the result of HIV infection or
who have only one of the conditions listed in Category A.
CATEGORY A: MILDLY SYMPTOMATIC
Children with two or more of the conditions listed below but none of the conditions listed
in Categories B and C.
! Lymphadenopathy (> 0.5 cm at more than two sites; bilateral = one site)
! Hepatomegaly
! Splenomegaly
! Dermatitis
! Parotitis
! Recurrent or persistent upper respiratory infection, sinusitis, or otitis media
CATEGORY B: MODERATELY SYMPTOMATIC

Children who have symptomatic conditions other than those listed for Category A or C
that are attributed to HIV infection.
Examples of conditions in clinical Category B include but are not limited to:
! Anemia (<8 gm/dL), neutropenia (<1,000/mm3), or thrombocytopenia (<100,000/mm3)

persisting > 30 days
! Bacterial meningitis, pneumonia, or sepsis (single episode)
! Candidiasis, oropharyngeal (thrush), persisting (>2 months) in children >6 months of age
! Cardiomyopathy
! Cytomegalovirus infection, with onset before 1 month of age
! Diarrhea, recurrent or chronic
! Hepatitis
! Herpes simplex virus (HSV) stomatitis, recurrent (more than two episodes within 1 year)
! HSV bronchitis, pneumonitis, or esophagitis with onset before 1 month of age
! Herpes zoster (shingles) involving at least two distinct episodes or more than one
dermatome
! Leiomyosarcoma
! Lymphoid interstitial pneumonia (LIP) or pulmonary lymphoid hyperplasia complex
! Nephropathy
! Nocardiosis
! Persistent fever (lasting >1 month)
! Toxoplasmosis, onset before 1 month of age
! Varicella, disseminated (complicated chickenpox)

adolescents, adults, and children (continued)
CATEGORY C: SEVERELY SYMPTOMATIC
! Serious bacterial infections, multiple or recurrent (i.e., any combination of at least two
culture-confirmed infections within a 2-year period), of the following types: septicemia,
pneumonia, meningitis, bone or joint infection, or abscess of an internal organ or
body cavity (excluding otitis media, superficial skin or mucosal abscesses, and
indwelling catheter-related infections)
! Candidiasis, esophageal or pulmonary (bronchi, trachea, lungs)
! Coccidioidomycosis, disseminated (at site other than or in addition to lungs or
cervical or hilar lymph nodes)

! Cryptococcosis, extrapulmonary
! Cryptosporidiosis or isosporiasis with diarrhea persisting >1 month
! Cytomegalovirus disease with onset of symptoms at age >1 month (at a site other
than liver, spleen, or lymph nodes)
! Encephalopathy (at least one of the following progressive findings present for at least
2 months in the absence of a concurrent illness other than HIV infection that could
explain the findings): a) failure to attain or loss of developmental milestones or loss of
intellectual ability, verified by standard developmental scale or neuropsychological
tests; b) impaired brain growth or acquired microcephaly demonstrated by head
circumference measurements or brain atrophy demonstrated by computerized
tomography or magnetic resonance imaging (serial imaging is required for children <2
years of age); c) acquired symmetric motor deficit manifested by two or more of the
following: paresis, pathologic reflexes, ataxia, or gait disturbance
! Herpes simplex virus infection causing a mucocutaneous ulcer that persists for >1
month; or bronchitis, pneumonitis, or esophagitis for any duration affecting a child >1
month of age
! Histoplasmosis, disseminated (at a site other than or in addition to lungs or cervical
or hilar lymph nodes)
! Kaposi’s sarcoma
! Lymphoma, primary, in brain
! Lymphoma, small, noncleaved cell (Burkett’s), or immunoblastic or large cell
lymphoma of B-cell or unknown immunologic phenotype
! Mycobacterium tuberculosis, disseminated or extrapulmonary
! Mycobacterium, other species or unidentified species, disseminated (at a site other
than or in addition to lungs, skin, or cervical or hilar lymph nodes)
! Mycobacterium avium complex or Mycobacterium kansasii, disseminated (at site
other than or in addition to lungs, skin, or cervical or hilar lymph nodes)
! Pneumocystis carinii pneumonia
! Progressive multifocal leukoencephalopathy
! Salmonella (nontyphoid) septicemia, recurrent
! Toxoplasmosis of the brain with onset at >1 month of age
! Wasting syndrome in the absence of a concurrent illness other than HIV infection that
could explain the following findings: a) persistent weight loss >10% of baseline OR b)
downward crossing of at least two of the following percentile lines on the weight-for-
age chart (e.g., 95th, 75th, 50th, 25th, 5th) in a child > 1 year of age OR c) <5th
percentile on weight-for-height chart on two consecutive measurements, >=30 days
apart PLUS a) chronic diarrhea (i.e., at least two loose stools per day for >30 days)
OR b) documented fever (for > 30 days, intermittent or constant)
Adapted from: US Centers for Disease Control and Prevention. 1994. Revised classification system for
human immunodeficiency virus infection in children less than 13 years of age. MMWR (RR–22).

Module 2 Overview of HIV Prevention in Mothers,
Infants and Young Children
SESSION 1 Comprehensive Approach to Reducing HIV Infection in

Module 2 Overview
Exercise 2.1 Local None, other than those noted 20 minutes
epidemiology: interactive below
discussion
SESSION 2 Mother-to-Child Transmission of HIV Infection

Exercise 2.2 Local None, other than those noted 20 minutes
terminology: interactive below
discussion
SESSION 3 Comprehensive Approach to Prevention of HIV Infection in

Exercise 2.3 STI Marked paper strips measuring 90 minutes
handshake: interactive about 5 x 8 cm.
group game
A basket, box, or paper bag to
hold paper strips
SESSION 4 Role of Maternal and Child Health Services in the

Prevention of HIV Infection in Infants and Young Children
Review local PMTCT Copies of local PMTCT policies 15 minutes
policies and programmes if not already in the Participant
Manual.

Session 3
! For Element 3: Prevention of HIV transmission from women infected with HIV to
their infants
! Local/national/regional summary of epidemiology of MTCT
! Brief introduction to local/national PMTCT policy and programme including
PMTCT targets
! For Element 4: Provision of treatment, care, and support to women infected with
HIV, their infants, and their families
! Local/national PMTCT-Plus targets
! Copies of patient brochures on personal risk reduction strategies (if available)
Module 2 Overview
Module 2–2 Overview of HIV Prevention in Mothers, Infants and Young Children
SESSION 1 Comprehensive Approach to Reducing HIV
Infection in Infants and Young Children
Advance Preparation
! Either recruit an expert on local and national epidemiology to present the
local HIV and MTCT information or research and develop the presenta-
tion yourself.
! Prepare slide(s) on local epidemiology if needed.
! Prepare handout summarising local epidemiology of MTCT if not already
in the Participant Manual.
Slides 1, 2 and 3
Module 2 Overview

! Describe the comprehensive approach to prevention of HIV infection in infants and
young children.
! Discuss mother-to-child transmission (MTCT) of HIV infection.
! Describe the four elements of a comprehensive approach to prevention of HIV
infection in infants and young children.
! Describe the role of maternal and child health (MCH) services in the prevention of
HIV infection in infants and young children.

Slides 4 and 5
Distribute the handout summarising national and regional epidemiology on HIV and
MTCT if it is not already in the Participant Manual.
Introduce local expert OR review country or local data on HIV and MTCT epidemiology.
Facilitate Group Work
Lead interactive discussion on local epidemiology, as described below.
Make These Points
! Discuss local statistics and rates of HIV infection, particularly among pregnant
women.
! Discuss how those factors will affect PMTCT services.
Exercise 2.1 Interactive discussion: local epidemiology

Module 2 Overview
Purpose To involve the participants in a discussion about local

epidemiology.
Duration 10 minutes
Introduction Ask participants whether they are familiar with local statistics
on HIV and MTCT or whether they are surprised by the data.
Activities Ask the members of the group to tell you what factors they—
as individuals and as healthcare workers—think are fuelling
the epidemic.
Write their responses on the flipchart or board in the front of

the room.
Debriefing Summarise the session by noting that HIV and MTCT are
fuelled by a number of individual behaviours, which may be
shaped by a range of personal, cultural, political, and legal
factors.
Slide 6
Explain that reducing HIV infection in infants and young children requires a
multidimensional approach that includes the four elements listed below.
When possible, use local examples to describe the implementation of the four elements.
Make These Points
! Emphasise that HIV prevention efforts reach fewer than one in five people at risk.
Reducing HIV infection in infants and young children requires a comprehensive

approach that includes the four elements listed below:
! Element 1: Primary prevention of HIV infection
! Element 2: Prevention of unintended pregnancies among women infected with HIV
! Element 3: Prevention of HIV transmission from women infected with HIV to
their infants
! Element 4: Provision of treatment, care, and support to women infected with HIV,
their infants, and their families
Module 2 Overview
Make These Points
! Emphasise that access to comprehensive MCH services (ie, antenatal, postnatal, and
child health) and HIV testing and counselling is central to any effort to reduce mother-
to-child transmission of HIV.
! Discuss the United Nation’s (UN) approach to comprehensive prevention of HIV
infection in infants and young children.
! Discuss the four elements of a comprehensive approach to PMTCT outlined on Slide 6.
The first element focuses on parents-to-be. The second element addresses family plan-
ning. The third and fourth elements focus on women who are HIV-infected, their infants,
and their families. State that the four elements will be discussed in detail in Session 3 of
this module.
Definition
PMTCT (prevention of mother-to-child transmission) is a commonly used
term for programmes and interventions designed to reduce the risk of
mother-to-child transmission (MTCT) of HIV.
Access to comprehensive MCH services (ie, antenatal, postnatal and child health
services) is central to efforts to reduce HIV infection in infants and young children.
The following sessions provide more details on the specific elements of the
comprehensive approach.

SESSION 2 Mother-To-Child Transmission of HIV Infection
Advance Preparation
Ask colleagues working in the HIV prevention and care field or any related
field to tell you local terms and phrases used to discuss sex, STIs, HIV
disease or condoms. Make a list of these terms to use for Exercise 2.2.
Slides 7 and 8
Begin this session by emphasising that PMTCT programmes function within region-
specific cultural and social contexts. Healthcare workers, patients, and policy makers
often use local terminology when discussing HIV/AIDS and related topics. Use the
interactive discussion below to define some of the terms used locally.
Exercise 2.2 Interactive discussion: local terminology

Module 2 Overview
Purpose To determine local language used in HIV/AIDS prevention,

care, and treatment programmes.
Duration 10 minutes
Introduction HIV disease has fostered the development of a number of words

in every language to describe the disease, how it is transmitted,
how it is prevented, and those thought to be infected and at risk.
Although these terms are at times stigmatising, it is important
that as healthcare workers we are familiar with the language
used by our patients. Additionally it is important that providers
are consistent with their use of words for new concepts.
Activities In the local language, have the healthcare provider briefly discuss
the risks of HIV transmission from a mother to her baby during
pregnancy, during labour and delivery, and when breastfeeding—
as she would explain these concepts to a patient.
Ask the group to identify the words/concepts used locally that
are the most useful and clear when working with pregnant
women. Concepts where consensus might be important include:
window period, condom, HIV, virus, ARVs, replacement feeding,
stigma, disclosure.
Ask the group to list the words used to describe HIV disease
and people who are HIV-infected.
Write these words on flipchart; chose the most appropriate
words to describe each concept, and agree to use this language
to avoid misinformation or stigmatising language.
Debriefing These concepts can be communicated to pregnant women,
even if they had not previously existed in the local language.
Refer to the Pocket Guide
Review MTCT, as described below.
The more technical term for MTCT is vertical transmission or perinatal transmission.
The majority of children infected with HIV acquire the virus through MTCT.
Use of the term “MTCT” attaches no blame or stigma to the woman who gives birth to a
child who is HIV-infected. It does not suggest deliberate transmission by the mother,
who is often unaware of her own infection status and unfamiliar with the transmission
risk to infants. Use of the term should not obscure the fact that HIV is often introduced
into a family through the woman's sexual partner.
MTCT can occur during:

! Pregnancy
Module 2 Overview
! Labour and delivery
! Breastfeeding
Slide 9
Make These Points
! Emphasise that MTCT may occur during pregnancy, labour, delivery and breastfeeding.
! Point out that without intervention (ARV prophylaxis or treatment) up to 40% of
breastfed infants born to mothers infected with HIV can become HIV-infected.

Risk of transmission without interventions
Most transmission occurs during labour and delivery, but depending on breastfeeding
practices and duration there is also substantial risk of HIV transmission during breast-
feeding.
Figure 2.1 shows that without intervention (ARV prophylaxis or treatment) up to 40% of
infants born to mothers infected with HIV who breastfeed can become HIV-infected.
Figure 2.1 HIV Outcomes of Infants Born to Women infected with HIV
60 to 75 infants
100 infants born to HIV-infected women who breastfeed,
will not be
without any interventions
HIV-infected
5–10 About 15 5–15

infants infants infants
infected infected infected
during during during
pregnancy labour and breast-
delivery feeding
25 to 40 infants will be HIV-infected

Module 2 Overview
Note: Figure 2.1 gives an overall picture of possible outcomes, and there will be
variability among different populations.
Slides 10, 11, and 12
Review interventions that decrease the risk of HIV transmission during pregnancy,
labour and delivery, and breastfeeding.
Make These Points
Much is known about specific factors that might put a woman at higher risk of
transmission, as outlined in the following text and Table 2.1.
! We can use this knowledge to identify interventions to decrease the risk of HIV trans-
mission to the infant during pregnancy, labour, and delivery, and breastfeeding.
Risk factors for transmission
A great deal is known about specific factors that may put a woman at higher risk of
transmitting HIV to her infant:
! Viral, maternal, obstetrical, foetal, and infant-related factors all influence the risk of
MTCT.
! The most important risk factor for MTCT is the amount of HIV virus in the mother's
blood, known as the viral load. The risk of transmission to the infant is greatest when
the viral load is high—which is often the case with recent HIV infection or advanced
HIV/AIDS.
Some of the risk factors for transmission are the same and some are different during
pregnancy, labour and delivery, and breastfeeding. These similarities and differences
are summarised in Table 2.1.
Table 2.1 Maternal factors that may increase the risk of HIV transmission
Pregnancy Labour and Delivery Breastfeeding
! High maternal viral load ! High maternal viral load ! High maternal viral load
(new or advanced (new or advanced (new or advanced
HIV/AIDS) HIV/AIDS) HIV/AIDS)
! Viral, bacterial, or para- ! Rupture of membranes ! Duration of
sitic placental infection more than 4 hours before breastfeeding
(eg, malaria) labour begins ! Early mixed feeding
Module 2 Overview
! Sexually transmitted ! Invasive delivery proce- (eg, food or fluids in
infections (STIs) dures that increase con- addition to breastmilk)
! Maternal malnutrition tact with mother's infect- ! Breast abscesses,
(indirect cause) ed blood or body fluids nipple fissures, mastitis
(eg, episiotomy, foetal ! Poor maternal
scalp monitoring)
nutritional status
! First infant in multiple ! Oral disease in the baby
birth
(eg, thrush or sores)
! Chorioamnionitis (from
untreated STI or other
infection)
Introduce information about the relationship between pregnancy and HIV infection as
described below.
HIV and pregnancy

Pregnancy itself does not seem to have an effect on progression of HIV/AIDS.
Women with HIV/AIDS, however, are more likely to experience pregnancy-
related complications such as premature delivery.

SESSION 3 Comprehensive Approach to Prevention of HIV
Infection in Infants and Young Children
Advance Preparation
Verify that a summary of local/national/regional epidemiology as well as a
brief introduction to local/national PMTCT programme are included in the
Participant Manual. If not, have copies available for distribution. Familiarise
yourself with these materials.
For Exercise 2.3 STI handshake: interactive group game, strips of paper
will be needed. To determine the number of strips needed, use the
following formula:
! Number of strips = total number of participants + 1/3 total number of

participants (eg, for 24 participants: 24 + 8 = 32 strips)
! Cut the strips to measure about 5 x 8 cm.
! For groups of fewer than 10 participants, write "HIV" on 1 strip.
! For groups of 10 to 20 participants, write "HIV" on 1 strip and the name
of a common local STI on another strip.
! Gather the "extra" strips (1/3 of total number of participants). Remove
two strips. Write "condom" on one and "abstinence" on the other and set
Module 2 Overview
aside.
Slides 13 and 14
Explain that the comprehensive approach to prevention of HIV infection in infants and
young children consists of four elements and that each of the four elements will be
discussed during this session. Introduce Element 1, as outlined below.
Although PMTCT programmes often focus on ARV prophylaxis, a comprehensive
approach to the prevention of HIV infection in infants and young children consists of
four elements:
Element 1 Prevention of primary HIV infection

Decreasing the number of mothers infected with HIV is the most effective way of
reducing MTCT. HIV infection will not be passed on to children if parents-to-be are not
infected with HIV. Primary prevention strategies include the following components:
Safer and responsible sexual behaviour and practices

Safe and responsible sexual behaviour and practices include, as appropriate, delaying
the onset of sexual activity, practising abstinence, reducing the number of sexual
partners, and using condoms.
Slide 15
While the main focus of this programme is on Element 3 (Prevention of HIV

transmission from women who are HIV-infected to their infants) and Element 4
(Provision of treatment, care, and support to women who are HIV-infected, their infants
and their families), special attention is given to preventing HIV infection in parents-to-be,
as outlined below.
This approach has come to be known as the “ABC” approach.
Module 2 Overview
A = Abstinence—Refrain from having sexual intercourse.
B = Be faithful—Be faithful to one partner not infected with HIV.
C = Condom use—Use condoms correctly and consistently.
Recent reports of increasing new HIV infections transmitted from husbands to wives
indicate a continued need to educate people about safer sex practices and other
behaviour changes. For example, being faithful to one partner not infected with HIV is a
partner reduction behaviour that has proven significant in slowing the spread of HIV
infection.
Behaviour change communication (BCC) efforts aim to change the behaviours that
place individuals at risk for becoming HIV-infected or spreading HIV infection. BCC
recognises that behaviour change is not simply a matter of increased knowledge. Many
factors, including family, church and community, influence change. BCC attempts to
create a household, community, and health facility environment whereby individuals can
modify their behaviour to decrease risk.
Factors contributing to women’s vulnerability to HIV include poverty, lack of information,

abuse, violence, and coercion by men who have several partners.
Especially among young women, the successful implementation of the “ABCs” outlined
above may require support from organised programs. Healthcare workers can help
women address these challenges through education and community linkages.

Introduce the four prevention strategies outlined below.
Provide access to condoms.

Condoms can help prevent HIV transmission when used correctly and consistently,
especially in high-risk settings. Programmes that promote condom use for HIV
prevention should also focus on condom use for PMTCT.
Provide early diagnosis and treatment of STIs.

The early diagnosis and treatment of STIs can reduce the incidence of HIV in the
general population by about 40%. STI treatment services present an opportunity to
provide information on HIV infection, MTCT, and referral for testing and counselling.
Make HIV testing and counselling widely available.

HIV testing and counselling services need to be made available to all women of
childbearing age because PMTCT interventions depend on a woman knowing her HIV
status.
Provide suitable counselling for women who are HIV-negative.

Counselling provides an opportunity for a woman who is HIV-negative to learn how to
protect herself and her infant from HIV infection. It can also serve as powerful
motivation to adopt safer sex practices, encourage partner testing, and discuss family
planning.
Module 2 Overview
Summarise the lessons from Element 1.
To review primary prevention of HIV, lead the group in the interactive game described
on the next page.
Exercise 2.3 Interactive group game: STI handshake
Purpose To explore the concept of HIV and STI transmission—both

with and without the use of protection—when individuals are
sexually active with multiple partners.
Duration 30 minutes
Introduction Begin by explaining to participants that you have an interesting

exercise for them. The purpose of the exercise will be clear upon
completion.
PART 1
Activities ! Instruct each participant to:
! Take one piece of paper from the basket/box/paper bag,
but do not look at it.
! Shake hands with three other people in the group, and
remember whom you shook hands with.
! When everyone has shaken hands with three people, ask them
to return to their seats and unfold their pieces of paper.
! Explain that most pieces of paper will be blank. Two people will
have marked papers. Ask the participants with the paper labelled
“HIV” to stand. Ask those with papers labelled with the common
STI to stand. Explain that these people represent someone who
is infected. Explain that the group will pretend that their
Module 2 Overview
handshakes represented sexual intercourse or some other risky
sexual contact.
! Ask everyone who shook hands with the person holding the
"HIV" paper to stand. Ask those who shook hands with the
person holding the "STI" paper to stand.
! Now ask the people still seated if they shook hands with any of
the new people standing. Ask them to stand as well.
! Continue this process until all the people who could have
contracted the infectious disease have been identified and are
standing.
! Stress that this is only an exercise: In real life, people make
conscious decisions about whether or not to engage in risky
behaviour.
Debriefing Engage the group in discussion by asking:

! What did you learn from this activity?
! Why did the disease spread so quickly?
! How can we slow the spread of STIs?
! How can we slow the spread of HIV?

PART 2
Activities ! Ask participants to refold their pieces of paper. Collect the

paper strips, starting with those marked with “HIV” or “STI.”
! Place into the empty basket/box/paper bag the following
items:
! The original strips marked with “HIV” and “STI”
! The two strips from the “extra “ pile marked “condom” or
“abstinence”
! Enough paper strips to total the number of participants in
the group
! Shake basket/box/bag and have each participant draw
one piece of folded paper, keep it folded, and shake
hands with three people as before. When they are finished
shaking hands, they should return to their seats and unfold
their papers.
! Ask those with the paper marked “HIV” or “STI” to stand.
! Ask participants who shook hands with those people to
stand.
! Ask anyone who shook hands with any of the people
standing to stand as well.
! Identify participants with the papers marked “condom” or
“abstinence.” Ask them to sit down. Then ask any
participants who shook hands with these two people to sit
Module 2 Overview
down as well.
Note to Instructor: There should be significantly fewer
people standing in Part 2 of this exercise than in Part 1.
Debriefing Start the discussion by asking the following questions:
! What happened this time?
! How did the use of condoms or abstinence affect the risk
of contracting an infectious disease in this group?
End the activity by recording participants' feelings about the
exercise on the flipchart, whiteboard, or blackboard.
Ask the following questions:
! How did you feel shaking hands in Part 2?
! How did you decide whom to shake hands with?
! Can you think of another way to
prevent an STI besides condoms or abstinence
(eg, mutual monogamy with a non-infected person)?
! What is the effect of multiple partners on the STI rate?
Slide 16
Introduce Element 2, as described below.
Element 2 Prevention of unintended pregnancies among women

infected with HIV
With appropriate support, women who know they are HIV-infected can avoid unintended
pregnancies and therefore reduce the number of infants at risk for MTCT.
The rapid spread of HIV has made access to effective contraception and family planning
services even more important throughout the world. Most women in resource-
constrained settings are unaware of their HIV status. Access to family planning
counselling and referral for women known or suspected to be HIV-infected and their
partners is critical in preventing unintended pregnancies. Such counselling also provides
an opportunity to discuss related risks, both present and future, and is a vital
component to reducing maternal and child morbidity and mortality.
! Effective family planning can help prevent unintended pregnancies and help women
who are HIV-infected protect their own health while taking care of their families.
! Providing safe and effective contraception and high-quality reproductive health coun-
selling contribute to informed decision-making about pregnancy choices
Module 2 Overview
Slide 17
Element 3 Prevention of HIV transmission from women

infected with HIV to their infants
PMTCT usually refers to specific programs to identify pregnant women infected with HIV
and to provide them with effective interventions to reduce MTCT.
Element 3 in this module provides an overview of PMTCT. Module 3 discusses PMTCT

interventions in detail.
Specific interventions to reduce HIV transmission from an infected woman to her child
include HIV testing and counselling, antiretroviral prophylaxis and treatment, safer
delivery practices, and safer infant-feeding practices. When an ARV drug is given to
mother and infant to prevent MTCT, it is referred to as ARV prophylaxis.
Note: This curriculum focuses on women infected with HIV-1; Appendix 2-A provides
information about PMTCT services for women infected with HIV-2.

Make These Points
! Reiterate the key interventions for reducing the risk of MTCT listed below.
PMTCT core interventions

! HIV testing and counselling
! Antiretroviral treatment and prophylaxis
! Safer delivery practices
! Safer infant-feeding practices
How these interventions work
! Identify women infected with HIV.
! Reduce maternal viral load.
! Reduce infant exposure to the virus during labour and delivery.
! Reduce infant exposure to the virus through safer feeding options.
Module 2 Overview
Ways to reduce risk of MTCT

! Antiretrovirals
! Elective cesarean section, where safe and feasible
! nfant-feeding counselling for safer feeding practice
! Early termination of pregnancy, where safe and legal
Discuss global trends in MTCT.
In industrialised countries where women infected with HIV receive triple drug ARV
treatment and do not breastfeed—and where elective cesarean sections are safe,
feasible, and commonly performed—the rate of MTCT has been reduced to about 2%.
ARV prophylaxis can reduce MTCT by 40–70%. The impact is greater (closer to 70%)
when women do not breastfeed, because current ARV prophylaxis regimens only
prevent HIV transmission during the early breastfeeding period. Studies are ongoing to
determine whether ARV prophylaxis for mother or child during breastfeeding can help
reduce the risk of HIV transmission during that period.
Partner involvement in PMTCT

PMTCT efforts should be as comprehensive as possible and acknowledge that
both mothers and fathers have an impact on transmission of HIV to the infant:
Module 2 Overview
! Both partners need to be aware of the importance of safer sex throughout
pregnancy and breastfeeding.
! Both partners should be tested and counselled for HIV.
! Both partners should be made aware of and provided with PMTCT inter-
ventions.

As a lead-in to the next slide, remind group of the following fact.
ARV prophylaxis for the mother

ARV prophylaxis given to a pregnant woman who is HIV-infected does not confer long-
term benefits to the woman herself. Pregnant women with advanced HIV infection
require combination ARV treatment to reduce the risk of AIDS-related illness. As
treatment becomes more available, there should be integration between treatment and
prophylaxis services.

Slide 18
Introduce Element 4, as described below.
Element 4 Provision of treatment, care, and support to women

infected with HIV, their infants and their families
Programmes for the prevention of HIV in infants and young children will identify large
numbers of women infected with HIV who will need special attention. Medical care and
social support are important for women living with HIV/AIDS to address concerns about
both their own health and the health and future of their children and families.
If a woman is assured that she will receive adequate treatment and care for herself, her
children, and her partner, she is more likely to accept HIV testing and counselling and,
if HIV-positive, interventions to reduce MTCT.
It is important to develop and reinforce linkages with programmes for treatment, care,
and support services to promote long-term care of women who are HIV-infected and
their families.
Treatment, care, and support services for women

Services for women include the following:
! Prevention and treatment of opportunistic infections

Module 2 Overview
! ARV treatment
! Treatment of symptoms
! Palliative care
! Nutritional support
! Reproductive health care, including family planning and counselling
! Psychosocial and community support
Care and support of the infant and child who are HIV-exposed
Children whose mothers are infected with HIV are at higher risk than other children for
illness and malnutrition for multiple reasons:
! They may be infected with HIV and become ill—even when adequate health care and
nutrition are provided.
! Those who receive replacement feeding lack the protective benefits of breastfeeding
against gastroenteritis, respiratory infections, and other complications.
! If their mother is ill, she may have difficulty caring for them adequately.
! Their families may be economically vulnerable due to AIDS-related illnesses and
deaths among adult relatives.
Nutritional support for the infant or child who is HIV-exposed
! Support the mother’s infant-feeding choice.
! Provide education on hydration and early reporting of diarrhoea.
! Monitor for growth and development.
! Monitor for signs of infection that can alter feeding patterns.
Infants and children who are HIV-exposed require regular follow-up care—especially
during the first 2 years of life—including immunisations, HIV testing, and ongoing
monitoring of feeding, growth, and development (See Module 7: Linkages to Treatment,
Care, and Support for Mothers and Families with HIV Infection).
Inform the group that these issues will also be addressed in Module 7: Linkages to
Treatment, Care, and Support for Mothers and Families with HIV Infection.
Module 2 Overview

SESSION 4 Role of Maternal and Child Health Services
in the Prevention of HIV Infection in Infants
and Young Children
Advance Preparation
No additional preparation is required for this session.
Slides 19 and 20
Instruct the group to refer to the materials on in-country policies and programmes.
Discuss the mutually supporting functions of MCH, PMTCT, and antenatal care services.
Maternal and child health services

Module 2 Overview
HIV infection is one of the most important health problems for pregnant mothers and
newborns in many developing countries. PMTCT programmes need to be integrated as
an essential part of MCH care.
MCH care encompasses a broad range of educational and clinical services that help
mothers, their children, and their families lead healthy lives. Although all four elements
of a comprehensive PMTCT programme are important, antenatal care is the most
common entry point for women into those programmes. MCH programmes facilitate
PMTCT by providing:
! Essential antenatal care
! Family planning services
! ARV treatment and prophylaxis
! Counselling and support for the woman's chosen infant-feeding method
All mothers and infants will benefit from integrating PMTCT into existing MCH care
services. Many elements of PMTCT programmes parallel and complement initiatives
that are in development or are already offered by providers of quality antenatal care (eg,
Safer Motherhood, Baby Friendly Hospitals, Baby Feeding, and Saving Newborn Lives).
Provide an overview of comprehensive MCH services, as described in the box below.
Make These Points
! Effective integration of PMTCT into postnatal MCH services is likely to strengthen

maternal care, infant care, and family care.
Comprehensive MCH services

! Recognise that the best approach to preventing HIV infection in infants
and children begins with prevention of primary infection in parents-to-be.
! Provide information to prevent unintended pregnancies in both women
who are HIV-positive and high-risk women with unknown status.
! Provide education in early recognition and treatment of STIs.
! Provide education about reducing the risk of MTCT.
! Link and refer patients to health care and community services that
include the following:
Module 2 Overview
! Nutritional care
! ARV treatment
! Psychosocial and/or spiritual support (such as support groups for
women with HIV)
! Treatment of symptoms
! Palliative care
! Economic assistance
! Educate patients about how to recognise symptoms of opportunistic
infections and measures they can take to prevent such infections.
! Educate patients about how to recognise early signs and symptoms of
HIV infection in the infant or child.
Integration of PMTCT into postnatal MCH services

Effective integration of PMTCT into postnatal MCH services is likely to strengthen
maternal care, infant care, and family care.
! MCH postpartum care services help protect the mother's health by providing medical
and psychosocial supportive care.
! MCH postnatal care services offer assessment of infant growth and development,
nutritional support, immunisations, and early HIV testing. If the infant is HIV-infected,
additional support services may include ARV treatment.
! MCH services provide social support, HIV testing, and counselling for family
members, referrals to community-based support programmes, and assistance with
contending with stigma.

The PMTCT programme
A comprehensive PMTCT programme provides the continuum of care for mother and
child.
The continuum begins with educating adolescent women about primary prevention of
infection and continues through treatment, care, and support to women who are HIV-
positive and their families.
PMTCT programmes ensure women receive education and services to reduce risk of
MTCT throughout pregnancy, labour and delivery, and infant feeding. They also provide
support for both mother and child, especially during the crucial years of childhood
growth and development. This comprehensive approach ultimately provides linkages to
existing community services to address the complex needs and issues involved in HIV
prevention, treatment, and management.
Summarise key points for Module 2, as presented in the box below.

! A comprehensive approach is needed to prevent HIV infection in infants
and young children.
Module 2 Overview
! The 4 elements of the comprehensive approach to PMTCT are:

! Primary prevention of HIV infection
! Prevention of unintended pregnancies in women infected with HIV
! Prevention of HIV transmission from women infected with HIV to their
infants
! Provision of treatment, care and support to women infected with HIV,
their infants and their families
! Without intervention the risk of MTCT is 25-40%.
! Combination interventions can reduce the MTCT rate by up to 40% in
breastfeeding populations.
! Because ARV prophylaxis alone does not treat the mother’s infection,
ongoing treatment, care, and support are needed.
! MCH services can act as an entry point to the range of services that
provide treatment, care, and support to the woman who is HIV-positive
and affected family members.
! Linkages to community services can enhance treatment, care, and support.
APPENDIX 2-A MTCT services for the woman who is
HIV-2 infected
The woman infected with HIV-2 should have access to the entire range of antenatal,
labour and delivery, and postnatal services as well as linkages to other services
designed for women infected with HIV-1. Offering the mother infected with HIV-2 short-
course ARV prophylaxis to prevent MTCT should follow national and local policy, if such
a policy statement exists.
The following information, adapted from the CDC (October 1998) provides pertinent
background on HIV-2 for consideration:
! HIV-2 infections are predominantly found in West Africa.

! HIV-2 infections:
! Have the same modes of transmission as HIV-1
! Also progress to AIDS
! Are associated with similar opportunistic infections
! Appear to be less transmissible from mother to child than HIV-1
! Develop more slowly and appear less virulent than HIV-1
! Testing for both HIV-1 and HIV-2 should be considered in the following situations:
! In settings where HIV-2 is present
Module 2 Overview
! When illnesses (such as opportunistic infections) appear in someone whose HIV-1
test is negative
! When an HIV-1 Western blot indicates certain indeterminate test band patterns
! The best approach to clinical treatment of HIV-2 is unclear. The following factors,
however, should be considered:
! Non-nucleoside reverse transcriptase inhibitors (NNRTIs), such as nevirapine, are
not as effective against HIV-2. Therefore, zidovudine therapy should be considered
for expectant mothers who are infected with HIV-2 and their newborn infants to
reduce MTCT risk, especially for women who become infected during pregnancy.
! Treatment response is more difficult to monitor than in women infected with HIV-1.
CD4 counts and physical signs of immune deterioration are currently being used for
monitoring.
! The woman’s wishes: the healthcare provider should have a frank discussion with
the woman infected with HIV-2 to explain the prevailing policy and practice and to
support her in making a decision with which she is comfortable.
! Continued surveillance to monitor the spread of HIV-2 is necessary.
Infant Feeding
The woman infected with HIV-2 should be advised to follow national and local infant-
feeding recommendations for women infected with HIV-1.

Notes
Module 2 Overview
Module 3 Specific Interventions to Prevent MTCT
SESSION 1 Antiretroviral Treatment and Prophylaxis for the Prevention

of MTCT
Lecture and slide None 30 minutes
presentation
SESSION 2 Antenatal Management of Women who are HIV- Infected

and Women with Unknown HIV Status
Exercise 3.1 Antenatal None 40 minutes
care: case studies
SESSION 3 Management of Labour and Delivery of Women who are

HIV-Infected and Women with Unknown HIV Status
Exercise 3.2 Labour and None 50 minutes
Module 3 Specific Inferventions
delivery ARV prophylaxis:
case studies
SESSION 4 Immediate Postpartum Care of Women who are HIV-

Infected and Women with Unknown HIV Status
Exercise 3.3 Immediate None 30 minutes
postpartum care of women
who are HIV-infected and
women with unknown HIV
status: case studies

SESSION 5 Immediate Newborn Care of Infants who are HIV-Exposed
and Infants with Unknown HIV Status

Exercise 3.4 Immediate None 50 minutes
postnatal care of infants
who are HIV-exposed:
case studies
For all sessions, also have available the following:

Session 1
! National policy/guidelines on antiretroviral treatment and prophylaxis for the
prevention of MTCT (PMTCT)
Session 2
! National guidelines on antental care (ANC)/Management HIV-infected women and
women with unknown status
! ANC and/or PMTCT confidentiality policy, policy on recording HIV status in
patient’s medical record (if not included in national guidelines)
Session 3
! National policy on management of labour and delivery for women infected with
HIV and women with unknown HIV status
! National policy on testing and counselling during labour
Session 4
! National guidelines on immediate postpartum care of women infected with HIV
and women with unknown HIV status
Session 5
! National guidelines on immediate newborn care of infants who are HIV-exposed
and infants with unknown HIV status
The Pocket Guide contains a summary of each session in this module.
Module 3–2 Specific Interventions to Prevent MTCT

SESSION 1 Antiretroviral Treatment and Prophylaxis for the
Prevention of MTCT
Advance Preparation
Ensure that national guidelines on ARV prophylaxis for prenatal care and
ARV treatment for pregnant women appear in the Participant Manual. If
not, have copies available for distribution. Familiarise yourself with these
guidelines.
Slides 1, 2 and 3
! Name specific interventions for preventing mother-to-child transmission (PMTCT).

! List locally available and recommended antiretroviral (ARV) regimens.
! Discuss the antenatal management of women infected with HIV and women whose
HIV status is unknown.
! Explain the management of labour and delivery in women infected with HIV and
women whose HIV status is unknown.
! Explain postpartum care of women infected with HIV and women whose HIV status is
unknown.

! Explain immediate newborn care of infants born to mothers who are HIV-infected and
mothers whose HIV status is unknown.
Slides 4, 5, 6, and 7
Introduce Session 1. Discuss the difference between ARV treatment and ARV
prophylaxis. Mention that ARV treatment can be offered to women infected with TB.

ARV treatment: Long-term use of antiretroviral drugs to treat maternal HIV/AIDS
and prevent PMTCT
ARV prophylaxis: Short-term use of antiretroviral drugs to reduce HIV
transmission from mother to infant
Make These Points
! Antiretroviral prophylaxis does not treat maternal HIV or provide long-term protection
for the infant.
! Antiretroviral treatment during pregnancy can improve a woman’s health and
decrease HIV transmission risk to the infant by reducing the maternal viral load.
ARV treatment
ARV drugs are effective for both treating maternal HIV infection and preventing MTCT.
Several antiretroviral regimens reduce the risk of MTCT in both breastfeeding and non-
breastfeeding women. The mechanisms by which these regimens prevent or reduce
mother-to-child HIV transmission include decreasing viral replication in the mother,
leading to a decrease in viral load in the infant and/or prophylaxis during and after
exposure to the virus.
Pregnant women who are HIV-infected need ARV treatment for their own health should
receive it, according to the treatment guidelines recommended by WHO. ARV treatment
during pregnancy, when indicated, will improve the health of the woman and decrease
the risk of transmission of HIV to the infant.
ARV treatment is recommended in the following situations: For detailed information,

please refer to Appendix 1-A.
If CD4 testing is available, it is recommended that baseline CD4 counts be documented

and ARV treatment offered to patients with:
! WHO Stage IV disease, irrespective of CD4 cell count

! WHO Stage III disease (including but not restricted to HIV wasting, chronic diarrhoea
of unknown aetiology, prolonged fever of unknown aetiology, pulmonary TB, recurrent
invasive bacterial infections, or recurrent or persistent mucosal candidiasis); with
consideration of using CD4 cell counts of less than 350/mm3 to assist with
decision-makinga
! WHO Stage I or II disease with CD4 cell counts of 200/mm3 or lower b
a
CD4 count advisable to assist with determining need for immediate therapy. For example, pulmonary TB
can occur at any CD4 level, and other conditions can be mimicked by non-HIV aetiologies (eg, chronic
diarrhoea, prolonged fever).
b
The precise CD4 count above 200/mm3 at which ARV treatment should be initiated has not been
established.

If CD4 testing is unavailable, it is recommended that ARV treatment be offered to
patients with:
! WHO Stage IV disease, irrespective of total lymphocyte count

! WHO Stage III disease (including but not restricted to wasting, chronic diarrhoea of
unknown aetiology, prolonged fever of unknown aetiology, pulmonary TB, recurrent
invasive bacterial infections, or recurrent/ persistent mucosal candidiasis), irrespec-
tive of total lymphocyte count c
! WHO Stage II disease, with a total lymphocyte count of less than or equal to
1,200/mm3 d
ARV treatment during pregnancy

For women diagnosed with HIV during pregnancy and eligible for treatment with ARVs,
treatment should be initiated as soon as possible. The start of treatment may be
delayed until after the first trimester. However, when the woman is severely ill, the
benefits of treatment outweigh any potential risk to the foetus. Efavirenz (EFV), an
antiretroviral drug that is considered potentially teratogenic is not recommended until
after the first trimester of pregnancy and should be avoided in women of childbearing
age unless effective contraception can be ensured. Module 3 Appendix 3-B provides
guidance for the use of antiretroviral drugs in pregnant women and women of
childbearing age.
Pregnant women receiving ARV therapy

Pregnant women receiving ARV therapy require ongoing care and monitoring
within the local HIV/AIDS programme. When co-infection with TB exists, addi-
tional drug therapy and clinical management are required to minimise side
effects that may occur when ARV drugs are coadministered with TB therapy.
Slides 8, 9 and 10
Discuss ARV prophylaxis using the information on the next page.
c
The recommendation to start ARV treatment in all patients with stage III disease, without reference to
total lymphocyte counts reflects a consensus of experts. The discussion took into account the need for a
practical recommendation that allows clinical services and TB programmes in severely constrained set-
tings to offer access to ARVs to their patients. As some adults and adolescents with stage III disease will
be presenting with CD4 counts above 200/mm3, some of them will receive antiretroviral treatment before
the CD4 less than 200/mm3 threshold is reached. However, if CD4 counts cannot be determined, the
experts did not consider starting ARVs earlier in these patients to be problematic.
d
A total lymphocyte count of less than or equal to 1200/mm3 can be substituted for the CD4 count when
the latter is unavailable and HIV-related symptoms exist. It is not useful in the asymptomatic patient.
Thus, in the absence of CD4 cell testing, asymptomatic HIV-infected patients (WHO Stage I) should not
be treated because there is currently no other reliable marker in severely resource-constrained settings.

Make These Points
! Emphasise that selection of ARV prophylaxis regimens is based on many factors.

! Antiretroviral prophylaxis alone will not protect breastfeeding infants from the risk of
HIV.
! Until recently, the emphasis of PMTCT guidelines has been on short-course prophy-
laxis (eg short-course ZDV or short-course NVP) in resource-constrained settings.
! New recommendations from WHO (2004) emphasise longer, combination prophylaxis
regimens, where feasible, but recognise the need for short-course prophylaxis where
the longer course is not yet provided or feasible.
ARV prophylaxis
Women who do not need treatment (ie women who are not “eligible” for treatment
based on the criteria above), or do not have access to treatment, should be offered
prophylaxis to prevent MTCT using one of a number of ARV regimens known to be
effective. ARV prophylaxis regimens vary and are selected based on efficacy, safety,
drug resistance, feasibility, and acceptability. Please refer to Appendix 3-A for a
complete listing of ARV prophylaxis regimens.
The first choice prophylaxis regimen for PMTCT

Zidovudine (ZDV) starting at 28 weeks of gestation, or as soon as possible
thereafter and intrapartum every 3 hours until delivery plus single-dose
nevirapine (NVP) at the onset of labour for the mother, and single-dose NVP
plus one week of ZDV for the infant.
Please refer to Appendix 3-A for a complete listing of ARV prophylaxis regimens.
Discuss the use of ZDV, NVP, and 3TC (see Appendices 3-A and 3-B) by presenting the
information below.

Drug information
Zidovudine (ZDV, AZT)

! Absorbed rapidly and completely after oral administration
! Prenatal and neonatal exposure to ZDV is generally well tolerated
! Mild anaemia may occur but usually resolves when treatment ends
! May be taken with or without food
Nevirapine (NVP)
! Absorbed rapidly and completely after oral administration and crosses the placenta
quickly
! Long half-life that benefits the infant
Lamivudine (3TC)
! Absorbed rapidly and completely after oral administration
! May safely be taken with other medications that treat HIV-related symptoms
WHO recommendations on longer prophylaxis regimens

Until recently, the emphasis of PMTCT guidelines has been on short-course
prophylaxis (eg short-course zidovudine or short-course nevirapine in resource-
constrained settings). New recommendations from WHO (2004) emphasise
longer, combination prophylaxis regimens, where feasible, while recognising the
need for short-course prophylaxis where longer regimens have not been
provided or are not feasible.
Note: NVP is not recommended for concurrent use with rifampin—a consideration when
TB treatment is indicated.
3TC has been known to increase in concentration when taken with cotrimoxazole
(TMP/SMX)—a drug commonly used in PCP prophylaxis. Altering dosages of either
drug, however, is not recommended.

SESSION 2 Antenatal Management of Women who are HIV-
Infected and Women with Unknown HIV Status
Advance Preparation
Ensure that the national policy on antenatal management of women who
are HIV-Infected and women with unknown HIV status appears in the
Participant Manual. If not, have copies available for distribution. Familiarise
yourself with these policies.
Review Exercise 3.1: Antenatal care case studies to be sure they reflect
local customs, issues, names, and policies. Ask local healthcare workers to
help you adapt the case studies if necessary.
Slides 11 and 12
Introduce the discussion on antenatal care.
Make These Points
! Testing and counselling serve as the gateway to PMTCT interventions.

! Early diagnosis and treatment of STIs reduces MTCT of HIV infection.
! A comprehensive approach to the care of the woman who is HIV-infected is important
for a successful PMTCT programme.
! Discuss routine ANC for all women, using the information on the next page.

Antenatal care
Antenatal care improves the general health and well being of mothers and their families.
Given the rapid spread of HIV infection worldwide, all pregnant women may be
considered at risk for acquiring HIV infection.
The ANC setting is a main source of health care for women of childbearing age. By
integrating PMTCT services into essential ANC services, healthcare programmes can
improve care—and pregnancy outcomes—for all their clients.
This session addresses integrating PMTCT services for and antenatal management of
women infected with HIV and women of unknown HIV status within the context of ANC
programmes.
Antenatal interventions can reduce the risk of MTCT. Good maternal health care helps
women with HIV infection stay healthy longer and care for their children better. When
mothers die prematurely, their children face higher rates of illness and death.
For the successful implementation of PMTCT programmes, the following elements need
to be included as part of ANC:
! Health information and education
! Education about safer sex practices and HIV
! Partner HIV testing and counselling
! Interventions to reduce the risk of MTCT
! Infant-feeding counselling and support for Safe Motherhood including malaria and TB
treatment
! Diagnosis and treatment of sexually transmitted infections (STIs)
Slide 13
Discuss routine ANC and ANC for women who are HIV-infected, using the information
below.

Make These Points
! Confidential HIV testing services must be made available to all women.

! Women whose HIV status is unknown are considered at risk for MTCT and coun-
selled accordingly.
! Women whose HIV status is unknown should be aware that testing can take place at
any time during their care.
! Screening for and treating opportunistic infections and common illnesses can greatly
improve the quality of life for pregnant women living with HIV infection.

Antenatal care of women infected with HIV
ANC for women infected with HIV includes the basic services recommended for all
pregnant women. However, obstetric and medical care should be expanded to address
the specific needs of women infected with HIV. (See Table 3.1.)
HIV infection in women of childbearing age presents a great challenge in resource-

limited settings. Determining a woman’s HIV status is the first step in providing
appropriate treatment, care and support services, including access to antiretroviral
prophylaxis when indicated. Availability of rapid testing allows women to be tested and
receive their HIV test results at the first prenatal visit. When HIV status is known,
mothers can be evaluated for ARV eligibility and offered the ARV treatment and
prophylaxis indicated, if available.
In some situations, because of the lack of accessible testing services or because a

woman refuses to be tested, her HIV status may remain unknown. In such
circumstances, the woman should be considered at risk for MTCT, and she should be
counselled accordingly during ANC. Women of unknown HIV status should be made
aware that testing is available at later ANC visits and be reminded of the benefits of
knowing their HIV status.
Discuss the prevention of opportunistic infections as well as other recurrent or chronic

infections.
Preventing opportunistic infections

Preventing opportunistic infections (OIs) can reduce rates of illness and death among
pregnant women who are HIV-infected. It also can reduce the risk of adverse pregnancy
outcomes, such as preterm labour and delivery, which can increase the risk of MTCT.
Prevention, screening, and treatment for TB, a leading cause of mortality

among persons who are HIV-infected, is particularly important.
Module 7, Appendix 7-A contains information on tuberculosis.
Healthcare workers should pay special attention to signs and symptoms of possible
opportunistic infections and follow protocols for prophylaxis of common problems. In
Module 7, Appendix 7-C provides information about pneumocystis carinii pneumonia
(PCP) prophylaxis.
Assessment and management of HIV-related illnesses

HIV-related illnesses can increase the risk of MTCT. Women should be monitored for
signs or symptoms of progressive HIV/AIDS.

Recurrent or chronic infection
Women infected with HIV are susceptible to other infections that can be treated in
keeping with local protocols. Examples include the following:
! TB
! Urinary tract infections
! Respiratory infections
! Recurrent vaginal candidiasis
! Malaria
Psychosocial and community support

Pregnancy is a time of unique stress, and healthcare workers may consider assessing
the amount of support a woman is receiving from family and friends. Women with HIV
usually have additional concerns related to their own health, their child’s health,
confidentiality, and the possibility that their HIV status might be disclosed to other
people. Referrals to AIDS support organisations and clubs should be made.
Explain the essential package of integrated ANC services, using the chart on the
next page.
Make These Points
! Integrated antenatal care services are the most successful approach to caring for
pregnant women with HIV.
! Comprehensive obstetric and medical care for women who are HIV-infected requires
specific interventions to reduce MTCT.

Table 3.1 Essential Package of Integrated Antenatal Care Services
Client history: Obtain routine data including medical, obstetric, and psychosocial history.
Determine drug history, known allergies, and use of alternative medicines such as herbal
products.
Physical exam and vital signs: Include visual and hands-on exam and assess for current
signs or symptoms of illness including AIDS, tuberculosis (TB), malaria and sexually
transmitted infections (STIs).
Abdominal exam: Include speculum and bimanual exams, where acceptable and feasible.
Lab diagnostics: Perform routine serology for syphilis including testing for anaemia. Perform
HIV testing as per country protocol based on availability and informed consent. When woman
is HIV-positive, obtain CD4 count and RNA polymerase chain reaction (PCR) (measures viral
load, response to ARV treatment), when available.
Tetanus toxoid immunisations: Administer when appropriate.
Nutritional assessment and counselling: Include iron and folate supplementation, monitor
for anaemia, adequate caloric and nutrient intake, and recommend realistic diet adjustments
based on local resources.
STI screening: Include risk assessment for STIs. Diagnose and treat early according to
protocols. Counsel about STIs, signs and symptoms and increased risk of HIV transmission.
Educate to avoid transmission or re-infection.
Opportunistic Infection (OI) Prophylaxis: Provide prophylaxis based on country protocols.
Screening and care for other infections: Screen and treat any locally prevalent parasitic,
bacterial, or fungal infections, including helminth infections. Treat herpes, candidiasis, PCP, and
any other AIDS-related OIs.
Tuberculosis (TB): Co-infection with tuberculosis is the leading cause of HIV mortality. All
women presenting for ANC services with a cough of more than 2 weeks’ duration should be
screened for TB, regardless of HIV status. Specific treatment protocols are recommended for
women infected with HIV, pregnant women, and women already receiving antiretroviral therapy.
Antimalarials: Malaria is a major cause of high maternal and infant morbidity and mortality and
is linked to increased MTCT (via placental infection). Malaria prophylaxis is needed in endemic
areas; identify acute cases and treat aggressively and promptly. Use insecticide on bed nets
where possible.
ARV prophylaxis during pregnancy: Provide in accordance with country PMTCT protocol.
ARV treatment during pregnancy: Refer for treatment when indicated according to country
protocols.
Counselling on infant feeding: All women require infant-feeding counselling and support.
When women do not know their HIV status, exclusive breastfeeding should be promoted and
supported. Women infected with HIV should consider replacement feeding when it is feasible,
acceptable, affordable, accessible, and safe; otherwise, exclusive breastfeeding with early
cessation is recommended.
Counselling on pregnancy danger signs: Provide women with information and instructions
on seeking early care for pregnancy complications such as bleeding, fever and pre-eclampsia.
Counselling on HIV/AIDS danger signs: Provide women with information and instructions on
seeking health care for symptoms of HIV disease progression, such as opportunistic infections,
chronic persistent diarrhoea, candidiasis, fever or wasting. Refer women to AIDS treatment
programmes when indicated and available.
Partners and family: HIV-related stress and lack of support have been linked to progression of
HIV infection. Refer women, partners, and families to community-based support clubs or
organisations when possible.
Effective contraception plan: Counsel about consistent use of condoms during pregnancy, as
well as throughout postpartum and breastfeeding periods to avoid new infection, re-infection
and further transmission. Include long-term family planning with partner involvement when
possible.

Familiarise participants with national guidelines on ANC and PMTCT and lead a
discussion based on antenatal care case studies.
Exercise 3.1 Antenatal care: case studies
Purpose To review national policies on ANC and PMTCT.

To review antenatal management in the context of women who
are HIV-infected.
Duration 25 minutes
Introduction The purpose of this exercise is to review national policies on

ANC and PMTCT, and review ANC management in the
context of HIV/AIDS.
Activities ! Distribute copies of the national policies on ANC and

PMTCT.
! Ask participants to take a few minutes to become familiar
with the policies.
! Write the key points of the policies on a flipchart.
! Ask participants to comment on whether these policies are
being followed in their respective clinical settings.
! Ask participants about any challenges or obstacles they may
experience when putting these policies into practice.
! Distribute copies of the ANC case studies.
! Ask for a volunteer to read the narrative section of the first case
study.
! Ask all participants for answers to the questions posed in the
case study.
! Repeat above steps for second case study in Exercise 3.1.
! Determine whether any participants disagree with any of
the answers offered.
! Ask whether this case study is similar to cases the participants Module 3 Specific Inferventions
may encounter in ANC.
! Write exceptions (ie, ways in which the participants’ experiences
differ from the case studies) on the flipchart.
! Ask participants to describe a particular case that has challenged
them in the ANC clinical setting, and how they resolved the case.
Debriefing ! Summarise how the local policies are reflected in local

practice.
! Remind participants that the policies serve as practice guidelines.
! Mention that each case is as unique as the person or
circumstances involved.

Exercise 3.1 Antenatal care: case studies
Case study 1
Selma, a 22-year-old single woman, tested HIV-positive at her first antenatal visit at 24
weeks gestation. At that time, she received post-test counselling and was encouraged
to bring her partner in for testing. She is now 28 weeks pregnant with her first child.
What are the ANC management steps that should be taken?
Case study 2
You are an antenatal clinic midwife. Louisa, your patient, is 30 weeks pregnant. When
you ask her about her delivery plans, she says that she wants to have the baby at
home. She informs you that this is her third child and even though she is HIV-infected,
this pregnancy (like her previous two) has been a healthy pregnancy. You can see that
she is determined to have a home delivery.
What do you tell Louisa?
Consider how you would approach meeting ANC and PMTCT care needs in the context
of home delivery. What would your next steps be?

SESSION 3 Management of Labour and Delivery of Women
Infected with HIV and Women with Unknown
HIV Status
Advance Preparation
Ensure that the national policy on management of labour and delivery in
women who are HIV-infected and women of unknown HIV status appears
in the Participant Manual. If not, have copies available for distribution.
Familiarise yourself with these policies.
Review the case studies to make sure they reflect local customs, issues,
names, and policies. Ask local healthcare workers to help you adapt the
case studies if necessary.
Slides 17, 18, 19 and 20
Discuss interventions that can reduce mother-to-child transmission during labour and
delivery.
Make These Points
! Reducing foetal exposure to infected maternal blood and body fluids reduces MTCT.
! Universal precautions can help reduce MTCT in the high-risk labour and delivery
setting.
! Safer practices in labour and delivery can minimise MTCT risk.

A significant number of infants, who are born to women who are
HIV-infected, become infected during labour and delivery. Adhering to
standard practices for delivery and to procedures that reduce foetal
exposure to maternal blood and secretions can reduce the risk of MTCT.
Interventions that can reduce MTCT include the following:

Administer ARV treatment and prophylaxis during labour in accordance with
national protocols.
! Continue ARV treatment/prophylaxis or implement ARV prophylaxis at labour to
reduce maternal viral load and provide protection to the infant.
Use good infection prevention practices for all patient care.

! Use universal precautions, which include use of protective gear, safe use and dispos-
al of sharps, sterilisation of equipment, and safe disposal of contaminated materials.
(For additional information, see Module 8: Safety and Supportive Care in the Work
Environment.)
Minimise cervical examinations.

! Perform cervical examination only when absolutely necessary and with appropriate
clean technique.
Avoid prolonged labour.

! Consider using oxytocin to shorten labour when appropriate.
! Use noninvasive foetal monitoring to assess need for early intervention.
Avoid routine rupture of membranes.

! Use a partogram to measure the progress of labour.
! Avoid artificial rupture of membranes, unless necessary.
Avoid unnecessary trauma during delivery.

! Avoid invasive procedures, including scalp electrodes or scalp sampling.
! Avoid routine episiotomy.

! Minimise the use of forceps or vacuum extractors.
Minimise the risk of postpartum haemorrhage.

! Actively manage the third stage of labour.
! Give oxytocin immediately after delivery.
! Use controlled cord traction.
! Perform uterine massage.
! Repair genital tract lacerations.
! Carefully remove all products of conception.

Use safe transfusion practices.
! Minimise the use of blood transfusions.
! Use only blood screened for HIV and when available syphilis, malaria, and hepatitis B
and C.
Slide 21
Discuss when to consider elective cesarean section versus vaginal delivery.
Considerations regarding mode of delivery

Cesarean section, when performed before the onset of labour or membrane rupture,
has been associated with reduced MTCT.
Consider the benefits and risks of vaginal delivery versus elective caesarean section,
including the safety of the blood supply and the risk of complications.
Slides 22 and 23
Use the information below to discuss HIV testing and methods for reducing the risk of
MTCT during labour in women with unknown HIV status.
Make These Points
! A mother who tests HIV-positive after childbirth can choose to provide post-exposure
prophylaxis for her infant.

! HIV testing after childbirth can influence a mother’s choice of feeding options.
! If a mother tests negative or refuses testing, encourage exclusive breastfeeding.
Lead a discussion based on the case study exercise on the next page.

Exercise 3.2 Labour and delivery ARV prophylaxis: case studies
Purpose To review national policies on testing and counselling during labour.

To discuss administering ARV prophylaxis during labour and delivery.
Duration 25 minutes
Introduction Using case studies, the purpose of this exercise is to review

national policies on testing and counselling during labour, and
to discuss administering ARV prophylaxis during labour and delivery.
Activities ! Refer to the Participant Manual or distribute copies of the

handout about national/local policies on testing and
counselling in labour and ARV prophylaxis.
! Ask participants to take a few minutes to read the policies.
! On a flipchart, record the policies’ main points.
! Ask participants to comment on their ability to follow the policies
in their own clinical settings.
! Ask participants about any challenges or obstacles to putting
these policies into practise.
! Distribute copies of the case studies.
! Ask a participant to read the narrative section of the first case
study.
! Ask the group for answers to the questions posed after each
case study.
! Write participants’ answers on the flipchart.
! Ask participants whether they disagree with any of the answers
offered.
! Do the same with the next case study in Exercise 3.2.
! Ask participants if any of the case studies are similar to cases
they may have encountered in ANC and labour and delivery
clinical settings.
! Ask participants if they can describe a particular case that has
challenged them in the ANC clinical setting.
! Ask them to describe what was done to resolve the challenges.
Debriefing ! Summarise for participants how closely the local policies

are reflected in local practice.
! Mention to participants that each case is as individual as
the person or circumstances involved.

Exercise 3.2 Case Studies—Labour and delivery ARV prophylaxis for mother
Case study 1
Consuelo arrives at the labour and delivery unit. This is her first baby. She hands you
her ANC card, which indicates that she was tested during pregnancy and is infected
with HIV. Her water broke 4 hours ago and her contractions are now less than 3
minutes apart. Consuelo earlier received a NVP tablet to take at home. When you
examine her, you find that she is 5 centimetres dilated.
After providing general support during labour, what is your first priority?
If you discover that she has not taken her NVP tablet, what do you do?
Case study 2
Deborah arrives to deliver. This is her fourth child and she tells you that she has had a
good pregnancy. Deborah has received no antenatal care and was never tested for HIV.
At this time, her contractions are regular and about 2 minutes apart. During your
examination, you find that she is 7 centimetres dilated.
Considering your national policy on testing and counselling during labour and delivery,
what are your next steps?

SESSION 4 Immediate Postpartum Care of Women who are
HIV-Infected and Women with Unknown HIV
Status
Advance Preparation
Ensure that national guidelines on immediate postpartum care of women
who are HIV-infected and women with unknown HIV status appear in the
Participant Manual. If not, have copies available for distribution.
Familiarise yourself with these policies.
Review the case studies to make sure the materials reflect local customs,
issues, names, and policies. Ask local healthcare workers to help you
adapt the case studies if necessary.
Slides 24, 25, 26, 27, 28 and 29
Using the information below, discuss postpartum care of women infected with HIV,
including newborn feeding, signs and symptoms of postnatal infection, and family
planning.
Make These Points
! Women who are HIV-infected require additional postpartum monitoring and support.
! Women taking ARVs require nutritional support and guidance.

! Infant-feeding support is required during the first two years of a child’s life with special
attention provided any time a mother elects to change her feeding practice.
! Early identification and treatment of infections can improve quality of life.
! Postpartum family planning can include both partners and prevent future HIV infection.

Postpartum care of women infected with HIV
When providing postpartum care to women infected with HIV, healthcare workers may
follow routine protocols, but several areas require additional attention:
Continuing care
Encourage and make plans for continued health care in the following areas:
! Routine gynaecologic care, including pap smears, if available.
! Ongoing treatment, care and support for HIV/AIDS and opportunistic infections along
with nutritional support.
! Treatment and monitoring of TB and malaria.
! Referral for antiretroviral treatment (or treatment eligibility)
! Referral for prophylaxis and treatment of OIs.
(For additional information, see Module 7, Linkages to Treatment, Care and Support for
Mothers and Families with HIV Infection.)
Newborn feeding
! Ensure that the mother chooses feeding options before she leaves the facility or hos-
pital after delivery.
! Support the mother’s choice of feeding option. (See Module 4, Infant Feeding in the
Context of HIV Infection, for additional information).
! Provide training and observe proper feeding technique prior to discharge.
Signs and symptoms of postnatal infection

Review the following symptoms of infection before the new mother leaves the clinic or
hospital and provide her with information on where to seek treatment for:
! Burning with urination
! Fever
! Foul smelling lochia
! Cough, sputum, shortness of breath
! Redness, pain, pus, or drainage from incision or episiotomy
! Severe lower abdominal tenderness
Education
Instruct the mother on perineal and breast care
!
! Ensure that the mother knows how to dispose of potentially infectious materials such
as lochia and blood-stained sanitary pads
Family planning
Contraception and child spacing should be discussed with every woman during
antenatal care and again in the immediate postpartum period. The main family planning
goals for the woman who is HIV-infected are:
! Preventing unintended pregnancy
! Appropriate child spacing, which can help reduce maternal and infant morbidity and
mortality
(See Module 2, Overview of HIV Prevention in Mothers, Infants and Young Children for
additional information.)

Slide 30
Discuss the benefits of HIV testing after delivery for women with unknown HIV status,
as outlined below.
Postpartum care of women with unknown HIV status

Women whose HIV status is unknown should receive the same postpartum care as
women with HIV infection (outlined above). They should be encouraged to be tested for
HIV and to follow national recommendations for feeding their infants.
HIV testing after delivery can assist women infected with HIV to:
! Initiate post-exposure ARV prophylaxis for the infant
! Choose safer infant-feeding options
Lead an interactive discussion based on the case study exercise below.
Exercise 3.3 Immediate postpartum care of women who are

HIV-infected: case studies
Purpose To review postnatal management of the woman with HIV infection.
Duration 25 minutes
Introduction The purpose of this exercise is to review postpartum management

practices in the context of HIV infection.
Activities ! Distribute copies of the postnatal case studies to the

participants.
! Ask a participant to read the narrative section of each case
study.
! Ask participants for answers to the questions at the end of each

case study.
! Ask participants if they disagree with any of the answers offered.
! Ask participants if any of these case studies is similar to cases
they may have encountered in their facilities.
! Ask participants if they can describe a particular case that has
challenged them in the postnatal clinical setting.
! Ask them to describe what was done to resolve the challenges.

Debriefing ! Review the major areas of importance including routine
postnatal care, counselling on infant feeding, and referral for
ongoing care.
! Mention how each case is as individual as the person and
circumstances involved.
Exercise 3.3 Immediate postpartum care of women who are HIV-infected: case
studies
Case study 1
Deborah presented to the labour and delivery ward without having had an HIV test
during her pregnancy. The result of the rapid HIV test performed during labour was
positive. When told of the test result, Deborah became upset but agreed to take the
NVP tablet. Subsequently, she had an uneventful labour and delivered a 2.4 kg healthy
boy she named William. Although breastmilk substitute is available at the clinic,
Deborah is determined to breastfeed her baby. It is now two hours after her delivery and
she is resting. Her mother and husband are staying with her.
What postpartum care does she require?

What HIV-specific services does she need?
What can you accomplish before she leaves the facility in 24 hours?
Case study 2
Consuelo, who is HIV-positive, has been following the ZDV and NVP regimen for herself
and her child. After a short labour, she delivered a 2 kg girl named Samantha. Consuelo
has chosen to use breastmilk substitute; she will be discharged in 48 hours.
What postpartum care does she require?

What HIV-specific services does she need?
What can you do to support her infant-feeding choice?
What services can you provide to her before she leaves in 24 hours?
What continuing support do you anticipate providing to her?

SESSION 5 Immediate Newborn Care of Infants who are
HIV-Exposed and Infants with Unknown HIV
Status
Advance Preparation
Ensure that national guidelines on immediate newborn care of infants who
are HIV-exposed and infants with unknown HIV status appear in the
Participant Manual. If not, have copies available for distribution.
Familiarise yourself with these policies. Be sure that you have enough
copies to distribute to all participants.
Review the case studies to make sure the materials reflect local customs,
issues, names, and policies. Ask local healthcare workers to help you
adapt the case studies, if necessary.
Discuss immediate newborn care of infants, using the information below.
Make These Points
! Universal precautions should always be followed when caring for newborn infants.
! BCG is not given to infants who are HIV-infected in low-prevalence countries.
The immediate care of the newborn exposed to HIV follows standard practice.
Regardless of the mother’s HIV status, all infants are kept warm after birth and are
handled with gloves until maternal blood and secretions have been washed off.
Immediate newborn care

! Maintain universal precautions throughout care and treatment. Wear gloves when giv-
ing injections, and clean all injection sites with surgical spirits. Dispose of all needles
according to facility policy.
! Clamp cord immediately after birth, and avoid milking the cord. Cover the cord with
gloved hand or gauze before cutting.
! Wipe infant’s mouth and nostrils with gauze when the head is delivered.
! Use suction only when meconium-stained liquid is present. Use either mechanical
suction at less than 100 mm Hg pressure or bulb suction, rather than mouth-operated
suction.

! Wipe the infant dry with a towel.
! Determine the mother’s feeding choice. If she is using breastmilk substitute, place the
infant on her body for skin-to-skin contact and provide help with the first feeding. If
she is breastfeeding, place the infant on the mother’s breast.
! Administer vitamin K, silver nitrate eye ointment, and Bacille Calmette Guérin (BCG)
according to national guidelines.
Slides 34, 35, 36, and 37
Discuss care of newborns who are HIV-exposed, using the country protocol and the
information below.
Make These Points
! Routine assessment for signs and symptoms of HIV infection is essential.

! HIV testing, immunisation against infectious diseases of childhood, and screening
and prevention of TB and malaria are part of ongoing healthcare.
! Even with prophylaxis, infants who are HIV-exposed are at increased risk of illness
and challenges related to growth and development.
! PCP prophylaxis is recommended for infants who are HIV-exposed, starting at six
weeks and continuing until HIV-infection can be ruled out.
ARV prophylaxis
ARV prophylaxis should be administered to the newborn according to country protocol.
(See Appendix 3-A).
Follow-up newborn care

Care of the newborn baby should follow standard practices. Care for babies exposed to
HIV should follow the approach described in Module 7, Linkages to Treatment, Care
and Social Support for Mothers and Families with HIV Infection.
Infants born to mothers with unknown HIV status Module 3 Specific Inferventions
In the immediate postpartum period, the goal is to reduce MTCT by minimising newborn
exposure to maternal blood and body fluids and by providing ARV prophylaxis to the
newborn. When HIV testing is unavailable or the mother’s HIV status is unknown,
newborn care should follow national or local policy.
! Newborns of mothers with unknown HIV status should be tested as soon as possible
after birth, if the mother consents.
! In some high-prevalence settings, national policy could recommend that all babies be
given a single oral dose of nevirapine 2 mg/kg liquid suspension as soon as possible
after birth, if the mother consents, whether or not the mother has been tested for HIV.
! The mother should receive counselling about feeding her infant, as described in
Module 4, Infant Feeding in the Context of HIV Infection.

Lead an interactive discussion based on the exercise below.
Exercise 3.4 Immediate newborn care of infants who are HIV-exposed:

case studies
Purpose To review ARV prophylaxis and newborn care of infants who are
HIV-exposed.
Duration 20 minutes
Introduction Tell the participants that this exercise will serve as a review of ARV
prophylaxis and postnatal care of infants.
Activities ! Distribute copies of the case studies to the participants.

! Make sure all participants have a pencil or pen.
! Ask participants to take five minutes to read the case studies.
! Instruct participants to write out their answers on a piece of
paper.
! Let participants know that the case studies will not be collected
but will be reviewed as a group.
! Lead a group discussion of each case study.
Debriefing ! Ask participants how they felt about providing answers to the
case study.
! Ask participants whether any areas in the module need
clarification.
! Answer any questions.
Exercise 3.4 Immediate newborn care of HIV-exposed infants: case studies

Case study 1
Deborah has just delivered her son, William. She tested HIV-positive during labour.
What HIV-specific infant interventions are required after the birth?

What are the components of follow-up care for William?
How can you help Deborah manage ongoing HIV-related care for herself and her infant?

Case study 2
Samantha, the newborn daughter of Consuelo (who is HIV-positive), is irritable and
cries often. Consuelo’s mother-in-law, who is visiting her at the facility and will be
helping care for the infant after discharge, is worried. You overhear her repeatedly
telling Consuelo that the baby needs breastmilk and that the breastmilk substitute is not
satisfying the baby.
What can you do to help Consuelo at this stressful time?

What support will Consuelo need from the PMTCT programme to continue using
breastmilk substitute after discharge?
Home birth case study
Louisa was diagnosed as HIV-positive during her one ANC visit prior to delivery at
home. She has returned to the health centre 6 days after the birth of Teresa, her
daughter. The baby appears to be happy, well hydrated, and thriving. Louisa remains
convinced she is not infected with HIV and that the baby is not at risk. In fact, she did
not give the NVP syrup to Teresa because the baby “didn’t need it” and Teresa is
breastfeeding.
Is this a typical response in your setting?

What services would you offer this mother?
What follow-up and referrals are necessary for this mother and her infant?
How will you deal with her denial of her diagnosis and risk for her infant?
Summarise the key points of this module from the box below.

! Integrating PMTCT services into the essential package of ANC services

promotes improved care for all pregnant women and provides the best
opportunity for a successful PMTCT programme.
! Specific interventions to reduce MTCT include ARV treatment and prophylaxis,
safer delivery procedures, and counselling and support for safe infant feeding.
! Using antiretroviral drugs for treatment and prophylaxis reduces the risk of
MTCT. Longer-course combination regimens are more effective, but short-
course prophylaxis regimens may be more feasible in some resource-
constrained settings.
! PCP prophylaxis and the prevention and treatment of TB and malaria are part of
comprehensive care for mothers infected with HIV and their infants.
! Safer delivery procedures include avoiding unnecessary invasive obstetrical
procedures and offering the option of elective caesarean section when safe and
feasible.
! Infant-feeding options to minimise the risk of MTCT require support and
guidance throughout ANC, labour and delivery and postpartum.

APPENDIX 3-A Antiretroviral prophylaxis regimens to
prevent MTCT
HIV-related treatment, care and support must be provided during the antenatal and postpartum periods. All
HIV-exposed infants should be followed-up for diagnosis of HIV, prophylaxis of opportunistic infection and
treatment, care and support.
All regimens are administered by mouth. Paediatric formulations are needed for all infant regimens.
Efforts must be made to monitor for side effects and support maternal infant adherence.
COURSE ANTENATAL INTRAPARTUM POSTPARTUM POSTNATAL

Zidovudine Mother: Mother: None Infant:
(ZDV) and ZDV 300 mg twice a ZDV 300 mg at onset NVP 2mg/kg oral
nevirapine day starting at 28 of labour and every 3 suspension immedi-
(NVP) weeks or as soon as hours until delivery ately after birth and
possible thereafter and single-dose NVP ZDV 4 mg/kg twice a
200 mg at onset of day for 7 days
labour
OR OR
OR
ZDV 600 mg at onset NVP 22 mg/kg
NVP mg/kg oral
oral
of labour suspension immedi-
suspension immedi-
ately after
ately after birth
birth
ZDV Mother: Mother: None Infant:
ZDV 300 mg twice a ZDV 600 mg at onset ZDV 4 mg/kg twice a
day starting at 28 of labour day for 7 days
weeks or as soon as
OR OR
possible thereafter
ZDV 300 mg at onset ZDV 2 mg/kg 4 times
of labour and every 3 a day for 7 days
hours until delivery
ZDV and NVP None None None Infant:
for infant NVP 2 mg/kg oral
(when mother suspension immedi-
has received no ately after birth and
ARV prophylaxis) ZDV 4 mg/kg twice a
day for 7 days. When
ZDV oral suspension
not available NVP 2
mg/kg as soon as Module 3 Specific Inferventions
possible after delivery
and a dose of NVP
72 hours after birth
NVP None Mother: None Infant:
Single-dose NVP 200 NVP 2 mg/kg oral
mg at onset of suspension immedi-
labour ately after birth
ZDV and Mother: Mother: Mother: Infant:
lamivudine ZDV 300 mg and ZDV 300 mg every 3 ZDV 300 mg and ZDV 4 mg/kg and
(3TC) 3TC 150 mg twice a hours until delivery 3TC 150 mg twice 3TC 2 mg/kg twice a
day starting at 28 and 3TC 150 mg a day for 7 days day for 7 days
weeks or as soon as every 12 hours until
possible thereafter delivery
= First choice regimen

APPENDIX 3-A Antiretroviral prophylaxis regimens to
prevent MTCT (continued)
COURSE ANTENATAL INTRAPARTUM POSTPARTUM POSTNATAL

ZDV and 3TC None Mother: Mother: Infant:
ZDV 600 mg and ZDV 300 mg and ZDV 4 mg/kg and
3TC 150 mg at onset 3TC 150 mg twice 3TC 2 mg/kg twice a
of labour followed by a day for 7 days day for 7 days
ZDV 300 mg every 3
hours and 3TC 150
mg every 12 hours
until delivery
ZDV + 3TC + Mother: Mother: None Infant:
saquinavir ZDV 300 mg, 3TC Continue antenatal NVP 2 mg/kg oral
(SQV/r) * 150 mg and SQV/r dosing schedule suspension
(Consider for 1000 mg/100 mg immediately after
MTCT prophylax- twice a day starting birth
is in women not at 36 weeks or as
OR
needing ARV soon as possible
therapy) thereafter ZDV 4 mg/kg twice a
day for 7 days
OR
NVP 2 mg/kg oral
suspension
immediately after
birth and ZDV 4
mg/kg twice a day
for 7 days
ZDV or Mother: Mother: None Infant:

stavudine ZDV 300 mg and Continue antenatal NVP 2 mg/kg oral
(d4T) + 3TC 150 mg and dosing schedule suspension
3TC + NVP † NVP 200 mg twice a immediately after
(This treatment day birth
regimen in
OR OR
pregnant
women also d4T 40 mg, 3TC 150 ZDV 4 mg/kg twice

provides MTCT mg and NVP 200 mg a day for 7 days
prophylaxis.) twice a day starting
OR
at 36 weeks or as
soon as possible NVP 2 mg/kg sus-
thereafter pension immediately
after birth and ZDV
4 mg/kg twice a day
for 7 days
* In women who do not require ARV, alternative triple-combination regimens for MTCT prophylaxis may be
considered. If the woman is in the third trimester of pregnancy, these regimens may include ZDV + 3TC +
nelfinavir (NFV) or ZDV + 3TC + efavirenz (EFV).
†
In women who require ART, this is the recommended first-line regimen. However, in the third trimester of
pregnancy, a regimen consisting of ZDV (or d4T) + 3TC + EFV may be considered.

Clinical Situation Recommendation
A: HIV-infected women with indi- First-line regimens: ZDV + 3TC + NVP or
cations for initiating ARV treat- d4T + 3TC + NVP
ment1 who may become pregnant
Efavirenz (EFV) should be avoided in women of
childbearing age, unless effective contraception
can be assured. Exclude pregnancy before starting
treatment with EFV.
B: HIV-infected women receiving Women
ARV treatment who become ! Continue the current ARV regimen2 unless it
pregnant contains EFV. If it does, substitution with NVP or
a PI should be considered if in the 1st trimester.
! Continue the same ARV regimen during the
intrapartum period and after delivery.
Infants
! If born to women receiving either 1st or 2nd-line
ARV regimens: 1-week ZDV OR single-dose
NVP OR 1-week ZDV and single dose NVP
C: HIV-infected pregnant women Women

with indications for ARV ! Follow the treatment guidelines as for non-preg-
treatment1 nant adults except that EFV should not be given
in the 1st trimester.
! First line regimens: ZDV + 3TC + NVP or
d4T + 3TC + NVP
! Consider delaying therapy until after the 1st
trimester, although in severely ill women the
benefits of early therapy clearly outweigh the Module 3 Specific Inferventions
potential risks.
Infants
! 1-week ZDV OR single-dose NVP OR 1-week
ZDV and single-dose NVP.

APPENDIX 3-B Clinical situations and recommendations
for the use of antiretroviral drugs in
pregnant women and women of child-
bearing potential in resource-constrained
settings
D: HIV-infected pregnant First-choice regimen: ZDV and NVP
women without indications
Women
for ARV treatment1
! ZDV starting at 28 weeks or as soon as possible there-
after. Continue ZDV at the same dose in labour. In
addition, women should receive single-dose NVP at the
onset of labour.
Infants
! Single-dose NVP and 1-week ZDV3
Alternative regimen: NVP only
Women
! Single-dose NVP
Infants
! Single-dose NVP
Alternative regimen: ZDV only
Women
! ZDV starting at 28 weeks or as soon as possible there-
after. Continue in labour.
Infants
! 1-week ZDV3
Alternative regimen: ZDV + 3TC
Women
! ZDV + 3TC starting at 36 weeks or as soon as possible
thereafter. Continue in labour and for 1 week postpartum.

Infants
! 1-week ZDV + 3TC
E: HIV-infected pregnant Follow the recommendations in Situation D, but preferably
women with indications for use the most efficacious regimen that is available and
starting ARV treatment1 feasible.
but treatment is not yet
available
F: HIV-infected pregnant If ARV treatment is initiated, consider 4: (ZDV or d4T) +
women with active 3TC + SQV/r.
tuberculosis If treatment is initiated in the third trimester (ZDV or d4T)
+ 3TC + EFV can be considered.
If ARV treatment is not initiated, follow the
recommendations in Situation D.

settings (continued)

G: Pregnant women of If there is time, offer HIV testing and counselling to
unknown HIV status at the women of unknown status and if positive, initiate
time of labour or women in intrapartum ARV prophylaxis.
labour known to be HIV-
infected who have not Women
received ARV drugs before ! Single-dose NVP. If in advanced labour do not give the
labour dose but follow the recommendations in Situation H.
Infants
! Single-dose NVP
Women
!ZDV + 3TC in labour and 1-week ZDV + 3TC
postpartum
Infants
! 1-week ZDV+3TC
If there is insufficient time for HIV testing and counselling

during labour, then offer testing and counselling as soon
as possible postpartum. Follow the recommendations in
Situation H for women testing positive postpartum.
H: Infants born to HIV- Infants
infected women who have ! Single-dose NVP as soon as possible after birth and
not received any ARV 1-week ZDV
drugs If the regimen is started more than 2 days after birth, it is
unlikely to be effective.

settings (continued)
1
WHO recommendations for initiating ARV treatment in HIV-infected adolescents and adults. If CD4 test-
ing is available it is recommended to offer ARV treatment to patients with: WHO Stage IV disease irre-
spective of CD4 cell count, WHO Stage III disease with consideration of using CD4 cell counts less than
350 10 6 cells/L to assist decision-making and WHO Stage I and II disease in the presence of a CD4 cell
count less than 200 10 6 cells/L. If CD4 testing is unavailable, it is recommended to offer ARV treatment to
patients with WHO Stage III and IV disease irrespective of total lymphocyte count or WHO Stage II dis-
ease with a total lymphocyte count less than 1200 10 6 cells/L.
2
Conduct clinical and laboratory monitoring as outlined in the 2003 revised WHO treatment guidelines.
3
Continuing the infant on ZDV for four to six weeks can be considered if the woman received antepartum
ARV drugs for less than four weeks.
4
ABC can be used in place of SQV/r; however, experience with ABC during pregnancy is limited. In the
rifampicin-free continuation phase of tuberculosis treatment, an NVP-containing ARV regimen can be
initiated.
Source: WHO. 2004. Antiretroviral drugs for treating pregnant women and preventing HIV infection in
infants: guidelines on care, treatment and support for women living with HIV/AIDS and their children in
resource-constrained settings. pp 39–41.

Module 4 Infant Feeding
Module 4 Infant Feeding in the Context of HIV
Infection
SESSION 1 Global Recommendations for Infant and Young Child Feeding
Exercise 4.1 Copies of national HIV infant-feeding policy or 30 minutes

Strategies for protocol, if not already in the Participant Manual
optimal feeding:
large group
discussion
SESSION 2 Feeding Options
Exercise 4.2 Copies of national HIV infant-feeding policy or 30 minutes

National and local protocol, if not already in the Participant Manual
policies on infant Information about local costs of infant-feeding
feeding: large supplements
group discussion
SESSION 3 Infant-Feeding Counselling and Support
Exercise 4.3 Copies of the list of patient roles for the role play 100 minutes
Infant-feeding Tins of commercially prepared infant formula,
counselling and measuring spoons, and feeding cups to
support: role play demonstrate correct preparation
Equipment to correctly make home-modified
infant formula (if used in your area)
If available, model of a breast to demonstrate
correct position during breastfeeding
PMTCT–Generic Training Package Trainer Manual Module 4–1


Session 2
! National HIV infant-feeding policy and applicable infant-feeding guidance
Session 3
! National guidelines on infant-feeding counselling and support
Module 4–2 Infant Feeding in the Context of HIV Infection

SESSION 1 Global Recommendations for Infant and Young
Child Feeding
Advance Preparation
Familiarise yourself with the 2003 UN recommendations on infant feeding
by mothers who are HIV-infected as well as national HIV infant-feeding

policy or protocol.
Slides 1 and 2
! Describe the current global recommendations for infant feeding in the context of HIV.
! Understand the importance of optimal infant and young child feeding for child health,
nutrition, growth, and development.
! Define the main options for infant feeding and the advantages and disadvantages of
each.
! Describe the steps for counselling mothers who are HIV-infected about infant feeding.
! Understand the importance of the postnatal follow-up and support required for appro-
priate infant feeding.
Slide 3 and 4
Present an introduction to infant and young child feeding, using the information below.
Make These Points

! Antiretroviral prophylaxis does not provide long-term protection for the infant.
! The longer the duration of breastfeeding, the greater the cumulative risk of MTCT.

Introduction
Antiretroviral (ARV) treatment and prophylaxis has substantially reduced mother-to-child
transmission (MTCT) of HIV. ARV prophylaxis, however, does not provide long-term
protection for the infant who is breastfeeding.
Without intervention, 5% to 20% of infants breastfed by mothers who are HIV-positive

may acquire HIV-infection through breast-feeding. Infant-feeding practices that carefully
follow national or UN guidelines can reduce the likelihood of MTCT through
breastfeeding and reduce the risk of infant death from diarrhoea and other childhood
infections.
Slides 4 and 5
Present the following basic facts about malnutrition, infant feeding, and child survival.
Make These Points

! Malnutrition a major cause of morbidity in children.
! Mothers who are HIV-infected require counselling and support for safer feeding prac-
tices.
Basic facts on malnutrition, infant feeding, and child survival

! Malnutrition is the underlying cause of death in about 60% of children younger than 5
years old worldwide and in about 50% of children that age in Africa.
! Being underweight was associated with 3.7 million deaths worldwide in the year
2000, and most of the deaths occurred in children younger than 5 years old.
! Poor feeding practices, such as those that provide insufficient nutritional balance or
contribute to diarrhoea, are a major cause of low weight and morbidity and mortality
in children.
! Counselling and support for infant feeding can improve feeding practices and, in turn,
prevent malnutrition and reduce the risk of death in children.
! For mothers who are HIV-positive, counselling and support may lead to improved
infant-feeding practices that may also help prevent MTCT.

Slides 7 and 8
Explain to participants the following UN infant-feeding recommendations for mothers

who are HIV-negative and mothers with unknown HIV status.
Questions often arise about mixed versus exclusive breastfeeding practices. Explain
rationale for avoidance of mixed feeding—irritability of intestinal mucosa, diarrhoea.

Infant-feeding recommendations for mothers who are HIV negative
and mothers with unknown HIV status
! Breastfeed exclusively (see definition below) for the first six (6) months of life.
! Continue breastfeeding for up to 2 years or longer.
! After the infant reaches 6 months of age, introduce complementary foods that provide
sufficient nutritional balance and are safe.
Mothers should also receive information about the risk of becoming infected with HIV
late in pregnancy or during breastfeeding. Women with unknown HIV status should be
encouraged to be tested for HIV.
Definition
Exclusive breastfeeding: The mother gives her infant only breastmilk except for
drops or syrups consisting of vitamins, mineral supplements, or medicines. The
exclusively breastfed child receives no food or drink other than breastmilk—not even
water.
Slide 9
Explain the UN infant-feeding recommendations for mothers who are HIV-infected.

Infant-feeding recommendations for mothers who are HIV-infected
! When replacement feeding is acceptable, feasible, affordable, sustainable, and safe,
mothers who are HIV-infected should avoid all breastfeeding. (Please see
"Definitions" below.)
! Otherwise, exclusive breastfeeding is recommended during the first months of life.
! To minimise HIV transmission risk, mothers who are HIV-positive should discontinue
breastfeeding as soon as feasible, taking into account local circumstances, the indi-
vidual woman’s situation, and the risks of replacement feeding (which include malnu-
trition and infections other than HIV).
! All mothers who are HIV-positive should receive counselling, which includes general
information about the risks and benefits of infant-feeding options and specific guid-
ance on selecting the option most likely to be suitable for their situation.
! Whatever choice a mother makes, she should be supported.
There is no evidence indicating a specific time for early cessation of breastfeeding for
all mothers—as it depends on each mother’s individual situation. It is recommended that
countries establish their own guidelines taking into account these recommendations.
Definitions
Acceptable: The mother perceives no significant barrier(s) to choosing a feeding

option for cultural or social reasons or for fear of stigma and discrimination.
Feasible: The mother (or other family member) has adequate time, knowledge, skills,
and other resources to prepare feeds and to feed the infant as well as the support to
cope with family, community, and social pressures.
Affordable: The mother and family, with available community and/or health system
support, can pay for the costs of the replacement feeds—including all ingredients, fuel
and clean water—without compromising the family's health and nutrition spending.
Sustainable: The mother has access to a continuous and uninterrupted supply of all
ingredients and products needed to implement the feeding option safely for as long as
the infant needs it.
Safe: Replacement foods are correctly and hygienically stored, prepared, and fed in
nutritionally adequate quantities; infants are fed with clean hands using clean utensils,
preferably by cups.
International Code of Marketing Breastmilk Substitutes

The importance of supporting safer infant-feeding practices is exemplified in the
International Code of Marketing of Breastmilk Substitutes. This code helps provide safe
and adequate nutrition for children by:
! Protecting and promoting breastfeeding
! Supporting proper and informed use of breast-milk substitutes when necessary
! Promoting acceptable marketing and distributing practices
Even in countries that have decided to provide infant formula to HIV-positive mothers,
health workers should resist all commercial promotion of formula under the Code, for
example by removing advertisements from health facilities; refusing to accept free
samples of formula and equipment (e.g. bottles), refusing to accept or use other gifts or
equipment with brand names, and making sure that any formula used in a health facility
is kept out of sight of mothers who do not need it.

Exercise 4.1 Strategies for optimal feeding: large group discussion
Purpose To review global strategies recommending optimal feeding for

infants and young children.
To identify local practices and application of the national HIV

infant-feeding policy or protocol.
Duration 15 minutes
Introduction Discuss national infant-feeding policy and practices in light of

the WHO infant-feeding recommendation which states: "When
replacement feeding is acceptable, feasible, affordable,
sustainable, and safe, avoidance of all breastfeeding by HIV-
infected mothers is recommended. Otherwise, exclusive
breastfeeding is recommended during the first months of life."
Activities ! Discuss the national HIV infant-feeding policy or protocol.

! Is it clear? Is it consistent with international recommendations
and does it provide guidance for your healthcare setting?
! Examine the following terms on the flipchart, whiteboard or
blackboard:
! Acceptable
! Feasible
! Affordable
! Sustainable
! Safe
! Consider the mothers whom you have met in your work.
Would they be able to implement replacement feeding based
on the above criteria?
! What other things can you think of that influence a mother’s
choice of feeding options, eg cultural influences?
Debriefing Ask the group to consider:

! How do cultural beliefs influence infant-feeding practices?
! How does a family’s economic or financial status affect infant-
feeding options?
! What other barriers are there to optimal feeding practices?
Slide 10
Explain the information below about how to implement the WHO infant-feeding
recommendations.

Guidance and support for implementing infant-feeding
recommendations
! Provide all mothers who are HIV-positive with counselling that includes general infor-
mation about the advantages and disadvantages of various infant-feeding options as
well as specific guidance for selecting the option most suitable for their situations.
! Support the mother's choice, whichever feeding option she chooses.
! Conduct local assessments to identify the range of feeding options that are accept-
able, feasible, affordable, sustainable, and safe in particular contexts.
! Develop information and education about MTCT, including facts about transmission
through breastfeeding, and target the material to the public, affected communities,
and families.
! Train, supervise, and support adequate numbers of people who can counsel women
who are HIV-positive about infant feeding.
! Provide updated training to counsellors when new information and recommendations
emerge.
! Extend the services of healthcare workers into the community using trained lay or
peer counsellors.

SESSION 2 Feeding Options
Advance Preparation
Discuss with local PMTCT staff the degree to which national infant-feeding
policies or protocols are reflected in current feeding practices.
Have available information about the local costs of commercial infant

formulas, sugar, and multivitamin syrups or powders that are used to

supplement home-modified animal milk formulas.
Keep the definitions of the terms acceptable, feasible, affordable,

sustainable, and safe visible on the flipchart or board so that you can refer
to them during Exercise 4.2 National and local policies on infant feeding:
large group discussion.
Note: This session reviews all feeding options. Discuss only those options
recommended for your local area and show only those slides that concur with local
policy.
Slides 11 and 12
Introduce the discussion on infant-feeding options, using the material below.
Use Slide 12 as a placeholder to present and discuss the national or local infant-feeding
policy.

Making decisions about infant feeding
Mothers with HIV infection must consider many factors when deciding on a feeding
option that is best for their infants. Healthcare workers play an important role in guiding
their decision-making process by providing infant-feeding counselling that includes the
following:
! Information about the risk of HIV transmission through breastfeeding

! Advantages and disadvantages of each available option
Respect for local customs, practices, and beliefs when helping a mother make infant-
feeding choices
Healthcare workers share in the responsibility to protect, promote, and support safe and
appropriate feeding practices. In addition to supporting women’s infant-feeding
decisions, referral is needed to trained infant-feeding counsellors for continued support
during the first two years of a child’s growth and development. Programs such as the
Baby Friendly Hospital Initiative have played a vital role in this important task as well.
(See Session 3 HIV Infant-Feeding Counselling and Support.)
An HIV-positive pregnant or newly-delivered woman will have to make a

decision among the locally-appropriate options available.
Slide 13
Discuss the option of replacement feeding using commercial formula.
Use the information presented in Table 4.1 to review the advantages and disadvantages
of using commercial infant formula. Use the information presented in Table 4.2 to
present information about the amount of commercial formula required by infants at
various ages.
Replacement feeding during the first 6 months of life

Replacement feeding means feeding infants who are receiving no breastmilk with a diet
that provides most of the nutrients infants need until the age at which they can be fully
fed on family foods. Unlike breastfeeding, it does not provide immune protection against
other diseases. During the first 6 months of life, replacement feeding should be with a
suitable breast-milk substitute. After six months the suitable breast-milk substitute
should be complemented with other foods.
If a woman is considering replacement feeding for the first six months there
are two types of breastmilk substitutes: commercial infant formula or home-
modified formula with micronutrient supplements. Cup feeding is
recommended over bottle feeding. (Refer to Appendix 4-B.)

Option 1: Commercial infant formula
Advantages and disadvantages of using commercial infant formulas are presented in

Table 4.1. Table 4.2 summarises how many tins of commercial infant formula are
required to feed infants each month.
Table 4.1 Commercial infant formula
Advantages
! Commercial formula poses no risk of transmitting HIV to the infant.

! Commercial formulas are made especially for infants.
! Commercial formula includes most of the nutrients that an infant needs.
! Other family members can help feed the infant.
! If the mother falls ill, others can feed her infant while she recovers.
Disadvantages
! Commercial formula does not contain antibodies, which protect infants from infec-
tion. An infant who is fed commercial formula exclusively is more likely to get diar-
rhoea and pneumonia and may develop malnutrition.
! A continuous, reliable formula supply is required to prevent malnutrition.
! Commercial formula is expensive.
! Families need soap for cleaning cups and utensils used in preparing the formula.
! Safe preparation of commercial formula requires clean water, boiled vigorously for
1-2 seconds; this also requires fuel.
! Formula should be made fresh for each feed, according to directions, day and
night, unless she has access to a refrigerator.
! The infant needs to drink from a cup, which may take time to learn.
! The mother must stop breastfeeding completely, or she will continue to be at risk of
transmitting HIV to her infant.
! In some settings, family, neighbours, or friends may question a mother who does
not breastfeed about her HIV status. (See Session 3 of this module.)
! Formula feeding offers the mother no protection from pregnancy.
Table 4.2 Commercial infant formula requirements in first 6 months
Month 500 g Tins/Month 450 g Tins/Month

1 4 5
2 6 6
3 7 8
4 7 8
5 8 8
6 8 9
Total 40 44

Slide 14
Discuss the option of feeding infant home-modified animal milk, using the information
below. Use Table 4.3 to review the advantages and disadvantages of using home-
modified infant formulas.
Option 2: Home-modified animal milk

Home-modified animal milk is only suitable when commercial formula is not available.
Infants require about 15 litres of modified animal milk formula per month for the first 6
months. Babies also require multi-nutrient supplements, in liquid or powder form, to help
prevent anaemia and other forms of malnutrition. Safe preparation and storage of the
home-modified animal milk is also essential for preserving nutritional value and
minimising the risk of malnutrition.
Formula may be prepared at home using fresh animal milks, dried milk powder, or
evaporated milk. Preparing formula with any of these types of milk involves
modifications to make the formula suitable for infants up to 6 months old. Modifications
include diluting the milk with boiled water in precise amounts to reduce the formula's
concentration and adding sugar to increase the formula's energy density. The required
dilution amount varies for different animal milks. Dilution is not required for infants 6
months and older who should also be receiving complementary foods.
Table 4.3 lists the advantages and disadvantages of using home-modified infant
formulas.
Suitable and unsuitable milks
Not all milks are suitable for use in home-modified infant formula.
The following milks are suitable for home-modified animal milk:
! Fresh (full-cream or whole) cow, goat, sheep, buffalo, or camel milk

! Full-cream or whole dried milk powder
! Evaporated milk
! Ultra-heat treated (UHT) milk
The following milks and liquids are not suitable for home-modified animal milk:
! Fresh animal milk already diluted by an unknown amount

! Skimmed or low-fat milk powder
! Sweetened or condensed milk
! Thin cereal-based gruels
! Fruit juice, teas, or sodas
Infants who are fed home-modified animal milk formulas require

micronutrient supplements because animal milks are relatively low in iron,
zinc, vitamin A, vitamin C and folic acid.

Table 4.3 Home-modified animal milk
Advantages
! Home-modified formula presents no risk of HIV transmission.
! Home-modified formula may be less expensive than commercial formula and is
readily available if the family has milk-producing animals.
! Mothers and caretakers already using commercial formula can use home-modified
formula when commercial formula is not available.

! Other family members can help feed the infant.
! If the mother falls ill, others can feed her infant while she recovers.
Disadvantages
! Home-modified formula does not contain antibodies, which protect infants from
infection.
! An infant who is fed home-modified formula exclusively is more likely to get diar-
rhoea and pneumonia and may become malnourished.
! Home-modified formula does not contain all of the nutrients and micronutrients that
infants need.
! Formulas based on animal milks are more difficult for infants to digest.
! The mother or caretaker may need to make fresh formula for each feeding, day
and night, unless she has access to a refrigerator.
! The mother or caretaker must dilute home-modified formula with clean water
(boiled vigorously for 1–2 seconds) and add sugar in the correct amount.
! The mother must stop breastfeeding completely, or the risk of transmitting HIV to
her infant will continue.
! Families will need access to a regular supply of animal milk, sugar, multi-nutrient
syrup or powder, fuel for boiling water, and soap for cleaning feeding cups and
utensils used in preparing the formula.
! Cup feeding is recommended but may take time to learn. (See Appendix 4-B.)
! In some settings, a mother who does not breastfeed may be questioned about her
HIV status by family, neighbours, or friends. (See Session 3 of this module.)
! Formula feeding offers the mother no protection from pregnancy.

Slide 15
Discuss the option of exclusive breastfeeding using the information presented below
and in Table 4.4.
Breastmilk feeding options

Mothers who choose to breastfeed should be made aware that:
From 5% to 20% of infants breastfed by HIV-positive mothers may acquire HIV-infec-

tion through breastfeeding.

! ARV prophylaxis provided during labour and to the infant shortly after birth does not
provide long-term protection for the infant who is breastfeeding.
! The risk of transmitting HIV to her infant during breastfeeding is greater:
! When the woman is more ill (by clinical or laboratory measures)
! When she has mastitis, breast abscess or other similar conditions
! When the child has ulcers in the mouth
Option 1: Exclusive breastfeeding

Advantages and disadvantages of exclusive breastfeeding are presented in Table 4.4.
Table 4.4 Exclusive breastfeeding
Advantages
! Breastmilk is easily digestible and gives infants all the nutrients and water they
need. They do not need any other liquid or food for the first 6 months.
! Breastmilk is always available and does not need any special preparation.
! Breastmilk protects infants and children from diseases, particularly diarrhoea and
pneumonia.
! Breastfeeding provides the close contact that deepens the emotional relationship
or bond between mother and child.
! Compared to mixed feeding, exclusive breastfeeding may lower the risk of passing
HIV.
! Breastfeeding reduces mother’s risk of some cancers and helps space her preg-
nancies.
Disadvantages
! Risk of MTCT exists as long as the mother who is HIV-infected breastfeeds
because breastfeeding exposes the infant to HIV.
! The risk of transmitting HIV through breastfeeding is increased if the mother has a
breast infection (eg, mastitis) or cracked and bleeding nipples.
! Family, friends, or neighbours may pressure mothers to give water, other liquids, or
foods to the infant.
! Although nearly all mothers have sufficient milk to feed their infants, some are con-
cerned that they do not have enough milk to breastfeed exclusively.
! Breastfeeding requires feeding on demand at least 8–10 times per day.
! Working mothers may need to find a strategy to continue to breastfeed exclusively
once they return to work, eg privately expressing milk during the workday and
arranging to store milk in a cool place.
! Breastfeeding mothers require an additional 500 kcal/day to support exclusive
breastfeeding during the infant’s first 6 months.

Slide 16
Discuss the option of exclusive breastfeeding with early cessation using the information
presented below and in Table 4.5.
Option 2: Exclusive breastfeeding with early cessation

Mothers who are HIV-positive and choose to breastfeed should discontinue

breastfeeding as soon as replacement feeding is acceptable, feasible, affordable,
sustainable, and safe for them and their babies, given local circumstances, the
individual woman’s situation, and the risks of replacement feeding for the infant’s age.
Before entering the period of breastfeeding cessation, which may take from a few days
to two weeks, mothers who are HIV-positive should receive support and guidance to
maintain breast health, psychosocial support, and infant nutritional support.
Advantages and disadvantages of exclusive breastfeeding with early cessation are

presented in Table 4.5.
Table 4.5 Exclusive breastfeeding with early cessation
Advantages
! Early cessation of breastfeeding terminates the infant's exposure to HIV through
breastfeeding.
Disadvantages
! Infants may become malnourished after breastfeeding stops if suitable breastmilk
substitutes are unavailable or are provided inappropriately.
! Infants may be at increased risk of diarrhoea if breastmilk substitutes are not pre-
pared safely.
! Cup feeding requires caregiver patience and time. If possible, mothers should be
taught how to feed infants, using a cup and expressed breastmilk, before breast-
feeding cessation. (See Appendix 4-B for a summary of the advantages of cup
feeding and practical suggestions for cup feeding an infant.)
! Infants may become anxious and even dehydrated if breastfeeding cessation is too
rapid.
! After six months, a milk source should continue to be given along with appropriate
other foods, see Appendix 4-C.
! Mothers' breasts may become engorged and infected during the transition period if
some milk is not expressed and discarded.
! Mothers are at risk of becoming pregnant if they are sexually active.
! Early breastfeeding cessation is not recommended for infants who are already
infected with HIV.

Slide 17
Discuss wet nursing as an option, using the information below including Table 4.6.
Option 3: Wet nursing
Mothers who are HIV-positive, in keeping with local custom, may consider using a wet
nurse as a breastmilk feeding option. It is important that mothers receive counselling
about the potential risk of HIV transmission from a wet nurse who is HIV-infected or a
wet nurse whose HIV status is unknown. Table 4.6 presents advantages and
disadvantages of wet nursing.
Table 4.6 Wet nursing
Advantages
! Use of a wet nurse poses no risk of HIV transmission provided the wet nurse is not
HIV-infected.
! Many of the other advantages of breastfeeding described above also apply to
breastfeeding using a wet nurse.
Disadvantages
! The wet nurse must be tested and found to be free of HIV infection.
! The wet nurse must protect herself from HIV infection during the entire time she is
breastfeeding.
! The wet nurse must be available to breastfeed the infant frequently throughout the
day and night, or she must express milk to be provided when she is away from the
infant.
! People might ask the mother why someone else is breastfeeding her infant.
Note: Additional education and support may be necessary to assist mothers who
choose to use wet nurses. For example, mothers and wet nurses should be familiar
with techniques for breastmilk expression, use of heat-treated breastmilk, and the
option of using breastmilk banks.
Slide 18
Review the process of expressing and heat-treating breastmilk, using the information on
the next page including Table 4.7.

Option 4: Expressing and heat-treating breastmilk
Table 4.7 presents advantages and disadvantages of expressing and heat-treating

breastmilk.
Table 4.7 Expressing and heat-treating breastmilk
Advantages
! The HIV virus is killed by heating the milk.

! Breastmilk is the perfect food for babies, and most nutrients remain in breastmilk
after heating.
! Breastmilk is always available.
! Other responsible family members can help feeding the baby.
Disadvantages
! Although heat-treated breastmilk does not contain HIV, it may not be as effective
as unheated breastmilk in protecting the baby from other diseases, but it is still bet-
ter than formula.
! Expressing and heating breastmilk takes time and must be done frequently.
! The baby will need to drink from a cup, which may take time to learn.
! The breastmilk needs to be stored in a cool place and used within one hour of
heating.
! Families will need clean water and fuel to wash the baby's cup and the container
used to store the breastmilk.
! People may wonder why the mother is expressing her milk.
Exercise 4.2 National and local policies on infant feeding: large group
discussion
Purpose To review feeding options for infants of mothers who are HIV positive.
To convey an understanding of the advantages and disadvantages of
each feeding option and how to make each option safer and healthier
for the infant and mother.
Duration 20 minutes
Introduction There are two categories of feeding options:
! Breastfeeding
! Replacement feeding
Briefly summarise the national HIV infant-feeding policy and how
similar or different it is from the UN recommendations.
Remind participants that this exercise is primarily about providing
appropriate information and support for feeding options.

Activities ! Start the discussion by asking participants to identify and discuss
strategies that minimise the risk of HIV transmission during
breastfeeding. Be certain to cover the following points:
! Only breastmilk means only breastmilk (exclusively breastfed
infants should receive nothing else—not even water).
! Proper breastfeeding technique minimises nipple fissures
(cracks) and mastitis.
! Early recognition and treatment of breast problems is
important for continued success.
As strategies to minimise the risk of MTCT, early cessation of
breastfeeding and wet nursing may or may not be appropriate,

given a patient's family, community, or cultural setting.
! Early cessation may bring physical discomfort for the mother
and emotional stress for both mother and infant.
! Mixed breast and replacement feedings increase the risk of
MTCT. Review the rationale—irritation of intestinal mucosa,
etc.
! Refer to the tables presented earlier in this module to identify the
primary benefits and risks of each breastfeeding option, ensuring
that early cessation of breastfeeding is mentioned. Ask
participants whether they can think of other factors that were not
mentioned.
! Encourage participants to consider strategies to minimise the
risks of each breastfeeding option. Ask participants to volunteer
some suggestions to the group.
! Record participants' responses on the flipchart, whiteboard, or
blackboard.
! Highlight factors crucial to safer replacement feeding (boiled
water, clean utensils, availability of vitamins and sugar for home-
modified formula, and cup feeding).
Debriefing ! Emphasise that each feeding option should be explored for safer
implementation practices.
! Remind participants that selecting an option is just the beginning
and that ongoing support will be required to maximise success.
and ensure proper growth and development of the child,
especially during the first two years of life.

SESSION 3 Infant-Feeding Counselling and Support
Advance Preparation
For the Exercise 4.3 role play, if necessary, adapt the sample roles provided
to reflect the jobs that your participants will have after completing the
course. For example, if your participants will all work in antenatal clinics,
then discard all postnatal roles, because they will not apply to your
participants. Make sure that the roles reflect all infant-feeding options in

your area.
Make copies of the sample roles for participants to use in the role-play
exercise.
If the session is being conducted at a location where participants can

demonstrate preparation of infant formula, have available measuring
spoons, powdered formula, mixing spoons, water, and feeding cups. For
home-modified formula, have available milk, sugar, water, vitamin syrup,
measuring spoons, feeding cups, and anything else that may be used in
your area to prepare formula.
Make These Points

! Safer infant-feeding practices and the challenges they represent vary from community
to community.
! Infant-feeding guidelines can direct counselling and education, promote safety, and
minimise MTCT risk.
Counselling about infant feeding

A woman who is HIV-infected should receive counselling that includes:
! Information about the risk of HIV transmission through breastfeeding

! Information about the advantages and disadvantages of various infant-feeding
options
! Guidance in selecting and adhering to the option most suitable for her situation
! Respect for local customs, practices, and beliefs when presenting infant-feeding
choices
How to prepare non-breastfeeding women for questions
In many cultures, women are expected to breastfeed their infants for one year or longer.
If the infant is not breastfed or if breastfeeding is discontinued early, questions about the
mother's HIV status may arise. Once a woman decides how she plans to feed her
infant, ideally during the antenatal period, the healthcare worker should help her
prepare to answer questions about her choice.

During the counselling process, healthcare workers should ask women specific
questions, such as "What will you say when your mother-in-law or neighbour asks you
why you are not breastfeeding or why you have stopped breastfeeding?" or "What will
you tell your husband when he tells you to give the baby porridge when you have
chosen to breastfeed exclusively?" The healthcare worker may help the mother prepare
to answer these questions. The counselling session may also be an opportunity to
further discuss issues that relate to disclosure of the mother's HIV status to the family.
As PMTCT programmes expand, community education and mobilization activities

should be developed to help women undertake the choice of not breastfeeding or
stopping breastfeeding early. They should also be aimed at helping mothers who
choose to exclusively breastfeed to maintain that choice.
For information on stigma related to replacement feeding or early cessation of

breastfeeding, see Module 5: Stigma and Discrimination Related to MTCT.
The final decision about her infant-feeding strategy should be the woman's, and she
must receive support for her choice.
Additional training in infant-feeding counselling and support
Infant-feeding counselling for women who are HIV-positive is an integral part of every
PMTCT programme and requires that counsellors have many specific skills. Special
WHO training courses exist about general breastfeeding and infant-feeding
counselling and support (a 40-hour course) and for HIV and infant-feeding
counselling (a 3-day course). Healthcare workers who are expected to provide infant-
feeding counselling should have this type of training. Specific infant-feeding
counselling skills include listening and learning, building the client's confidence, giving
support, and providing information.
Slides 19 and 20
Review the following information about infant-feeding counselling, education, and

support.
Infant-feeding counselling, education, and support is

! Provided during both the antenatal and postnatal periods
! Based on country or local guidelines and includes an understanding of the sustain-
able resources accessible to the mother and her family
! Based on the individual woman's circumstances, including her health, social, and
financial status as well as her customs and beliefs
Infant-feeding counselling, education, and support also

! Includes information on various feeding options, including the advantages and disad-
vantages of each
! Provides women with the skills needed to feed their infants safely
! Includes demonstrations and/or opportunities for practice
! Encourages partner or family involvement in infant-feeding decisions

! Supports women when they disclose their HIV status to loved ones.
Slide 21
Explain the recommended scheduling for counselling visits, using the information below.
Counselling visits

Mothers who are HIV positive should receive infant-feeding counselling over the course
of several sessions. At least one counselling session should take place during the
antenatal period. If possible, do this some time after post-test counselling, but not
immediately after the mother learns her test results.
The counsellor should visit the mother and infant immediately after the birth and
schedule another visit within 7 days to monitor postpartum and infant-feeding progress.
It is advisable to schedule monthly follow-up sessions whenever the mother brings the
child to the clinic for well-baby checkups or immunisations. Additional sessions may be
required during special high-risk periods, such as when the:
! Child is sick
! Mother returns to work
! Mother decides to change feeding methods
Slides 22 and 23
Figure 4.1 presents a flowchart that lists steps to be followed for counselling mothers
who are HIV-infected about their infant-feeding choices. Use the following directions to
go through the flowchart and review the steps with the participants.

Infant-feeding counselling steps for women who are HIV-infected
The flowchart in Figure 4.1 illustrates the six steps for counselling mothers infected
with HIV about infant feeding. Use the flowchart on the next page as follows:
If this is the mother's first infant-feeding counselling session and…
She is early in her pregnancy:

! Do Steps 1–4.
! Ask her to return in her third trimester to learn how to implement the feeding
method (Step 5).
She is late in her pregnancy:
! Do Steps 1–5.
She already has a child and is breastfeeding or mixed feeding:
! Do relevant parts of Steps 1–5.
She already has a child and is using only replacement feeding:
! Do relevant parts of Step 5 and Step 6.
If the mother has already been counselled and chosen a feeding option and…
She is still pregnant or newly delivered, but has not yet been counselled on how to
succeed in her selected feeding method:
! Begin with relevant parts of Step 5.
If she already has a child:
! Begin with Step 6.
If this is a follow-up visit…
! Begin with Step 6.

Figure 4.1 Infant-feeding counselling for women
who are HIV-positive counselling flowchart
Step 1
Explain the risks of MTCT.
Step 2
Explain the advantages and disadvantages of different

feeding options starting with the mother's initial preference.
Step 3
Explore with the mother her home and family situation.
Step 4
Help the mother choose an appropriate feeding option.
Step 5
Demonstrate how to practise the chosen feeding option.
Provide take-home flyer.
How to practise How to practise other How to practise

exclusive breastfeeding breastmilk options replacement feeding
Step 6
Explain when and how to ! Provide follow-up counselling and support.
stop breastfeeding early. ! Repeat Steps 3-5 if the mother changes her original
choice.
Postnatal Visits Discuss feeding for

! Monitor growth. infants 6 to 24 months.
! Check feeding practices
and whether any change
is desirable.
! Check for signs of
illness.

Postnatal visits
During each postnatal visit, clinic staff should review information from the infant-feeding
counselling session and focus on issues most relevant to the mother. Reinforcing
essential and relevant information supports optimal infant nutrition, growth, and
development while minimising risks.
Facilitate and discuss reactions to the role play about infant-feeding counselling in
Exercise 4.3 below.
Exercise 4.3 Infant-feeding counselling and support: role play
Purpose To provide information on issues that may arise when counselling

for infant feeding.
Duration 70 minutes
Introduction Ask participants to pair up with another person; one will play the
role of "mother" and one will act play the role of "infant-feeding
counsellor." If there are an odd number of participants, assign
three people to one of the groups.
Ask participants to refer to the "Infant-feeding counselling for
mothers who are HIV-infected" flowchart in Figure 4.1.
Activities Sample roles are printed on the page following this exercise. Feel
free to use them or adapt the roles to a setting that is more
realistic for your group. Some of the sample roles apply in
antenatal settings and others in postnatal settings. Pick roles that
are appropriate to participants' learning needs but make sure that
a range of feeding options is presented. Co-facilitator of session
should meet with "mothers" separately.
! Assign each "mother" a patient role (see suggested roles for
Exercise 4.3 below) based on scenarios typical for your area.
! Have the "mothers" introduce themselves to their "infant-feed-
ing counsellors," noting whether they are in an antenatal or
postnatal setting.
! Ask the "infant-feeding counsellors" to take the lead and follow
the flowchart steps that are applicable to their patients.
! Allow 30 minutes for the participants to complete the role-play.
! After 30 minutes, ask the participants to reconvene as a large
group. Conduct the debriefing for the exercise in the large
group.
Debriefing Ask the "mothers" what they thought of the counselling session.
! What were the main points learned in the session?
! How has the session changed the way you would feed your
infant?
! If you would not make any changes, why not?

Exercise 4.3 Infant-feeding counselling and support: role play
Ask the "infant-feeding counsellors" to talk about the session by

answering the following questions.
! Were there difficulties with any of the steps? If so, why were
they difficult?
! Which steps were most troublesome?
! What can participants do to become more competent in provid-
ing infant-feeding support?

! Did you feel that you needed to use counselling skills to work
with a "mother" who was fearful, anxious, or upset?
Below are sample "mother" roles for the role-playing exercise on infant-feeding
counselling and support. Use these roles or create roles that more accurately reflect
your participants' needs. Photocopy this page (or write scenarios on separate slips of
paper). If you photocopy the page, use scissors to cut along the dashed lines,
separating the roles into strips. Give each "mother" one of the strips to help her
remember the details of her role during the exercise.

Suggested patient roles for Exercise 4.3, infant-feeding counselling
and support
Antenatal visit
Your name is Jennifer. You are HIV-infected and will probably breastfeed because you
know that you cannot afford to buy commercial infant formula. You breastfed your first
baby. This is your second child, due in 1 month.
Antenatal visit
Your name is Jasmine. You are HIV-infected and expect to give birth next month.
Because you want to protect your baby from HIV infection, you want to know more
about home-modified formulas. You and your husband own two cows, so it would be
convenient and inexpensive to make your own home-modified formula, but you
understand that it is quite complicated.
Antenatal visit
Your name is Maya. You are HIV-infected and expect to give birth in 3 months. Your
home and financial situation are such that you feel confident that you could purchase
and prepare commercially available infant formula. However, you have heard that many
infants get diarrhoea when fed formula, so you are concerned.
Postnatal visit
Your name is Mercy. You have been breastfeeding your baby for 3 months and would
like advice on reducing your baby's risk of HIV. You are willing to stop breastfeeding and
start cup feeding the baby, but you are worried about discomfort from engorged breasts
and how to comfort your baby during the transition period.
Postnatal visit
Your name is Pairing. You have been feeding your 3-month-old baby commercial
formula since he was born. You have several questions about cleaning the cups and
equipment, diluting formula when the money is tight, and introducing complementary
foods.

Review the key points in this module, as discussed in the box below.

! All women who are HIV-positive need infant-feeding counselling and support.
! HIV transmission risk continues the entire time a mother who is HIV-infected
breastfeeds her child.
! The mother has the right to choose how she wants to feed her infant; the health-
care worker's job is to support her choice.
! Mothers who are HIV-positive should avoid breastfeeding when replacement feed-
ing is acceptable, feasible, affordable, sustainable, and safe.
! Exclusive breastfeeding and early breastfeeding cessation are appropriate when
breastfeeding is the chosen option.
! Counselling, education, and support are key to establishing and maintaining safer
infant-feeding practices.
! Postnatal counselling and infant follow-up are required throughout the first 2 years
of the infant's life.
! PMTCT staff can prevent spillover or misuse of replacement feeding in three ways:
! Promote exclusive breastfeeding for the general population
! Discourage use of replacement milk supplies by mothers whose infants do not
need them
! Respect the International Code of Marketing of Breast Milk Substitutes

APPENDIX 4-A United Nations infant-feeding
recommendations for mothers who are HIV-
infected
UN infant-feeding recommendations (2001) for mothers who are HIV-infected are as

follows:
! When replacement feeding is acceptable, feasible, affordable, sustainable, and safe
(terms defined in Session 1), avoidance of all breastfeeding by HIV-infected mothers
is recommended.
! Otherwise, exclusive breastfeeding is recommended during the first months of life.
! To minimise HIV transmission risk, HIV-positive mothers should discontinue breast-
feeding as soon as feasible, taking into account local circumstances, the individual
woman's situation, and the risks of replacement feeding (which include malnutrition
and infections other than HIV).
! The UN suggests early cessation of breastfeeding with safe transition (over a period
of a few days or up to 2 weeks), recognising that this is difficult and that the mother
and infant will require support.
! When HIV-positive mothers choose not to breastfeed from birth or stop breastfeeding
later, counsellors or healthcare workers should provide them with specific guidance
and support for at least the first 2 years of the child's life to ensure adequate replace-
ment feeding.
! Programmes should make replacement feeding safer for HIV-positive mothers and
families.
! All HIV-infected mothers should receive counselling, which includes promotion of gen-
eral information about the risks and benefits of various infant feeding options, and
specific guidance in selecting the option most likely to be suitable for their situation.
! Whatever a mother decides, she should be supported in her choice.
This appendix was adapted from the following:
! WHO and UNAIDS. 2003. HIV and infant feeding: Guidelines for decision-makers, Retrieved 30 July
2004, from http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/HIV_IF_DM.pdf
! WHO and UNAIDS. 2003. HIV and infant feeding: Guidelines for health care managers and supervisors.
Retrieved 30 July 2004, from http://www.who.int/child-adolescent-health/New_Publications/NUTRI-
TION/HIV_IF_MS.pdf

APPENDIX 4-B Advantages of cup feeding
Breastmilk substitutes should be given from a cup.

Healthcare workers should explain to mothers and families that cup feeding is
preferable for the following reasons:
! Cups are safer, as they are easier to clean with soap and water than bottles.
! Cups are less likely than bottles to be carried around for a long time (which gives
bacteria the opportunity to multiply).

! Cup feeding requires the mother or other caregiver to hold and have more contact
with the infant and provides more psychosocial stimulation than bottle feeding.
! Cup feeding is better than feeding with a cup and spoon because spoon feeding
takes longer and the mother may stop before the infant has had enough. However,
some caregivers prefer to use a cup and spoon.
Feeding bottles are not necessary and for most purposes they are not the preferred
option.
Using feeding bottles and artificial teats should be actively discouraged because:
! Bottle feeding increases the infant's risk of diarrhoea, dental disease, and ear infec-
tions.
! Bottle feeding increases the risk that the infant will receive inadequate stimulation
and attention during feedings.
! Bottles and teats need to be thoroughly cleaned with a brush and then boiled for ster-
ilisation; this takes time and fuel.
! Bottles and teats cost more than cups and are less readily available.
Healthcare workers should receive training to show mothers and families how to cup feed.
How to feed an infant with a cup

! Hold the infant sitting upright or semi-upright on your lap.
! Hold the cup of milk to the infant's lips.
! Tip the cup so that the milk just reaches the infant's lips and it rests lightly on the
infant's lower lip.
! The infant will become alert and open its mouth and eyes.*
! Do not pour the milk into the infant's mouth. Hold the cup to the infant's lips and
let the infant take it.
! When the infant has had enough, he/she will close its mouth and take in no more
milk.
! Measure the infant's intake at each feeding over 24 hours.
* Low-birthweight infants will start to take milk with the tongue. A full-term or older infant will suck the milk, spilling
some.
! WHO, UNICEF, and USAID. 2004. HIV and infant feeding counselling tools. Currently in print, to be available in
late 2004 from http://www.who.int/child-adolescent-health/NUTRITION/HIV_infant.htm
! WHO and UNAIDS. 2003. HIV and infant feeding: Guidelines for decision-makers, Retrieved 30 July 2004, from
http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/HIV_IF_DM.pdf
Retrieved 30 July 2004, from http://www.who.int/child-adolescent-
health/New_Publications/NUTRITION/HIV_IF_MS.pdf

APPENDIX4-C Feeding from 6–24 months
All infants, including infants who continue to be breastfed, require nutritious foods
beginning at about 6 months of age. The term complementary food refers to any food,
whether manufactured or locally prepared, suitable as a complement to breastmilk or a
breastmilk substitute. This term is preferred because it implies that the newly introduced
foods are provided in addition to the milk feeds; they are not intended to replace milk at
this point. Replacement feeding describes the use of alternative foods when there is no
breastfeeding, such as a commercial or home-modified breastmilk substitute.
Infants should receive continued frequent breastfeeding or cup feeding with commercial
infant formula or other milk into the second year of life.
Recommendations for complementary feeding should be based on locally available
foods and feeding practices. General principles for complementary feeding include the
following:
Introducing complementary foods

! Begin introducing complementary foods in small amounts at 6 months of age. The
amount of food required will increase as the child gets older. (See table below.)
! After complementary foods have been introduced, the infant will continue to need
breastmilk or milk in some form frequently throughout the day.
! For infants who are not breastfed, animal milk requirements after 6 months are about
1 to 2 cups per day.
! Infants older than 6 months do not require dilution of animal milks. However, fresh
animal's milk should still be boiled.
! No special preparation is needed for processed, pasteurised, or ultra-heat treated
(UHT) milk. However, the mother or caregiver should increase the number of comple-
mentary feedings as the child gets older. The appropriate number of feedings
depends on the energy density of the local foods and the usual amounts consumed
at each feeding. When no milk is available, the diet should include other animal-
source foods and/or enriched foods.
! The table on the next page shows the type, frequency, and amounts of complemen-
tary foods that the average healthy infant requires at different ages. If the energy
density or the amount of food per meal is low, more frequent feedings may be
required.
! Energy requirements are higher for unhealthy infants because of the metabolic
effects of infections. Energy requirements also are higher for infants who are severely
malnourished and undergoing nutritional rehabilitation.
! Gradually increase food consistency and the variety of foods offered as the infant
gets older, adapting to the infant's nutritional requirements and physical abilities.

APPENDIX 4-C Feeding from 6–24 months (continued)
Age Texture Frequency Amount at each

meal+
6 months Soft porridge; well 2 times a day plus 2–3 tablespoons
mashed frequent milk
vegetable, meat, feeds
or fruit

7–8 Mashed foods 3 times a day plus 2/3 cup
months frequent milk
feeds
9–11 Finely chopped or 3 meals plus 1 2/3 cup
months mashed foods, snack between
and foods that
baby can pick up
12–24 Family foods, 3 meals plus 2 1 full cup
months chopped or snacks between
mashed if meals plus milk
necessary feeds
If baby is not breastfed, give in addition: 1-2 cups of milk per day, and 1-2 extra meals
per day
+ This chart should be adapted to the local context, using local utensils to show the amount
One cup = 250 ml
! Offer children 6 months and older an increasing variety of nutrient-dense foods. On a

daily basis, or as often as possible, they should eat animal foods such as meat, poul-
try, fish, eggs, dairy products, or other adequate local sources of protein. Children
should also eat fruit and vegetables that are rich in vitamin A daily. Satisfying the
nutritional needs of children in this age group through a vegetarian diet is difficult.
! If nutritionally adequate complementary foods or fortified complementary foods are
not available locally, consider giving the child a vitamin-mineral supplement to avoid
growth and development deficiencies.
! Mothers and caregivers should avoid giving drinks with low nutrient value, such as
tea and coffee (which interfere with iron absorption) and sugary drinks such as soda.
The amount of juice offered should be limited to avoid displacing more nutrient-rich
foods.
! Avoid offering foods that may cause choking, such as those that have a shape or
consistency that could cause the food to become lodged in the trachea. Foods to
avoid include nuts, grapes, and raw carrots.
Responsive feeding
! Feed infants directly and assist older children when they feed themselves, being sen-
sitive to when the infant or child is hungry or full.
! Feed slowly and patiently, encouraging the child to eat, but do not force food.
! Encourage food intake by experimenting with different food combinations, tastes, and
textures, especially if the child refuses to eat.
! Minimise distractions during meals if the child loses interest easily.
! Remember that feeding times are periods of learning and love: talk to children during
feeding, using eye-to-eye contact.

APPENDIX 4-C Feeding from 6–24 months (continued)
Good hygiene and proper food handling

! Wash hands before food preparation and eating.
! Store foods safely and serve foods immediately after preparation.
! Use clean utensils to prepare and serve food.
! Use clean cups and bowls to feed children.
! Avoid using feeding bottles, which are difficult to keep clean.
Feeding children with allergies and illnesses

Mothers and caregivers of infants and young children with a family history of allergies or
food sensitivities should delay introducing cow's milk, egg whites, and fish until after the
infant reaches 12 months of age, and should not feed the child peanuts or other nuts
until after the child is 3 years old.
When the child’s age permits, mothers and caregivers should give the child increased
amounts of fluids when they are ill, and encourage them to eat semisolid or solid foods.
After the illness, mothers and caregivers should offer their children at least one extra
meal a day and encourage them to eat more.
! WHO, UNICEF, and USAID. 2004. HIV and infant feeding counselling tools. Currently in print, to be
available in late 2004 from http://www.who.int/child-adolescent-health/NUTRITION/HIV_infant.htm
! WHO and UNAIDS. 2003. HIV and infant feeding: Guidelines for decision-makers, Retrieved 30 July
2004, from http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/HIV_IF_DM.pdf
Retrieved 30 July 2004, from http://www.who.int/child-adolescent-health/New_Publications/NUTRI-
TION/HIV_IF_MS.pdf

Module 5 Stigma and Discrimination
Module 5 Stigma
Related to MTCT
Total Time: 180 minutes (120 minutes if alternative exercise 5.3 is used
rather than the PLWHA panel)
SESSION 1 Introduction to the Concepts of Stigma and Discrimination and

International Human Rights
Exercise 5.1: Labels Notecards or sheets of 8.5" x 11" or A4 60 minutes

interactive game paper (one per person participating in the
interactive game)
Tape
SESSION 2 Values Clarification (Individual Perspective)
Exercise 5.2 Examples of 30 minutes

stigma and discrimination: None, other than those listed below
large group discussion
SESSION 3 Dealing with Stigma and Discrimination in Healthcare Settings and

Communities
Exercise 5.3 PLWHA See Appendices 5-B & 5-C. 90 minutes

Panel Note: preparation for the PLWHA Panel
or should begin about 1 month before the
training.
Index card or pieces of paper for questions
Basket or box
Alternative Exercise 5.3 See Appendix 5-D. 30 minutes
Stigma and discrimination: Copies of Case Study for participants
case study

Session 1
! National policies on discrimination, equal rights, and human rights
Module 5 Stigma
! National policies on discrimination, equal rights, and human rights relevant to

people with HIV
! Local or national policies regarding patient rights within PMTCT and ANC services
The Pocket Guide contains a summary of Sessions 1 and 3.
Module 5–2 Stigma and Discrimination Related to MTCT

SESSION 1 Introduction to the Concepts of Stigma and
Discrimination and International Human Rights
Advance Preparation
Prepare for Exercise 5.1 Labels interactive game by writing on a note card
(or piece of paper) a "label" for a person who is HIV-infected and could be
stigmatised or stereotyped. Prepare enough "labels" so that each
participant receives one. Write the labels large enough that participants
are able to see them across the room. Labels could include:
Module 5 Stigma
! Man with HIV infection ! Clergy with HIV infection
! Sex worker ! Housewife with HIV infection
! Child with HIV infection ! Gay man
! Government official ! Gay woman
! Woman with HIV ! Mother who is HIV-positive
! Drug user
On the remaining note cards or pieces of paper, write generic labels of
people not usually associated with HIV/AIDS-related stigma or
stereotyping (for example, doctor, nurse, healthcare worker, or training
participant).
Lead the group through the following exercise. It is recommended that the facilitator
participate in this exercise.
Note This exercise works best if started immediately prior to introducing the module,
preferably either as participants return from a lunch or tea/coffee break or first thing in
the morning, depending on the time of day.
Exercise 5.1: Labels interactive game
Purpose To help recognise the role of stereotypes in stigma.

Duration 20 minutes
Introduction As each participant enters the room, attach—by tape or safety pin—a
"label" on his or her back (without letting the participant see the label).
Explain that each person has a label. During this exercise, the
participants should behave toward each other as society might treat a
person with the label each person is wearing.
Activities ! Ask the group to mingle and chat with each other, reacting to others
according to the label they are wearing, but without telling them what
the label is.
! After 5 to 7 minutes, ask the group to sit in their seats.

Debriefing Start the discussion by asking the following questions:
! Who can guess what their label is?
! How did it feel to be treated in a stereotyped way?
! What was the experience like for you?
! Were you puzzled or surprised by how you were treated?
After the initial discussion, ask the group to take the labels off their
backs and look at them.
Ask the group to identify specific ways to combat stereotypes and

Module 5 Stigma
help decrease stigma in their clinical settings. Write the participants’

suggestions on the flip chart, whiteboard, or blackboard.
Encourage each person to "de-role" by stating their name and

something positive about themselves.
Slides 1, 2 and 3
Review module objectives.
Explain that upon completion of this module, the participants will be able to:
! Define and identify HIV/AIDS-related stigma and discrimination.
! Better understand international and national human rights issues.
! Clarify personal values and attitudes with regard to HIV/AIDS prevention and care.
! Know how to address stigma and discrimination in the context of providing PMTCT
services.
Slide 4
Introduce the concepts of stigma and discrimination, as discussed on the next page.

Introduction to the concepts of stigma and discrimination
HIV/AIDS is not only the greatest health challenge of our time, but it is also the greatest
human rights challenge. Those aware they are HIV-infected shoulder the twin burdens
of stigma and discrimination. Fear of becoming infected underlies stigma and
discrimination, which remain major impediments to preventing HIV transmission and
providing treatment, care, and support to people who are HIV-infected and their families.
HIV/AIDS-related stigma is increasingly recognised as the single greatest challenge to
slowing the spread of the disease at the global, national, and community/provider level.
The most effective responses to the HIV/AIDS epidemic are those that work to prevent
the stigma and discrimination associated with HIV, and to protect the human rights of
Module 5 Stigma
people living with HIV and those at risk of infection.
What is stigma?
Stigma refers to unfavourable attitudes and beliefs directed toward someone or
something.
HIV/AIDS-related stigma
HIV/AIDS-related stigma refers to all unfavourable attitudes and beliefs directed toward
people living with HIV/AIDS (PLWHA) or those perceived to be infected, and toward their
significant others and loved ones, close associates, social groups, and communities.
Stigmatising attitudes are often directed not only toward the person with HIV, but also
toward behaviours believed to have caused the infection. Stigma is particularly
pronounced when the behavior linked to the origin of a particular disease is perceived to
be under the individual’s control, such as prostitution or injection drug use.
People who often are already socially marginalised—poor people, indigenous

populations, men who have sex with men, injection drug users, and sex workers—
frequently bear the heaviest burden of HIV/AIDS-related stigmatisation. People who are
HIV-infected are often assumed to be members of these groups, whether they are or not.
Make These Points

! Emphasise that HIV/AIDS stigma is often more severe than stigma associated with
other diseases.
! HIV transmission is believed to be under the control of the individual, so unlike
tuberculosis, for example, people with HIV may be blamed for their illness.
! In many settings, people who are affected by HIV are the same people who are
already marginalised in society, ie, poor people and indigenous people.
Slides 5 and 6
Discuss discrimination as well as the difference between stigmatisation and

discrimination, as described in the box on the next page.

What is discrimination?
Discrimination is the treatment of an individual or group with partiality or prejudice.
Discrimination is often defined in terms of human rights and entitlements in various
spheres, including healthcare, employment, the legal system, social welfare, and
reproductive and family life.
Stigmatisation and discrimination

Stigmatisation reflects an attitude, but discrimination is an act or behaviour.
Discrimination is a way of expressing, either on purpose or inadvertently, stigmatising
thoughts.
Module 5 Stigma
Stigma and discrimination are linked. Stigmatised individuals may suffer discrimination
and human rights violations. Stigmatising thoughts can lead a person to act or behave
in a way that denies services or entitlements to another person.
Stigma and discrimination have been documented in association with other disfiguring
or incurable infectious diseases, including tuberculosis, syphilis, and leprosy. However,
HIV/AIDS-related stigma appears to be more severe than the stigma associated with
other life-threatening infectious diseases.
Three phases of the HIV/AIDS epidemic

Three phases of the HIV/AIDS epidemic have been identified: the epidemic of
HIV; the epidemic of AIDS; and the epidemic of stigma, discrimination, and denial.
The third phase is as central to the global AIDS challenge as the disease itself.
Examples of discrimination
! A person with HIV is denied services by a healthcare worker.
! The wife and children of a man who recently died of AIDS are ostracised from the
husband's familial home or village after his death.
! An individual loses his job because it becomes known that he/she is HIV-infected.
! A person finds it difficult to get a job once it is revealed that he/she is HIV-infected.
! A woman who decides not to breastfeed is assumed to be HIV-infected and is
ostracised by her community.

Slide 7
Discuss international human rights and HIV-related stigma, using the information below.
Make These Points

Summarise any pertinent national/local laws related to human rights and HIV-related
stigma or discrimination.
Module 5 Stigma
International human rights and HIV-related stigma and discrimination
Freedom from discrimination is a fundamental human right founded on principles of
natural justice that should be universally applied to people everywhere. According to
recent United Nations Commission on Human Rights resolutions, "discrimination on the
basis of HIV/AIDS status, actual or presumed, is prohibited by existing human rights
standards." In other words, discrimination against PLWHA or people thought to be
infected is a clear violation of human rights.
The forms of stigma and discrimination faced by people with HIV/AIDS are varied and
complex. Individuals are stigmatised and discriminated against not only because of their
HIV-positive status but also because of what that status implies. UNAIDS-sponsored
research in India and Uganda showed that women with HIV/AIDS may be doubly or triply
stigmatised—as women, as PLWHA, as the spouse of a person who is HIV-infected, or
the widow of a person who died of AIDS. A woman may face additional stigmatisation as
a "woman who is HIV-infected and is pregnant and/or has children.” For example, she
may be treated poorly or denied medical and psychosocial support services.
Slides 8 and 9
Discuss the role of the PMTCT programme in protecting, respecting, and fulfilling
human rights as described in the box below.
Make These Points

! Review the specific rights listed below one at a time and invite participants to com-
ment on popular cultural views on each of these rights.
! Explain that gender relationships in a culture have an impact on human rights and on
vulnerability to becoming infected with HIV.

Protect, respect, and fulfill human rights in relation to HIV
! All women and men, irrespective of their HIV status, have a right to determine the
course of their sexual and reproductive lives and to have access to information
and services that allow them to protect their own and their family’s health.
! Children have a right to survival, development, and health.
! Women and girls have a right to information about HIV/AIDS and access to the
means of protecting themselves against HIV infection.
! Women have the right to access to HIV testing and counselling and to know their
HIV status.
Module 5 Stigma
! Women have a right to choose not to be tested or to choose not to be told the
result of an HIV test.
! Women have a right to make decisions about infant feeding, on the basis of full
information, and to receive support for the course of action they choose.
A summary of the International Guidelines on HIV/AIDS and Human Rights, as adopted

by the Second International Consultation (July 2002), can be found in Appendix 5-A.
These 12 guidelines urge governments to review laws, policies, systems, and practices
to ensure protection of the human rights of people at-risk for or infected with HIV.

SESSION 2 Values Clarification (Individual Perspective)
Advance Preparation
Review the examples of stigma and discrimination provided for this session
in Exercise 5.2 and consider local examples that could be included in this
list.
Module 5 Stigma
Discuss how stigma is expressed, using the information below.
The face of stigma

HIV/AIDS-related stigma is complex, dynamic, and deeply ingrained. The points below
may provide PMTCT programmes with a framework for developing and implementing
interventions to address HIV/AIDS-related stigma and discrimination.
Attitudes and actions are stigmatising.

People are often unaware that their attitudes and actions are stigmatising. A word,
action or belief may be unintentionally stigmatising or discriminatory toward an individual
who is HIV-infected. People often exhibit contradictory beliefs and behaviours. For
example, consider the following:
! A person who is opposed to stigmatisation or discrimination may simultaneously

believe that PLWHA indulge in immoral behaviours, deserve what they get, or are
being punished by God for their sins.
! A person who claims to know that HIV cannot be transmitted through casual contact
may still refuse to buy food from a vendor who is HIV-infected or allow his family to
use utensils once used by a PLWHA.
Choice of language may express stigma.

! Language is central to how stigma is expressed. People may not realise that they are
stigmatising with their choice of words in referring to HIV disease or PLWHA. One
way that language can be stigmatising is in the use of derogatory references to those
with HIV/AIDS. In some countries people refer to HIV, not by name, but rather indi-
rectly as, for example, "that disease we learned about" and refer to PLWHAs as
“walking corpse” and “expected to die”.

Lack of knowledge and fear foster stigma.
Knowledge and fear interact in unexpected ways that allow stigma to continue. Although
most people have some understanding of HIV transmission and prevention, many lack
in-depth or accurate knowledge about HIV. For example, many do not understand the
difference between HIV and AIDS, how the disease progresses, the life expectancy of
PLWHA, or that HIV/AIDS-related opportunistic infections (such as tuberculosis) are
treatable and curable. Others equate an HIV-positive test result with imminent death.
The fear of death is so powerful that many people will avoid individuals suspected to
have HIV—even though they know that HIV is not transmitted through casual contact.
Shame and blame are associated with HIV/AIDS.

Module 5 Stigma
Sexuality, morality, shame, and blame are associated with HIV/AIDS. Stigmatisation
often centres on the sexual transmission of HIV. Many people assume that individuals
who are HIV-infected must have been infected through sexual activities deemed socially
or religiously unacceptable. People who are HIV-infected are often presumed to be
promiscuous, careless, or unable to control themselves, and therefore responsible for
their infection.
Stigma makes disclosure more difficult.

Disclosure, the sharing of HIV status with others, is advocated but often difficult—and
uncommon—in practice. Most people believe that disclosure of HIV infection should be
encouraged. Yet many people infected with HIV avoid disclosing their HIV status for fear
that doing so will subject them to unfair treatment and stigma. Some of the benefits of
disclosure are the following:
! Disclosure can encourage partner(s) to be tested for HIV.

! Disclosure can help prevent the spread of HIV to partner(s).
! Disclosure allows individuals to receive support from partner(s), family, and/or
friend(s).
Stigma can exist even in caring environments.

Care and support can coexist with stigma. Caregivers who offer love and support to
family members living with HIV/AIDS may also exhibit stigmatising and discriminatory
behaviour (such as blaming and scolding). In many cases, the caregivers don't
recognise this behaviour as stigmatising.
! Stigmatising attitudes exist even among those individuals, communities and health-
care workers who are opposed to HIV/AIDS-related stigma.
! People can have both correct and incorrect information about HIV at the same time.
For example, an individual's understanding of the routes of HIV transmission may be
accurate in some respects but inaccurate in others.
! People express both sympathetic and stigmatising attitudes toward PLWHA.
! Families that provide genuine and compassionate care may sometimes stigmatise
and discriminate against a family member with HIV/AIDS.
Lead the participants in a discussion of examples of stigma and discrimination in a

variety of settings as described below.

Exercise 5.2 Examples of stigma and discrimination: large group discussion
Purpose To encourage participants to consider examples of stigma and

discrimination in their own settings.
Duration 10 minutes
Introduction Start the discussion by suggesting that many of us have either witnessed
or heard stories about cases of stigmatising and discriminatory treatment
of PLWHA.
Explain that this exercise provides an opportunity to share some of those
stories.
Module 5 Stigma
Activities ! Show Slide 13.
! Ask the participants to give examples of stigmatising or discriminatory
messages or attitudes in the media (newspapers, television, or radio
programmes). Give participants a couple of minutes to supply three or
four examples. If participants have difficulty citing examples in the
media category, offer the examples on the next page and move on to
the next category.
! Ask the participants for examples of stigmatisation or discrimination
they may have witnessed in healthcare settings. Again, if you need to
get the discussion restarted, refer to examples for this category in the
material below.
! Ask the participants for examples of stigmatisation or discrimination
they may have witnessed in the workplace.
! While still showing Slide 13, ask the participants for examples of
stigmatisation or discrimination that they have witnessed
! In the context of religion
! In the family or community
! Again, give the participants a few minutes to supply three to four
examples in each category.
! When participants offer examples that repeat patterns or themes
mentioned in the discussion of earlier categories, you can close the
discussion.
Debriefing ! Conclude by showing and explaining the effects of stigma as
described in the next section.
Make These Points

! Stigma and discrimination may be found in all aspects of society. Review the categories
listed below and compare with the lists developed by participants during Exercise 5.2.

Examples of stigmatisation and discrimination
In the media
! Suggesting in the media that there are specific groups of people with HIV who are
guilty (such as sex workers or injection drug users) whereas others (such as
infants) are innocent
! Depicting HIV/AIDS as a death sentence, which perpetuates fear and anxiety, and
labels HIV as a disease that cannot be managed like any other chronic disease
! Using stereotypical gender roles, which may perpetuate women's vulnerability to
sexual coercion and HIV infection
Module 5 Stigma
In health services
! Refusing to provide care, treatment, and support to PLWHA
! Providing poor quality of care for PLWHA
! Violating confidentiality
! Providing care in stand-alone settings (such as clinics for sexually transmitted
infections) that further stigmatise and segregate PLWHA
! Using infection-control procedures (such as gloves) only with patients thought to
be HIV-positive, rather than with all patients
! Advising or pressuring PLWHA to undergo procedures, such as abortion or
sterilisation, that would not be routinely suggested for others
In the workplace
! Requiring testing before employment
! Refusing to hire people who are HIV-infected and HIV-affected
! Mandating periodic HIV testing
! Being dismissed because of HIV status
! Violating confidentiality
! Refusing to work with colleagues who are HIV-infected because of fear of
contagion
In the context of religion
! Denying participation in religious/spiritual traditions and rituals (such as funerals)
for PLWHA
! Restricting access to marriage for PLWHA
! Restricting participation of PLWHA in religious activities
In the family and local community
! Isolating people who are HIV-infected
! Restricting participation of PLWHA in local events
! Refusing to allow children who are HIV-infected or HIV-affected in local schools
! Ostracising of partners and children of PLWHA
! Using violence against a spouse or partner who has tested HIV-positive
! Denying support for bereaved family members, including orphans

Slide 14
Discuss the effects of stigma, using the information below.
Effects of stigma
Stigma is disruptive and harmful at every stage of the HIV/AIDS continuum, from
prevention and testing to treatment and support. For example, people who fear
discrimination and stigmatisation are less likely to seek HIV testing while persons who
Module 5 Stigma
have been diagnosed may be afraid to seek necessary care. PLWHA also may receive
suboptimal care from workers who stigmatise them.
! Stigma may reduce an individual's choices in healthcare and family/social life.

! Stigma may limit access to measures that can be taken to maintain health and quality
of life.
HIV/AIDS-related stigma fuels new HIV infections.

! Stigma may deter people from getting tested for the disease.
! Stigma may make people less likely to acknowledge their risk of infection.
! Stigma may discourage those who are HIV-infected from discussing their HIV status
with their sex partners and/or those with whom they share needles.
! Stigma may deter PLWHA from adopting risk-reduction practices that may label them
as HIV-infected.
Stigma and discrimination can lead to social isolation.

A study in South Africa found that both men and women who are HIV-infected face
social isolation, rumours and gossip, ejection from the home, rejection by the
community, and verbal abuse. One person in the study stated, "There are those who will
tell you face-to-face that you are no longer needed in their friendship, those who will just
isolate you." Another said, "People make jokes about HIV-infected people and point
fingers at them."
Stigma and discrimination can limit access to services.

HIV/AIDS-related stigma and discrimination may discourage individuals from contacting
health and social services, thereby increasing the risk of transmission to partners or
children. In many cases, those people most in need of information, education and
counselling will not benefit from these services—even when they are available.
Secondary stigma (stigma by association)

The effects of stigma often extend beyond the infected individual to stigma by
association also known as secondary stigma. Secondary stigma is evidenced in
statements like "If I sit near someone with AIDS, others will think that I have AIDS too."
HIV/AIDS programme social workers and peer educators in South Africa reported that
they were sometimes stigmatised because of their work with PLWHA.

Stigma and PMTCT services
Stigma and discrimination pose distinct challenges to the delivery of PMTCT services.
Notably, in many areas women may avoid replacement feeding because they know that
they will be labelled as HIV-infected if they are not breastfeeding. The children of
mothers who participate in PMTCT programmes may experience secondary
stigmatisation because people assume that they are HIV-infected.
Slide 15
Module 5 Stigma
Discuss the consequences of stigma in the PMTCT programme setting.
Consequences of stigma in PMTCT programmes

! Discourages women from accessing antenatal care services
! Prevents people from receiving HIV testing and, as a result, PMTCT services
! Discourages women from discussing their HIV tests and disclosing results to
their partner(s)
! Discourages women from accepting PMTCT interventions eg, ARV teatment
and prophylaxis
! Discourages the use of recommended PMTCT safer infant-feeding practices
(replacement feeding or early cessation of breastfeeding)

SESSION 3 Dealing with Stigma and Discrimination in
Healthcare Settings and Communities
Advance Preparation
Prepare for Exercise 5.3 PLWHA Panel:
! See Appendix 5-B for information on planning and hosting a PLWHA

panel.
! When possible, about 1 month before the training course, contact an
Module 5 Stigma
AIDS service organisation to recruit 1 to 4 PLWHA who have publicly
disclosed their HIV status and who are comfortable and self-confident
talking about it.
! Brief the panellists about the training course, its objectives, and the
participants (who they are, their job positions, their attitudes toward
people with HIV).
! Advise the panellists that they may cancel their commitment at any
time and that they should not feel obligated to answer questions that
make them feel uncomfortable.
! Develop a question/interview guide. A sample guide appears in
Appendix 5-C at the end of this module. If you use the sample guide,
be sure to adapt it to local expectations.
Note: If panellists cannot be recruited, there is an Alternative exercise

5.3 Stigma and discrimination: case study in Appendix 5-D. If using the
alternative exercise:
! Adapt the case study so the characters and setting are more repre-
sentative of participants’ workplace(s). If necessary, interview PMTCT
staff to generate a case study based on actual examples of stereotyp-
ing and stigma in the community.
Total Session Time: 90 minutes for the PLWHA Panel (30 minutes if
using the Alternative Exercise 5.3)
Slides 16 and 17
Introduce the concept that each of us has a role in reducing the stigma and
discrimination directed to PLWHA. Interventions in which each of us can participate or
support can be implemented on many levels in a variety of settings.

Addressing stigma in PMTCT programmes
To increase participation in PMTCT services, programmes should implement interven-
tions that address HIV/AIDS-related stigma. These efforts should occur at all levels:
! National
! Community, social, and cultural
! PMTCT site
! Individual
Stigmatisation is a social process that must be addressed on the community level.

Because PMTCT healthcare workers and patients are influenced by the community and
culture in which they live, it is essential that PMTCT programmes collaborate with the
Module 5 Stigma
community to address HIV/AIDS-related stigma and discrimination. This session

presents various interventions that may be implemented by PMTCT programmes and
the communities they serve. These interventions cover a wide range of activities; each
programme should set priorities for initial interventions and phase in additional efforts
over time.
Slides 18 and 19
Discuss efforts to address HIV/AIDS-related stigma on the national level, as described

below.
National level
High-level political support for national HIV/AIDS initiatives and policies that address the
human rights of PLWHA is important. High-ranking politicians and other high-profile
individuals, such as television stars and musicians, may serve as leaders and role
models in these efforts. It is essential to secure both formal and informal support at the
national level, without which local initiatives will struggle to succeed.
National level activities that affect HIV/AIDS and PMTCT-related legislation and
healthcare practice may include the following:
! Support and advocate legislation that protects the rights of PLWHA as human beings
and patients.
! Support legislation that protects the legal rights of women in health care, education,
and employment.
! Advocate for laws supporting anti-discrimination policies—at the administrative, bud-
getary, and judicial levels.
! Support national efforts to scale-up treatment of HIV with antiretroviral (ARV) drugs
for those in need.
! Advocate for quality treatment programmes for people with drug addictions.
! Involve consumers in national advocacy and elicit their help in designing, developing
and evaluating programmes and policies.

! Advocate for sufficient funding for PMTCT services and staff training.
! Publicise programme successes by inviting national and local politicians to clinics to
see how PMTCT programmes work.
! Ensure that the problems—and solutions—are communicated to those who have the
power and authority to address them when issues require national level solutions
(such as national shortages in ARV prophylaxis and shortages in the supply of
breastmilk substitutes).
! Educate national leaders about the importance of PMTCT programmes.
! Encourage national leaders to serve as role models in their professional and personal
lives.
Encourage leaders to hire staff that are HIV-infected.
Module 5 Stigma
!
! Encourage leaders to praise the good work of PMTCT clinics to the public and to
the press.
! Encourage leaders to visit an AIDS service organisation.
! Encourage leaders to speak out against emotional, verbal and physical abuse
directed at women infected with HIV.
! Remind leaders to promote funding of HIV/AIDS care programmes.
! Suggest that leaders be tested for HIV.
Slides 20 and 21
Discuss community-level interventions, as described below.
Make These Points

! Communication about HIV/AIDS among members of a community is essential for nor-
malising HIV and reducing stigma.
! Discuss the concept "Silence = Death" and invite participants to identify particular
people in their communities who may be able to influence community perspectives on
HIV/AIDS in either their personal or professional roles.

Community level
HIV/AIDS education and training
Provide HIV/AIDS education and training to members of the community, especially key
opinion leaders, traditional birth attendants, traditional healers, healthcare staff in
referring organisations, religious leaders, and managers in private industry. Educational
and informational initiatives can accomplish the following:
! Increase knowledge about HIV

! Increase awareness of issues faced by PLWHA
! Increase awareness of domestic violence faced by newly diagnosed women
Communicate, through community leaders, that violence against women is
Module 5 Stigma
inappropriate, immoral, and/or illegal

! Encourage leaders to make their workplaces HIV-friendly
! Promote PMTCT activities as an integral part of healthcare and HIV/AIDS prevention
and treatment
! Educate the community about PMTCT interventions (including ARV prophylaxis and
safer infant-feeding practices), stressing the importance of community and family
support in PMTCT initiatives
! Increase referrals to and from PMTCT services
! Secure the involvement of community members and PLWHA in organising, develop-
ing, and delivering HIV education, prevention, and support programmes.
Community awareness of PMTCT interventions

Increase community awareness of PMTCT interventions to help men and women
recognise their roles and responsibilities in protecting themselves and their families
against HIV infection.
Greater community awareness should also strengthen social support for the partner,
extended family, and community. The people who cope the best with their HIV infection
tend to be those who have social and family support.
For example, families and close friends can help remind those with HIV infection take
their medicines on time. If the person with HIV is pregnant, family members often help
ensure that she gives birth at the health centre and that she takes her ARV prophylaxis.
They can also help ensure that the baby receives ARV prophylaxis and support infant-
feeding methods that reduce the risk of HIV transmission.
Community partnerships
Build partnerships with churches, schools, and social or civic organisations when develop-
ing PMTCT services. Promoting PMTCT services in community organisations will enhance
sustainability and will help develop a broad base of support for the PMTCT initiative.
Other community level interventions

Additional community level interventions may include the following:
! Facilitating the exchange of information and ideas among healthcare professionals and
other caregivers of PLWHA through roundtable case discussions and social activities
! Providing input into curricula for students in healthcare professions (nurses, mid-
wives, physicians)

PLWHA involvement
Invite PLWHA to become involved in national and local initiatives. Doing so will
empower them. It will also help the community realise that PLWHA are not the cause of
the HIV/AIDS problem but are part of the solution. Involving PLWHA in initiatives will:
! Help PLWHA gain and practise life skills in communication, negotiation, conflict reso-
lution, and decision-making, which empowers them to challenge HIV/AIDS-related
stigma and discrimination
! Encourage PLWHA to join together to challenge stigma and discrimination.
! Promote the active involvement of PLWHA in national and local activities to foster
positive perceptions of people living with HIV
Module 5 Stigma
! Support the establishment of PLWHA organisations and networks, including those
that enable people to demand recognition and defend their rights
Training programmes for PLWHA

Develop and implement training programmes for PLWHA to help them advocate for their
rights and take an active role in their own healthcare. By participating in interventions
(such as PMTCT services or HIV prevention and care education) as volunteers,
advisors, board members, or paid employees, PLWHA will demonstrate their ability to
remain productive members of the community. This normalises the experience of living
with HIV infection.
Discuss interventions at the PMTCT programme level, using the information below.
PMTCT programme level

PMTCT services should be integrated into and supported by the local community.
Although PMTCT programmes often reflect the communities in which they are based,
they can take the lead in challenging long-held community perceptions and practices,
including stigmatisation of and discrimination against PLWHA and PMTCT patients.
Integration of PMTCT interventions into antenatal care (ANC) services

Integrate all PMTCT interventions into mainstream antenatal care (ANC) services for all
women. Offer voluntary HIV testing and education to all clinic attendees, regardless of
their perceived HIV risk. Mainstreaming (or bundling) HIV services with routine ANC
services helps normalise HIV/AIDS.
Participation of partners
Develop ways to increase the participation of partners in all aspects of PMTCT services.
Educate partners about PMTCT interventions (including ARV treatment and prophylaxis
and modified infant-feeding practices) and stress the importance of partner testing,
partner and family support in PMTCT, particularly with respect to ARV prophylaxis and
infant feeding.
As an example, two sites in Kenya invited men to visit the PMTCT clinic for counselling
and testing and PMTCT education designed specifically for a male audience. As a result
of these interventions, the programme:

! Improved spousal communication about PMTCT
! Increased HIV testing among male partners of PMTCT patients
! Increased HIV test disclosure rates for both partners
Educational sessions
Offer group or individual education sessions (onsite and offsite), which can help draw
attention to the role that partners play in HIV transmission and reduce stigmatisation of
women.
! Couples counselling offers another opportunity to reduce the blame that can be
directed at women and emphasise the couple's shared responsibility in PMTCT.
Module 5 Stigma
When male partners do not normally attend ANC clinics, PMTCT

programmes should reach out to them in male-friendly settings
(eg workplaces, barber shops, bars, cafeterias).
Healthcare worker training

Educate and train healthcare workers. The success or failure of a PMTCT programme
depends upon the attitudes, skills, and experience of its employees. Training healthcare
workers at all levels (manager, nurse, midwife, physician, social worker, counsellor and
outreach worker) is critical to the success of PMTCT initiatives. Employee training
should include:
! Complete and accurate information about the transmission of HIV and the risks fac-
tors for infection
! Activities that address HIV/AIDS-related stigma
Understanding the perspectives and rights of PLWHA and their families

In addition to presenting information, it is important for educational initiatives to address
employee attitudes, correct misinformation, and assess skills.
Educate healthcare workers to better understand the perspectives and rights of PLWHA
and their families. Without adequate HIV-related education, staff may have irrational
fears, practise inappropriate care, and use stigmatising language and behaviour.
Accordingly, training healthcare workers to reduce stigmatising behaviour will address
assumptions about the educational, social, economic, and class status of PLWHA and
encourage participants to examine their prejudices.
During training activities, strive to increase awareness of the language used to describe
HIV/AIDS and PLWHA. The training should include:
! Exercises designed to encourage participants to explore personal attitudes and preju-
dices that might lead them to use stigmatising language
! Summaries of institutional confidentiality, anti-discrimination, and infection control poli-
cies as well as the consequences of policy breaches and grievance procedures
If possible, at least one member of the PMTCT staff should have special training in HIV
testing and counselling and infant feeding. If possible, a member of the staff should also
receive additional training in screening, counselling, and referral of women experiencing
or at risk of domestic violence.

Infection control
Ensure infection control by providing all healthcare workers with the necessary equip-
ment and supplies (including high-quality, well-fitting gloves) needed to adhere to infec-
tion control policies and prevent transmission of HIV in the workplace (See Module 8:
Safety and Supportive Care in the Work Environment). Apply universal precautions to all
patients regardless of assumed or established HIV status.
Patient confidentiality
Safeguard patient confidentiality by developing policies and procedures and establishing
discrete plans for implementing them. Confidentiality in healthcare facilities is also
discussed in Module 6, HIV Testing and Counselling for PMTCT. Confidentiality policies
should include:
Module 5 Stigma
! Directions on how to record and securely store patient information
! Assurances that neither PLWHA nor their medical files (whether paper or electronic)
will be labelled to reveal HIV status
! Assurances that all patient consultations, from the initial contact with the receptionist
to the consultation with the physician, will respect personal information
The confidentiality policy should emphasise that all personal conversations and
consultations should take place in private settings. It should also establish:
! Policies for disclosure of medical information to a patient's family (which should only
occur with the patient's informed consent)
! Policies for addressing and disciplining breaches of confidentiality
! Steps patients can take to address breaches of confidentiality
! Requirements for staff confidentiality training
! The critical importance of confidentiality and the effects that breaches may have on
individual patients and the PMTCT service as a whole
Role models
Encourage PMTCT staff to serve as role models by treating PLWHA just as they would
treat patients assumed to be HIV-negative. Healthcare workers are role models, and
their attitudes toward PLWHA are often imitated in the community. Staff should aim to
normalise all casual contacts with PLWHA.
Knowing the local community

Get to know the local community, which will help to identify local HIV-related stereotypes
and rumours. Ensure that these misconceptions are addressed at appropriate times
during PMTCT services. In many cultures, for example, women who bottle-feed or cup-
feed their infants may be labelled as HIV-infected. In such cultures, PMTCT workers
should address this stereotype during counselling and educational sessions and
emphasise the importance of safer infant-feeding practices for reducing MTCT.
Women’s rights
Advocate for women's rights. Ensure that women diagnosed with HIV are educated
about their rights and know where to turn for help, including legal advice, to challenge
discrimination and stigmatisation.
Peer and community support

Facilitate peer and community support. Recognise that support groups in the ANC
setting provide an opportunity for pregnant women who are HIV-infected to share
experiences and be linked to other support services. PMTCT programmes can facilitate
such support groups by:

! Supporting mentoring programmes. South Africa's Mothers-to-Mothers-to-Be is a
mentorship programme for pregnant women who are HIV-infected. Mothers who are
HIV-infected and have recently given birth return to the ANC facility as mentors to
educate, counsel, and support pregnant women who are HIV-infected.
! The mother-mentors share personal experiences to encourage adherence to treat-
ment, help with making infant-feeding decisions, and assist with negotiating care and
support services. The mentoring has resulted in better understanding and greater
acceptance of interventions to reduce MTCT.
! Encouraging peer support. Encourage PLWHA to pair up with another person—HIV-
positive or negative—who can provide friendship, companionship, advice, or mentoring.
Involving PLWHAs in PMTCT programmes can help address stigma and discrimination
Module 5 Stigma
issues and promote better understanding of and support for those with HIV infection.
Counselling and education for PLWHA

Counselling and education for PLWHA, provided either within the PMTCT service or
through linkages to other services, can address HIV-related stigma in a number of ways:
! Counsellors can encourage, empower, and support PLWHA to disclose their HIV sta-
tus to family and eventually to friends. As more people disclose their HIV status,
PLWHA become more visible, which encourages community acceptance of PLWHA.
! Counsellors should be trained to ask all their patients, particularly women, about
domestic violence. Women found to be at risk of physical, verbal, or emotional abuse
should receive support and referrals.
Slide 25
Discuss the responsibilities of PMTCT Programme Managers as described below.
Make These Points

! Early involvement of supervisory staff in the PMTCT programme is essential for
reducing stigma and discrimination.
! The commitment of the programme manager is key to effectively implementing poli-
cies that will facilitate access to and use of PMTCT programmes.

Role of PMTCT programme managers
It is vital for PMTCT programme managers to ensure that policies and procedures are in
place to protect individuals from discrimination and stigmatisation. PMTCT programme
managers also play an important role in the development, implementation, and
enforcement of confidentiality policies. Some of the actions managers can take to
reduce stigma and discrimination include the following:
! Maintain policies against discriminatory recruitment and employment practices.
! Support workers who are HIV-infected so they continue to perform optimally in their
positions.
! Offer flexible hours and access to healthcare services.
Establish policies that guarantee all patients equal treatment regardless of HIV status.
Module 5 Stigma
!
! Ensure procedures for reporting discrimination and protocols for disciplining staff who
breach the non-discrimination policy.
! Promote the programme's policies to staff and patients, and remind patients that they
can file a complaint if they feel they have been the target of discrimination.
In addition, programme managers can also help ensure that all staff follow universal
precautions, which may reduce the stigma associated with fear of infection. The
manager can:
! Update the facility's infection control policy as necessary.
! Ensure ongoing access to infection control supplies and equipment.
! Make sure that staff members apply universal precautions at all times.
! Discipline employees who breach the universal precautions policy.
! Make post-exposure prophylaxis (PEP) accessible to staff in cases of accidental
exposure to blood and body fluids as per national/local policy where it exists.
Facilitate the PLWHA panel, using Appendices 5-B and 5-C as guides.
Note: If a panel cannot be recruited the Alternative Exercise 5.3 Stigma and
discrimination case study is available in Appendix 5-D.
Exercise 5.3 PLWHA Panel
Purpose To give PLWHA an opportunity to share their experiences in the

healthcare system and to help educate healthcare workers.
Duration 60 minutes
Introduction Tell the group that you have invited a panel of PLWHA to speak
today.
Explain that discussing PMTCT and HIV/AIDS care from the

perspective of patients may help healthcare workers offer more
compassionate care.

Activities ! As noted in Appendix 5-B, this panel presentation should be
facilitated by an experienced moderator.
! The moderator should start the panel presentation after the
panellists are comfortably seated. Panellists should sit side-by-
side in the front of the training room so they are facing the
participants.
! The moderator should start the panel presentation by either
introducing the panellists or having them introduce themselves
(include panellists' names, positions, and agency/organisation).
Module 5 Stigma
! The moderator may start by asking the panellists questions

using an interview/question guide. (A sample of an interview
guide is included in Appendix 5-C.) Questions may be posed in
any order, and the moderator may ask a single panellist
multiple questions before moving on to the next panellist.
! The PLWHA should be treated as respected teachers
throughout their stay. If the panellists have agreed to a Q&A
format, the moderator should ensure that the participants'
questions are reasonable, the panellists are comfortable
answering them, and the participants remain compassionate
and nonjudgemental.
! The moderator should make sure the discussion is interesting
and stimulating and covers a variety of topics.
Debriefing Allow the opportunity for both panellists and participants to express
thoughts that triggered emotional responses during the discussion.
At the end of the session, the moderator should thank the

panellists.
Panel discussions are emotionally charged and thought-provoking.

Following the panel it is important to give participants a short tea
break.
Slides 26, 27, 28, 29 and 30
Review the key points of this module, as summarised in the box on the following page.

Module 5: Key points
! While stigmatisation reflects an attitude, discrimination is an act or behaviour.
! Discrimination is often defined in terms of human rights and entitlements in health
care, employment, the legal system, social welfare, and reproductive and family
life.
! Stigma and discrimination are interlinked. Stigmatising thoughts can lead to dis-
crimination and human rights violations.
! International and national human rights declarations affirm that all people have
the right to be free from discrimination on the basis of HIV/AIDS status.
Module 5 Stigma
! PMTCT programme staff have a responsibility to respect the rights of all women
and men, irrespective of their HIV status.
! HIV/AIDS-related stigmatisation and discrimination may discourage PLWHA from
accessing key HIV services. It may also:
! Discourage disclosure of HIV status
! Reduce acceptance of safer infant-feeding practices
! Limit access to education, counselling, and treatment even when services are
available and affordable
! PMTCT programme staff can help reduce stigma and discrimination in the health-
care setting, in the community, and on the national level.
! Encourage PMTCT staff to serve as role models by treating PLWHA just as they
would treat patients assumed to be HIV-negative.
! Involve PLWHAs in every aspect of the PMTCT programme.
! Promote partner participation and community support.

APPENDIX 5-A International Guidelines on HIV/AIDS and
Human Rights
GUIDELINE 1:
States should establish an effective national framework for their response to HIV/AIDS,
which ensures a coordinated, participatory, transparent and accountable approach,
integrating HIV/AIDS policy and programme responsibilities across all branches of
government.
GUIDELINE 2:
Module 5 Stigma
States should ensure, through political and financial support, that community
consultation occurs in all phases of HIV/AIDS policy design, programme implementation
and evaluation and that community organisations are enabled to carry out their
activities, including in the field of ethics, law and human rights, effectively.
GUIDELINE 3:
States should review and reform public health laws to ensure that they adequately
address public health issues raised by HIV/AIDS, that their provisions applicable to
casually transmitted diseases are not inappropriately applied to HIV/AIDS and that they
are consistent with international human rights obligations.
GUIDELINE 4:
States should review and reform criminal laws and correctional systems to ensure that
they are consistent with international human rights obligations and are not misused in
the context of HIV/AIDS or targeted against vulnerable groups.
GUIDELINE 5:
States should enact or strengthen anti-discrimination and other protective laws that
protect vulnerable groups, people living with HIV/AIDS and people with disabilities from
discrimination in both the public and private sectors, ensure privacy and confidentiality
and ethics in research involving human subjects, emphasise education and conciliation
and provide for speedy and effective administrative and civil remedies.
GUIDELINE 6:
States should enact legislation to provide for the regulation of HIV-related goods,
services and information, so as to ensure widespread availability of qualitative
prevention measures and services, adequate HIV prevention and care information, and
safe and effective medication at an affordable price.
GUIDELINE 7:
States should implement and support legal support services that will educate people
affected by HIV/AIDS about their rights, provide free legal services to enforce those
rights, develop expertise on HIV-related legal issues and utilise means of protection in
addition to the courts, such as offices of ministries of justice, ombudspersons, health
complaint units and human rights commissions.

APPENDIX 5-A International Guidelines on HIV/AIDS and
Human Rights (continued)
GUIDELINE 8:
States, in collaboration with and through the community, should promote a supportive
and enabling environment for women, children and other vulnerable groups by
addressing underlying prejudices and inequalities through community dialogue, specially
designed social and health services and support to community groups.
GUIDELINE 9:
Module 5 Stigma
States should promote the wide and ongoing distribution of creative education, training
and media programmes explicitly designed to change attitudes of discrimination and
stigmatisation associated with HIV/AIDS to understanding and acceptance.
GUIDELINE 10:
States should ensure that government and the private sector develop codes of conduct
regarding HIV/AIDS issues that translate human rights principles into codes of
professional responsibility and practice, with accompanying mechanisms to implement
and enforce these codes.
GUIDELINE 11:
States should ensure monitoring and enforcement mechanisms to guarantee the
protection of HIV-related human rights, including those of people living with HIV/AIDS,
their families and communities.
GUIDELINE 12:
States should cooperate through all relevant programmes and agencies of the United
Nations system, including UNAIDS, to share knowledge and experience concerning
HIV-related human rights issues and should ensure effective mechanisms to protect
human rights in the context of HIV/AIDS at international level.
Source: OHCHR, UNAIDS. 2002. HIV/AIDS and Human Rights International Guidelines, Revised Guideline 6: Access to
prevention, treatment, care and support. Geneva, August 2002, pp 10–12.

APPENDIX 5-B Guidelines for PLWHA panels
Purpose Learners will gain insight into the psychological and physical
effects of HIV infection, the role of health policy, and the grief and
loss experienced by survivors of persons who die of HIV/AIDS.
Room Setup Ensure panellists are comfortable and can be seen and heard by
all audience members. Chairs at a skirted table set up on a raised
platform may be preferable; podiums may be intimidating for
Module 5 Stigma
panellists. Ensure each panellist has access to a microphone, if

available, and to a glass of water.
Instructions Several steps are involved in developing a panel of HIV-affected

individuals:
Choose a qualified facilitator. The facilitator (or moderator) must

have experience working with and leading groups (eg, a social
worker, psychologist, or nurse experienced in caring for PLWHA.
Meet with the facilitator at least one week prior to the panel
presentation to review the purpose of the exercise and the role of
the facilitator. Provide practice questions for the panel and
discuss strategies for averting problems.
Obtain suggestions for panellists and respect confidentiality.

When looking for people who would be willing to serve on a
PLWHA panel, consult with a local AIDS service organisation’s
staff and with healthcare workers for references and sources. Ask
them to suggest several potential panellists. Be sure not to
schedule too far in advance, in case the individual becomes too ill
to participate.
In accordance with confidentiality policies, do not identify by name

any speaker who is HIV-infected in written agendas or printed
materials without his or her explicit permission. Ask the referring
agency or individual for suggestions on ways to contact panellists
without compromising their anonymity.
Interview potential panellists in advance. Interview panellists

beforehand to ensure they will be able to comfortably and
succinctly articulate the impact of HIV/AIDS on their lives. Assess
whether the prospective panellists have central nervous system
(CNS) symptoms—a PLWHA with confusion, depression, or poor
concentration is usually not appropriate for a panel. PLWHA and
family members who express a great deal of anger may make
audience members and other panel members defensive or angry,
preventing the group from achieving the purpose of the exercise.

APPENDIX 5-B Guidelines for PLWHA panels (continued)
Instructions Budget for panel honoraria and expenses. Whenever possible,

(continued) pay panellists an honorarium and offer food, transportation, and
child care reimbursement, as needed. If policy allows, be
prepared to make payments in cash on the day of the panel
workshop. Make sure to obtain a signed receipt from panellists.
Prepare the panel. Make initial contact to assess the individual's
Module 5 Stigma
willingness to participate in the panel. Provide information about
the date, time, and objectives of the activity.
About 3 to 7 days before the event, contact the panellists to see

whether they have questions about the panel and to assess their
physical health. Also discuss which issues they are planning to
focus on and review concerns regarding anonymity
(photographers, media presence).
The facilitator's role is critical to the panel's success. The

facilitator can:
! Arrange to meet with all panellists before the panel to help

alleviate their anxiety.
! Review the format for the panel: time allowed for each
presentation, when and how the audience will ask questions.
! Ask panellists how they would prefer to be introduced to the
audience. Panellists may prefer to introduce themselves so
they control how much identifying information they disclose.
! Be supportive. Assure panellists that they may refuse to
respond to any question—at any time and for any reason.
! When the panellists are speaking, monitor time closely to
ensure that everyone gets a chance to speak. Gently remind
panellists when they are exceeding the time limit.
! Facilitate Q&A.
! At the end of the panel discussion, the facilitator should be
available to provide panellists with support and to thank each
panellist.
Adapted from Mountain-Plains Regional AIDS Education and Training Center. 1994. HIV/AIDS
Curriculum, 5th Edition. Mountain-Plains Regional AETC: Denver, CO.

APPENDIX 5-C Sample question guide to be used with
PLWHA panellists
Directions: The following is a sample question guide to be used with a panel of people
with or affected by HIV. This list covers extensive ground. Do not attempt to address
every question.
Adapt this list to suit the focus and objectives of your panel and to the willingness of
panellists to discuss a topic area. Delete unnecessary questions, highlight key
questions, and add questions as necessary.
Module 5 Stigma
Share your question guide with the panellists prior to the day of the panel.
Please start by telling us about yourself, focusing on the history of your HIV infection.
1. Testing and counselling

! When were you diagnosed?
! What was it that made you go for the HIV test?
! How was the test result conveyed to you?
! How did you react after you were told that you were HIV-positive?
! What happened that night? How about later that week?
! What questions did you have during that first week?
! In retrospect, how can we improve our services to better anticipate the
needs of people who are newly diagnosed with HIV?
2. Disclosure
! Who was the first person you told about your HIV status?
! What was the person’s reaction?
! Tell us about other reactions you have received.
! Who has been supportive?
! Do you work? Were you working at the time you were diagnosed?
! If so, do they know you are HIV-infected?
! How did your supervisors and colleagues react?
! How did the healthcare system receive you?
! Tell us about the care you received.
3. HIV-related care
! How did the healthcare system receive you?
! Tell us about the care you received.
4. PMTCT
! If you could design a PMTCT service, what would you make sure was
included?
! What is important about the staff we recruit?

APPENDIX 5-D Alternative exercise 5.3
This exercise is optional and may be used in settings where a PLWHA panel cannot be
recruited.
Alternative Exercise 5.3 Stigma and discrimination: case study
Purpose To explore our own culturally-conditioned feelings and attitudes

with respect to HIV/AIDS-related stigma and discrimination.
Module 5 Stigma
To discuss any inadvertent breaches of confidentiality that may
have perpetuated stigma and discrimination.
To consider ways that we, as healthcare workers, can help

combat HIV/AIDS-related stigma and discrimination.
Duration 90 minutes
Introduction Explain that this exercise is a small-group discussion to explore

the face of stigma and ways that we as healthcare workers may
inadvertently perpetuate stigma.
Activities ! Separate participants into four small groups (ideally 3 to 5

people per group).
! Distribute copies of the case study to participants.
! Give participants approximately 15 minutes to discuss the case
study, ask the small groups to reconvene as a large group.
! Assign the following topic to the groups:
! First group: discuss the issues of stigma and discrimination
highlighted in the case study.
! Second group: present ideas for ways PMTCT services can
minimise stigma and discrimination.
! Third group: discuss community-based initiatives that could
be developed to reduce stigma and discrimination
! Fourth group: consider national policy/legal changes that
could be advocated
! Ask the groups to reconvene; then have each summarize the
primary points of their discussion. Ask the other groups if they
have anything else to add.
! Write the most important points on the flipchart.
Debriefing Close the exercise by asking participants to consider what they

can do to address HIV/AIDS-related stigma and discrimination in
their homes, workplaces, places of worship, communities, and
other settings.
Tell participants they may answer aloud or keep their responses

private.

APPENDIX 5-D Alternative exercise 5.3 (continued )
Case study
Two PMTCT nurses, Joan and Yvette, were in the ANC clinic break room. Their
conversation evolved from the usual discussion about family and children into a
discussion about Fay, a patient they saw earlier today. Joan and Yvette remembered
Fay quite clearly from the morning clinic, maybe because she is such an attractive and
outgoing woman or maybe because she was the first patient of the morning. They
couldn't help but talk about the fact that Fay, who is now 5 months pregnant with her
first child, was just diagnosed with HIV. Nor could they help speculating whether Fay's
Module 5 Stigma
husband (who is well-known in the community) is also HIV-infected—and if he is, where

he got infected.
The nurses were unaware that the window in the break room was open to the outside
courtyard, where Eunice, an afternoon ANC patient, had excused herself and her
mischievous toddler to wait for her appointment.
Eunice, who was related to Fay by marriage, went straight home after her appointment
and told her husband about Fay's HIV diagnosis. The next day Eunice's husband told a
friend at work who, a week later, mentioned the story in front of Fay's husband. Fay's
husband went home that night, accused Fay of being HIV-infected, and asked her to
leave the house.
Questions to consider:
! What about HIV/AIDS-related stigma and discrimination does this case study high-
light? (eg, How was Fay stigmatised? How was Fay discriminated against and by
whom?)
! What issues does this raise in terms of PMTCT policies? How can these policies help
minimise stigma and discrimination?
! What policies should be in place?
! What training should be provided to ensure staff adherence to the policies?
! What else needs to happen to ensure that the policies are implemented and
enforced?
! What barriers do you foresee?
! What community-based initiatives could be implemented to reduce the kind of stigma
and discrimination faced by Fay and her husband (and, indirectly, her child)?
! Are any national policy/legal changes suggested by this case study? If so, what are
they, and how would you go about ensuring it happens?

Module 6 HIV Testing and Counselling for PMTCT
SESSION 1 Overview of HIV Testing and Counselling of Pregnant Women
Exercise 6.1 Confidentiality role play Copies of Confidentiality role play 50 minutes
script
Module 6 HIV Testing

SESSION 2 HIV Testing
Exercise 6.2 Rapid testing Copies of national or local testing 60 minutes

demonstration policies, if not already in the
Participant Manual
Rapid test kits and supplies
SESSION 3 Pre-Test Information and Counselling
Exercise 6.3 Providing information: None, other than those noted 60 minutes
small group session on next page
SESSION 4 Post-Test Information and Counselling
Exercise 6.4 Post-test counselling: None, other than those noted 90 minutes
small group role play on next page

Session 1
! National HIV testing policy
! National confidentiality policy
! National policy on opt-in vs. opt-out, informed consent & disclosure
recommendations (if not included in above)
Session 2
! Algorithm for HIV testing (eg, rapid test and/or ELISA)
! Policy on diagnostic testing of the infant exposed to HIV, including HIV antibody or
viral testing
! Algorithm(s) for diagnosing HIV infection in an infant born to a mother who is HIV-
infected
Session 3
! National pre-test information and counselling policies or guidance
Session 4
! National post-test counselling policies or guidance for both women who test HIV-
positive and women who test HIV-negative
Module 6–2 HIV Testing and Counselling for PMTCT

SESSION 1 Overview of HIV Testing and Counselling of
Pregnant Women
Advance Preparation
Review Exercise 6.1 Confidentiality role-play and the script to be sure both
reflect local customs, issues, and policies. Ask local healthcare workers to
help you adapt the script if necessary. Change the names from "Mary" and
"Mrs. Johnson" to common local names.
Make copies of Exercise 6.1 Confidentiality role-play script.
Slides 1, 2 and 3

! Discuss the integration of HIV testing and counselling into antenatal care (ANC)
settings.
! Discuss the healthcare worker's role in maintaining confidentiality.
! Provide information to pregnant women about HIV testing.
! Explain the meaning of positive and negative HIV test results.
! Identify the needs of women who are newly diagnosed with HIV.
This module is designed to provide the healthcare worker with the basic knowledge and
introductory skills for testing and counselling in ANC settings. Additional HIV testing and
counselling training should be considered when possible.
Slides 4, 5, 6, and 7
Introduce HIV testing and counselling, using content on the following page.

Make These Points
! Testing and counselling should be accessible to all women of childbearing age.
! Testing and counselling may help women make informed changes for the future.
! Specific PMTCT interventions depend upon a woman knowing her HIV status.
! Counselling for women who are HIV-negative is aimed at modifying behaviours that
increase the risk of HIV infection.
HIV testing and counselling services

Specific PMTCT interventions depend on whether a woman knows her HIV status.
Therefore, HIV testing and counselling services:
! Play a vital role in identifying women who are HIV-positive

! Provide an entry point to comprehensive HIV/AIDS treatment, care, and support
! Help patients identify and take steps to reduce behaviours that increase the risk of
HIV infection or transmission
! Need to be available to all women of childbearing age, especially those who are
pregnant
! Need to be available to male partners, where possible
HIV testing is a process that determines whether a person is infected with HIV.
HIV counselling is the confidential dialogue between individuals and their healthcare
workers to help patients examine their risk of acquiring or transmitting HIV infection.
In this training module, the term counselling refers to discussions between

healthcare workers and patients/patients specific to HIV testing. Counsellors
may be healthcare workers such as doctors, nurses, midwives, educators,
trained lay people or volunteers (see Appendix 6-A).
Together, testing and counselling may enhance a person’s understanding of

HIV/AIDS and help the person make informed choices for the future.
Testing and counselling for PMTCT

In the context of MTCT prevention, testing and counselling is a flexible intervention that
is integrated into several settings where pregnant women and women of childbearing
age receive services—antenatal, labour and delivery, postnatal, family planning, and
others. Increasingly these programs are providing pre-test information and post-test
counselling.
All pregnant women presenting to ANC should receive information on the following:
! Safer sex practices

! Prevention and treatment of sexually transmitted infections (STIs)
! Prevention of HIV in infants and young children including interventions for PMTCT
! HIV testing, post-test counselling, and follow-up services

Advantages of testing and counselling for PMTCT
Testing and counselling pregnant women who are HIV-negative about HIV infection
helps them remain uninfected.
For pregnant women who are HIV-positive and know their status, counselling may
help them:
! Make informed decisions about their pregnancy.

! Receive appropriate and timely interventions to reduce MTCT including:
! Antiretroviral treatment/prophylaxis
! Infant-feeding counselling and support
! Information and counselling on family planning
! Receive education on the importance of delivering in a setting where universal pre-
cautions and safer obstetric practices are implemented.
! Secure early access to HIV treatment, care and support services.
! Receive information and counselling on the prevention of HIV transmission to others.
! Receive follow-up and ongoing health care for themselves and their HIV-exposed
infants.
! Disclose their results to partners and family members.
Disadvantages of testing and counselling for PMTCT
There may be disadvantages associated with testing and counselling programmes:

! Women may experience diagnosis-related stigmatisation or discrimination. Although
many women worry about negative reactions, most receive understanding and sup-
port from partners as well as other family members.
Slide 8
Introduce the guiding principles of confidentiality, informed consent, and post-test

support and services for PMTCT. Discuss the importance of maintaining confidentiality
using the content below.
Make These Points

! Confidentiality is the first of the three guiding principles for testing and counselling in
PMTCT settings (the other guiding principles are informed consent and post-test sup-
port and services).
! Confidentiality is important for establishing patient trust.
! This trust is central to the decision to consent to testing. As such, confidentiality is
one of the keys to ensuring a successful PMTCT programme.

Guiding Principles for Testing and Counselling for PMTCT
Confidentiality
Maintaining confidentiality is an important responsibility of all healthcare workers and is
essential to establishing patient trust. Information that is shared between healthcare workers
and patients must be kept private. It is essential that a private venue/room be used for all
discussions of HIV-related matters, particularly HIV diagnosis. Patients should be informed
that personal and medical information, including HIV test results, may be disclosed to other
healthcare providers to ensure that they receive appropriate medical care.
Healthcare workers should emphasise, however, that only those healthcare workers
who are directly involved in the patient's care will have access to the patient’s records—
and only on a “need-to-know” basis.
All medical records and registers, whether or not they include HIV-related information,
should be kept confidential and stored in a safe, secure place.
Slide 9
Discuss the importance of informed consent, using content below.
Make These Points

! Informed consent, the second of the guiding principles for testing and counselling in
PMTCT, requires that the patient receives clear and accurate information about HIV
testing and that the healthcare worker providing the information respects the individ-
ual’s right to decide whether to be tested.
Informed consent
Informed consent is another guiding principle of testing and counselling; it is the process
during which each patient receives clear and accurate information about HIV testing to
ensure that the patient understands she has the right and the opportunity to decline testing.
In the context of PMTCT, written informed consent is not required but it is the
responsibility of the program staff to make certain that the following elements of
informed consent are addressed:
! Ensuring an understanding of the purpose and benefits of services

! Ensuring an understanding of the testing and counselling process
! Respecting the patient’s testing decision
Slide 10
Introduce the guiding principles of post-test counselling and support.

Make These Points
! Provide test results in a private venue/room.
! Assure the patient that the session and the test results will be kept confidential.
! Inform the patient that follow-up treatment, care, and support is available, including
support for disclosure when needed.
Post-test support and services

The result of HIV testing should always be offered in person. Along with the result,
appropriate post-test information, counselling or referral should also be offered.
Lead the participants through the confidentiality role play and the questions at the end
of the exercise.
Exercise 6.1 Confidentiality role-play
Purpose To review and apply the principle of confidentiality (summarised

above).

Duration 20 minutes
Introduction ! Ask participants to refer to the role-play script.

! Ask two volunteers to read the script in which Mary, a fictional
patient, receives her HIV test results.
! Change the patient’s name from Mary to one that is culturally
appropriate.
! Introduce the characters by reading the exercise introduction to
the group.
Activities ! Move two chairs to the front of the room and arrange them to
face each other.
! Ask volunteers to be seated in the chairs.
! Ask them to choose the role of counsellor or patient.
! Ask them to read and role-play their lines for the group.
! After they finish, ask them to return to the group.
! Thank them for their assistance and ask the group to applaud
their efforts.
! Pose the following questions:
! Is the space appropriate for this interaction?
! How do you think Mary felt about this space and the privacy
of this space?
! How would you improve this?
! Who else at the clinic is permitted access to Mary’s records?
! How do you explain this to Mary?

Debriefing ! Ask the volunteers to summarise how they felt when playing their
roles.
! Ask the participants to cite the greatest challenges to preserving
confidentiality in the clinical settings where they work.
! Record those challenges on the flipchart.
Exercise 6.1 Confidentiality role-play script
Introduction: Mary is returning to the ANC clinic for her HIV test results. Her
counsellor, Mrs. Johnson, is prepared to meet with her and has confirmed that Mary
is HIV-positive. Mary has been married for six months and is excited about her
pregnancy. The clinic is busy, and Mrs. Johnson has made a space in the back of the
room to sit and talk with Mary.
Mrs. Johnson Hello, Mary. Glad to see you here on time for your
appointment. Have a seat.
Mary Hello, Mrs. Johnson. I have been so nervous, waiting
for my test result. Do you have good news for me?
Mrs. Johnson Well, Mary, do you remember what we discussed on
your last visit?
Mary Yes. You said that if the second test came back
positive, then I would have HIV infection.
Mary looks around. She can see the waiting area

from her seat, and notices the clinic is crowded. Mrs.
Johnson observes Mary looking towards the waiting
area.
Mrs. Johnson I wish we had a private office to sit in Mary, but space
is so limited here. I am certain that no one will hear
us talking back here.
Mary I just want you to know, Mrs. Johnson, that if my test
is positive, and my husband finds out, I will be in big
trouble. Please tell me my test is not positive.
Mrs. Johnson I’m sorry, Mary. Your second test did, in fact, come
back positive.
She pauses, giving Mary a chance to hear what she
has just said.
Mrs. Johnson I know this is very difficult for you, but I am here to
help you through this.
Mary Oh, Mrs. Johnson, what will I do? My husband and I
are so excited. Before we were married, I had another
boyfriend, and I didn’t always use protection.
Mary starts to cry.
Mrs. Johnson You must be feeling very overwhelmed right now,
Mary. Please know that everything you tell me will be
held in strict confidence, including your test results.
Let’s discuss, now, how you will get through the rest
of today.
Slides 11 and 12
Compare the "opt-in" and "opt-out" approaches to HIV testing, using the content below.
Make These Points

! National and regional policies generally reflect either of two approaches to testing
and counselling (opt-in or opt-out).
! Emphasise the approach to testing and counselling used locally.
! The "opt-out" strategy helps to normalise HIV testing as a routine component of ANC.
“Opt-in” and “Opt-out” approaches to HIV testing in PMTCT settings

There are two approaches to HIV testing in the PMTCT/ANC settings. Each provides
easily understood information to the patient about HIV and the risks and benefits of
testing. The approaches differ in how patients agree to test for HIV. The differences are
summarised as follows:
! Opt-in After the patient has received information about HIV and testing, she is given
the choice of refusing or consenting to an HIV test. This option is presented in a neu-
tral, supportive manner. Women who “opt in” explicitly request to be tested, and their

informed consent—written or oral—is clearly established. The opt-in approach
requires an active step by the individual woman to agree to be tested.
! Opt-out HIV testing, in combination with information on HIV, is offered as a routine
part of a standard package of care. The woman is given the opportunity to decline the
test should she choose to do so. The opt-out approach emphasises that HIV testing
is an expected part of ANC. However, testing is still voluntary under the opt-out
approach: the woman has a right to refuse testing. The provider should identify the
problem and solve issues that are preventing a woman from accepting testing.
Preferred ANC testing strategy: Opt-out

The opt-out strategy is recommended for HIV testing and counselling in the ANC
setting.
! Opt-out testing helps normalise HIV testing and makes the test a routine ANC
component.
! It is likely to increase the number of women who are tested for HIV.
! The choice of testing strategies should be made at a national, regional, district,
or local level.
! PMTCT programme staff must adhere to the guiding principles of testing and
counselling (informed consent, confidentiality, and the provision of post-test
services).

SESSION 2 HIV Testing
Advance Preparation
! Make copies of national HIV-testing algorithms/protocols, if not already
in the Participant Manual.
Have on hand information about the rapid tests approved for use and
the related testing supplies.
! Invite someone skilled at performing the rapid test to provide a demon-
stration of the rapid test during Exercise 6.2.*
! Have available rapid test kits and supplies for demonstrating sampling
and testing procedures.
* Note: In some areas, laboratory personnel are available to provide education on
locally available rapid testing.
Slides 13 and 14
Briefly discuss HIV testing and the factors that influence a programme’s choice of HIV
tests, using the content below.
Overview of HIV testing

HIV testing detects antibodies or antigens associated with HIV in whole blood, saliva, or
urine. Blood sampling is the most common mode of testing. The results of different tests
can be combined to confirm HIV test results. When properly administered, HIV tests
offer a high degree of accuracy. However, those who administer or handle the HIV
testing process must be trained so that the accuracy of testing is preserved.
Several factors influence the selection of the type of HIV test by individual facilities and
national policymakers:
! National or local testing policy

! Availability and expertise of laboratory or other trained personnel
! Availability of supplies and laboratory support
! Evaluation of specific tests in the country
! Cost of test kits and supplies

Slide 15
Describe the five main steps in HIV testing. Explain that, regardless of the type of test,
these steps are followed:
All testing follows the same basic steps:

1. Sample is obtained. Most often, a blood sample is taken from a person's fingertip or
arm.
2. Sample is processed. This can be done on site—for example, at the ANC clinic or
in labour and delivery for rapid tests—or in a laboratory.
3. Healthcare worker obtains results.
4. Healthcare worker provides results to the patient during post-test counselling.
! In an adult, a positive HIV antibody test result means that the person is infected
with HIV.
! A negative result usually means that the person is not infected with HIV. In rare
instances, a person with a negative or inconclusive result may be in the “window
period.” This is the period of time between the onset of infection with HIV and
the appearance of detectable antibodies to the virus. The window period lasts
for 4 to 6 weeks but occasionally up to 3 months after HIV exposure. Persons at
high risk who initially test negative should be retested 3 months after exposure

to confirm results.
5. Healthcare worker provides post-test counselling, support, and referral.
Slide 16
Briefly explain that there are two main types of tests:
! Antibody testing
! Viral assay
HIV rapid tests and ELISA, both of which are antibody tests, are the most commonly
used HIV tests in the ANC setting.
Discuss the important differences between rapid tests and ELISA, using the content on
the next page.

Antibody tests
When HIV enters the body, the body responds by making a protein called an antibody
that can be detected by one of several methods:
! Rapid HIV test
! Enzyme-linked immunosorbent assay (ELISA)
! Western blot test
Rapid HIV tests and ELISA are the most commonly used HIV tests in the ANC setting.
Rapid testing
All rapid tests share the following characteristics:
! Highly accurate when performed correctly
! Usually performed on whole blood (either taken as a finger prick or drawn as a
sample); occasionally saliva is collected by using a swab
! Do not require special laboratory equipment or refrigeration
! Results are ready within 30 minutes
! Tests can be done on a single specimen
! Clinic staff can be trained to perform the tests
Benefits of rapid testing include:
! Blood samples can be analysed in the clinic.
! Same-day results are more convenient for the patient.
! Providers can avoid missed opportunities when there is no follow-up care.
! Pregnant women who are HIV-positive can be informed immediately about MTCT
interventions and possible treatment options.
! Providers do not need to track down test results from an outside laboratory.
! There is less risk of specimen mix-up or misplacement.
A positive rapid test result is confirmed either by a different rapid test or by another
laboratory test. If the results of the two tests differ, a third test is generally done in a
laboratory. See Figure 6.1 for a sample algorithm. It is recommended that healthcare
workers follow their programme's approved testing protocols.
Although most rapid tests can detect HIV-1 and HIV-2, usually they do not differentiate
between the two types of HIV. This is significant for PMTCT programs because
nevirapine (NVP), which is used for ARV treatment and prophylaxis, is not as effective
against HIV-2. In places where HIV-2 is common, different test procedures are needed
to screen for HIV-1 and HIV-2 and to distinguish between them.
Slide 17
Discuss the serial rapid testing algorithm in Figure 6.1.

Figure 6.1 Rapid HIV testing algorithm (Serial testing)
Pre-Testing Education and/or Counselling
First HIV Rapid Test
Negative Test
Positive Test*
Result
Result
Counsel for Negative Result
Second HIV Rapid Test
Positive Test
Negative Test
Result
Result
Counsel for Positive Result
Third HIV Rapid Test
Positive Test Negative Test

Result Result
Counsel for Positive Result Counsel for Negative Result
* In the context of labour in a MTCT-prevention setting, it is advised to give a single dose of nevirapine on the basis of a
single positive rapid test. This should then be confirmed after delivery.

Explain that a positive rapid test result is confirmed either by a different rapid test or by
another laboratory test. If the results of the two tests differ, a third test is generally done
in a laboratory.
ELISA
ELISA is also used to identify antibodies to HIV in blood, urine, or saliva. Generally, a
blood sample is taken with a needle from a vein in the arm, and sent to a laboratory for
testing by technicians.
The limitations of ELISA include the following:
! Tests are done in batches of 40–90 specimens.

! Positive results must be confirmed either with another ELISA (using a test kit from a
different manufacturer) or by Western blot. The Western blot is a highly “specific”
antibody test because it is particularly accurate in providing a negative test result on
samples from people who are truly negative. Both confirmatory tests can be done on
the initial blood sample.
! Reporting of results may take several days or weeks, and women may not return for
test results or may give birth before the results are ready.
! Laboratories and trained laboratory technicians are required.
! The test is sensitive to temperature, and reagents require refrigeration.

Slide 18
Discuss the second category of HIV tests—HIV viral assays—using the content below.
Viral tests or assays

Virologic testing or assays directly detect the presence of HIV in blood specimens as
opposed to the antibody test, which detects the presence of antibody as an indirect
measure of the presence of virus. Viral assays/tests must be done by trained personnel
in the laboratory.
There are two main types of tests:
! p24 antigen tests measure one of the proteins found in HIV (antigen).
! PCR (polymerase chain reaction) tests detect viral DNA or RNA:
! DNA PCR detects the presence of the virus in the blood and is used for diagnosis
of the infant less then 18 months.
! RNA PCR detects and measures the amount of virus in blood (viral load).
.
Note: In some areas, laboratory personnel are available and eager to provide education
about locally available rapid testing. This opportunity should not be missed and can be
used in combination with the exercise that follows.
Distribute the following handouts, if not already in the Participant Manual.
! Information about rapid tests in local use

! Information about local test protocols
! National and local policies on testing and counselling in antenatal care settings
Lead a discussion based on the testing demonstration (if observed) and the role play
below:
Exercise 6.2 Rapid testing demonstration
Purpose To review the steps involved in rapid testing
Duration 60 minutes
Introduction ! Determine which protocols are in place for processing rapid tests
in participants’ facilities.
! Explain that the group will examine 2 or 3 approved rapid tests.
! One test will be selected to demonstrate the steps involved in
collecting and processing a specimen.

Exercise 6.2 Rapid testing demonstration
Activities Demonstrate the testing of blood sample for the HIV test:
! Request that one participant volunteer to play the role of "patient."
Assure volunteer that he/she will not actually be tested.
! Trainer will assume the role of healthcare worker who is collecting
the blood sample for testing.
! Ask all other participants to observe the interaction between
participant volunteer and healthcare worker.
! Ask participant volunteer to sit facing healthcare worker.
! Observe the steps of rapid testing:
! Assemble all materials—test kit, wipes, band aid, etc.
! Confirm that "patient" has received information on testing.
! Confirm that "patient" has chosen to be tested.
! Determine if "patient" has any further questions.
! Review steps in testing process.
! Allow "patient" to select testing site (finger for pin-prick).
! Simulate (do not perform) sampling technique as indicated.
! Simulate (do not perform) next steps in test completion, based
on the test used.
! Assure "patient" that he/she will be notified of results in a timely
and confidential manner.

! Take the opportunity to recommend to the "patient" that his/her
partner come in for testing.
! Process rapid test or send for processing as per protocol.
! Provide test result and post-test counselling.
Debriefing Review the following:
! Testing algorithm for testing process used
! Confidentiality of testing and services
! Informed consent procedures based on local/national policy
(specifically whether opt-in or opt-out approach is used)
! Post-test counselling procedures
! Complete the exercise by reviewing the comfort level of both
healthcare worker and "patient" when playing their respective roles
during the exercise.
Slide 19
Introduce diagnostic testing of infants who are HIV-exposed, using the content below.
Diagnostic testing of infant and young children exposed to HIV

Because ARV prophylaxis reduces but does not eliminate MTCT, programme staff
should identify or develop services that provide follow-up care and HIV diagnostic
services for infants and young children of mothers infected with HIV.
In resource-constrained settings, where virological testing may not be available, follow

the sample antibody testing algorithm for children 18 months and older in Figure 6.2.

If a child exposed to HIV develops signs or symptoms of HIV infection, early diagnosis
and intervention is critical. This is discussed in detail in Module 7: Linkages to
Treatment, Care, and Support for Mothers and Families with HIV Infection.
Slide 20
Discuss protocols for testing infants who are HIV-exposed, as presented below.
HIV antibody testing of infants and young children less than 18 months
Early diagnosis of infection in these infants is difficult, especially in resource-constrained
settings, and is further complicated by breastfeeding. Since maternal antibodies cross
the placenta, all infants born to mothers infected with HIV will test antibody positive,
irrespective of their own infection status. Because maternal antibodies persist, antibody
testing prior to 18 months cannot provide a reliable diagnosis of infant infection status,
especially when the child is breastfeeding. In resource-constrained settings where
breastfeeding is common, initial antibody testing is recommended at 18 months. As
shown in Figure 6.2. In countries with increased capacity for multiple testing and where
replacement feeding or
early weaning is
common, testing can be Figure 6.2 HIV diagnosis in children 18 months and older with
antibody tests in resource-constrained settings

done at 9–18 months.
However, healthcare
Non-Breastfeeding
workers should consider infant
Breastfeeding
infant
repeating the test at 18
months to confirm the HIV antibody test HIV antibody test
status of the child.
Positive Negative Positive Negative
Appendix 6-B provides antibody antibody antibody antibody
test test
guidance on the post-test test test
counselling session. Child is Child is NOT

Child is Repeat test at
HIV-infected least 6 weeks
HIV-infected HIV-infected after complete
For children who are not cessation of
breastfeeding
breastfeeding or where Refer for Refer for
treatment, care
breastfeeding cessation treatment, care
and support and support
occurred at least 6 weeks
Positive Negative
previously: antibody antibody
test test
! A negative HIV
antibody test result for Child is Child is
HIV- NOT
a child 18 months or infected infected
older indicates that the
child is not HIV- Refer for
treatment, care
positive. and support
! A positive HIV antibody

test at 18 months or
older indicates that the child is infected with HIV.
OR

! A negative HIV antibody test result for a child age 9–18 months indicates that the
child is not infected with HIV.
! A positive HIV antibody test at 9–18 months of age indicates that the child may have
antibodies from the mother and the test should be repeated at 18 months.
For children who are breastfeeding:
! If the test is negative at 18 months of age or older and the infant was breastfeeding in
the last 6 weeks, the antibody test should be repeated 6 weeks after complete
cessation of breastfeeding.
! A positive HIV antibody test result at 18 months indicates that the child is HIV-
infected.
Slides 21 and 22
Discuss testiing infants using viral assays that detect HIV in the blood, as presented
below.
Make These Points

! Viral assays, which detect the actual virus (not the antibody to the virus), can be used
to diagnose HIV infection at a much earlier age than the antibody test.
! Using a viral assay, infants may be tested as early as 6 weeks of age.
! If the infant is breastfed, the test should be repeated 6 weeks after complete
cessation of breastfeeding.

HIV viral assays in infants
Viral assays that detect HIV in the infant's blood, such as the DNA or RNA PCR test,
may be used to diagnose HIV infection in infants at a younger age than antibody testing.
Early diagnosis of HIV
allows the provider to Figure 6.3 HIV diagnosis in infants and young children less than 18 months
promptly initiate with viral assay in resource-constrained settings
counselling about
methods of infant Non-Breastfeeding Breastfeeding
infant infant
feeding and facilitates
early clinical care for *Virology test from *Virology test from
the infant who is HIV- 6 weeks or older 6 weeks or older
infected. Positive Negative Positive Negative

test test test test
Programs need to
develop practical and Child is Child is NOT Child is Repeat test at
least 6 weeks
HIV-infected HIV-infected HIV-infected
appropriate guidelines after complete
cessation of
based on locally avail- Refer for
breastfeeding
Refer for
able diagnosis tech- treatment, care treatment, care
and support and support
nologies and additional
evidence as it Positive Negative
antibody antibody
becomes more readily test test
available for early

Child is Child is
diagnosis. A viral HIV- NOT
assay can be per- infected infected
formed from age 6

Refer for
weeks to allow deci- treatment, care
and support
sions related to ARV
treatment and care.
Where virological test-
ing is available, the * Recommended virological tests include HIV DNA PCR and HIV RNA PCR assays
sample algorithm in
Figure 6.3 may be used. When virological tests are rarely available and severe cost
constraints exist, a viral test may be done, regardless of breastfeeding, if the child pre-
sents with symptoms of HIV at less than 18 months of age.
For children who are not breastfeeding, consider testing the infant from age 6 weeks.
! If a DNA PCR or RNA PCR test is positive, the child is HIV-infected.
! If a DNA PCR or RNA PCR test is negative, the child is not HIV-infected.
For children who are breastfeeding, consider testing the child from 6 weeks–6 months.
! If a DNA PCR or RNA PCR test is positive, the child is considered HIV-infected.
! If a DNA PCR or RNA PCR test is negative, repeat viral assay 6 weeks after
complete cessation of breastfeeding.
! If a DNA PCR or RNA PCR test is negative 6 weeks after complete cessation of
breastfeeding, the child is not HIV-infected.
! If a DNA PCR or RNA PCR test is positive 6 weeks after complete cessation of
breastfeeding, the child is HIV-infected.

SESSION 3 Pre-test Information and Counselling
Advance Preparation
Ensure that participants have copies of
Appendix 6-D Providing pre-test information.
Slides 23 and 24
Discuss the need to provide pre-test information, using the content below.
Pre-test information
The process of pre-test information and education begins with offering basic information

about HIV/AIDS. Printed materials, videos, presentations, and role-playing exercises
may be used to present content in a group setting. It is important to present the informa-
tion again during the initial and subsequent ANC visits.
Providing pre-test information helps prepare women and their partners to understand
the testing and counselling process. This process is not to be confused with individual
pre-test counselling, which helps patients explore personal HIV risk behaviours and
related issues and concerns.
A healthcare worker with basic training in HIV counselling typically provides pre-test
information in group sessions. Healthcare workers and counsellors jointly work together
to identify patients who need individual pre-test counselling and referral.
Slide 25
Discuss individual pre-test counselling, using the content below.

Make These Points
! Remind participants that they may need to initiate one-on-one interventions to help
clarify information presented in group sessions.
! It is important to assess, on a case-by-case basis, whether an ANC patient needs to
be referred to a skilled counsellor in a voluntary testing and counselling (VTC) setting
for additional support.
Individual pre-test counselling

Where possible, individual pre-test counselling may be incorporated into routine ANC
visits. Where this is not practical, healthcare workers may refer patients for individual
pre-test counselling or for clarification of information provided in group sessions.
Counsellors should assess whether referral to individual pre-test counselling is neces-
sary based on national or clinic guidelines. In some countries, individual counselling is
recommended when a woman has concerns, questions, or uncertainties. A description
of basic counselling is found in Appendix 6-C.
Components of the pre-test information and counselling sessions

! Basic HIV/AIDS information
! HIV transmission and prevention
! STIs and HIV
MTCT and prevention
! HIV testing processes

! Benefits and risks of HIV testing
! Confidentiality
! Implications of positive and negative test results
! Identification of HIV support services
! Family planning
! Availability and benefits of testing and counselling services for couples

Slide 26
Introduce the option of providing counselling in a group setting.
Make These Points

! Information provided in a group setting as part of ANC services needs to be adapted
to the needs of the patients in the group.
! Videos (or DVDs) may help reinforce key concepts.
! Support the option of individual counselling for those who request it.
Group pre-test counselling

Key considerations for providing information to groups include:
! Adapting the scope and depth of information to the group's knowledge base
! Reinforcing behaviour change efforts, including safer sex practices
! Using teaching modalities, such as videos or role plays, to reinforce key concepts
! Having sufficient knowledge and skills to comfortably answer questions
! Recognising the option for individual counselling and referral
Each woman should receive all the information she needs to make an informed decision

about being tested for HIV. Most experts suggest providers support and encourage
women to be tested at the initial visit because many women begin ANC late in
pregnancy or are seen only once before delivery. In some cultures, the decision to be
tested may require support from family members and entail a return visit with family
decision makers. Healthcare workers in ANC services can make an effort to welcome
family decision-makers into the care setting and provide the same information and pre-
test counselling that would be given to the woman individually.
When testing and counselling is part of ANC services, each woman must be reassured
that declining an HIV test will not affect her access to ANC or related services. She
should also be informed that if she changes her mind, an HIV test can be provided
during a later visit.
Slides 27 and 28
Using the content on the next page for clarification, discuss providing counselling for
couples.

Counselling couples
When possible, health care workers may encourage male partners to attend the ANC
testing and counselling sessions.
Advantages of couples counselling

! Counselling male partners of pregnant women provides an opportunity to encourage
men to practise safer sex by using condoms and by limiting the number of partners.
! During counselling, healthcare workers can emphasise the man's responsibility for
protecting the health of his wife or partner and their family.
! Testing both partners together as a couple may reduce the likelihood that the woman
will be “blamed” for bringing HIV infection into the family.
! Identifying discordant couples during counselling (one partner is HIV-negative and the
other one is HIV-positive) will provide the opportunity to discuss safer sex practices.
Discordance in couples
Many couples are discordant. Yet a woman often believes that her HIV test results reflect
her partner’s status; she assumes that if she is negative then her partner is also
negative, which is not always the case. If her partner is in fact HIV-positive and he infects
the mother during pregnancy, the risk of transmitting HIV to the infant is very high.
Responsibilities of the healthcare worker when working with couples

Healthcare workers can encourage women to persuade their partners to participate in
ANC services and seek testing for HIV, regardless of the woman’s test result. Skill
building, problem solving, and practising what the woman will say to her partner may
help a woman disclose her results and refer her partner for testing. Alternatively, male
partners can be referred to voluntary counselling and testing services (VCT). Specific
information about agency hours, location, and services may be provided. If either the
patient or her partner receives a positive HIV test result, refer the couple for treatment,
care, and social support.
Considerations in counselling couples

! Establish a relationship with each partner.
! Assure them of confidentiality and support.
! Assess each person's understanding of HIV/AIDS.
! Avoid allowing one person to dominate the conversation.
! Explain the testing process.
! Discuss post-test counselling:
! Ask whether they would prefer to receive the results separately or together. Most
experts recommend receiving results together as a pre-condition for couples coun-
selling.
! Mention the possibility of discordant results (if one partner is infected while the
other is not) and prepare them for this possibility.

! Provide information on available PMTCT interventions: ARV prophylaxis, infant-
feeding practices.
! Confirm the benefits of knowing one's HIV status; discuss concerns or potential risks
of such knowledge.
! Ask who else might be affected by test results.
! Confirm the couple's willingness to be tested.
! Be prepared to refer the couple for further counselling if indicated.
Assist the participants as they practise providing pre-test information.
Exercise 6.3 Providing information: small-group session
Purpose To review pre-test information and allow the group to practise

providing information.
Duration 45 minutes
Introduction Emphasise that the focus of this session is the provision of pre-test
information.
Explain that this exercise will review what has been taught and allow

the group to practise providing information to groups.
Activities ! Divide participants into three groups. Appendix 6-D contains

suggested content for three group information sessions. Assign
one information session scenario to each group and ask the
participants to complete the following tasks:
! Refer to the bulleted topics and discuss how you might present
each one to an audience.
! Use the questions and answers under the bullets as a guide.
! Ask one person in the group to record the important information
for each topic on paper.
! Assign each participant one topic from the bulleted list to present
to the full group.
! Ask each participant to think carefully about the important
information recorded for his/her topic; ask the recorder to write it
for you if necessary.
! When ready, have each participant present the topic to the entire
training group.
! Once the presentation has been completed, verify that the
important information was addressed.
! Ask the participants to inform the presenter about which
information they did not understand.
! Ask whether there are any questions.
! As time permits, rotate presenters until each participant has
presented once.

Exercise 6.3 Providing information: small-group session
Debriefing ! Providing information in a clear way takes practice.

! How does it feel to be an educator? Evaluate whether you
answered questions comfortably and provided emotional support.
! Basic counselling skills used every day may help the healthcare
worker communicate effectively.
! Remember that formal, one-on-one pre-test counselling should be
offered when indicated.

SESSION 4 Post-Test Information and Counselling
Advance Preparation
Ensure that participants have copies of Appendices 6-E, 6-F, and 6-G,
which appear at the end of this module. The role play scenarios appear in
Appendix 6-G.
Slides 29 and 30
Discuss post-test information and counselling for all women, using the content below.
Make These Points

! Post-test counselling is important for all women, whether their HIV test results are
negative or positive.
Post-test counselling
All HIV test results, whether positive or negative, must be given in person. Initial post-
test counselling sessions are provided to each patient separately and privately, unless
the post-test counselling is being provided to a couple.
The post-test counselling session for both the woman who is HIV-positive and the one
who is HIV-negative has several goals:
! Provide the woman with her HIV test result.
! Help her understand the meaning of the result.
! Provide the appropriate PMTCT essential messages.
! Offer support, information, and referral.
! Encourage risk-reducing behaviour.
! Encourage disclosure and partner testing.
Slide 31
Discuss post-test counselling for women who are HIV-negative, using the content below.

When the woman is HIV-negative…
A negative result on an HIV antibody test means that a woman is not infected with HIV.
Post-test counselling provides an opportunity for a woman who is HIV-negative to learn

how to protect herself and her infant from HIV infection. It is important that women know
that if they become infected during pregnancy or while breastfeeding they face an
increased risk of MTCT. Post-test counselling—even for those who test negative for
HIV—provides women with a powerful incentive to adopt safer sex practices, discuss
family planning, understand the issue of discordance, and encourage partner testing
(see Session 3). Detailed steps in providing post-test counselling for women who are
HIV-negative are in Appendix 6-E.
Components of post-test counselling for women testing HIV-negative

! Discuss the meaning of the result.
! Provide information about how to prevent future HIV infection.
! Inform her about the high risk of transmitting HIV to the infant if she is newly
infected during pregnancy or breastfeeding.
! Inform her that counselling is available in the future if needed.
Slide 32
Discuss post-test counselling for women who are HIV-positive, using content below.
When the woman is HIV-positive…

A woman who tests HIV-positive is infected with HIV. Counselling women who test
positive for HIV is challenging for healthcare workers, and patient reactions can range
from acceptance to disbelief. The healthcare worker must remain non-judgemental,
supportive, and confident throughout the counselling process. Healthcare workers
should remember that they have the skills to provide difficult information to patients and
they can draw on their experience.
Because women may present late in pregnancy or only attend ANC once, key PMTCT
messages will need to be provided during the post-test counselling session. Also during
the post-test counselling session, the healthcare worker should encourage the woman
who is HIV-positive to attend subsequent ANC visits. During those visits, key PMTCT
messages can be reinforced and follow-up counselling provided. Referral for HIV
treatment, care, and support is necessary.

See the detailed steps for providing post-test counselling for women who test HIV-
positive in Appendix 6-F.
Components of post-test counselling for women testing HIV-positive

! Discuss the meaning of the test result.
! Determine whether she understands the meaning of the result and let her talk
about her feelings.
! Talk about her immediate concerns.
! Inform her about essential PMTCT issues. Discuss and support initial ARV
treatment, prophylaxis, and infant-feeding decisions.
! Discuss disclosure and partner testing.
! Encourage her to attend subsequent ANC visits and the importance of delivering
in a PMTCT facility.
Slide 33
Discuss the disclosure process for women who are HIV-positive, using the content
below.
Disclosure of HIV status

During the initial post-test counselling session, the counsellor may begin the discussion
about disclosure. By disclosing her HIV status to her partner and family, the woman may
be in a better position to:
! Encourage the partner(s) to be HIV tested.
! Prevent the transmission of HIV to her partner(s).
! Access PMTCT interventions.
! Receive support from her partner(s) and family when accessing PMTCT and HIV
treatment, care, and support services.
It is important to respect the woman's choice regarding the timing and process of
disclosure. A woman may perceive disadvantages in disclosing her HIV diagnosis. In
some communities, women who are HIV-infected and their families may face
stigmatisation and discrimination. (See Module 5: Stigma and Discrimination Related to
MTCT). If the woman has indicated that her partner(s) and family may react negatively
to her HIV status, the counsellor can help the woman problem-solve and build skills to
use when she discloses her HIV status.
Discuss the ongoing care needs of women who are HIV-positive, using the content
below.

Subsequent ANC visits
In most countries, pregnant women are encouraged to attend scheduled ANC visits
throughout their pregnancy. However, in many resource-constrained settings, many
pregnant women attend ANC once, often late in pregnancy, and do not make
subsequent visits.
If pregnant women do make subsequent visits, the following topics should be addressed
in the first ANC visit and reinforced during subsequent ANC visits:
! Interventions for PMTCT (Module 3: Specific Interventions to Prevent MTCT)
! Infant-feeding options (Module 4: Infant Feeding in the Context of HIV Infection)
! Follow-up care and treatment for the woman and her infant (Module 7: Linkages to
Treatment, Care and Support for Mothers and Families with HIV Infection)
! Social support (Module 7: Linkages to Treatment, Care and Support for Mothers and
Families with HIV Infection and Module 8: Safety and Supportive Care in the Work
Environment)
! Family-planning options (Module 2: Overview of HIV Prevention in Mothers, Infants,
and Young Children)
Counselling and testing for women of unknown HIV status at the

time of labour and delivery
In some settings, women who have not been tested during ANC or did not attend ANC
may present to the health service at the time of labour with unknown HIV status.
National and local policies can provide guidance on how to test and counsel women of
unknown HIV status during labour and delivery. Although it may be difficult to offer
counselling or obtain informed consent during labour, it is recommended that the opt-out
approach to testing be used (See Session 1) during labour and that post-test
counselling be provided after delivery. In these circumstances, decisions about
antiretroviral therapy will be based on national or local policies (see Module 3 Specific
Interventions to Prevent MTCT). In some cases it will be possible to provide ARV
prophylaxis to the mother and the infant and in other cases it will only be possible to
provide ARV prophylaxis to the infant.
Assist the participants as they practise providing post-test counselling. Please refer to
Appendix 6-G for the scenarios and checklist to be used in Exercise 6.4.

Exercise 6.4 Post-test counselling: small-group role-play
Purpose To practise post-test counselling through role playing.
Duration 60 minutes
Introduction This exercise will provide an opportunity for participants to practise

post-test counselling.
Activities ! Divide group into teams of six participants each.

! Ensure participants have copies of the role play scenarios for
post-test counselling and counselling checklist (Appendix 6-G).
! Assign each team two scenarios: one from the scenarios for HIV-
negative results, and one from the scenarios for HIV-positive
results.
! Instruct the teams as follows:
! For each scenario, select one participant to play each patient
and one to play the counsellor.
! The patient and counsellor should be seated so they are facing
each other.
! Using the Counselling Checklist, the pair should follow the first
scenario.
! If the counsellor has difficulty (if he or she doesn’t know exactly
what to say or how to answer the patient), another team

member may help by tapping the counsellor on the shoulder
and assuming the counsellor’s place.
! When the role-play is finished, the pair should spend 5 minutes
reviewing the experience with the rest of their team, asking such
questions as, "Was anything important left out of the session?"
! The team should repeat the process for the second scenario.
! Ask the participants to exchange roles and continue switching until
each member practises post-test counselling (using both
scenarios, time permitting).
Debriefing Ask participants to consider the following questions:

! How did you feel in your role as a counsellor?
! What was the hardest part of counselling?
! How can basic communication skills be used during counselling
sessions?
! What positive reactions did you experience in the session?
Record reactions and experiences on the flipchart.

Review key points from this module, as described in the box below.

! Pre-test information, HIV testing and post-test counselling should be available to
all pregnant women on an “opt-in” or “opt-out” basis as determined by national or
local policy.
! The healthcare provider and the facility must maintain confidentiality of HIV
status.
! Partner testing and couples counselling are encouraged.
! Rapid tests with same day results are the recommended procedure for most ANC
settings.
! Infant diagnosis is complex but important for clinical management.
! Standard diagnosis is done by antibody test at 18 months.
! Earlier diagnosis is possible with PCR testing.
! Post-test counselling is important for all women:
! For HIV-negative women, emphasise the prevention of HIV infection.
For women infected with HIV, provide referrals to the PMTCT program and
options for treatment, care and support.

! Disclosure skills building should be encouraged for all women regardless of HIV
status.

APPENDIX 6-A Training, roles, and responsibilities of HIV
counsellors
Counsellor level Roles and responsibilities

Senior counsellor (coordinator, ! Support and supervise other coun-
supervisor) Experienced counsellor sellors
with advanced training in counselling ! Monitor counsellors
! Train groups of counsellors
! Accept referrals of difficult or com-
plex cases
! Facilitate and supervise support
clubs occasionally
Professional counsellor ! Pre- and post-test counselling
Counsellor with an appropriate back- ! Couples counselling
ground in nursing, teaching, or a relat- ! Follow-up counselling
ed field, who participates in ongoing
training
! Support for peer and lay counsellors
! Identification and assessment of
adverse events or mental health
consequences and indications

Peer counsellor ! Advocacy and community mobilisa-
Counsellor from the same background tion
as the patient, often a woman who has ! HIV education and preventive coun-
been involved in PMTCT projects; also selling
peer counsellors in the workplace, ! Follow-up and supportive coun-
youth peer counsellors, counsellors selling in uncomplicated cases
with HIV/AIDS
! Integration of persons living with
HIV/AIDS into community activities
Lay counsellor ! Pre- and post-test counselling for
Counsellor with pre- and post-test routine cases
training and training in ongoing coun- ! Follow-up and supportive coun-
selling selling for uncomplicated cases
Adapted from World Health Organisation (WHO). 2003 (July). Guidance on the Provision of T & C for Women in
Antenatal Care, Childbirth, and Resource-Constrained Settings [Draft].

APPENDIX 6-B Talking with parents about their child's HIV
test results
Prepare for the talk with parent or guardian.

! Make sure you have the child's test result and inform the parent that you have the
result.
! Schedule an appointment.
Greet the parent and establish rapport.

! Ask if the parent or guardian has had any questions since the child's blood test.
Answer the questions and let the patient know that counselling will continue to be
available to help with important decisions.
Inform the parent of the test result.

! Ask, "Are you ready to receive your child's HIV test result?"
! State, in a neutral tone, "The baby's test result is positive. That means that the baby
has HIV infection."
! Pause and wait for the parent to respond before continuing. Give the parent time to
express any emotions.
If the parent would like to see proof of the result, provide it.
! Check the parent's understanding of the result's meaning. Discuss and support the
parent's feelings and emotions.
! Explain that the blood test revealed evidence of HIV, the virus that causes AIDS, in
the baby's body. Review the testing procedure with the parent and check to be sure
he or she understands the test results. Explain the accuracy of the test. Allow time for
silence.
! Reassure the family that, although there is no cure, there are treatments for infections
that the child can receive. Emphasise that children can live many years before they
become sick with AIDS-related illnesses. Talk about available ARV treatments for HIV.
! Recognise that many people may interpret this diagnosis as a death sentence.
Anticipate reactions of grief, shock, disbelief, denial, and anger. Offer appropriate
support.
Discuss ways to keep the child healthy.

! Emphasise the need for immunisations.
! Talk about good nutrition.
! Stress that the child should be allowed to live an active life and play like other
children whenever possible.
! Review the importance of prompt medical attention as well as preventive care. If the
baby is less than 12 months old, stress the importance of PCP prophylaxis; ensure
access to cotrimoxazole, and instruct the parent in how to give the liquid.
! Refer the child for HIV treatment and care if not provided in your facility.

APPENDIX 6-B Talking with parents about their child's HIV
test results (continued)
Review Universal Precautions.

! Reassure the family that close contact with family members and normal baby care do
not transmit HIV.
! Review measures for diaper/nappy changing (no gloves are necessary), blood spills
(use a barrier), and open sores (they should be covered).
Identify other family members who may be at risk of HIV infection.

! Identify, counsel, and test siblings who may be at risk. Families must be given the
time and support to do this.
Identify a support system.

! Identify a personal support system for the family.
! Assess the psychological status of mother and other family members.
! Refer family to a support group, if they are interested.
! Provide the family with written material that they can take home, if they are
interested.

Review issues of confidentiality.
! Introduce disclosure issues.
! Explain how confidentiality is handled in the clinical setting.
Assess the family's understanding of the diagnosis, treatment, and care at each
visit.
! Review and offer additional information as appropriate.

APPENDIX 6-C Basic counselling skills
Empathising
Empathy is the identification with and understanding of another person’s situation,
feelings, and motives. To empathise is to see the world through the other person’s eyes
and understand how that person feels. The counsellor should listen to the patient
carefully and try to understand the patient’s situation and feelings without being
judgmental. Empathy should not be confused with pity.
Active listening
The active listener pays attention to what the patient says and does, and listens in a
way that shows respect, interest, and empathy. Active listening is more than just hearing
what the patient says. It means paying close attention to the content of the message as
well as the feelings and worries that can be expressed through movement, tone of
voice, facial expression, and posture.
Open questioning and probing

Open-ended questions elicit more than one-word answers. They often begin with “how,”
“what,” or “why.” Such questions encourage the patient to express feelings freely and to
share information relevant to the situation. Probing uses questions to help the patient
express feelings and information more clearly. Probing often is necessary when the
counsellor needs more information about a patient’s feelings or situation.
Focusing
Patients often are overwhelmed by many problems, and they may try to address all of
their problems at once. It is important for the counsellor and the patient to stay focused
on the goals of the counselling session. Counsellors might need to refocus or redirect
patient questions that can be addressed later in the session. If the patient wants to talk
about other emotional or personal issues, the counsellor should consider providing
referrals for additional support.
Correcting inaccurate information

It is the responsibility of the counsellor to provide patients with accurate information and
correct misconceptions. The counsellor should identify false information and correct it
quickly. This must be done sensitively so the patient does not feel inadequate or
become defensive. It is not always necessary to give detailed explanations of facts.

APPENDIX 6-C Basic counselling skills (continued)
Characteristics of a good counsellor

! Establish rapport by greeting patients with respect, introducing themselves, and
explaining their roles as counsellors.
! Understand the issue at hand, whether it is HIV risk reduction, HIV testing, infant
feeding, family planning, or HIV treatment and procedures.
! Sensitive to cultural and psychological factors that might affect patients’ decision-
making process.
! Nonjudgmental and treat patients with respect and kindness.
! Present information sensitively, using language patients understand.
! Encourage patients to ask questions.
! Listen actively to patients’ concerns.
! Recognise when it is necessary to refer patients for additional help or support.
! Notice and respond to nonverbal communication (body language).

APPENDIX 6-D Providing pre-test information,
exercise 6.3
Information session: Group 1

Introduction
Group information sessions can be offered in the ANC clinic setting. As a group, review
the following topics one at a time and discuss which key points should be covered in a
group information session. Use the questions and answers below to guide you.
! An overview of HIV and AIDS

! Sources and prevention of HIV transmission
! Sexually transmitted infections (STIs) and HIV
! Mother-to-child transmission of HIV and prevention
What is the difference between HIV and AIDS?

HIV is the virus that causes AIDS. Someone can be infected with HIV and not know it.
An infected person might not feel ill for many years. AIDS is the disease caused by the
HIV virus. When you get AIDS your body's defence system has been very weakened by
the HIV virus.
There is no cure for HIV and AIDS, but drugs are available that can help prevent related
infections. Some drugs are available that slow the virus and help HIV-infected people
stay healthy for many years.
What is happening in our country? How many people are HIV-infected? How
many are men, how many are women or children?
Share recent national statistics on the spread of HIV and its prevalence in women
attending antenatal and STI clinics.
What are some common myths about HIV?

Share commonly held beliefs and myths about HIV and AIDS.
How can you get HIV?

The most common way to get HIV is by having unprotected sex with an HIV-infected
person. A baby can get HIV from an HIV-infected mother during pregnancy, labour and
delivery, or breastfeeding. HIV infection can also be transmitted when people share
equipment (needles/syringes) to inject drugs or any other substance (vaccines,
vitamins). It can also be transmitted by sharing other sharp objects such as blades or
piercing equipment used in any process (piercing/scarification) that involves blood. HIV
can be transmitted to a person who receives blood that has not been screened for HIV.
What are some ways to prevent HIV infection?

! Sexual abstinence—not having sex
! Practising faithfulness between two uninfected partners
! Limiting sexual contact to one partner who is HIV negative
! Avoiding drug abuse
! Not sharing contaminated needles

exercise 6.3 (continued)
What kinds of things may put you at risk for HIV?

! Having unprotected sex with a person with HIV infection
! Engaging in high-risk behaviours, including having several sex partners, having anal
sex
! Using drugs of abuse or sharing contaminated needles
! Not knowing whether your partner is HIV negative or positive
! Having a sexually transmitted infection (eg gonorrhoea or syphilis) can increase the
risk of getting HIV by 2–5 times
What are ways to decrease the risk of getting HIV?

Add to patient’s suggestions other options for decreasing the risk of HIV, such as:
! Do not have unprotected sex with a high-risk partner.
! Always use condoms, if several partners.
! Talk to your partner about HIV testing.
! Talk about HIV concerns with a partner or friend.
! Reduce alcohol and/or drug use.
! Avoid places where you often participate in high-risk behaviours.

! Abstain from sex or use condoms until you and your partner have been tested.
What are choices that could decrease your risks?

! Emphasise the importance of making small, reasonable changes rather than setting
unrealistic goals, such as never having sex again. Ask patients to share their plans
with a close friend or someone they trust.
How do babies get HIV from their mothers who are HIV-infected?
! If a woman is HIV-infected and pregnant, there are three ways her baby can get HIV:
in the womb during the pregnancy, labour and delivery, or during breastfeeding.
! Although the risk of infecting the baby is always present, a woman who is HIV-
infected can give birth to a baby who is HIV-negative. Inside the womb the placenta
acts like a filter between the mother and the baby. So the mother and the baby have
separate blood systems. This helps prevent the mother from giving HIV to the baby in
the womb. But sometimes blood does cross between the blood systems of the
mother and baby. So some babies can get HIV in the womb.
! There are two other ways a mother who is HIV-infected can give the virus to her
baby. The most likely way is during labour and delivery. This is because the baby
comes into direct contact with the mother's blood. A mother also can give HIV to her
baby during breastfeeding.
! It is hard to tell whether a newborn baby is infected. However, the baby can be tested
for infection as per the site’s testing policy.
! The good news is there are medicines that can greatly reduce the risk of a mother
transmitting HIV to the baby during delivery. These medicines offer new hope to
families.

What is the Prevention of Mother-to-Child Transmission of HIV, or PMTCT

programme?
This programme helps reduce the chance that babies born to HIV-infected women will
be infected with HIV. The programme has several parts:
! Testing and counselling to help uninfected women remain free of HIV and protect
their families from the disease and to help women who are HIV-infected receive
special care to reduce HIV-transmission to their babies
! Medicine—antiretroviral treatment—to reduce the baby’s risk of getting HIV
! Counselling and support for safer infant-feeding practices
! Referral to treatment, care, and support programmes

Introduction
the following bulleted topics one at a time and discuss which key points should be
covered in a group information session. Use the questions and answers below to guide
you.
! HIV testing process

! Benefits and risks of HIV testing
! Confidentiality
! Implications of test results, both positive and negative
How is HIV testing conducted?

! Testing is offered to all pregnant women. Everyone has the right to refuse HIV
testing.
! The test tells if a woman is infected with HIV or not. On very rare occasions, if a
woman has had a recent risk or exposure, the test results may not reflect that
exposure. Therefore, it is recommended that a woman who has recently been at risk
be retested 3 months from her risk exposure.
! A positive HIV test means a woman has the HIV virus in her blood. It does not mean
she has AIDS; it does not tell her when she will get sick. A negative HIV test means
she does not have the HIV in her body.
! Share the site’s testing process, whether rapid or standard ELISA.

What are the advantages of knowing the test results?

! Knowing her HIV status can help a woman make informed decisions about her
pregnancy.
! If she is HIV-infected, knowing her status can help her access HIV services for
herself and to prevent transmitting HIV infection to her baby.
! Knowing her HIV status allows her to reduce the risk of infecting other people.
! Early testing makes it easier to plan for the future.
! If a woman finds out she is HIV negative, she can learn how to stay uninfected and
keep her family safe from HIV infection.
! There are many preventive health care services that can improve a woman’s quality
of life and prolong her life.
! Increasingly, medications for the treatment of HIV infection are becoming available.
These medications reduce the damage that HIV does to the body and prolongs life.
What are the disadvantages of testing for HIV?

! A woman might experience a little discomfort or bruising during the blood sampling
process (a finger prick or blood taken from the arm).

! Programmes may not be readily available for help or treatment, but she can be
referred.
! There is sometimes the risk of being stigmatised or discriminated against.
Who can receive information about your test results?

! Test results are confidential and become part of a woman’s medical records. They
can only be shared with healthcare workers who are involved in her care and
treatment—and only on an “as-needed” basis. She has the right to decide if anyone
other than healthcare workers may receive this information, and she is entitled to
receive support in that disclosure process.

Introduction
the following bulleted topics one at a time and discuss which key points should be
covered in a group information session. Use the questions and answers below to guide
you.
! Identifying HIV support services

! Family planning
! Individual counselling for risk assessment
! Testing and counselling for couples

What types of services are available in your community for the person who is
HIV-infected?
Have each participant think about the types of services that might be needed if test
results showed the participant (or participant’s partner) was HIV-infected. PMTCT pro-
grammes can help link people to many services for themselves, their infant or child, and
their family such as:
! Nutritional support
! Couples counselling
! Medical treatment and medicines to prevent transmission to the infant
! Treatment to prevent opportunistic infections
! Spiritual support, referral to a faith-based organisation
! Peer support groups
! Classes to learn safer infant-feeding practices
! Safe water programs
Who can benefit from family planning classes?

! Couples are encouraged to attend classes together when possible. Information may
be presented on condom use and safer sex practices to prevent both the spread of
HIV infection and unintended pregnancies.

! In some cultures, where sexual relations are limited during pregnancy and
immediately following childbirth, information may be provided to help couples
encouraging them to maintain closeness through non-risk behaviours.
! Fathers can learn to appreciate their role as responsible guardians of the health and
welfare of their wife and family.
When is it better to refer someone for individual counselling?

! Counsellors should assess whether referral to individual pre-test counselling is neces-
sary based on national or clinic guidelines. In some countries, individual counselling is
provided only when a woman has concerns or questions. During this time, sensitive
issues can be discussed more openly with the assurance of complete confidentiality.
! When the patient has questions that cannot be answered by PMTCT/ANC staff—
such as questions about STIs and risky sex practices—the questions can be
answered in an individual counselling session and suggestions can be provided to
help reduce harm to the individual and the partner(s).
What are the benefits of couples counselling?

! Each person has the right to complete information about HIV/AIDS and its
transmission.
! Both partners may come to understand the benefits and risks of testing, and the benefit
of knowing their status while receiving assurance that confidentiality will be maintained.
! Together, they can work on family planning issues, and accepting responsibility for
preventing unintended pregnancies and the spread of HIV infection.
! Together, they can come to understand the value of their partnership for protecting
their family’s health and planning for the future.

APPENDIX 6-E Post-test counselling checklist,
HIV-negative result
Counselling is a relationship and provides an opportunity to establish a rapport with the

patient, answer questions, and make sure the patient understands the information you
are providing.
" Make sure you have the patient’s test result and inform the patient that you have the
result.
" Greet the patient.
" Ask whether the patient has any questions since being tested. Answer questions and
let the patient know counselling will continue to be available to help with important
decisions.
" Recap the pre-test information/counselling session. Let the patient know you are
doing this to make sure he or she remembers important information.
" Indicate that the HIV test result is ready and provide results in a straight forward man-
ner. State in a neutral tone: “Your test result is negative.”
" Pause and wait for the patient to respond before continuing. Give the patient time to
" Explore the patient's understanding of the meaning of the results.
" Discuss and support the patient's feelings and emotions.

" If there was a recent risk exposure, discuss the need to re-test.
" Talk about specific risk reduction strategies with the patient:
!
Partner referral for testing and if negative faithfulness
!
Use of condoms
!
Limiting the number of sexual partners
" Talk with the patient again about disclosure and about partner testing.
" Discuss discordance.
" Inform the patient that counselling is available for couples.
" Emphasise the importance of protecting herself from infection while pregnant or
breastfeeding, and explain how doing that will lower the risk that her infant will
become HIV infected.
" Ask whether the patient has questions or concerns. Give the patient contact informa-
tion for the clinic should any new concerns arise.
" Discuss support issues and subsequent counselling sessions.
" Remind women and families that counselling or referral to counselling will be avail-
able throughout the pregnancy to help them plan for the future and to obtain services.

APPENDIX 6-F Post-test counselling checklist,
HIV-positive result
Counselling is a relationship and provides an opportunity to establish a rapport with the
patient, answer questions, and make sure the patient understands the information you
are providing.
" Greet the patient.
" Make sure you have the patient’s test result and inform the patient that you have the
result.
" Ask whether the patient has any questions since being tested. Answer questions and
let the patient know counselling will continue to be available to help with important
decisions.
" Recap the pre-test information/counselling session. Let the patient know you are
doing this to make sure he or she remembers important information.
" Indicate that the HIV test result is ready and provide it in a straight forward manner.
State in a neutral tone: “Your test result is positive”.
" Pause and wait for the patient to respond before continuing. Give the patient time to
" Check the patient's understanding of the meaning of the results.
" Explore and support the patient's feelings and emotions.
" Normalise the patient's feelings and emotions.
Inform the patient of essential PMTCT issues. Discuss and support initial decisions
"
about:
!
Antiretroviral treatment and prophylaxis
!
Infant-feeding options
!
Childbirth plans
!
Adequate nutrition
!
Address Positive Living and provide referral for preventive health care services
!
Prompt medical attention, prophylaxis, and treatment of opportunistic infections
!
Stress management and support systems
" Explain that the woman’s test results do not indicate whether her partner is infected
and that her partner will need to be tested.
" Discuss disclosure and support issues.
" Address risk reduction that is necessary to protect her partner(s) and herself from
re-infection:
!
Condom use
!
Reducing the risk of infecting others and screening and treatment for sexually
transmitted infections
" Identify sources of hope for the patient, such as family, friends, community-based ser-
vices, spiritual supports, and treatment options. Make referrals when appropriate.
" If the patient already has children, discuss and plan for testing of children.
" Ask whether the patient has questions or concerns. Give the patient contact informa-
tion for the clinic should concerns arise.
" Remind mothers and families that counselling will be available throughout the preg-
nancy to help them plan for the future and obtain necessary services.

APPENDIX 6-G Role play scenarios for post-test counselling,
exercise 6.4 and counselling checklist
Scenarios for HIV-negative test results

Scenario 1 Shonda is 17 years old and has been dating her boyfriend for one year.
She started having unprotected sexual relations with him three months ago, and is now
pregnant. She suspects that her boyfriend may be at risk for HIV since he has not been
faithful to her, although he denies this. During her first visit to ANC, she decided to be
tested, just in case she is infected.
Scenario 2 Paul and Maria have been married for 2 years. They are now planning to
start their family. Before they married, Paul experimented with drugs, including needle
sharing. Although he has never had any HIV symptoms, they have decided to both be
testing prior to starting a family.
Scenario 3 Lisa is a student in computer school and is in her third trimester of

pregnancy. Although she is in a committed relationship with the father of her child, in the
past she had multiple sexual partners and engaged in unprotected sex. After attending
her first ANC visit she understood that she might be at risk for HIV and, as she does not
want to put her partner or baby at risk, she decided to be tested.
Scenarios for HIV-positive test results

Scenario 1 Debbie is working on a truck route as a commercial sex worker and sees

many men each week. She has tried to get them to use condoms but many of them
refuse. She is in her 28th week of pregnancy and this is her first visit to the ANC clinic.
She is worried about her baby’s safety and has agreed to be tested for HIV.
Scenario 2 Margaret and Steven have been married for six years and have three
children. She is now in her second trimester of pregnancy and suspects they may be
having twins. Last year, the couple had separated for approximately four months. During
that time, Steven had sexual relations with someone whom, he later found out, was
HIV-infected. Margaret is aware of this and, because of the pregnancy, knows that the
baby is at risk for HIV-infection if she has HIV. Steven has refused testing, but she was
tested and he has accompanied her to the clinic today to hear her results.
Scenario 3 Christine works in housekeeping at the ANC clinic. She is well liked by all
the staff and recently found out she is going to have her first baby. Prior to working at
the clinic, she was a patient in a community drug rehabilitation programme in a nearby
town. No one at the clinic is aware of this. She knows, because of previous behaviours,
that she needs to be tested for HIV. She approached one of the healthcare workers and
asked for her help getting tested. She is very concerned that other staff may find out
and wants test results kept confidential between her and this one healthcare worker.

APPENDIX 6-G Counselling checklist (continued)
Counselling checklist
As you observe your colleagues role play, indicate the techniques they use by placing
a check in the appropriate box.
Skills and Specific strategies, statements, behaviours $
#
techniques
Establishing a ! Greets the patient; shakes hands if appropriate #
relationship ! Offers a seat #
! Leans forward when talking #
! Makes eye contact (when appropriate) #
! Shows interest in the patient #
! Other (specify): #
Listening ! Looks at the patient #

! Body language indicates attentiveness to speaker #
! Makes eye contact to indicate care and interest (when appropriate) #
! Facial expression indicates caring and interest in the patient #
! Uses minimal encouragers such as yes, okay, etc. #
! Checks to be sure the counsellor understands what the patient is saying #
! Occasionally sums up patient's statements #
Empathy ! Comments on patient's challenges while also indicating patient's #

strengths
! Reflects statements back to patient to indicate understanding #
Questioning ! Uses closed-ended questions to get basic information such as demo- #

graphic data
! Avoids overuse of closed-ended questions #
! Uses open-ended questions to get more in-depth information from #
patient
! Style of questioning reflects interest, care, and concern, not interrogation #
! Asks relevant questions #
Clarifying ! Checks understanding of what the patient is saying #

! Uses phrases such as: “ Are you saying that…?” or “Correct me if I #
am wrong…”
Providing ! Provided information on HIV #

technical ! Provided information on the testing process and results #
information ! Discussed confidentiality #
(on pre-test ! Explained the meaning of the test result #
counselling, test- ! For HIV-negative patients, provided information on staying negative #
ing procedures, ! For HIV-positive patients, provided information on the meaning of the #
test results, post- test result and PMTCT
test counselling)

Module 7 Linkages to Treatment, Care, and
Support for Mothers and Families With
HIV Infection
SESSION 1 Linkages with Local Treatment, Care, and Support Services for
Mothers and Families
Exercise 7.1: Community linkages: None, other than those noted 70 minutes
small group discussion below
SESSION 2 Treatment, Care, and Support of the Mother who is HIV-Infected
Exercise 7.2: Postpartum case study None, other than those noted 45 minutes
below
SESSION 3 Treatment, Care, and Support of the Infant and Young Child Exposed
to HIV

Module 7 Linkages
Exercise 7.3: Clinical presentation of Three cards, 4"x 6" or similar, with 35 minutes
HIV in infants the following headings (one per
card): GI, Pulmonary, Immune
Function

Q Overheads or PowerPoint slides for this Module (in Presentation Booklet)
Q Overhead or LCD projector, extra extension cord/lead
Q Flipchart or whiteboard and markers or blackboard and chalk
Q Pencil or pen for each participant

Session 1
! Listing of local agencies providing clinical and social support services for mothers
and families with HIV
Session 2
! Guidelines on postpartum care of the mother with HIV infection
! Guidelines on prevention and treatment of opportunistic infections such as PCP
and TB
! National guidelines on HIV care and treatment for adults, including ARV treatment
! Any other national guidelines on treatment of symptoms and palliative care,
nutritional support, and social and psychosocial support (If not included above)
Session 3
! Guidelines for follow-up visits and immunisation schedule for the infant or child
who is HIV-exposed
! Clinical guidelines on the care and treatment (including ARV treatment) of infants
and children who are HIV-exposed or HIV-infected

Module 7 Linkages
Module 7–2 Linkages to Treatment, Care, and Support for Mothers and Families with HIV Infection
SESSION 1 Linkages with Local Treatment, Care, and
Support Services for Mothers and Families
Advance Preparation
No additional advance preparation is required for this session.
Slides 1 and 2

! Explain the treatment, care, and support needs of mothers with HIV infection and
their infants who are HIV-exposed.
! Identify local supportive resources for mothers, children, and their families.
! Develop and strengthen linkages with treatment, care, and support services for
women and children infected with or exposed to HIV.
Slides 3 and 4
Discuss the different kinds of linkages to care and support services that may help
mothers and families, using the information below. Module 7 Linkages
Make These Points

! Strengthening linkages to existing support services provides continuity of care for
mothers, infants, and families.
! Referral systems expand on services offered through MCH and PMTCT programmes.
! Community-based service organisations, including NGOs and faith based
organisations, can address psychosocial as well as medical needs.
! Team building is essential to promoting community linkages.

The follow-up treatment, care, and support that women who are HIV-infected receive
after delivery, and the care of their children and families, can be strengthened if linkages
are made with comprehensive community health services that include HIV/AIDS
treatment and care, social support, and patient advocacy. It is important that treatment
and care extend beyond PMTCT prophylaxis for women, infants, and family members at
risk for or infected with HIV.
Linkages can be fostered in many ways:

! Programme developers can establish linkages by integrating PMTCT services into
existing maternal and child health (MCH) services.
! Clinicians and healthcare workers can expand their practices to include necessary
referrals and then follow up to ensure families have easy access to linked services.
! Community workers, including lay counsellors, can assist women in obtaining treat-
ment, care, and support services.
Linkages between MCH and HIV services
! MCH services are entry points for PMTCT and for the treatment, care, and support of
women who are HIV-infected and their infants and other family members.
! PMTCT is integrated into MCH services through training (building human capacity)
and programme development.
! Caring for and treating families affected by HIV is a shared responsibility.
! All children born to women who are HIV-infected require close follow up and appropri-
ate care.
! Community MCH workers may be encouraged to provide information on health promo-
tion and disease prevention, as well as care and support services to these families.
! Specialists in HIV who care for women and children may provide consultation, anti-
retroviral treatment, and help with the ongoing management of HIV infection.
Linkages with other health programmes for special needs
! Some programmes target specific health needs, such as family planning, treatment of
sexually transmitted infections (STIs), or assistance with substance abuse.
! Disease-specific programmes, such as those for people with tuberculosis (TB) may
benefit women who are HIV-infected. TB, which is highly prevalent in certain coun-
tries, is a leading cause of mortality in persons infected with HIV. (See Appendix 7-A.)
! Nutritional support programmes for mothers and children are especially important for
people living with HIV/AIDS (PLWHA).
Module 7 Linkages
Linkages to community-based AIDS service organisations
Linkages to community-based organisations can provide the resources to help women
who are HIV-infected and their families cope with the isolation, social stigma, and emo-
tional pressures that often accompany a diagnosis of HIV. They also may provide women
infected with HIV a way to become involved in voluntary or paid HIV-related work.
! Non-governmental organisations (NGOs), faith-based organisations (FBOs), and simi-

lar agencies often provide treatment, care, and support services for mothers who are
HIV-infected and family members.
! Linkages between healthcare programmes and other community based and faith-
based organisations may improve patient care.
! Faith-based organisations and traditional healers may offer another important source
of social and community support.
! Many community agencies may also provide education, counselling, and testing
about HIV prevention and safer sex.
! Linkages to programmes for preventing and treating malaria or TB, or to programmes
that offer nutritional support help women gain access to needed services.
! Relationships between health clinics and community programmes may offer connec-
tions to counselling, peer education support groups, and networks for PLWHA.
! Organisations of PLWHA are one of the most important sources of support for moth-
ers diagnosed with HIV infection in PMTCT programmes and for their families.
! Community organisations often help PLWHA with specific needs such as housing, trans-
portation, food assistance, legal assistance and advice, and income-generating activities.
Building community teams for shared responsibility

! Formalise connections among MCH programmes, health systems, and
community programmes, whenever possible.
! As people who work in community agencies and healthcare settings learn more
about services available outside of their own setting, people living with
HIV/AIDS can gain access to a wider range of services.
Module 7 Linkages
Lead the small group discussion on community linkages.

Exercise 7.1 Community linkages: small group discussion
Purpose Identify the range of services locally available to PLWHA.

Encourage interagency networking and linkages.
Facilitate client referral to community services.
Duration 60 minutes
Introduction Once a healthcare worker recognises when to refer a patient to a

local organisation offering needed services, the next step is to find
out where to refer people.This exercise will provide participants a
chance to share information on the continuum of HIV-related services
offered in their community. By the end of this exercise all participants
should have compiled a listing of HIV-related resources.
Activities Using participant sign-up sheets, identify and divide participants by

geographic location or association with a particular facility (not more
than 4–5 groups if possible).
Ensure each group has copies of Appendix 7-B Community resource
information worksheet.
Using Appendix 7-B as a guide, ask each small group to identify
available community resources and record them on paper.
Also using Appendix 7-B ask them to address each category of
community resource in the left-hand column and answer the
following questions:
! Are they familiar with a resource for each listing? For example,
do they know of a local support group or club for PLWHA?
! Are they aware of the address, location, hours of operation?
! For each resource listed, do they know of a contact person for
networking and referral?
! Are there resources missing in their list?
! Can they think of other resources that are not included?
! Are they in contact with key community members who they might
partner with to expand their resource list?
Allow 35–40 minutes for this process.
Ask each group to assign a spokesperson who can report on the
group’s findings.
Module 7 Linkages
List services on flipchart or blackboard as group spokesperson

provides information.
Debriefing Remind participants that establishing linkages requires community

teamwork.
Healthcare workers need to become familiar with local services,

including physical location, hours of operation, what specific services
are provided, and a contact name and telephone number for making
referrals.
SESSION 2 Treatment, Care, and Support of the Mother
with HIV Infection
Advance Preparation
Review Exercise 7.2: Postpartum case study to be sure it reflects local
customs, issues, and policies. Ask local healthcare workers to help you
adapt the exercise, if necessary. Change the names from "Bea" to a
common local name.
Slides 5, 6 and 7
Discuss the postpartum care of mothers who are HIV-infected, using the information
below.
Make These Points

! Postpartum care includes physical assessment, infant-feeding support, family plan-
ning, and referral for HIV/AIDS treatment.
! A mother’s chosen feeding option will not always reflect national and regional poli-
cies.
! Condoms protect against both STIs—including HIV—as well as unintended future
pregnancies.
Module 7 Linkages

Postpartum care of the mother with HIV infection
Healthcare workers should ensure that women who are infected with HIV and have
given birth in a healthcare facility return for postpartum appointments or are visited at
home.
Women who have given birth at home should be evaluated 1 week after the birth and
again at 6 weeks.
Include the following during visits:
Assessment of healing
! Check wound healing.
! Monitor uterine involution.
! Confirm cessation of postpartum bleeding.
Infant-feeding support
(Also see Module 4, Infant Feeding in the Context of HIV Infection.)
! Assess progress of infant feeding.
! Assist the mother to safely implement her chosen feeding option.
! Assess family support for the infant-feeding option.
! Work with the mother to develop a plan to address challenges.
Sexual and reproductive care

(Also see Module 2, Overview of HIV Prevention in Mothers, Infants, and Young
Children)
! Discuss condom use as dual protection (against STIs, including HIV, and for family
planning).
! Support the mother's choice of contraceptive method.
! Discuss the importance of safer sex to prevent the spread of HIV and other STIs.
! Provide advice regarding early STI treatment, including symptom recognition and
where to go for STI assessment and treatment.
! Answer any questions the woman may have about safer sex behaviours.
Make These Points

Module 7 Linkages
! Providing linkages to supportive services for primary care—including HIV/AIDS care

and psychosocial support—is a part of postpartum care.
! Discuss importance of linking patients to a range of support services, using the infor-
mation below.
Related services for HIV treatment, care, and support
The postpartum period is an ideal time to link the woman who is HIV-infected to
comprehensive care that will support her health, prevent complications, and improve her
ability to live with HIV.
A range of related services should be provided directly or by referral, including those
listed below:
! Prevention and treatment of ! Nutritional support
opportunistic infections ! Social and psychosocial support
! ARV treatment when indicated and ! Faith-based support
available ! Home-based care
! Treatment of symptoms and palliative
care
Slides 8 and 9
Discuss prevention and treatment of opportunistic infections, using the information

below.
Make These Points

! Refer participants to national and regional guidelines for managing opportunistic
infections such as PCP.
! Cotrimoxazole, though commonly used for bacterial and PCP prophylaxis, is not well-
tolerated by everyone. Should an adverse reaction occur, another drug may be sub-
stituted according to national or local protocol.
! Discuss prevention and treatment of other opportunistic infections in mothers who are
HIV-infected, using the information below.
! When presenting TB information, keep in mind that women who have received BCG
and women who have had a positive skin test should not receive an annual skin test.
Module 7 Linkages

Prevention and treatment of opportunistic infections
Infections are a major complication of HIV. Preventing opportunistic and other infections
will help a woman stay healthier and preserve her immune system.
Prevention and treatment of malaria

Recommend the use of insecticide-treated bed nets to prevent malaria in areas where it
is endemic. Offer malaria treatment and prophylaxis according to national guidelines.
Pneumocystis carinii pneumonia prophylaxis

WHO recommends the use of cotrimoxazole to help prevent pneumocystis carinii
pneumonia (PCP) in adults who meet any one of several criteria listed in Appendix 7-C.
Cotrimoxazole also may reduce the risk of other bacterial infections and toxoplasmosis.
Prophylaxis, screening, and treatment for TB

An estimated 40% of persons who are HIV-infected will develop TB in their lifetime.
Refer to country protocols regarding prophylaxis, screening, and treatment of TB,
particularly in high prevalence areas. (See Appendix 7-A for recommendations.)
Immunisations
Recommendations for immunisations should follow national and WHO guidelines for
adults who are HIV-infected.
Slide 10
Discuss ARV treatment to reduce the risk of MTCT, using the information below.
Make These Points

! ARV prophylaxis does not provide long-term protection from MTCT or treat maternal
HIV.
! Referral for combination antiretroviral treatment is important for both mother and
infant, especially those who are breastfeeding.
Module 7 Linkages
Antiretroviral treatment
Although ARV prophylaxis during pregnancy reduces the risk of MTCT, it does
not provide any long-term benefit to the mother. When indicated, (ie, when the
patient meets clinical criteria to start antiretroviral treatment) antiretroviral treat-
ment to suppress viral replication and promote a better quality of life is needed.
Support for antiretroviral treatment for women who are HIV-infected is becoming
increasingly available. Women initially followed in PMTCT settings should be linked to
treatment services for themselves and their families (PMTCT-Plus). International and
national policies and guidelines provide support for this process including criteria for
initiating treatment. See Appendix 3-B for WHO recommendations.
Combining ARV drugs to reduce the HIV viral load as much as possible—and for as
long as possible—is the standard of care for HIV treatment. A combination of three or
more ARV drugs, referred to as highly active antiretroviral therapy (HAART), slows
replication of HIV.
The advantages are

! Improved health status
! Decreased MTCT rates
! Reduced HIV-related hospitalisations
! Reduction in number of deaths from AIDS
A high level of patient adherence to ARV treatment and care regimens may reduce drug
resistance and ensure better efficacy. Creative strategies to help patients achieve
optimal adherence are essential components of successful HIV/AIDS treatment
programmes. Consider the following methods:
! Provide education and establish patient readiness prior to initiating treatment.

! Recognise that immediately postpartum, women will require additional support.
! Consider the use of practical adherence tools such as pill boxes, and written instruc-
tions.
! Explore patient’s daily meal patterns, work schedule, and sleep patterns to find the
best time to take medications.
! Develop culturally appropriate strategies to overcome barriers and support adherence
when possible.
Slide 11
Discuss palliative care, using the information below.

Module 7 Linkages
Make These Points

! Introduce and then discuss symptom treatment and palliative care for mothers who
are HIV-infected, using the information on the following page.

Treatment of symptoms and palliative care
PLWHA are subject to HIV symptoms that can limit participation in family and
community activities. Healthcare interventions that focus on managing symptoms and
relieving discomfort can improve a woman's quality of life. Simple management of
common HIV symptoms, such as nausea, vomiting, fatigue and skin problems can ease
discomfort. Assessment and management of more complex issues such as pain, weight
loss and wasting resulting from disease progression can improve comfort, function and
emotional well-being.
Palliative care is patient and family-centred care that:

! Provides access to information and honours a person’s choices
! Optimises quality of life
! Anticipates, prevents, and treats suffering
! Addresses physical, emotional, social, and spiritual needs
Slide 12
Discuss nutritional counselling and support, using the information below.
Make These Points

! Emphasise that women who are HIV-infected and are exclusively breastfeeding
require an additional 500 kcal/day.
Nutritional counselling, care, and support

Often, people with HIV infection or AIDS have symptoms that make food preparation
and eating difficult. Appendix 7-D lists some of the symptoms of HIV/AIDS and ways in
which people may reduce or overcome those symptoms while maintaining adequate
nutrition.
Women receiving HIV-related medications require counselling on specific dietary

Module 7 Linkages
practices and nutritional needs, in order to successfully manage side effects and avoid
nutrition-related complications. Antenatal counselling for safer infant-feeding practices
and postnatal support for the feeding option a woman selects may help ensure
adequate nutrition and the proper growth and development of her child.
PLWHA are especially vulnerable to bacterial infections because their immune systems
become weakened. Emphasise to PLWHA the importance of cleanliness during food
preparation and storage.
Adequate nutrition, exercise, rest, good hygiene practices, and abstinence from harmful
habits such as smoking, alcohol, and drug abuse support overall health and improve
immune function.
Slide 13
Using the information below, discuss social and psychosocial support for mothers who
are HIV-infected, including faith-based support.
Social and psychosocial support

Because people with HIV face stigma in many communities (See Module 5, Stigma and
Discrimination Related to MTCT), women who are HIV-infected often are reluctant to
disclose their serostatus to partners, family, or friends. Moreover, a woman who has
learned of her HIV serostatus during prenatal HIV testing may still be adjusting to her
diagnosis. Regular monitoring of mental health and psychosocial care and support are
critical at all stages of HIV infection. The following services should be offered directly or
by referral:
! Support to help the woman come to terms with her diagnosis

! Psychosocial support for the mother and for the infant who is exposed to HIV in
cases when the infant's HIV status is uncertain and when a positive diagnosis is
made
! Community support, including referrals to community-based and faith-based pro-
grammes
! Peer group counselling and support from health agencies or NGOs
! Support and counselling to assist women who are HIV-infected and their partners
with disclosure issues
Faith-based support
Faith-based involvement provides mothers who are HIV-infected with spiritual and
psychosocial support. It also may provide them with an important sense of belonging to
a larger community that offers them compassionate care. In many programmes, faith-
based organisations are providing comprehensive treatment, care, and support
services.
Home-based care
In many resource-limited settings, home-based care provides services to PLWHA when
hospital and outpatient services are expensive or not accessible. The advantages of
home-based care for patients and families, and for communities and the healthcare
system include:
Module 7 Linkages
! Care is provided in a familiar, supportive environment that allows for continued partic-
ipation in family matters
! Medical expenses are reduced
! The local community is involved in caring for PLWHA, which may help counter myths
and misconceptions
! The burden on the healthcare system is eased
Healthcare workers may offer direct psychosocial support and referrals to commu-
nity resources. AIDS service organisations in the community may provide social
support through peer group counselling, clubs, or referrals to other services.

Lead Exercise 7.2, a case study addressing postpartum issues.
Exercise 7.2: Postpartum case study
Purpose To prepare participants to handle common problems that mothers

may present during postpartum visits.
Duration 30 minutes
Introduction Distribute copies of the postpartum case study.
Explain to participants that the case study will help them

evaluate and make recommendations for addressing common
problems that may arise at postpartum checkups.
Activity ! Ask participants to divide into three groups.

! Instruct them to read through the case study together.
! Ask each group to assign one person (the group recorder) to
write down key issues in the case study.
! Ask each group to list each issue that the healthcare worker
needs to address.
! Tell participants that the groups have 15 minutes to discuss
and develop strategies to resolve the issues on their lists.
! Ask the group recorder to write down the strategies for each
issue.
! Ask each group to tell you the key issues discussed. Write
these on a flipchart in the front of the room—on the left side
of the paper; leave the right-hand column for recording
strategies.
Debriefing Ask group: did they feel that this case study was appropriate for
discussing a postnatal visit?
Module 7 Linkages
What other issues typically come up?
Women who are HIV-infected often require special consideration

for both treatment and emotional support.
Consider referral for ARV treatment as resources and national

policies allow.
Case study
Bea is a 24-year-old woman who was diagnosed as HIV-infected during her recent
pregnancy. She and her infant received the appropriate medication to prevent MTCT, as
recommended by the country programme. She has returned for her 6-week follow-up visit.
Bea has chosen to exclusively breastfeed. She feels, however, that the baby is always
hungry and is wondering if her breastmilk is enough; she has also been giving him
supplemental vitamins. Bea and her husband, who is also HIV-infected, would like to
resume sexual relations. She has been told that she will not need to use protection
because breastfeeding eliminates her chances of getting pregnant.
Upon examination, Bea appears to be doing well. She has a 0.3 cm fissure (crack) at
the base of her right nipple. There is no observable redness, heat, or sign of infection.
Bea reports that she has been feeling more tired than usual and has about half her
normal energy, but does not have any other physical complaints. She wants to know
whether starting HIV medicine may help her feel better.
Bea's husband has been sitting in the waiting room. He is currently unemployed. While
Bea is getting dressed, he says, "I have always taken good care of my family, but now,
without money coming in, I don't see how we are going to make it. I feel like God is
punishing me, somehow, for infecting my wife with HIV."
What are the important issues for Bea and her husband?
In reviewing responses, be certain that the group addresses the following issues:
1) Bea will require a great deal of support for continuing with her choice of exclusive
breastfeeding:
a) Review nutritional benefits of breastfeeding and check the supplemental
vitamins she is giving to her infant.
b) Find out why she feels that the baby is always hungry. What signals is he
giving her? Is he gaining weight?
c) Review her breastfeeding technique.
Module 7 Linkages
d) Assure her that nearly all women do have sufficient breastmilk.

2) While breastfeeding does promote lactation amenorrhoea (not having menses),
protection against further infection with HIV or STIs is recommended. It is also
important to let her know that breastfeeding is not a reliable form of contraception.
If she does not want to become pregnant right away, she needs to use an effective
method of contraception. Discuss how she can protect herself and her husband by
correctly and consistently using condoms or other barrier methods. Also, use this
opportunity to discuss long-term family planning.
3) Review signs and symptoms of breast infection and remind Bea that early
intervention to maintain her skin intact and prevent future problems is important.
Review breast care.

4) Assure Bea that if she is exclusively breastfeeding (8–10 times daily), this may be
the reason for her fatigue. This is also an emotionally stressful time for both her
and her husband with a new baby to care for. Review her diet to ensure that she is
consuming adequate calories (500 kcal/day more than she ate before she was
pregnant) and eating nutritious foods while breastfeeding. Let her know that you
will help link her to HIV care and antiretroviral treatment, when indicated. If it
appears her caloric intake is adequate, and she has social support, consider that
fatigue may be due to HIV infection and/or an OI. Consider referral for treatment or
ask her to tell her HIV provider.
5) Her husband sounds burdened by guilt and overwhelmed with his responsibilities.
Referring him for professional counselling may be indicated.
Module 7 Linkages
SESSION 3 Treatment, Care, and Support of the Infant and
Young Child Exposed to HIV
Advance Preparation
For Exercise 7.3: Write on the flipchart the following four categories
related to follow-up care for infants or children who are HIV-exposed: HIV
testing; Immunisation; Growth and development; and Monitoring for
signs/symptoms of HIV infection.
Become familiar with recommended follow-up care for infants and children
by reviewing the Pocket Guide, Module 2, Overview of HIV Prevention in
Mothers, Infants, and Young Children.
Slides 14 and 15
Discuss healthcare and support for infants and children exposed to HIV, using the
information below.
Make These Points

! When regular healthcare visits are not possible, the healthcare worker will need to
develop strategies to assist the mother with monitoring infant growth and develop-
ment.
! Refer to national and regional immunisation guidelines in addition to WHO recom-
mendations.
Module 7 Linkages
PMTCT interventions reduce, but do not eliminate, the risk of HIV transmission from
mother to infant. Regular follow-up care is critical for an infant born to a mother with
HIV/AIDS and for an infant whose mother’s HIV status is unknown. This includes an
infant who has received ARV prophylaxis, because HIV exposure increases an infant’s
risk of illness and failure to thrive, whether or not the infant has HIV infection.
Module 6, HIV Testing and Counselling for PMTCT contains information on HIV testing
and diagnosis for infants and young children. The timing of testing and methods used
vary according to infant-feeding practices and availability of specific tests.

Regular visits for health assessment and health promotion
To ensure that infants receive essential care, adequate nutrition, and support for feed-
ing, the newborn should be seen in the healthcare facility or at home. The schedule for
healthcare visits should be in accordance with national policy or as suggested below:
! If the infant was born at home, an assessment at the time of delivery followed by a
visit in 7 days to monitor feeding progress is strongly advised. Special considerations
apply when the infant is receiving ARV prophylaxis. (See Appendix 3-A.)
! It is recommended that subsequent visits be scheduled to coincide with a country's
recommended schedule for immunisations. WHO recommends subsequent visits as
follows:
! At ages 6, 10, and 14 weeks
! Once a month from 14 weeks to 1 year
! Every 3 months from the ages of 1 to 2
Anytime the infant becomes ill or the mother suspects a problem, seeking early medical
intervention is strongly encouraged.
Immunisation
Infants born to mothers who are HIV-infected should be immunised according to
national or local guidelines. Please refer to WHO immunisation recommendations
(Appendix 7-E).
Nutrition and infant-feeding support

As discussed in Module 4, Infant Feeding in the Context of HIV Infection, at each visit,
workers should assess and support a mother's choice about infant feeding. Discussions
about infant feeding are especially important in the early months of life and as new
foods are introduced.
Infants who fail to grow require special attention. Workers should assess feeding prac-
tices and diet for infants older than 6 months and provide appropriate counselling that
considers locally available food, family circumstances and feeding customs. Underlying
infections should be treated immediately or ruled out as a cause of growth failure.
Discuss follow-up care for infants and children who are HIV-exposed, including the
Module 7 Linkages
concept of failure to thrive and the importance of monitoring growth and development,
especially in the first 2 years of life.
Make These Points

! Education about early signs and symptoms of both HIV- and non-HIV related condi-
tions may help avoid serious outcomes for the infant.
! Acute diarrhoea is a potentially life-threatening condition in young infants and must
be reported and treated as soon as possible.
! Integrated Management of Childhood Illness (IMCI) provides guidance to healthcare
providers regarding provision of treatment.
Each visit with the healthcare worker should include the following:
! Assess for common illnesses and manage appropriately as directed by the Integrated
Management of Childhood Illness (IMCI) guidelines.
! Identify non-specific symptoms or conditions that could be related to HIV infection
using the HIV-adapted IMCI algorithms if available.
! Provide HIV testing as indicated in Module 6, HIV Testing and Counselling for
PMTCT.
! Provide PCP prophylaxis based on WHO guidelines (Appendix 7-C) or national policies.
! Promote health and prevention of illness.
! Monitor growth and assess causes of growth failure, if observed.
! Check immunisation status and immunise as indicated (Appendix 7-E).
! Provide PCP prophylaxis.
! Treat for helminth infection if the parasite load in the environment is high or as rec-
ommended by IMCI guidelines.
! Screen, provide prophylaxis for, or treat TB if indicated.
! Prevent and treat malaria, as indicated based on national policy or guidelines.
! Treat anaemia, as indicated based on national policy or guidelines.
! Counsel caregivers on infant feeding, nutrition, ARV treatment when indicated and
other care as appropriate.
! Ensure that the mother has access to family planning and support for her own health.
Because the health of mother and child is so closely related, assessment of maternal
health and nutrition should be concurrent with assessment of the infant and appropriate
referrals for maternal care should be given during infant checkups.
Slides 19 and 20
Using the content on the next page, discuss prevention of PCP infection.
Module 7 Linkages
Make These Points

! PCP prophylaxis is indicated for infants who are HIV-exposed until they are tested
and found to be HIV-negative.
! Refer to national and local policies on PCP prophylaxis in infants.

Prevention of PCP infection
PCP is a leading cause of death in young infants with HIV. Every infant born to a mother
with HIV infection should receive cotrimoxazole to prevent PCP, beginning at 6 weeks
and continuing at least through 6 months of age, unless a viral assay shows the infant
has no HIV infection. PCP prophylaxis should continue in infants who are HIV-exposed
until they are 1 year old or virologic testing shows the infant is not infected (see
Appendix 7-C).
HIV testing
ARV prophylaxis reduces, but does not eliminate, MTCT. Therefore, services must be
identified or developed to provide follow-up care and HIV diagnostics to infants of
mothers who are HIV-infected and appropriate treatment offered when indicated. Infants
of breastfeeding mothers who are HIV-infected are at increased risk for acquiring HIV
after birth; the greatest risk of transmission is believed to occur within the first months of
life. Module 6, HIV Testing and Counselling for PMTCT, discusses laboratory
assessment of infants who are HIV-exposed.
Discuss presentation and assessment of HIV in infants and children, using the
information below.
Make These Points

! ARV prophylaxis reduces MTCT, however, infants who are HIV-exposed require diag-
nostic testing and close monitoring to determine their HIV status.
! Mothers who are HIV-infected and continue to breastfeed their infants increase the
cumulative risk of MTCT over time.
! Recognising symptoms of HIV in infants can help mothers access early treatment for
themselves and their infants.
! Supportive counselling must be provided to parents receiving notice of an infant’s
positive HIV test.
Module 7 Linkages
Clinical presentation and assessment of an infant born to a mother
who is HIV-infected
An infant born to a mother who is HIV-infected and presents with symptoms of illness
should be assessed using the IMCI guidelines as adapted for areas with a high
prevalence of HIV infection.
The signs and symptoms most commonly associated with HIV infection in infants are
low weight and/or growth failure; pneumonia, including PCP; oral candidiasis (thrush);
lymphadenopathy; parotid gland swelling; recurrent ear infections; persistent diarrhoea,
and TB (Table 7.1). Healthcare workers should teach mothers and other caregivers to
recognise early signs of those conditions and to seek early care for the child.
Interventions to relieve symptoms, such as oral rehydration for acute diarrhoea,

nutritional interventions to promote weight gain, PCP prophylaxis, and screening for TB,
are important strategies for improving the health of infants who are HIV-infected.
Table 7.1. Clinical conditions or signs of HIV infection

in a child who is HIV-exposed
Specificity for HIV infection Signs and conditions
Common in children who are ! Chronic, recurrent otitis media with discharge
HIV-infected; also seen in ill, ! Persistent or recurrent diarrhoea
uninfected children ! Failure to thrive
! Tuberculosis
Common in children who are ! Severe bacterial infections, particularly if recurrent
HIV-infected; uncommon in ! Persistent or recurrent oral thrush
uninfected children ! Chronic parotitis (often painless)
! Generalised persistent noninguinal lymphadenopa-
thy in two or more sites
! Hepatosplenomegaly
! Persistent or recurrent fever
! Neurologic dysfunction
! Herpes zoster (shingles), single dermatome
! Persistent generalised dermatitis unresponsive to
treatment
Module 7 Linkages
Specific to HIV infection ! Pneumocystis carinii pneumonia

! Oesophageal candidiasis
! Lymphoid interstitial pneumonitis
! Herpes zoster (shingles) with multidermatomal
involvement
! Kaposi's sarcoma

Slides 21 and 22
Discuss caring for infants who are HIV-infected and integrating HIV paediatric care into
ongoing care. Introduce the concept of paediatric ARV treatment, using the information
below.
Make These Points

! Review WHO recommendations for ARV treatment and refer to national and local
policies.
! Family beliefs play an important role in determining initiation of and adherence to
antiretroviral treatment regimens when an infant is HIV-infected.
Care of the infant with documented HIV infection

The suspicion or confirmation of HIV diagnosis in an infant or child is difficult for the
parents. Workers should discuss the diagnosis compassionately and confidentially, and
they should offer the parents information about services available for the child (see
Module 6, HIV Testing and Counselling for PMTCT, Appendix 6-B).
Integrating the care of infants who are HIV-infected into ongoing care using IMCI
Several countries have adapted guidelines, including those outlined in IMCI, to include
recognition of the special needs of children with HIV infection and to help healthcare
workers assess and provide better management when HIV is suspected or confirmed.
Adhering to guidelines may help integrate the care of children with symptomatic HIV
infection into MCH services.
Where ARV treatment is available, healthcare workers must monitor infants and children
(considering laboratory findings, when available) for symptoms of HIV infection that
would make them candidates for ARV treatment, and refer them for appropriate HIV
treatment and care.
Before treatment begins, healthcare workers need to assess a family’s beliefs about drugs
and treatment, the family’s readiness to begin treatment, and their ability to follow a dosing
Module 7 Linkages
schedule. Treatment decisions follow international and national policies and guidelines.
When CD4 cell assays are available the use of the CD4 cell percentage is
recommended for decision-making on ARV treatment rather than the absolute CD4 cell
count, because the former varies less with age.
For infants who are seropositive aged less than 18 months, WHO
recommends the initiation of ARV therapy in the following circumstances:
The infant has virologically proven infection (using either HIV DNA PCR, HIV
RNA assay, or immune-complex dissociated p24 antigen) and has:
! WHO Paediatric Stage III HIV disease (ie clinical AIDS) irrespective of CD4%; or
! WHO Paediatric Stage II HIV disease, with consideration of using CD4 <20% to
assist in decision-making; or
! WHO Paediatric Stage I (ie, asymptomatic) and CD4% <20%. (asymptomatic
children, ie, WHO Stage I, should only be treated when there is access to CD4
assays).
If virological tests to confirm HIV infection status are not available but CD4 cell
assays are available, WHO recommends that ARV treatment can be initiated in
infants who are HIV-seropositive and have WHO Stage II or III disease and a CD4
percentage below 20%. In such cases, HIV antibody testing must be repeated at
age 18 months in order to definitively confirm that the children are HIV-infected;
ARV therapy should only be continued in infants with confirmed infection.
For children who are HIV-seropositive aged 18 months or older, WHO
recommends initiation of ARV therapy in the following circumstances:
! WHO Paediatric Stage III HIV disease (clinical AIDS), irrespective of CD4%; or
! WHO Paediatric Stage II disease, with consideration of using CD4 <15% to
assist in decision-making; or
! WHO Paediatric Stage I (asymptomatic) and CD4 <15%.
Breastfed infants are at risk of HIV infection during the entire period of breast-
feeding. A negative virological or antibody test at one age does not exclude the
possibility of infection occurring subsequently if breastfeeding continues.
Module 7 Linkages

Lead participants through the following exercise, which will provide information on
monitoring for signs and symptoms in infants who HIV-infected.
Exercise 7.3: Clinical presentation of HIV in infants
Purpose To familiarise participants with the signs and common conditions in

infants who are HIV-infected.
Duration 20 minutes
Introduction Consider the following 4 categories as they relate to follow-up of
infants and children who are HIV-exposed:
! HIV testing
! Immunisation
! Growth and development
! Monitoring for signs and symptoms of HIV
This exercise will focus on the last category, monitoring for signs and
symptoms of HIV.
Activity ! Begin new page on flipchart and write: "Signs/symptoms of HIV
infection in infants and children."
! Ask participants what they think is the most common presenting
sign of HIV infection in an infant or child. If they need a clue, say
"This relates to general appearance." Answers:
! Being underweight
! Being small for their age
! Failure to thrive
! Record participants' responses on flipchart.
! Ask the group to identify which body systems or organs may be
involved in early presentation of HIV infection. Answers:
! Organs: lymph, liver, spleen, lungs
! Systems: GI, neurologic, dermatologic, immune
! Record participants' responses on flipchart.
! Divide participants into three groups and assign one card to each
group with the following headings (one per card): GI, Pulmonary,
Module 7 Linkages
Immune Function.
! Ask each group to list on their cards symptoms indicating HIV
infection related to their card heading.
! Ask each group to determine if this symptom is HIV-specific and
what their recommendation for next steps would be (including
prophylaxis).
! Ask one spokesperson from each group to record on the flipchart
their list of symptoms and treatment recommendations.
! Review the clinical conditions or signs in Table 7-1 and discuss
any conditions the group did not mention.
Debriefing Stress to participants that educating mothers to recognise early
symptoms of HIV infection and seek medical care immediately can
prevent complications and even death.
Discuss the key points, using the information below.

! A continuum of care is provided through linkages between PMTCT, MCH and
available HIV treatment, care, and support services, including those offered by
NGO and FBO groups in the community.
! Linkages to NGOs and FBOs may help families living with HIV/AIDS gain
access to social support and assistance with specific needs such as housing,
transportation, food, and income-generating activities.
! Postpartum care includes clinical assessment, infant-feeding support, family
planning, and referral for HIV-related treatment and care.
! Infants who are HIV-exposed require follow-up care to monitor growth and
development, immunisations, and prophylaxis for infections. They also require
testing to determine HIV status.
! IMCI guidelines may help healthcare workers integrate care for children who are
HIV-exposed or HIV-infected into ongoing MCH services.
! PMTCT-Plus programmes provide linkages to antiretroviral treatment for
mothers who are HIV-infected, their children, and other family members.
! Timing of testing and diagnosis of HIV infection in infants and young children
varies according to feeding practices and available tests.
Module 7 Linkages

APPENDIX 7-A Tuberculosis (TB)
Background
HIV infection leads to increased susceptibility to TB, promotes progression of recent and
latent Mycobacterium tuberculosis infection to active TB disease, increases the risk of
recurrence, and complicates the clinical course of TB disease. TB is cited as the leading
cause of death among persons who are HIV-infected; an estimated 40% of PLWHA
acquire TB during their lifetime.
In sub-Saharan Africa, up to 70% of patients with pulmonary TB are HIV-infected. TB

prevention, screening, care, and treatment are becoming priority concerns in patients
who are HIV-infected; prevention, screening, care, and treatment of HIV/AIDS are
priority concerns in patients with TB.
Case Detection
Cough is the most common symptom of pulmonary TB. All patients referred to a health
facility, irrespective of their HIV status, with a cough lasting 2–3 weeks should be
screened for TB. Other TB symptoms include:
! Fever
! Haemoptysis
! Weight loss
! Chest pain
! Fatigue
BCG Vaccine
Bacille Calmette-Guerin (BCG) is a live attenuated vaccine given intradermally to
protect young children against severe TB. The usual dose is 0.05 ml in neonates and
infants under 3 months of age, and 0.1 ml in older children.
WHO’s policy regarding this vaccine states that BCG should not be given to children
with symptomatic HIV infection (ie AIDS). In asymptomatic children, the decision to give
BCG should be based on the local risk of tuberculosis:
! Where the risk of tuberculosis is high, BCG is recommended at birth or as soon as
possible thereafter, in accordance with standard policies for immunisation of children
who are not HIV-infected;
Module 7 Linkages
! In areas where the risk of tuberculosis is low but BCG is recommended as a routine
immunisation, BCG should be withheld from individuals known or suspected to be
infected with HIV.
Treatment
Treatment protocols for both active and latent TB are standardised. In each country,
guidance is provided on screening, treatment, and monitoring of the patient with TB.
Prophylaxis against TB should be part of a package of care for people living with
HIV/AIDS. This prophylaxis is recommended for individuals who are HIV-infected and
test positive for TB infection, and those in whom active TB has been excluded.
APPENDIX 7-A Tuberculosis (TB) (continued)
Prophylaxis may also be considered for individuals who are HIV-infected and living in a
community with a high prevalence of TB infection, where skin testing is unavailable. Six
to nine months of isoniazid (INH) is the regimen recommended for preventive treatment
of latent TB infection.
Patients who are HIV-infected and who have active TB should also receive
cotrimoxazole therapy to prevent secondary bacterial and parasitic infections.
When selecting drugs to treat TB, women taking oral contraceptives, pregnant women,
and patients who are HIV-infected and receiving ART require special consideration. With
careful clinical management, however, patients with HIV-related TB can receive
simultaneous TB and HIV treatment. The revised (2003) WHO guidelines, Scaling up
antiretroviral therapy in resource-limited settings: treatment guidelines for a public health
approach, provide up-to-date information on ARV therapy for the special category of
patients who are receiving concomitant TB treatment.
In primary care settings and PMTCT programmes healthcare workers can play an active
role in TB screening, as well as in treatment or referral for treatment and monitoring of
patients with TB and HIV.
Adapted from WHO. 2004. Scaling up antiretroviral therapy in resource-limited settings: Treatment guidelines for a public
health approach. WHO: Geneva. Retrieved 30 July 2004, from http://www.who.int/hiv/pub/mtct/en/arvdrugsguidelines.pdf
Module 7 Linkages

APPENDIX 7-B Community resource information worksheet
Use this form to list the contact information for agencies that provide services to families
living with HIV/AIDS.
COMMUNITY RESOURCES THAT SUPPORT THE PMTCT PROGRAMME

Resource Category We Have We Need
Voluntary testing and
counselling for partners
Health care
(STIs, reproductive
health, TB treatment,
etc.)
HIV/AIDS care and ARV

treatment
Nutritional support
Support group or club

Module 7 Linkages
Community-based AIDS
service and faith-based
organisations
APPENDIX 7-C Pneumocystis carinii pneumonia
prophylaxis in adults and infants
Note: Revised recommendations for HIV care in resource-constrained settings are in

development. Once these are finalised, the content in this section will be updated to
reflect these recommendations.
Category Recommendation for Adults

Client selection and ! All persons with symptomatic HIV (WHO Stage II, III, IV)
duration of prophylaxis ! Asymptomatic individuals with CD4 counts below
500/mm3 or equivalent total lymphocyte count
! Cotrimoxazole should be taken for life or until ARV
agents become available and therapy results in restora-
tion of CD4 count of 500/mm3 or higher
Drug regimen ! Recommended dose: cotrimoxazole 960 mg once daily (1
double-strength tablet or 2 single-strength tablets daily)
Preparation ! Most commonly, oral tablet
Adverse events requiring ! Severe cutaneous reaction, such as fixed drug reaction
discontinuation and or Stevens-Johnson syndrome; renal or hepatic insuffi-
substitution ciency; severe haematologic toxicity
Category Recommendation for Infants who are HIV-Exposed
Client selection and ! Infants who have been exposed to HIV, starting at 6
duration of prophylaxis weeks and continuing for at least 6 months, preferably
until HIV infection can be ruled out
! Infants less than age 12 months, who are HIV-infected,
regardless of symptoms or CD4 count
! Infants more than 12 months of age, who are in primary
care settings and PMTCT programmes, if symptomatic; if
AIDS is diagnosed; if CD4 is below 15% (when informa-
tion is available); or prior PCP diagnosis
Drug regimen ! Trimethoprim (TMP) 150 mg/m2 and sulfamethoxazole
(SMX) 750 mg/m2 once daily
Preparations ! Oral suspension: TMP 8 mg/mL and SMX 40 mg/mL
Module 7 Linkages
! If suspension is unavailable, crushed tablets may be used

Adverse events requiring ! Severe cutaneous reaction such as fixed drug reaction or
discontinuation and Stevens-Johnson syndrome, renal or hepatic insufficien-
substitution cy; severe haematologic toxicity
FOR AN EXPLANATION OF THE WHO STAGING OF HIV, SEE APPENDIX 1-A.
Adapted from: World Health Organisation (WHO). 2003. A Reference Guide on HIV-Related Care, Treatment, and
Support of HIV-Infected Women and Their Children in Resource Constrained Settings. WHO: Geneva [Draft].

APPENDIX 7-D Suggestions to maximise food intake for
PLWHA
Symptom Suggested Strategy

Fever and loss of ! Drink high-energy, high-protein liquids, fruit juices.
appetite ! Throughout the day, eat small portions of preferred soft foods
with a pleasant aroma and texture.
! Eat nutritious snacks whenever possible.
! Drink liquids often.
Sore mouth and ! Avoid citrus fruits, tomatoes, spicy foods.
throat ! Avoid very sweet foods.
! Drink high-energy, high-protein liquids with a straw, if available.
! Eat foods at room temperature or cooler.
! Eat thick, smooth foods such as pudding, porridge, mashed
potato, mashed carrot or other non-acidic vegetables and fruits.
Nausea and ! Eat small snacks throughout the day and avoid large meals.
vomiting ! Eat toast and other plain, dry foods.
! Avoid foods that have a strong aroma.
! Drink diluted fruit juices, other liquids, soup.
! Eat simple boiled foods, such as porridge, potato, beans.
Loose bowels ! Eat bananas, mashed fruits, soft rice, porridge.

! Eat smaller meals, more often.
! Eliminate dairy products to see if they are the cause.
! Decrease high-fat foods.
! Avoid foods with insoluble fibre ("roughage").
! Drink liquids often.
Fat malabsorption ! Eliminate oils, butter, margarine and foods that contain or are
prepared with them
! Eat only lean meats.
! Eat fruit, vegetables, other low-fat foods.
Severe diarrhoea ! Drink liquids frequently.
Module 7 Linkages
! Drink oral rehydration solution.

! Drink diluted juices.
! Eat bananas, mashed fruits, soft rice, porridge.
Fatigue and ! Have someone precook foods to save energy and time spent in
lethargy preparation.
! Eat fresh fruits that don't require preparation.
! Eat snack foods often throughout the day.
! Drink high-energy, high-protein liquids.
! Set aside time each day for eating.
Woods, MN: 1999. Dietary recommendations for the HIV/AIDS patient. In: Nutritional Aspects of HIV Infection,
ed. T. Miller and SL. Gorbach, Arnold Press, London. pp 191–203.
APPENDIX 7-E WHO immunisation recommendations1
Age of Infant Vaccine

Birth BCG*, OPV-0
6 weeks DPT-1, OPV-1

9 months2 Measles2
Key:
BCG = Bacille Calmette Guerin
OPV = oral polio vaccine
DPT = diphtheria, pertussis, tetanus
1
Additional immunisations, for yellow fever or other diseases, for example, may be included in national recommenda-
tions that account for local disease prevalence.
2
An additional, early dose of measles vaccine should be given at age 6 months if the following conditions are met:
! Measles morbidity and mortality before age 9 months represents more than 15% of cases and deaths.
! There is a measles outbreak.
! The infant has a high risk of measles death. This includes infants:
! with documented HIV infection
! living in refugee camps
! admitted to the hospital or
! affected by disasters
* BCG—do not give in low prevalence countries to infants or children who are HIV-infected; in high prevalence coun-
tries give to all children except children with symptoms of HIV/AIDS.
All children who have been exposed to HIV should be fully immunised according to their
age. Because most children who are HIV-infected do not have severe immune
suppression during the first year of life, immunisation should occur as early as possible
after the recommended age to optimise the immune response.
BCG and yellow fever. Children with known symptomatic HIV infection should not
receive BCG and yellow fever vaccines. However, because most infants who are HIV-
infected are asymptomatic at birth, when BCG immunisation occurs, and thus will have
unknown HIV status, the birth BCG immunisation should be given.
Module 7 Linkages
Oral polio vaccine. If the child has diarrhoea and is scheduled to receive OPV, the
dose should be given as scheduled. However, the dose should not be counted in the
schedule, and an additional dose of OPV should be given after the diarrhoea has
resolved.
Diphtheria, pertussis, tetanus. Children who have either recurrent convulsions or

active central nervous system disease or who have had shock or convulsions within 3
days of receiving a DPT vaccination should not receive subsequent DPT vaccination.
For those children, substitute DT (diphtheria–tetanus) formulation; all other
immunisations may be given.

APPENDIX 7-E WHO immunisation
recommendations (continued)
Hepatitis B vaccine. WHO recommends that the hepatitis B vaccine be included in

routine childhood immunisation schedules for all children in all countries. Give the
hepatitis B vaccine according to any of the following schedules:
! Option 1: Give hepatitis B vaccine at 6, 10, and 14 weeks (3 doses), to coincide with
the DPT schedule. The disadvantage of this option is that it does not protect against
perinatal hepatitis B infection.
! Option 2: Give hepatitis B vaccine at BIRTH, 6, and 14 weeks (3 doses); the last two
doses coincide with the 1st and 3rd doses of the DPT schedule.
! Option 3: Give hepatitis B vaccine at BIRTH, 6, 10, and 14 weeks (4 doses); the last
three doses coincide with the DPT schedule.
Options 2 or 3 are preferred for countries with high prevalence of maternal HIV and with
a high rate of perinatal hepatitis B transmission. The 3-dose schedule (Option 2) is less
expensive, but may be more complicated to administer, because the immunisation
schedule differs for the 6-, 10-, and 14-week well baby visits. Whereas, the 4-dose
schedule (Option 3) may be easier to administer in practice, but is more costly, and
vaccine supply issues may make it unfeasible.
Haemophilus influenzae type B. Vaccinate at 6, 10, and 14 weeks. In some areas a

booster at 12 to 18 months is recommended, if available.
Sources: Adapted from WHO, Department of Vaccines and Biologicals. 2001. Introduction of hepatitis B vaccine into
childhood immunization services. Management guidelines, including information for health workers and parents.
Retrieved 30 July 2004, from www.who.int/vaccines-documents/DocsPDF01/www613.pdf
WHO, Department of Vaccines and Biologicals. 2000. Introduction of haemophilus influenzae type B vaccine into immu-
nization programmes: Management guidelines, including information for health workers and parents. Retrieved 30 July
2004, from http://www.who.int/vaccines-documents/DocsPDF99/www9940.pdf
Module 7 Linkages
Module 8 Safety
Module 8 Safety and Supportive Care in the Work
Environment
SESSION 1 Universal Precautions and Creating a Safe Work Environment

Exercise 8.1 Reducing HIV None, other than those noted 30 minutes
transmission risk in MCH below
settings: case study
SESSION 2 Handling and Decontamination of Equipment and Materials

Exercise 8.2 Promoting a None, other than those noted 30 minutes
safe work environment below
resource list: group
discussion
SESSION 3 Managing Occupational Exposure to HIV Infection

Exercise 8.3 PEP case None, other than those noted 45 minutes
study: small-group below
discussion
SESSION 4 Supportive Care for the Caregiver

Exercise 8.4 Compassion None, other than those noted 60 minutes
fatigue/burnout in PMTCT below
programmes: large group
discussion

Module 8 Safety

Note: This module is not intended to be a comprehensive course in infection control in

healthcare settings but rather it complements existing protocols and reinforces safety
principles in PMTCT settings.
Session 1
! National guidelines, policies, standards of procedure on universal precautions in
MCH/ANC settings
Session 2
! National guidelines, policies, standards of procedure on handling and
decontamination of equipment and materials if not included previously in Session 1
! National policy on risk reduction in the obstetric setting
Session 3
! National post-exposure prophylaxis (PEP) policy
Module 8–2 Safety and Supportive Care in the Work Environment

Module 8 Safety
SESSION 1 Universal Precautions and Creating a Safe
Work Environment
Advance Preparation
Review the case study in Exercise 8.1 to be sure it reflects local customs,
issues, policies, and names. Ask local healthcare workers to help you
adapt the case studies, if necessary.
Slides 1, 2 and 3
After completing the module, participants will be able to:

! Describe strategies for preventing HIV transmission in the healthcare setting.
! Define universal precautions (UP) in the context of the prevention of mother-to-child
transmission (PMTCT) of HIV.
! Identify key steps and principles involved in the decontamination of equipment and
materials.
! Assess occupational risk and identify risk-reduction strategies in maternal and child
health (MCH) settings.
! Describe the management of occupational exposure to HIV.
! Identify measures to minimise stress and support healthcare workers and caregivers.
Slides 4, 5, 6, 7 and 8
Introduce the basic concepts of HIV transmission and prevention of transmission.

Module 8 Safety
Make These Points
! Less than 1% of needle-stick injuries involving known HIV-infected blood are linked to
actual HIV transmission.
! Disinfection or sterilisation of equipment used in invasive procedures prevents
patient-to-patient transmission of HIV.
Basic concepts of HIV infection prevention

HIV infection can be transmitted through contact with blood or body fluids, either by
direct contact with an open wound or by needle-stick injury.
Blood is the primary fluid known to be associated with HIV transmission in the
healthcare setting; small quantities of blood may be present in other body fluids.
HIV transmission to healthcare workers is almost always associated with needle-stick

injuries during the care of a patient who is HIV-infected. In practice, transmission occurs
when administering
! Intravenous injections
! Blood donations
! Dialysis
! Transfusions
Patient-to-patient transmission of HIV infection can be prevented by disinfecting or

sterilising equipment and devices used in percutaneous procedures.
Transmission of infectious agents in the healthcare setting can be prevented by using

infection control measures, including adherence to universal precautions, safe
environmental practices, and ongoing education of employees in infection prevention.
Bloodborne pathogens are viruses, bacteria, or other disease-causing microorganisms

carried in blood. There are many different bloodborne pathogens such as the hepatitis B
virus, hepatitis C virus, syphilis spirochete, brucellosis bacteria and the human
immunodeficiency virus (HIV). This training module will focus on HIV.
Slides 9 and 10
Discuss the concepts of universal precautions and creating a safe work environment,
using the information presented below.

Module 8 Safety
Make These Points
! Handwashing remains one of the most important strategies for limiting the spread of
infection
! The level of precautions used depends on the procedure involved—not on the
patient’s diagnosis.
Universal precautions
Universal precautions are practices designed to protect healthcare workers and patients
from exposure to bloodborne pathogens.
It is not feasible or cost-effective to test all patients for all pathogens before providing
care. Therefore, the level of precautions employed should be based on the nature of the
procedure involved, not on the patient’s actual or assumed HIV status.
Definition
Universal precautions: A simple set of effective practices designed to
protect health workers and patients from infection with a range of
pathogens including bloodborne viruses. These practices are used when
caring for all patients regardless of diagnosis.
Creating a safe work environment

Creating a safe work environment involves practising universal precautions, managing
the work environment, and providing ongoing infection prevention education for
employees.
In practice, actions to implement universal precautions include the following:

! Washing hands before and after direct contact with patients
! Disinfecting or sterilising all devices and equipment used during invasive procedures
! Avoiding needle recapping; especially two-handed needle recapping
! Using needles or scalpel blades on one patient only
! Safely disposing of needles (hypodermic and suture) and sharps (scalpel blades,
lancets, razors, and scissors) in puncture- and leak-proof safety boxes
! Using gloves when in contact with body fluids, non-intact skin, or mucous mem-
branes
! Using masks, eye protection, and gowns (or plastic aprons) when blood or other
body fluids could splash
! Applying waterproof dressing to cover all cuts and abrasions
! Promptly and carefully cleaning spills involving blood or other body fluids
! Using systems for safe waste collection and disposal

Module 8 Safety
Slides 11 and 12
Discuss the management of a safe work environment and the importance of ongoing
education to reinforce infection control policies.
Make These Points
! Working with a mother who is HIV-infected can create additional emotional stress and
requires special precautions in the obstetric setting.
! Sharps containers must be readily accessible.
! Training in the safe and efficient use of new equipment can minimise risk of occupa-
tional injury.
Managing the work environment

Ensure that universal precautions are implemented, monitored, and evaluated
periodically.
! Establish and implement policies and procedures for reporting and treating occupa-
tional exposure to HIV infection.
! Attain and maintain appropriate staffing levels.
! Implement supportive measures that reduce staff stress, isolation, and burnout (eg,
ensure the availability of protective equipment).
! Acknowledge and address the multifaceted needs of healthcare workers who are
HIV-infected.
! Provide protective clothing and equipment, including gloves, plastic aprons, gowns,
goggles, and other protective devices.
! Provide and use appropriate disinfectants to clean up spills involving blood or other
body fluids.
! Increase availability of—and staff access to—puncture-resistant sharps containers.
Ongoing education for employees in infection prevention
! Orient all staff, including peer and lay counsellors, to the site’s infection control
policies.
! Ensure that all workers who are routinely exposed to blood and body fluids (eg,
physicians, midwives, nurses, and housekeeping personnel) receive preliminary and
ongoing training on safe handling of equipment and materials.
! Require that supervisors regularly observe and assess safety practices and remedy
deficiencies as needed.

Module 8 Safety
Use the case study below to review and apply principles of universal precautions in
MCH high-risk settings.
Exercise 8.1 Reducing HIV transmission risk in MCH settings: case study
Purpose To review the application of universal precautions as described in this
session, focusing on high-risk settings.
Duration 20 minutes
Introduction Briefly summarise national/local universal precautions policies and

use this exercise as an opportunity to discuss how policies are
implemented in participants’ work settings.
Instructions ! Ask participants to refer to the case study below, which is in the
Participant Manual.
! Ask for volunteers to read each paragraph. Pause after each
paragraph to allow the group to respond to questions and
participate in the discussion.
! Determine which universal precaution principle applies in each
paragraph, and record on flipchart.
Debriefing Review risk reduction in MCH settings.
Case study
Margaret arrives at the labour and delivery unit of your local hospital. She hands you a
small card that identifies her as someone who has received care at the neighbouring
ANC clinic. This card is coded to let you know that she is HIV-infected. She explains
that her contractions are steady now and about four minutes apart. You perform a
cervical examination and estimate that Margaret has at least 2 more hours until delivery.
You give her nevirapine prophylaxis at this time.
Does your clinical protocol require healthcare workers to use gloves when caring for
patients who are HIV-infected? According to universal precautions, would the same gloving
requirements apply for all labour and delivery patients, regardless of HIV status?
In your facility, are gloves in good supply and available in a variety of sizes?
What do we know about the relationship between MTCT and cervical examinations for
pregnant women who are HIV-infected?
It has now been several hours since Margaret’s waters broke (rupture of membranes).
She is exhausted. After checking her partogram a decision is made to use oxytocin to
shorten her labour.
Why is it important to shorten the time between the rupture of membranes and delivery
by a woman who is HIV-infected?

Module 8 Safety
Margaret is now fully dilated and ready to deliver. As the head is delivered, you use
gauze to carefully free the infant’s mouth and nostrils of fluids. Then, with one final
push, the infant is delivered completely. You hand the newborn to a gloved assistant,
who wipes him dry and continues with neonatal care. Then the placenta is delivered.
Itemise the protective clothing that would be appropriate in a labour and delivery setting.
Consider the need for proper disposal of sharps used in labour and delivery. Does your
facility have conveniently located containers for the disposal of sharps?
At your facility, what are the policies for disposing of waste materials? What should be
done with the placenta and other contaminated materials?
Margaret was your 12th delivery in the past 24 hours. You need to get home and tend to
your family but your replacement has not yet arrived. You speak with your supervisor
and she is able to locate someone else to take your place.
Why is it important that you not stay and continue to work tonight?
In your facility, do you have someone who will help you find staffing relief if needed?

Module 8 Safety
SESSION 2 Handling and Decontamination of Equipment
and Materials
Advance Preparation
No additional preparation is required for this session.
Provide an overview of this session by explaining that activities for reducing the risk of
HIV transmission in the MCH setting include:
! Handling and disposing of sharps safely
! Using personal protective equipment such as gloves, aprons, eyewear, and footwear;
assessing protective equipment for tears, size requirements, condition
! Sterilising equipment used for invasive procedures
! Reducing risk in the labour and delivery setting
Slides 16 and 17
Present information on the handling and disposal of sharps. As you proceed, ask
participants for their input about procedures for proper handing and disposal of sharps.
Make These Points

! Sharps containers need to be readily accessible in key areas.
! Never overfill or re-use sharps containers.
PMTCT—Generic Training Package Trainer Manuall Module 8–9

Module 8 Safety
Handling and disposal of sharps

Most HIV transmission to healthcare workers in work settings is the result of skin
puncture with contaminated needles or sharps. These injuries occur when sharps are
recapped, cleaned, or inappropriately discarded.
Recommendations for use of sterile injection equipment

! Use a sterile syringe and needle for each injection and to reconstitute each unit of
medication. If single-use syringes and needles are unavailable, use equipment
designed for steam sterilisation.
! Use new, quality-controlled disposable syringes and needles.
! Avoid recapping and other manipulations of needles by hand. If recapping is neces-
sary, use a single-handed scoop technique.
! Collect used syringes and needles at the point of use in a sharps container that is
puncture- and leak-proof and that can be sealed before completely full.
! Completely destroy or bury needles and syringes so that people cannot access them
and so that groundwater contamination is prevented.
When it is necessary to recap, use the single-handed scooping method:

! Place the needle cap on a firm, flat surface.
! With one hand holding the syringe, use the needle to “scoop” up the cap, as shown
in Step 1, Figure 8.1.
! With the cap now covering the needle tip, turn the syringe upright (vertical) so the
needle and syringe are pointing toward the ceiling.
! Use the forefinger and thumb on your other hand to grasp the cap just above its
open end and push the cap firmly down onto the hub (the place where the needle
joins the syringe under the cap) (Step 2, Figure 8.1).
Tips for careful handling of sharps

! Always point the sharp end away from yourself and others.
! Pass scalpels and other sharps with the sharp end pointing away from staff; or
place the sharp on a table or other flat surface (a receiver) where it can then be
picked up by the receiving person.
! Pick up sharps one at a time and do not pass handfuls of sharp instruments or
needles.

Module 8 Safety
Figure 8.1 One-handed recap method
Step 1: Scoop up the cap
Step 2: Push cap firmly down
Sharps containers
Using sharps disposal containers helps prevent injuries from disposable sharps. Sharps
containers should be fitted with a cover, and should be puncture-proof, leak-proof, and
tamper-proof (ie, difficult to open or break). If plastic or metal containers are unavailable
or too costly, use containers made of dense cardboard (cardboard safety boxes) that
meet WHO specifications. If cardboard safety boxes are unavailable, many easily
available objects can substitute as sharps containers:
! Tin with a lid

! Thick plastic bottle
! Heavy plastic box
! Heavy cardboard box
Recommendations for safe use of sharps containers

! All sharps containers should be clearly marked “SHARPS” and/or have pictorial
instructions for the use and disposal of the container.
! Place sharps containers away from high-traffic areas and as close as possible to
where the sharps will be used. The placement of the container should be practical
(ideally within arm’s reach) but unobtrusive. Do not place containers near light
switches, overhead fans, or thermostat controls where people might accidentally put
one of their hands into them.
! Attach containers to walls or other surfaces if possible. Position the containers at a
convenient height so staff can use and replace them easily.
! Never reuse or recycle sharps containers.

Module 8 Safety
! Mark the containers clearly so that people will not unknowingly use them as garbage
receptacles.
! Seal and close containers when 3 ⁄4 full. Do not fill safety box beyond full 3⁄4 line.
! Avoid shaking a container to settle its contents to make room for more sharps.
Slide 18
Discuss procedures for effective handwashing, using the content below.
Make These Points

! Reinforce the importance of handwashing and the central role it plays in infection
control.
Handwashing
The following strategies settings are strongly recommended for reducing transmission of
bloodborne pathogens and other infectious agents to patients and personnel in
healthcare settings:
! Soap and water handwashing, using friction, under running water for at least 15
seconds.
! Use of alcohol-based hand rubs (or antimicrobial soap) and water for routine decont-
amination or hand antisepsis.
Handwashing
Handwashing with plain soap and water is one of the most effective
methods for preventing transmission of bloodborne pathogens and limiting
the spread of infection.

Module 8 Safety
Hand hygiene recommendations
Wash before: ! Putting on gloves
! Examining a patient
! Performing any procedure that involves contact with blood or
body fluids
! Handling contaminated items such as dressings and used
instruments
! Eating
Wash after: ! Removing gloves

! Examining a patient
! Performing any procedure that involves contact with blood or
body fluids
! Handling contaminated items such as dressings and used
instruments
! Making contact with body fluids, mucous membranes, non-
intact skin, or wound dressings
! Handling soiled instruments and other items
! Using a toilet
Slide 19
Discuss the range and importance of personal protective equipment.
Make These Points

! If personal protective equipment is in short supply, prioritise use according to level
of risk.
! Reducing occupational exposure to HIV infection is achieved by avoiding direct
contact with blood or fluids containing blood.
Personal protective equipment

Personal protective equipment safeguards patients and staff. Use the following
equipment when possible:
! Gloves
! Aprons
! Eyewear
! Footwear
When resources for purchasing protective equipment are limited, purchasing gloves
should receive priority over other protective equipment.

Module 8 Safety
Gloves
The use of a separate pair of gloves for each patient helps prevent the transmission of
infection from person to person. Protection with gloves is recommended when:
! There is reasonable chance of hand contact with blood, other body fluids, mucous
membranes, or broken or cut skin
! An invasive procedure is performed
! Contaminated items are handled
Tips for effective glove use

! Wear gloves that are the correct size.
! Use water-soluble hand lotions and moisturisers often to prevent hands from
drying, cracking, and chapping. Avoid oil-based hand lotions or creams because
they will damage latex rubber surgical and examination gloves.
! Do not wear rings because they may serve as a breeding ground for bacteria,
yeast, and other disease-causing microorganisms.
! Keep fingernails short (less than 3 mm (1/8 inch) beyond the fingertip). Long
nails may provide a breeding ground for bacteria, yeast, and other disease-
causing microorganisms. Long fingernails are also more likely to puncture
gloves.
! Store gloves in a place where they are protected from extreme temperatures,
which can damage the gloves.
Aprons
Rubber or plastic aprons provide a protective waterproof barrier along the front of the
healthcare worker.
Eyewear
Eyewear, such as plastic goggles, safety glasses, face shields, or visors, protect the
eyes from accidental splashes of blood or other body fluids.
Footwear
Rubber boots or leather shoes provide extra protection to the feet from injury by sharps
or heavy items that may accidentally fall. They must be kept clean. When possible,
avoid wearing sandals, thongs, or shoes made of soft materials.
Strategies for resource-constrained settings

Universal precaution measures are difficult to practise when supplies are low
and protective equipment is not available. Use resources cost-effectively by
prioritising the purchase and use of supplies, eg, if gloves are in short supply,
use them for childbirth and suturing instead of routine injections and bed-making.
The most important way to reduce occupational exposure to HIV is to decrease
contact with blood. Facilities should develop and use safety procedures that allow
them to deliver effective patient care without compromising personal safety.

Module 8 Safety
Discuss decontamination, cleaning, disinfection, and sterilisation of equipment.
Make These Points

! All contaminated equipment used in invasive procedures should be decontaminated,
disinfected, and/or sterilised to avoid patient-to-patient transmission of infection.
Decontamination of equipment
The method used to neutralise or remove harmful agents from contaminated equipment
or supplies should be based on:
! Risk of infection associated with the instrument or piece of equipment
! Decontamination process the object can tolerate
Definitions
Decontamination: The first step in making equipment safe to handle. This
requires a 10 minute soak in a 0.5% chlorine solution.1 This important step kills
both hepatitis B and HIV.
Cleaning: Efficient cleaning with soap and hot water is essential prior to disin-
fection or sterilisation.
! Removes a high proportion of microorganisms.
! Removes contaminants such as dust, soil, salts, and the organic matter that pro-
tects them.
Disinfection: A chemical procedure that eliminates most recognised pathogenic
microorganisms. Does not destroy all microbial forms (eg, bacterial spores).
Sterilisation: Destroys all microorganisms
Slides 20 and 21
Discuss decontamination, cleaning, disinfection, and sterilisation of equipment.
1
If making a 0.5% chlorine solution from liquid household bleach which is 3.5% chlorine concentrate, mix 1:7 dilution of
household bleach to water. A 1:7 dilution is the same as 1 part bleach to 6 parts water. A "part" can be used for any
unit of measure (eg, ounce, gram, cup, litre or even a bottle). For more information, refer to http://www.engender-
health.org/ip/instrum/inm7.html.

Module 8 Safety
Make These Points

! Adherence to safe work practices can reduce worker stress and fear of nosocomial
HIV infection.
Safe work practices

Proper planning and management of supplies and other resources are essential in
reducing the occupational risks of HIV infection. To reduce occupational risks:
! Assess risks in the work setting.

! Explore different strategies for meeting resource needs.
! Develop standards and protocols that address safety, risk reduction, post-exposure
prophylaxis (PEP) follow-up, and first aid.
! Maintain an optimal workload.
! Institute measures to prevent or reduce healthcare worker stress.
! Orient new staff to infection control procedures.
! Provide ongoing staff education and supervision.
Risk reduction in the obstetric setting

The potential for exposure to HIV-contaminated blood and body fluids is greatest during
labour and delivery. Module 3, Specific Interventions to Prevent MTCT, includes
recommendations for safer obstetric practices designed to minimise this risk.
In labour and delivery settings, healthcare workers should:

! Provide appropriate and sensitive care to all women regardless of HIV status.
! Work in a manner that ensures safety and reduces the risk of occupational exposure
for themselves and their colleagues.
Tips for reducing the risk of occupational exposure in the obstetric setting
! Cover broken skin or open wounds with watertight dressings.
! Wear suitable gloves when exposure to blood or body fluids is likely.
! Wear an impermeable plastic apron during the delivery.
! Pass all sharp instruments on to a receiver, rather than hand-to-hand.
! Use long, cuffed gloves during manual removal of a placenta.
! Modify surgical practice to use needle holders to avoid using fingers for needle
placement.
! Workers with dermatitis should not work in obstetrics.
! When episiotomy is necessary, use an appropriate-size needle (21 gauge,
4 cm, curved) and needle holder during the repair.
! When possible, wear gloves for all operations.
! When possible, wear an eye shield during caesarean section and episiotomy
suturing.
! If blood splashes on skin, immediately wash the area with soap and water. If
splashed in the eye, wash the eye with water only.
! Dispose of solid waste (eg, blood-soaked dressings and placentas) safely
according to local procedures.

Module 8 Safety
Use the group discussion below to assess and compare resources available for
promoting a safe work environment.
Exercise 8.2 Promoting a safe environment resource list: group discussion

Purpose To compare and contrast the availability of safety resources,
practices, and materials in our programmes.
Duration 15 minutes
Introduction Ensure all participants have copies of Promoting a Safe Work
Environment: Resource List (next page and in the Participant
Manual).
This exercise provides an opportunity to share experiences with
safety supply shortages or resource limitations in the workplace
and to develop strategies to deal with these limitations.
Activity ! Discuss each category as a group.
! Using the headings summarise the group discussion on the
flipchart (eg, different sterilisation methods used, examples of
innovative strategies when supplies are short).
Debriefing Discuss the importance of flexibility and adaptability in meeting
safety needs and requirements.
Encourage the group to share ideas on creative strategies used to
overcome resource limitations in their own workplace.

Module 8 Safety
Exercise 8.2 “Promoting a safe environment” resource list

Personal protective equipment
! Gloves—various sizes
! Aprons
! Eyewear
! Footwear
! Waterproof dressings
Materials
! Cleaning and disinfecting agents
! Equipment for sterilisation
! Sharps disposal containers
! Waterproof waste containers for contaminated items
! Alcohol-based hand rubs or anti-microbial soap
Safety standards
! Policies on use of universal precautions
! Procedures for disposal of infectious or toxic waste
! Procedures for sterilisation of equipment
! Policies on handling and disposal of sharps
! Protocols for management of post-exposure prophylaxis (PEP), including ARVs
and hepatitis B immunisation
! Procedures for minimising exposure to infection in high-risk settings, such as
labour and delivery
Education
! New employee orientation to infection control procedures
! Ongoing training to build skills in safe handling of equipment
! Monitoring and evaluation of safety practices to assess implementation and
remedy deficiencies

Module 8 Safety
SESSION 3 Managing Occupational Exposure to HIV
Infection
Advance Preparation
Review Exercise 8.3 PEP case study to be sure it reflects local customs,
issues, policies, and names. Ask local healthcare workers to help you
adapt the case study, if necessary.
Slides 22, 23, 24 and 25
Introduce the concept and discuss implementation of post-exposure prophylaxis.
Post-exposure prophylaxis
Either of the following exposures could put a healthcare worker at risk of HIV infection if
the exposure involves blood, tissue, or other body fluids containing visible blood:
! Percutaneous injury (eg, a needlestick or cut with a sharp object)
! Contact with mucous membrane or non-intact skin (eg, exposed skin that is chapped,
abraded, or affected by dermatitis)
After occupational HIV exposure, a short-term course of ARV drugs (eg, one month)
may be used to reduce the likelihood of infection. This is referred to as post-exposure
prophylaxis (PEP), and is a key part of a comprehensive universal precautions strategy
for reducing staff exposure to infectious agents in the workplace.
In healthcare settings the occupational risk of becoming HIV-infected due to a
needlestick is low (less than 1%). Most cases involve injuries from needles or sharps
that have been used on a patient who is HIV-infected. The risk of HIV transmission from
exposure to infected fluids or tissues is believed to be lower than from exposure to
infected blood.
Risk of exposure from needlesticks and contact with blood and body fluids exists in
settings where:
! Safe needle procedures and universal precautions are not followed
! Waste management protocols are inadequate or not consistently implemented
! Protective gear is in short supply
! Rates of HIV infection in the patient population are high
To minimise the need for PEP, national strategies for education and training of key
partners in healthcare waste management is necessary.

Module 8 Safety
Benefits of making PEP available for healthcare workers:

! Promotes retention of staff who are concerned about the risk of exposure to HIV in
the workplace
! Increases staff willingness and motivation to work with people who are HIV-infected
! Reduces the occurrence of occupationally-acquired HIV infection in healthcare workers
A comprehensive PEP protocol outlines the methods for preventing occupational
exposure to HIV and other bloodborne pathogens including:
! Summary of the system for supervising and monitoring the implementation of
universal precautions
! Discussion of safe practices for the disposal of infectious waste
! Outline of strategies for ensuring that protective materials are in sufficient supply
(with examples of potential substitutes for these materials if necessary)
A sample PEP protocol is found in Appendix 8-B.
The PEP protocol should:

! Establish guidelines for PEP for the healthcare setting.
! Be used to educate staff and managers at designated intervals.
! Ensure that HIV counselling, testing, and ARV drugs are available for PEP.
! Ensure an HIV test is done when starting and after completing PEP.
! Ensure HIV antibody testing if illness compatible with an acute retroviral syndrome
occurs.
! As part of counselling, encourage exposed persons to use precautions to prevent
secondary transmission during the follow-up period.
! Evaluate exposed persons taking PEP within 72 hours after exposure and monitor for
drug toxicity for at least 2 weeks.
! Maintain a facility register of occupational exposures.
! Educate healthcare workers to report all occupational accidents so that they are
recorded on the facility register of occupational incidents.
Make These Points

! Since PEP needs to be administered soon after exposure (within 2 hours), 2
dosages of the recommended PEP regimen should be accessible at the clinical
facility at all times.

Module 8 Safety
Guidelines for providing PEP
Healthcare workers should report occupational exposure to HIV immediately after it
occurs. Early rapid testing of the source patient (the patient involved in the incident) can
help determine the need for PEP—and may avert the unnecessary use of ARV drugs,
which may have adverse side effects. If necessary, PEP should begin as soon as
possible after exposure, ideally within 2 hours.
Staff who are at risk for occupational exposure to bloodborne pathogens need to be
educated about the principles of PEP management during job orientation and on an
ongoing basis. Currently there is no single approved PEP regimen; however, dual or
triple drug therapy is recommended and believed to be more effective than a single
agent.
Drug selection for PEP depends on the following factors:

! Type of injury and transmission device
! Source patient’s HIV viral load and treatment history
! ARV drugs available at the facility
Importance of ARV treatment for post-exposure prophylaxis on-site

Due to the need to start PEP as soon as possible after exposure (ideally, within
2 hours), a minimum of two doses of ARV treatment should be available and
accessible at the facility at all times.
ARV treatment should be provided in accordance with national or institutional

protocol. A minimum treatment of 2 weeks and maximum of 4 weeks is recommended.
If possible, consulting with a HIV specialist is recommended, particularly when exposure
to drug-resistant HIV may have occurred.
It is important that healthcare workers have ready access to a full month’s supply of
ARV treatment once PEP is initiated.
Some healthcare workers taking PEP experience adverse symptoms including nausea,
malaise, headache, and anorexia. Pregnant workers or women of child-bearing age who
may be pregnant may receive PEP, but must avoid efavirenz, which has harmful effects
on the foetus. PMTCT programmes should support workers while they are taking PEP
and help manage any side effects.
Introduce the case study and lead small group discussion on PEP.

Module 8 Safety
Exercise 8.3 PEP case study: small group discussion

Purpose To review implementation of PEP protocols.
Duration 30 minutes
Introduction This exercise will review the implementation of PEP protocols.
Instructions ! Divide participants into three groups
! Distribute copies of PEP Case Study: Nurse Andrews, if not
already in the Participant Manuals
! Instruct each group to read the case study and record on paper
the stepwise process needed to implement a PEP protocol.
! Allow 20 minutes for this task.
! Once completed, ask each group to read out the first step they
recorded.
! Assuming that this step is correct, record on flipchart.
! Discuss any inaccuracies or variations.
! Repeat above procedure for all steps in the PEP protocol.
Debriefing It is important to understand the processes involved in PEP

implementation.
Access to ARV treatment is critical. Therefore, a minimum of two
doses (per your facility standard protocol) should be available and
accessible at all times.
Case study
Nurse Andrews is working late in the labour and delivery unit. When removing an intra-
venous needle from the arm of a patient who is in labour, Nurse Andrews accidentally
punctures her finger.
After this occupational exposure, what is the very first thing Nurse Andrews should do?
List each subsequent step according to the PEP protocol.
Case study answers:

1. If bleeding occurs following percutaneous injury, allow a few seconds to bleed prior to
washing with soap and water. (In other words, do not “milk.”)
2. Inform supervisor, if applicable, of type of exposure and action taken.
3. Explain to patient what has occurred and obtain patient’s consent for HIV rapid testing.
4. Obtain consent for rapid testing for Nurse Andrews.
5. Assure both patient and Nurse Andrews that confidentiality will be strictly maintained.
6. Provide support to Nurse Andrews.
7. If the result is positive on the initial HIV test, counsel and refer for treatment.
8. With her consent, start Nurse Andrews on PEP regimen within 2 hours, even if HIV sta-
tus of the patient is unknown. If patient’s HIV test is negative, discontinue prophylaxis.
9. If Nurse Andrews’ initial HIV test is negative (and the patient’s HIV test positive),
re-test Nurse Andrews’ for HIV at 6 weeks, 3 months, and 6 months post exposure.

Module 8 Safety
SESSION 4 Supportive Care for the Caregiver
Advance Preparation
In preparation for Exercise 8.4, discuss the prevalence of compassion
fatigue with participants who are local PMTCT workers. If they don’t
recognise the syndrome, enquire if they have ever seen the signs and
symptoms of compassion fatigue/burnout in their staff/colleagues. Ask what
can be done on the personal and organisational levels to prevent and/or
manage compassion fatigue/burnout.
Review the question guide for Exercise 8.4 and adapt it to the expectations
of the trainees, their situations, and interests.
Slides 26 and 27
Introduce the topic of compassion fatigue, also known as “burnout”, using the
information below.
Make These Points

! Compassion fatigue/burnout is common amongst healthcare workers in the HIV or
other caring fields, who are working under stressful conditions for extended periods
of time.
! Compassion fatigue/burnout can be dealt with constructively; it is also preventable.
! A combination of individual and organisational supports can prevent and manage
compassion fatigue.

Module 8 Safety
Compassion fatigue
Healthcare workers who provide ongoing care of pregnant women who are HIV-infected
(or whose HIV status is unknown) and their infants are vulnerable to compassion fatigue
or “burnout.”
Burnout syndrome stems from extended exposure to intense job-related stress and
strain. Burnout syndrome is characterised by:
! Emotional exhaustion: feelings of helplessness, depression, anger, and impatience

! Depersonalisation: detachment from the job and an increasingly cynical view of
patients and co-workers
! Decreased productivity: due to a real or perceived sense that their efforts are not
worthwhile and do not seem to have an impact.
Signs and symptoms of burnout

Behavioural Physical
! Frequent changes in mood ! High blood pressure
! Eating too much or too little ! Palpitations, trembling
! Drinking alcohol and/or smoking too ! Dry mouth, sweating
much ! Stomach upset
! Becoming “accident prone”
Occupational
Cognitive ! Taking more days off
! Unable to make decisions ! Fighting with co-workers
! Forgetful, poor concentration ! Working more hours but getting less
! Sensitive to criticism done
! Having low energy, being less
motivated
Institutional or job-related risk factors for burnout

! Work overload, limited or no breaks
! Long working hours
! Poorly structured work assignment (worker not able to use skills effectively)
! Inadequate leadership and support
! Lack of training and skill-building specific to your job
Personal risk factors for burnout include

! Unrealistic goals and job expectations
! Low self-esteem
! Anxiety
! Caring for patients with a fatal disease
Slide 28
Review the personal strategies for preventing or minimising compassion fatigue/burnout.

Module 8 Safety
Personal strategies for minimising or preventing burnout syndrome
Seeking support from others, taking care of yourself, and engaging in restorative
activities, such as reading and exercising may reduce or minimise burnout syndrome.
Tips for managing burnout

! Find or establish a support group of peers.
! Search out a mentor—someone who can confidentially support you, listen to
you, and guide you.
! Read books or listen to tapes that provide strategies for coping with stress.
! Take a course to learn about a subject relevant to your work (or take a
refresher course on a previously-studied subject).
! Take structured breaks during work hours.
! Make time for yourself and your family.
! Exercise, eat properly, and get enough rest.
Use the exercise below to explore with the group factors that contribute to caregiver
compassion fatigue/burnout in PMTCT programmes.
Exercise 8.4 Compassion fatigue/burnout in

PMTCT programmes: large group discussion
Purpose To examine the factors that contribute to burnout and develop
creative prevention strategies.
Duration 45 minutes
Introduction We will identify factors that contribute to compassion fatigue/
burnout in the PMTCT setting.
We will also be looking for creative strategies for preventing or
minimising compassion fatigue/burnout.
Activity ! Ask participants to answer the questions that follow this exercise.
! Summarise answers on the flipchart.
! Ask participants to share stories and personal experiences or
observations about compassion fatigue/burnout in their own clin-
ical settings.
! Encourage the group to work together to consider ways to
address compassion fatigue/burnout.
! Record on flipchart.
Debriefing PMTCT programmes present unique challenges for healthcare
professionals.
Within each clinical setting, tools can be developed to help prevent
compassion fatigue/burnout.

Module 8 Safety
Exercise 8.4 Questions for discussion

! What is the greatest daily challenge in your clinical setting?
! Comment on staffing for testing and counselling at your facility. Are there
enough counsellors? What are the training requirements?
! Does your facility orient staff to the workplace?
! Does your facility meet staffing requirements?
! Does your agency provide ongoing education to ensure adequate, updated
skills?
! Does your organisation ensure that staff has all the necessary supplies and
materials?
! Does your facility support and assist staff?
! Is there someone you can turn to help you with your workplace concerns?
! Are you connected to community services that make your job easier?
! Do you have your own source of peer support? Who are your supporters?
! Do you use your own stress-reduction techniques that work well for you?
! What are three things that would make your job easier?
! Share your personal experiences about compassion fatigue/burnout in your clini-
cal setting with the larger group.
Summarise the module by reviewing key points, as described below.

! Universal precautions apply to all patients, regardless of diagnosis.
! Key components of universal precautions include:
! Handwashing
! Safe handling and disposal of sharps
! Use of personal protective equipment
! Decontamination of equipment
! Safe disposal of infectious waste materials
! Safe environmental practices
! Needle-stick injuries from patients who are HIV-infected are the most common
source of HIV transmission in the workplace.
! Cleaning, disinfection, and sterilisation of all instruments used in invasive proce-
dures reduce risk of patient-to-patient transmission of infection.
! During labour and childbirth, safe care reduces the risk of occupational expo-
sure.
! Short-term ARV treatment reduces the risk of HIV infection after occupational
exposure.
! Burnout syndrome is related to intense, prolonged job stress but can be man-
aged and the effects minimised by individual and organisational supports.

Module 8 Safety
APPENDIX 8-A Guidelines for cleaning, sterilisation, and
disposal of infectious waste materials
Level of Risk Items Decontamination Method

High risk or Equipment and Sterilisation is a process that destroys all
critical instruments that microorganisms, including HIV. Use the
penetrate the following methods:
skin or body ! Use of steam under pressure is the pre-
ferred method.
! Use ethylene oxide gas or other low-tem-
perature process for heat-sensitive equip-
ment.
! Use chemical sterilants with adequate pre-
cleaning and follow proper protocols.
Moderate risk or Equipment and Sterilise with heat or steam.
semi-critical instruments that Use high-level disinfection. This method
touch non-intact destroys all microorganisms with the exception
skin or mucous of high numbers of bacterial spores. Use the
membranes following methods:
! Boil for 20 minutes, or longer if above sea
level.
! Perform chemical disinfection with glu-
taraldehyde, stabilised hydrogen peroxide,
chlorine, or peracetic acid, followed by a
sterile water rinse or a tap water and alco-
hol rinse; dry with forced air, when possible.
Note: Intermediate-level disinfectants for
certain semi critical items do not kill all
viruses, fungi, or bacterial spores.
Low risk or Equipment and Perform low-level disinfection with diluted

non-critical instruments that germicidal detergent solution, isopropyl
touch intact skin alcohol, or 1:500 dilution of household bleach.
When possible, high-risk or critical equipment and instruments should be pre-packaged,

disposable, and designed for single use.
Cleaning
Cleaning removes all foreign material (dirt, body fluids, and lubricants) from objects by
washing or scrubbing the object using water and detergents or soaps. Detergents and
hot water are generally adequate for the routine cleaning of floors, beds, toilets, walls,
and rubber draw sheets.
To clean a spill involving body fluids
! Use heavy-duty rubber gloves and remove body fluid with an absorbent material
! Discard the material in a leak-proof container.

Module 8 Safety

disposal of infectious waste materials (continued)
Note the following when handling soiled linen:

! Use gloves, but avoid handling as much as possible.
! Do not sort or rinse in patient care areas.
! Transport linen soiled with large amounts of body fluid in leak-proof bags.
! Fold linen so that the soiled parts are on the inside.
Safe disposal of infectious waste materials

The purpose of waste management is to:
! Protect people who handle waste items from injury, and
! Prevent the spread of infection to healthcare workers and the local community.
To dispose of solid waste contaminated with blood, body fluids, laboratory specimens,
or body tissue:
! Place in leak-proof containers and burn, or
! Bury in a pit 2.5 meters (about 8 feet) deep, at least 30 meters (about 98 feet) from a
water source.
To dispose of liquid waste, such as blood or body fluids, pour liquid waste down a drain
connected to an adequately treated sewer or pit latrine.
Recommendations on disposal of sharps

Disposable sharp items, such as hypodermic needles, require special handling because
they are the items most likely to injure healthcare workers. If these items are disposed
of in the municipal landfill, they are a danger to the community.
Note the following to dispose of sharps containers safely:

! Wear heavy-duty gloves.
! When the sharps container is three-quarters full, completely seal the opening of the
container using a cap, a plug, or tape.
! Be sure that no sharp items are sticking out of the container.
! Dispose of the sharps container by burning, encapsulating, or burying it.
! Remove the heavy-duty gloves.
! Wash your hands and dry them with a clean cloth or air dry.
Burning waste containers

High-temperature burning destroys waste and kills microorganisms. This method reduces
the bulk volume of waste and ensures that the items are not scavenged and reused.
Encapsulating waste containers

Encapsulation is recommended as the easiest way to dispose of sharps safely. In this
method, collect sharps in puncture-resistant and leak-proof containers. When the
container is three-quarters full, pour a material such as cement (mortar), plastic foam, or
clay into the container until completely filled. After the material has hardened, seal the
container and dispose it in a landfill, store it, or bury it.

Module 8 Safety
disposal of infectious waste materials (continued)
Burying waste
In healthcare facilities with limited resources, safe burial of waste on or near the facility
may be the only option available for waste disposal. Take the following precautions to
limit health risks:
! Restrict access to the disposal site. Build a fence around the site to keep animals
and children away.
! Line the burial site with a material of low permeability (for example, clay or cement),
if available.
! Select a site at least 30 meters (about 98 feet) away from any water source to pre-
vent contamination of the water table.
! Ensure that the site has proper drainage, is located downhill from any wells, is free of
standing water, and is not in a flood-prone area.
! The bottom of the burial pit should be at least 1.5 meters above the groundwater
level during the wet season.
This appendix includes original material and material adapted from the following:
• Tietjen, Bossemeyer, McIntosh. Prevention: Guidelines for Healthcare Facilities with Limited Resources. JHPIEGO
Corporation, Baltimore, March 2003. http://www.reproline.jhu.edu/english/4morerh/4ip/IP_manual/ipmanual.htm
• International Council of Nurses, World Health Organization (WHO) and the Joint United Nations Programme on
HIV/AIDS (UNAIDS). 2000. Fact Sheet 11 HIV and the workplace and Universal Precautions (Fact sheets on
HIV/AIDS for nurses and midwives), http://www.who.int/health-services-delivery/hiv_aids/English/fact-sheet-
11/index.html
• World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS). 1999. HIV in
Pregnancy: A Review. Pp 39–42. Retrieved 3 June 2004, from http://www.who.int/reproductive-
health/publications/rhr_99_15/rhr99-15.pdf

Module 8 Safety
APPENDIX 8-B Managing occupational exposure to HIV: a

sample protocol
Immediate steps
Any healthcare worker accidentally exposed to blood or body fluids must take the
following steps:
! Wash the wound and skin sites exposed to blood and body fluids with soap and water.
! For percutaneous injuries (those that break the skin) where bleeding occurs, allow
bleeding for a few seconds before washing with soap and water.
! Flush mucous membranes exposed to blood and body fluids with water.
! Topical use of antiseptics is optional.
! Do not apply caustic agents, such as bleach, onto the wound or inject antiseptics or
disinfectants into the wound.
! Immediately inform the supervisor, or person in charge, of the exposure type and the
action taken.
Once informed, the supervisor should take the following actions:

! Assess the exposure to determine the risk of transmission.
! Inform the patient about the exposure and request permission for HIV testing.
! Inform the healthcare worker about the exposure and request permission for HIV testing.
! Perform rapid testing on both specimens following testing procedures. If rapid testing is
not available, send both samples to the closest designated laboratory for HIV testing.
! Immediately arrange for the healthcare worker to visit the nearest physician who
manages this type of injury.
! Provide immediate support and information on post-exposure prophylaxis (PEP) to
the healthcare worker.
! Record the exposure in the facility register or the appropriate form and forward the
information to the individual or department assigned to manage such exposures.
! Maintain the confidentiality of all related records.
PEP
! In all cases of accidental exposure, start PEP within 2 hours of the exposure,
whether or not patient’s HIV status is known.
! Discontinue PEP after you have confirmed that the patient’s HIV test is negative.
! If the patient is HIV-infected (with a positive test result), continue PEP.
! ARV therapy should be provided according to national or facility protocol. A minimum
of two weeks and a maximum of four weeks treatment is recommended. When possi-
ble, consultation with a HIV specialist, particularly when exposure to drug resistant
HIV may have occurred, is recommended.
! If the healthcare worker’s initial HIV test is positive, counsel the person on the test
result and refer to a HIV/AIDS programme for treatment, care and support.

Module 8 Safety
APPENDIX 8-B Managing occupational exposure to HIV: a
sample protocol (continued)
! Always have a minimum of two doses of the approved PEP ARV regimen available
and accessible at your facility at all times.
! If the healthcare worker’s initial HIV test is negative, repeat the HIV test at the follow-
ing post-exposure intervals: 6 weeks, 3 months, and 6 months.
! Healthcare worker should receive follow-up care for 6 months.
! If the healthcare worker converts from a negative to a positive test result, which is
rare, refer the worker to an HIV/AIDS programme for treatment, care, and support.
Post-exposure counselling for the healthcare worker

! Healthcare worker must be counselled to either abstain from sexual intercourse or
use condoms for 6 months after the exposure or until receiving the third negative test
result.
! Healthcare worker should not donate blood, plasma, organs, tissues, or semen for
6 months after the exposure or until receiving the third negative test result.
! Breastfeeding should be discouraged during this period.
! Offer counselling support to the healthcare worker and, if requested, to the health-
care worker’s spouse or sexual partner, to help them manage the implications of and
stress related to the exposure.
Source: Adapted from CDC. 2001. Updated US public health service guidelines for the management of occupational
exposure to HBV, HCV and HIV and recommendations for postexposure prophylaxis. MMWR 50(No. RR-11): 1–42.
Retrieved 30 July 2004, from http://www.cdc.gov/mmwr/PDF/rr/rr5011.pdf and World Health Organization. Post-exposure
prophylaxis Retrieved 30 July 2004, from http://www.who.int/hiv/topics/prophylaxis/en/index.html

Module 8 Safety
Notes

Glossary
Acquired immunodeficiency
syndrome (AIDS) A: Acquired, (not inherited) to differentiate from a
genetic or inherited condition that causes immune
dysfunction
I: Immuno-, because it attacks the immune
system and increases susceptibility to infection
D: Deficiency of certain white blood cells in the
immune system
S: Syndrome, meaning a group of symptoms or
illnesses as a result of the HIV infection
AIDS is the most advanced stage of HIV infection.
Acute illness An illness, such as pneumonia, that begins

suddenly and usually is of short duration. Many
acute illnesses can be cured by medical treatment.
AIDS See Acquired Immunodeficiency Syndrome.
Anaemia A condition in which there is a low blood level of

red blood cells, haemoglobin, or in total volume.
ANC See Antenatal Care.
Glossary
Antenatal care (ANC) Care of a pregnant woman and her unborn child or
foetus before delivery.
Antibiotic A medicine that kills infection-causing organisms.
Antibody A specialised serum protein produced by B

lymphocytes in response to an exposure to foreign
protein (antigen).
Antigen A substance that can trigger an immune response

causing the production of antibodies as part of the
body's defense against infection and disease.
ARV See Antiretroviral Drugs, Antiretroviral Prophylaxis,

Antiretroviral Treatment.
PMTCT—Generic Training Package Trainer Manual Glossary–1

Antiretroviral prophylaxis Short-term use of antiretroviral drugs to reduce HIV
transmission from mother to infant.
Antiretroviral treatment Long-term use of antiretroviral drugs to treat

maternal HIV/AIDS and prevent PMTCT.
Asymptomatic Without symptoms of illness or disease.
Bacterium A type of germ that causes infection.
Bloodborne pathogen Microorganisms, such as viruses or bacteria, that

are carried in blood and can cause disease.
Breastmilk substitute Any food being marketed or otherwise represented

as a partial or total replacement for breastmilk,
whether or not suitable for that purpose. A
breastmilk substitute can be commercial infant
formula or home-modified animal milk.
CD4 cells T-lymphocyte cells in the immune system involved

in protection against infections. When HIV actively
multiplies, it infects and kills CD4 cells.
CD4 count A test that measures the number of CD4 cells in

the blood, thus reflecting the state of the immune
system. A normal count in a healthy adult is
600–1200 cells/mm3. When the CD4 count of an
adult falls below 200 cells/mm3, there is a high risk
of opportunistic infection.
Cell The basic unit of living matter.
Cessation of breastfeeding Completely stopping breastfeeding, including

suckling.
Chorioamnionitis Inflammation of the membranes covering the

foetus.
Chronic illness Any persistent medical condition that can be

managed but not cured with treatment.
Glossary
CMV See Cytomegalovirus.
Codex Alimentarius Commission Created in 1963 by Food & Agricultural

Organization (FAO) and WHO to develop food
standards, guidelines and other information
including practice guidelines under the Joint
FAO/WHO Food Standards Programme. The main
purposes of this Programme are protecting
consumers health and ensuring fair trade practices
in the food trade, and promoting coordination of all
food standards work undertaken by international
governmental and non-governmental organisations.
Glossary–2
Combination ARV therapy Use of three or more antiretroviral medications to
more effectively combat HIV disease and suppress
viral load.
Commercial infant formula Breastmilk substitute formulated industrially in

accordance with applicable Codex Alimentarius
standards to satisfy the nutritional requirements of
infants during the first months of life up to the
introduction of complementary foods.
Complementary food Any food, whether manufactured or locally

prepared, used as a complement to breastmilk or
to a breast-milk substitute. In general,
complementary foods should not start before the
age of 6 months.
Counselling The confidential dialogue between individuals and

their care providers. The term counselling can refer
to discussions between healthcare workers and
clients/patients specific to HIV testing to help
clients examine their risk of acquiring or
transmitting HIV infection.
Cryptococcus A fungal organism that infects the central nervous

system (brain and spinal cord) causing
cryptococcal meningitis. Some of the symptoms
include fever, headache, vomiting, and loss of
appetite. A serious opportunistic infection in
persons living with HIV/AIDS.
Cryptosporidium An organism that infects the intestines (gut). Some

of the symptoms include diarrhoea, pain, and
weight loss.
Cup feeding Being feed from or drinking from an open cup

irrespective of its contents.
Cytomegalovirus (CMV) A virus that infects systems of the body. Some of

the signs and symptoms include pneumonia,
Glossary
retinitis, diarrhoea, and other problems.
DNA PCR HIV DNA polymerase chain reaction (PCR) is a

laboratory test to detect the presence of the virus
in the blood. It is used for diagnosis of the infant
less than 18 months.
Dehydration Loss of fluid from body tissues.
Diarrhoea Frequent loose and watery bowel movements often

caused by bacteria, parasites, and drug use.
People with HIV commonly develop diarrhoea ,
which can lead to wasting.

Disclosure Sharing of HIV status with others. Most people
believe that disclosure of HIV infection should be
encouraged. Yet many people infected with HIV
avoid disclosing their HIV status for fear that doing
so will subject them to unfair treatment and stigma.
Benefits of disclosure include: encouraging
partner(s) to be HIV tested; preventing the spread
of HIV to partner(s); and receiving support from
partner(s), family, and/or friend(s).
Discrimination An act or behaviour based on prejudice.

Discrimination is a way of expressing, either on
purpose or inadvertently, stigmatising thoughts.
Disinfection Elimination of most or all microorganisms other

than bacterial spores, accomplished by the
application of liquid chemicals or by wet
pasteurisation (75°C for 30 minutes after detergent
cleaning).
ELISA See Enzyme Linked Immunosorbent Assay.
Encephalopathy Degeneration (failing) of the brain that causes

decreased functioning in activities of daily living
and progresses over weeks or months.
Enzyme A protein that helps promote biochemical reactions

but that is not affected by them.
Enzyme Linked Immunosorbent A laboratory assay (test) to identify the presence of

Assay (ELISA) HIV antibodies in body fluids. A positive ELISA test
result is usually confirmed by another test such as
a second ELISA or a test called the Western blot.
Epidemic A disease affecting or tending to affect a

disproportionately large number of individuals
within a population, community, or region at the
same time.
Evaluation A measurement of the changes in a situation

Glossary
resulting from an intervention. A formal evaluation

of a PMTCT programme will demonstrate how
much it contributed to changes in the indicators.
Exclusive breastfeeding Providing breastmilk only (including expressed

breastmilk), and no other food or drink, including
water. The only exceptions are drops or syrups
consisting of vitamins, mineral supplements, or
medicines.
Failure to Thrive (FTT) Weight loss or gradual but steady deterioration in

weight gain from the expected growth, as indicated
in a child's growth card.
Glossary–4
Fungus A germ that can cause infection, including a yeast
infection such as thrush. Fungal infection occurs
commonly in those with weakened immune
systems, including AIDS.
Germs Organisms, including bacteria, viruses, and fungi,

that can cause infection.
Haematocrit The percentage of red blood cells in the blood.
Haematologic Relating to blood.
Haemoglobin A protein found in red blood cells that carries

oxygen.
Healthcare provider A doctor, nurse, midwife, programme manager, or

others whose activities include working directly with
patients or clients in a healthcare setting. Also
referred to as healthcare worker.
Helminth infection Intestinal disease caused by wormlike parasites.
Hepatic Relating to the liver.
Hepatitis Inflammation of the liver that may be caused by

bacterial or viral infection, parasitic infestation,
alcohol, drugs, toxins, or transfusion of
incompatible blood.
Hepatomegaly Swollen or enlarged liver.
Herpes A virus that causes sores in the mouth, on the

genitals, or elsewhere on the body.
Highly Active Antiretroviral

Therapy (HAART) Stands for the use of at least three ARV drugs in
combination to suppress viral replication and
progression of HIV disease by reducing the viral
load to undetectable levels.
HIV rapid test A simple test for detecting HIV antibodies in blood
or other body fluids that produces results in less Glossary
than 30 minutes.
Home care The provision of treatment and care in the home of

the person living with HIV/AIDS.
Home-prepared formula Replacement food (or breastmilk substitute)

prepared at home from fresh or processed animal
milk, suitably diluted with water and amended with
sugar and micronutrients.

Human immunodeficiency Stands for human immunodeficiency virus, the
virus (HIV) virus that causes AIDS. HIV breaks down the
body’s defence against infection and disease—the
body’s immune system—by infecting specific white
blood cells, leading to a weakened immune
system. It is transmitted through blood, blood
products, semen, vaginal fluids, and breastmilk.
Immune system A collection of cells and proteins that works to

protect the body from potentially harmful, infectious
microorganisms, such as bacteria, viruses and
fungi.
Immunisation Vaccination to protect against a specific infection

by injecting a weakened or killed form of a disease-
causing organism into the body to activate the
body’s immune response without causing the full-
blown disease. Currently there is no vaccine or
immunisation to protect against HIV.
Immunocompromised Having a weak or damaged immune system as

measured by a low CD4 count. Also, see
Immunosuppressed.
Immunosuppressed When the body’s immune function is damaged and

incapable of performing its normal functions.
Immunosuppression may occur due to certain
drugs (e.g., in chemotherapy) or because of certain
diseases such as HIV infection.
Implementation The specific steps taken when attempting to reach

a specific goal, is known as "implementation." The
implementation phase occurs after goals have
been set and a strategy has been agreed upon.
In utero Refers to events that occur in the uterus (womb)

during pregnancy.
Indicators Summary measures used to provide information on

Glossary
the status of activities related to each step of the

PMTCT programme cycle.
Infant who is HIV-exposed Infant born to a mother infected with HIV and
exposed to HIV through pregnancy, in childbirth, or
during breastfeeding.
Infection Invasion and growth of germs in the body.
Integrated Management of
Childhood Illness (IMCI) An approach to management of child health,
developed by WHO and UNICEF, that focuses on
the well-being of the whole child. IMCI aims to
reduce death, illness, and disability, and to promote
improved growth and development among children
younger than 5 years.
Glossary–6
Intervention An action or strategy to address a particular
problem or issue and to accomplish a specific
result.
Intrapartum Occurring during labour and delivery (childbirth).
Lymphadenopathy A swelling of the lymph glands in the body. The

most common areas of swelling with HIV infection
are the neck, under the arms, and in the groin. Also
called swollen glands.
Lymphocyte A type of white blood cell produced in the lymphoid

organs that is primarily responsible for immune
responses. Present in the blood, lymph and
lymphoid tissues.
MAC See Mycobacterium Avium Complex.
Malaria An infectious disease characterized by cycles of

chills, fever, and sweating, caused by a parasite
transmitted by a host mosquito.
Medication adherence Taking medicine exactly as recommended by a

healthcare provider without missing doses.
Monitoring Routine tracking of information or indicators about

a programme and its intended outputs through
record keeping and regular reporting. Also called
performance monitoring.
Mother-to-child transmission
(MTCT) of HIV Transmission of HIV from a woman infected with
HIV to her child during pregnancy, childbirth, and
breastfeeding. Also referred to as vertical
transmission or perinatal transmission.
MTCT See Mother-to-Child Transmission.
Mycobacterium Avium Complex Organisms that invade the intestines (gut) and
other organs.
Neutrophil A type of white blood cell that kills foreign Glossary

organisms such as bacteria and fungus.
Neutropoenia Low neutrophil count in the blood that is associated

with HIV infection.
OI See Opportunistic Infection.
Oesophagitis An infection or inflammation of the oesophagus.
Opportunistic infection (OI) A disease caused by a microorganism that does

not normally cause illness in a person with a
healthy immune system, but that may cause
serious disease when the immune system is
weakened.

Oral thrush A fungal infection of the mouth that looks like white
patches or curdled milk.
Output indicators Evidence of programme results, such as the

number of people trained.
Pandemic A disease occurring over a wide geographic area

and affecting an exceptionally high proportion of
the population ie, malaria, HIV.
PCP See Pneumocystis Carinii Pneumonia.
PCR See Polymerase Chain Reaction.
PEP See Post-Exposure Prophylaxis.
Perinatal transmission See Mother-to-Child Transmission of HIV; Also

known as vertical transmission.
Platelet A type of blood cell (thrombocyte) that facilitates

blood clotting. Also see Thrombocytopoenia.
PMTCT Prevention of mother-to-child transmission of HIV.
Pneumocystis Carinii A severe, life-threatening lung infection that causes

Pneumonia (PCP) fever, dry cough, and difficulty breathing.
Polymerase Chain Reaction A viral assay (test) that detects the presence or the
(PCR) amount of a virus in the blood. For HIV, the DNA-
PCR indicates the presence of the virus. The HIV
RNA-PCR measures the amount of virus, often
referred to as the viral load.
Post-exposure prophylaxis (PEP) Short-term use of ARV drugs following

occupational HIV exposure such as a
percutaneous injury (eg, a needlestick or cut with a
sharp object) or contact of mucous membrane or
nonintact skin (eg, exposed skin that is chapped,
abraded, or afflicted with dermatitis) with blood,
tissue, or other body fluids containing visible blood
to reduce the likelihood of infection.
Glossary
PEP is a key part of a comprehensive Universal

Precautions strategy for reducing exposure to
infectious agents in the workplace.
Postnatal care Care for a mother and infant in the 6 weeks

following birth. Postnatal care is vital for ensuring
that mother and child remain healthy and should
include prevention, early detection, and treatment of
complications and disease. Guidance and support
of infant feeding and maternal nutrition, family
planning, childhood immunisations and referrals to
needed services provide continuity of care.
Prenatal care See Antenatal Care.
Glossary–8
Prevalence The percentage of a population that is affected with
a particular disease at a given time.
Programme cycle Process of assessing a situation and then

planning, implementing, monitoring and evaluating
a responsive public health programme.
Prophylaxis Treatment to prevent the onset of a particular

disease (primary prophylaxis) or recurrence of
symptoms in an existing infection that has been
brought under control (secondary prophylaxis).
PMTCT prophylaxis refers to using antiretroviral
drugs to reduce HIV transmission from mother to
infant.
Replacement feeding The process of feeding infants who are receiving

no breastmilk with a diet that provides the nutrients
infants need until the age at which they can be fully
fed on family foods. During the first six months, this
should be with a suitable breastmilk substitute such
as commercial formula, or home-prepared formula
with micronutrient supplements. After six months,
the suitable breastmilk substitute should be
complemented with other foods.
Replicate To duplicate or make more copies of something.
RNA PCR HIV RNA polymerase chain reaction, also called

viral load testing, detects and measures the
amount of virus in blood.
Safer sex Ways to have sex that reduce the risk of acquiring
or transmitting HIV and other STDs such as use of
a latex condom or other barrier. See Unprotected
Sex.
Seropositive A blood test result that indicates infection. A test

can indicate the presence of antibodies to an
organism (antibody positive) or the presence of the
Glossary
organism or its proteins (antigen positive).
Sexually Transmitted
Diseases/Infections (STD/STI) Diseases that people get by having intimate sexual
contact, including having sex (vaginal, oral, or anal
intercourse) with someone who already has the
disease. There are many different kinds of STDs
including herpes, HIV, and syphilis. All STDs are
preventable.
Side effect Unintended action or effect of a medication or

treatment.

Specificity The ability of a test to correctly exclude individuals
who do not have a given disease or disorder. For
example, a certain HIV test may have proven to be
90% specific. If 100 healthy individuals are tested
with that method, only 90 of those 100 healthy
people will be found “negative” or disease-free by
the test. The other 10 people also do not have the
disease, but their test results seem to indicate they
do. For that 10%, their “positive” findings are a
misleading false-positive result. When it is
necessary to confirm a diagnosis that requires
therapy, a test’s specificity is one of the important
indicators. The more specific a test is the fewer
“false-positive” results it produces.
Splenomegaly Inflamed or enlarged spleen.
STDs/STIs See Sexually Transmitted Diseases/Infections.
Sterilisation Completely eliminating or killing all microorganisms

by application of steam under pressure, dry heat,
or ethylene oxide and other gases, or by soaking in
other liquid chemicals for prolonged periods.
Stigma Refers to all unfavourable attitudes and beliefs

directed toward people living with HIV/AIDS
(PLWHA) or those perceived to be infected, as well
as their significant others and loved ones, close
associates, social groups, and communities.
Symptomatic Showing signs of illness or disease.
TB See Tuberculosis.
Thrombocytopoenia An abnormally low number of platelets

(thrombocytes) due to disease, reaction to a drug
or toxic reaction to chemotherapy treatments. If the
platelets are too few, bleeding could occur.
Tuberculosis (TB) A contagious bacterial infection that damages the

Glossary
lungs and other parts of the body. TB is a

respiratory illness and is mainly transmitted through
coughing. The most common and serious co-
infection and OI related to HIV/AIDS.
Universal precautions A simple set of effective practices designed to

protect health workers and patients from infection
with a range of pathogens including blood borne
viruses. These practices are used when caring for
all patients regardless of diagnosis.
Unprotected sex The exchange of blood, semen and/or vaginal

fluids that occurs during sexual activity when
condoms and other barrier methods such as latex
or polyurethane are not in use.
Glossary–10
Vertical transmission See Mother-to-Child Transmission of HIV.
Viral load The amount of HIV in the blood as measured by

HIV RNA PCR.
Viral resistance Changes in the genetic makeup of HIV that

decrease the effectiveness of antiretroviral drugs.
Usually occurs in response to drug treatment
especially when there is incomplete treatment or
poor adherence to appropriate treatment.
Virus A type of germ that causes infection.
Wasting (syndrome) Condition characterised by loss of more than 10%

of body weight and either unexplained chronic
diarrhoea (lasting more than 1 month) or chronic
weakness and unexplained, prolonged fever
(lasting more than 1 month).
Western blot A laboratory test for specific antibodies to confirm

repeatedly reactive results on the HIV ELISA test.
Western blot is the validation test used often for
confirmation of other test results.
Wet-nursing Breastfeeding of an infant by someone other than

the infant's mother.
Window period The period of time between the onset of infection

with HIV and the appearance of detectable
antibodies to the virus. The window period lasts for
4 to 6 weeks but occasionally up to 3 months after
HIV exposure.
Glossary

Notes
Glossary
Glossary–12
Resources
Resources
Key General Resources on PMTCT
Brocklehurst P and J Volmink. 2002. Antiretrovirals for reducing the risk of mother-
to-child transmission of HIV infection (Cochrane Review), in The Cochrane
Library, Issue 3. Update Software: Oxford, England.
Center for HIV Information. 2004. Women, children, and HIV: resources for
prevention and treatment. 3rd ed. Retrieved 19 August 2004, from
www.womenchildrenhiv.org
DeCock KM et al. 2000. Prevention of mother-to-child HIV transmission in resource-

poor countries: Translating research into policy and practice. JAMA 283(9):
1175–1182.
Rutenberg N et al. 2003b. HIV voluntary counseling and testing: An essential

component in preventing mother-to-child transmission of HIV. Horizons
Research Summary. Population Council: Washington, DC. Retrieved 30 July
2004, from http://www.popcouncil.org/pdfs/horizons/pmtctvct.pdf
WHO. 2004. Antiretroviral drugs for treating pregnant women and preventing HIV
infection in infants. Guidelines on care, treatment and support for women living
with HIV/AIDS and their children in resource-constrained settings.WHO:
Geneva. Retrieved 19 August 2004, from
http://www.who.int/hiv/pub/mtct/guidelines/en/
WHO. 2004. Scaling up antiretroviral therapy in resource-limited settings: Treatment

guidelines for a public health approach. WHO: Geneva. Retrieved 30 July 2004,
from http://www.who.int/hiv/pub/mtct/en/arvdrugsguidelines.pdf
AIDS Education and Training Centers National Resource Center. 2003. U.S. public
health service perinatal guidelines: Recommendations for the use of antiretroviral
drugs in pregnant HIV-1 infected women for maternal health and to reduce perinatal
HIV-1 transmission in the United States. Includes 49 slides, 6 case studies, and
speaker notes. Retrieved 30 July 2004, from
http://aidsetc.org/ppt/nrc_perinatal_guidelines_11-03.ppt
Bulterys M et al. 2002. Advances in the prevention of mother-to-child HIV-1

transmission: Current issues, future challenges. AIDScience 2(4). Retrieved 30 July
2004, from http://aidscience.org/Articles/aidscience017.asp
PMTCT—Generic Training Package Trainer Manual Resources–1

Resources
Dabis F (ed). PMTCT Intelligence Report. Bordeaux Working Group. Retrieved 30 July
2004, from http://www.who.int/reproductive-health/rtis/MTCT/monthly_publications/ir-
12-2001pdf
Granich R and J Mermin. 2001. HIV, Health, and Your Community: A Guide for Action.
Hesperian Foundation: Berkeley, CA.
John Snow, Inc./DELIVER. 2003. Guide for Quantifying HIV Test Kits. John Snow,
Inc./DELIVER, for the US Agency for International Development: Arlington, VA.
Retrieved 30 July 2004, from
http://www.deliver.jsi.com/pdf/g&h/guide_quantifying.pdf
Kriebs J. 2002. The global reach of HIV: Preventing mother-to-child transmission.

J Perinat Neonatal Nurs 16(3): 1–10.
Luzuriaga K and J Sullivan. 2002. Pediatric HIV-1 infection: Advances and remaining
challenges. AIDS Rev 4(1): 21–26.
Marshall M and K Adjei-Sakyi. August 2003. Female condom and dual protection:
training for community-based distributors and peer educators. Centre for
Development and Population Activities (CEDPA): Washington, DC. Retrieved 30 July
2004, from http://www.cedpa.org/publications/dualprotection/dualprotection.html
Rutenberg N et al. 2003a. Family planning and PMTCT services: Examining

interrelationships, strengthening linkages. Horizons Research Summary. Population
Council: Washington, DC. Retrieved 30 July 2004, from
http://www.popcouncil.org/pdfs/horizons/pmtctfp.pdf
Rutenberg N et al. 2003c. Infant feeding counseling within Kenyan and Zambian
PMTCT services: How well does it promote good feeding practices? Horizons
Research Summary. Population Council: Washington, DC. Retrieved 30 July 2004,
from http://www.popcouncil.org/pdfs/horizons/pmtctif.pdf
US Health & Human Services (HHS) and Centers for Disease Control & Prevention
(CDC) Global AIDS Program (GAP) Training Team. 2004 January. Developing a
strategy for effective training: Guiding principles and key approaches. Draft.
US Public Health Service Task Force. 2004. Recommendations for use of antiretroviral
drugs in pregnant HIV-1-infected women for maternal health and interventions to
reduce perinatal HIV-1 transmission in the United States. Retrieved 15 August 2004,
from www.aidsinfo.nih.gov/guidelines/perinatal/PER_062304.html
WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS). 2000. Fact
Sheet 10: Women and HIV and mother-to-child transmission (Fact sheets on
HIV/AIDS for nurses and midwives). Unpublished. Retrieved 30 July 2004, from
http://www3.who.int/whosis/factsheets_hiv_nurses/fact-sheet-10/index.html
Resources–2
Resources
Key Online Resources on PMTCT in Resource-Constrained Settings
http://www.cdc.gov/nchstp/od/gap
CDC’s Global AIDS Program (GAP) exists to help prevent HIV infection, improve
care and support, and build capacity to address the global HIV/AIDS pandemic.
GAP provides financial and technical assistance through partnerships with
communities, governments, and national and international entities working in
resource-constrained countries.
http://www.jhpiego.org
Through advocacy, education and performance improvement, JHPIEGO helps
host-country policymakers, educators and trainers increase access and reduce
barriers to quality health services in low-resource settings throughout Africa,
Asia, Latin America and the Caribbean.
http://www.who.int/child-adolescent-health/NUTRITION/HIV_infant.htm
The WHO Child and Adolescent Health and Development website provides
information about infant and young child nutrition as well as listing key resources
in this field.
http://www.who.int/3by5/en
The WHO drive to provide HIV/AIDS treatment to three million people by the end
of 2005.
http://www.WomenChildrenHIV.org
http://WomenChildrenHIV.org.za
This website, and its mirror site, disseminates state-of-the-art clinical information
and training resources on mother-to-child transmission of HIV (MTCT) and
related topics. It communicates the best practices in PMTCT and caring for
infected women, children and families in resource-constrained settings.
http://www.cdc.gov/hiv/dhap.htm
Centers for Disease Control and Prevention (CDC) site for information on HIV/AIDS
in the United States.
http://www.fhi.org
Family Health International (FHI) works to address the needs of communities and
countries ravaged by HIV/AIDS. FHI’s publications present comprehensive, state-of-
the-art information on every aspect of HIV/AIDS prevention and care, treatment, and
mitigation by sharing lessons learned from many years of experience with HIV/AIDS
in the developing world.
http://www.fightglobalaids.org
The Student Global AIDS Campaign (SGAC) is a national, student-based
organization that uses advocacy, lobbying and the media to help end the global
AIDS pandemic. The SGAC also raises money for student AIDS organizations
abroad to support their work fighting AIDS on the ground.
http://www.globalhealth.org/view_top.php3?id=227
Global Health Council works to ensure that all who strive for improvement and
equity in global health have the information and resources they need to succeed. To
achieve this goal, the Council serves as the voice for action on global health issues
and the voice for progress in the global health field.

Resources
http://www.popcouncil.org/hivaids/index.html
The Population Council’s activities include efforts to alleviate the epidemic’s effects;
elucidate the basic science of infection and the determinants of the epidemic; work
toward prevention; promote policy development; reduce stigma and discrimination;
and promote the treatment, care, and support of people with HIV.
http://www.reproline.jhu.edu/video/hiv/tutorials/English/index.htm
ReproLearn Multimedia tutorials provide doctors, faculty, and healthcare trainers
with technical information they need to provide high-quality healthcare and to train
other healthcare providers about the needs of women with HIV/AIDS.
http://www.safemotherhood.org
The Safe Motherhood Initiative is a worldwide effort that aims to reduce the number
of deaths and illnesses associated with pregnancy and childbirth.
http://www.synergyaids.com
The Synergy Project provides technical assistance and services to the USAID to
design, evaluate, and coordinate HIV/AIDS programmes and identify and
disseminate lessons learned.
http://www.unaids.org
UNAIDS (Joint United Nations Programme on HIV/AIDS) provides information on
epidemiology, treatment, and programme development.
http://www.usaid.gov/pop_health/aids
USAID (United States Agency for International Development) is an independent
agency of the US federal government that develops community-based advocacy and
support programs for people living with HIV/AIDS, and provides support for orphans
and vulnerable children whose families have been affected by HIV/AIDS. USAID
also supports voluntary testing and counselling centers.
http://www.who.int/hiv/en
WHO (World Health Organization) offers information on epidemiology, treatment,
and programme development for HIV/AIDS.
http://www.worldbank.org/hiv_aids/globalprogram.asp
The World Bank is working with all regions in the developing world that are affected
by HIV/AIDS. The AIDS programme offers global learning and knowledge sharing on
approaches and best practices for addressing HIV/AIDS.
Resources–4
Resources
MODULE 1—Introduction to HIV/AIDS
Key Resources
CDC. 1992. 1993 Revised classification system for HIV infection and expanded
surveillance case definition for AIDS among adolescents and adults. MMWR
Morb Mortal Wkly Rep 41(RR-17).
DeCock K et al. 2000. Prevention of mother-to-child HIV transmission in resource-
1175–1182.
Bradley-Springer L et al. (eds). 2002. Human Immunodeficiency Virus Infection: 2002

Sourcebook for the Healthcare Clinician. Unpublished. Retrieved 30 July 2004, from
http://www.aidsetc.org/pdf/tools/sourcebook_2002_mpaetc.pdf
Bradley-Springer L. 1999. HIV/AIDS Nursing Care Plans, 2nd Edition. Skidmore-Roth

Publishing: El Paso, TX.
Lawn J et al. 2003. Part One: The unheard cry for newborn health, in The Healthy
Newborn: A Reference Manual for Program Managers. Unpublished. pp. 1.1–1.64.
http://www.careusa.org/careswork/whatwedo/health/downloads/healthy_newborn_ma
nual/part1.pdf For complete manual, go to
http://www.care-package.org/careswork/whatwedo/health/hpub.asp
CDC. 1998. Human Immunodeficiency Virus Type 2. Retrieved 30 July 2004, from
http://www.cdc.gov/hiv/pubs/facts/hiv2.htm
CDC. 1994. 1994 Revised classification system for human immunodeficiency virus
infection in children less than 13 years of age. MMWR Morb Mortal Wkly Rep
43(RR-12): 1–10.
Kirton C (ed). 2003. ANAC’s Core Curriculum for HIV/AIDS Nursing, 2nd ed. Sage:
Thousand Oaks, CA.
Kitahata M. 2002. Comprehensive health care for people infected with HIV in
developing countries. BMJ 325: 954–957.
Lyall E (ed). 2001. British HIV Association. Guidelines for the management of HIV
infection in pregnant women and the prevention of mother-to-child transmission. HIV
Med 2: 314–334.
Marais H et al. 2002. Report on the Global HIV/AIDS Epidemic. UNAIDS: Geneva.
Retrieved 30 July 2004, from http://www.unaids.org/html/pub/global-
reports/barcelona/brglobal_aids_report_en_pdf.pdf
McCoy D et al. 2002. Interim Findings on the National PMTCT Pilot Sites: Lessons and
Recommendations. Health Systems Trust: Durban, South Africa. Retrieved 30 July
2004, http://www.doh.gov.za/aids/docs/2002/pmct/PMTCT_Interim1.pdf
Mofenson L and P Munderi. 2002. Safety of antiretroviral prophylaxis of perinatal

transmission for HIV-infected pregnant women and their infants. J Acquir Immune
Def Syndr 30: 200–215.

Resources
Pantaleo, G, C Graziosi and A S Fauci. 1993. The immunopathogenesis of human

immunodeficiency virus infection. N Engl J Med 328(5): 327–335.
Tuomala R et al. 2002. Antiretroviral therapy during pregnancy and the risk of an
adverse outcome. N Engl J Med 364: 1863–1870.
UNAIDS. 2003.AIDS Epidemic Update 2003. UNAIDS: Geneva. Retrieved 30 July 2004,
from http://www.unaids.org/Unaids/EN/Resources/Publications/corporate+publications/
aids+epidemic+update+-+december+2003.asp
UNAIDS. 2003. Regional HIV/AIDS statistics and features, end of 2003. Retrieved 30
July 2004, from http://www.unaids.org/html/pub/topics/epidemiology/slides02/
slide02_epicore2003_en_ppt.ppt
University of British Columbia. The Therapeutic Guidelines for the Treatment of

HIV/AIDS and Related Conditions [electronic version]. Retrieved 30 July 2004, from
http://cfeweb.hivnet.ubc.ca/guide/page/secta/consa.html

guidelines for a public health approach. [2003 Revision]. WHO: Geneva. Annex E:
WHO staging system for HIV infection and disease in adults and adolescents, p. 61,
http://www.who.int/hiv/pub/prev_care/en/arvrevision2003en.pdf
WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS). 2000. Fact
Sheet 10: Women and HIV and mother-to-child transmission (Fact sheets on
HIV/AIDS for nurses and midwives). Unpublished. Retrieved 30 July 2004, from
http://www3.who.int/whosis/factsheets_hiv_nurses/fact-sheet-10/index.html
MODULE 2—Overview of Prevention of HIV Infection in

Key Resources
Preble EA and EG Piwoz. 2001. Prevention of Mother-to-Child Transmission of HIV

in Africa: Practical Guidance for Programs. Support for Analysis and Research in
Africa (SARA) Project/Academy for Educational Development: Washington, DC.
http://www.aed.org/publications/healthpublications/mtctjuly17.pdf
Rutenberg N et al. 2002. Integrating HIV prevention and care into maternal and
child health care settings: Lessons learned from Horizon studies. The Population
Council: New York.
WHO. 2001. New Data on the Prevention of Mother-to-Child Transmission of HIV

and Their Policy Implications: Conclusions and Recommendations. WHO
Technical Consultation on Behalf of the UNFPA/UNICEF/WHO/UNAIDS Inter-
Agency Task Team on Mother-to-Child Transmission of HIV. WHO: Geneva.
Resources–6
Resources
Askew I and M Berer. 2003. The contribution of sexual and reproductive health services
to the fight against HIV/AIDS: A review. [electronic version]. Reproductive Health
Matters 11 (22): 51–73. Retrieved 30 July 2004, from
http://www.popcouncil.org/pdfs/frontiers/journals/AskewBerer.pdf
Baggaley R et al. Men Make a Difference: Involving Fathers in the Prevention of Mother-
to-Child HIV Transmission. Unpublished. Retrieved 30 July 2004, from
http://topics.developmentgateway.org/pmtct/rc/filedownload.do?itemId=249493
Callahan K and L Cucuzza. Family Planning Plus: HIV/AIDS Basics for NGOs and
Family Planning Program Managers. Integrating Reproductive Health and HIV/AIDS
for NGOs, FBOs & CBOs, Vol. 1. Centre for Development and Population Activities
(CEDPA): Washington, DC. Retrieved 30 July 2004, from
http://www.cedpa.org/publications/familyplanningplus/familyplanningplus.html
CDC. 1998. Human Immunodeficiency Virus Type 2. Retrieved 30 July 2004, from
http://www.cdc.gov/hiv/pubs/facts/hiv2.htm
DeCock KM et al. 2000. Prevention of mother-to-child HIV transmission in resource-

1175–1182.
DeZoysa I. 2002. Strategic approaches for preventing HIV infections in infants:

Balancing priorities in different settings. Presented at the XIV International AIDS
Conference, Barcelona, Spain, 7–12 July.
Epstein H et al. 2002. HIV/AIDS Prevention Guidance for Reproductive Health

Professionals in Developing-Country Settings. The Population Council and UNFPA:
New York. Retrieved 30 July 2004, from
http://www.popcouncil.org/pdfs/hivaidsguidance.pdf
Gaillard P et al. 2002. Reduction of HIV in infants: WHO strategic approaches.

Presented at the XIV International AIDS Conference, Barcelona, Spain, 7–12 July.
Hankins C. 2002. Preventing mother-to-child transmission of HIV in developing

countries: Recent developments and ethical considerations. Reprod Health Matters
8(15): 87–92.
Howard-Grabman L and G Snetro. 2002. How to Mobilize Communities for Health and
Social Change. Save the Children and Johns Hopkins University Center for
Communication Programs/Population Communication Services: Baltimore, MD.
Lawn J et al. 2003. Part One: The unheard cry for newborn health, in
The Healthy Newborn: A Reference Manual for Program Managers.
Unpublished. pp. 1.1–1.64. Retrieved 30 July 2004, from
http://www.careusa.org/careswork/whatwedo/health/downloads/healthy_newborn_ma
nual/part1.pdf
Moore M. 2003. A Behavior Change Perspective on Integrating PMTCT and Safe

Motherhood Programs: A Discussion Paper. The CHANGE Project AED: Washington,
DC. Retrieved 30 July 2004, from http://www.changeproject.org/pubs/PMTCT-
SafeMotherhood.pdf
Preble EA and EG Piwoz. 2002. Prevention of Mother-to-Child Transmission of HIV in

Asia: Practical Guidance for Programs. Linkages Project/Academy for Educational
Development: Washington, DC. Retrieved 30 July 2004, from
http://www.aed.org/publications/AsiaPMTCT.pdf

Resources
Rutenberg N et al. 2003a. Family planning and PMTCT services: Examining

interrelationships, strengthening linkages. Horizons Research Summary. Population
Council: Washington, DC. Retrieved 30 July 2004, from
http://www.popcouncil.org/pdfs/horizons/pmtctfp.pdf
Rutenberg N et al. 2003b. HIV voluntary counseling and testing: an essential

component in preventing mother-to-child transmission of HIV. Horizons Research
Summary. Population Council: Washington, DC. Retrieved 30 July 2004, from
http://www.popcouncil.org/pdfs/horizons/pmtctvct.pdf
Rutenberg N et al. 2003c. Infant feeding counseling within Kenyan and Zambian
PMTCT services: How well does it promote good feeding practices? Horizons
Research Summary. Population Council: Washington, DC. Retrieved 30 July 2004,
from http://www.popcouncil.org/pdfs/horizons/pmtctif.pdf
White V et al. 2003. Men and Reproductive Health Programs: Influencing Gender
Norms. The Synergy Project: Washington, DC. Retrieved 30 July 2004, from
http://www.synergyaids.com/SynergyPublications/Gender_Norms.pdf
Wilson, P. 1999. Our Whole Lives; Sexuality Education for Grades 7-9. Unitarian
Universalist Association: Boston. www.uua.org/bookstore.
MODULE 3—Specific Interventions to Prevent MTCT
Key Resources
Anderson JR. 2002. Care of Women with HIV Living in Limited Resource Settings:
HIV and Pregnancy. Johns Hopkins HIV Women’s Health Program: Baltimore,
MD. Retrieved 30 July 2004, from
http://www.reproline.jhu.edu/video/hiv/tutorials/English/index.htm
Dabis F and V Leroy. 2000. Preventing mother-to-child transmission of HIV:

Practical strategies for developing countries. AIDS Read 10(4): 241–244.
Perinatal HIV Guidelines Working Group, US Public Health Service Task Force.
2004. Public health service task force recommendations for use of antiretroviral
drugs in pregnant HIV-1-infected women for maternal health and interventions to
reduce perinatal HIV-1 transmission in the United States. Retrieved 19
September 2004, from http://AIDSinfo.nih.gov
Anderson JR (ed). 2001. A Guide to the Clinical Care of Women with HIV. US
Department of Health and Human Services, Health Resources and Services
Administration: Rockville, MD.
Besser M et al. 2002. Changing Obstetric Practices in the Context of HIV: An Evaluation
of Service Provision in the National PMTCT Learning Sites. Health Systems Trust:
Durban, South Africa. Retrieved 30 July 2004, from
ftp://ftp.hst.org.za/pubs/pmtct/pmtctobs.pdf
Bhana N et al. 2002. Zidovudine: A review of its use in the management of vertically-
acquired pediatric HIV infection. Paediatr Drugs 4(8): 515–553.
Resources–8
Resources
Brocklehurst P and J Volmink. 2002. Antiretrovirals for reducing the risk of mother-to-
child transmission of HIV infection [Abstract]. Cochrane Database Syst Rev (1):
CD003510. Retrieved 30 July 2004, from
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=
12076484&dopt=Abstract
Bulterys M et al. 2002. Role of traditional birth attendants in preventing perinatal

transmission of HIV. BMJ 324: 222–225.
CDC. 2002. The Science of HIV Prevention: A Review of Proven Approaches and
Future Directions. CDC: Atlanta, GA.
Chris Hani Baragwanath Hospital Perinatal HIV Research Unit. 2004. South African
Patient Brochures on HIV Infection, Testing, Treatment, and Management during
Pregnancy. Retrieved 30 July 2004, from
http://www.womenchildrenhiv.org/wchiv?page=pi-13-00
Connor EM and RS Sperling et al. 1994. Reduction of maternal-infant transmission of

human immunodeficiency virus type 1 with zidovudine treatment for the pediatric
aids clinical trials group protocol 076 study group. NEJM 331: 1173–1180. Retrieved
30 July 2004, from http://content.nejm.org/cgi/content/full/331/18/1173
Cunningham C et al. 2002. Development of resistance mutations in women receiving

standard antiretroviral therapy who received intrapartum nevirapine to prevent
perinatal human immunodeficiency virus type 1 transmission: A substudy of pediatric
AIDS clinical trials group protocol 316. J Infect Dis 186(2): 181–188.
Dabis F and DK Ekouevi et al. 2003. Effectiveness of a short course of zidovudine +

lamivudine and peripartum nevirapine to prevent HIV-1 mother-to-child transmission.
The ANRS 1201 ditrame-plus trial, Abidjan, Cote d’Ivoire. IAS Conf HIV Pathog Treat
2003 Jul 13–16;2nd: Abstract No. 219 Antiviral Therapy 8 (Suppl. 1):S236. Retrieved
30 July 2004, from http://www.aegis.com/conferences/2ndiashivpt/219.html
DeCock KM et al. 2000. Prevention of mother-to-child HIV transmission in resource-poor

countries: Translating research into policy and practice. JAMA 283(9): 1175–1182.
Gielen AC et al. 2001. Quality of life among women living with HIV: The importance of
violence, social support and self-care behaviors. Soc Sci Med 52(2): 315–322.
Hirschhorn L et al. 2003. Tool to Assess Site Program Readiness for Initiating
Antiretroviral Therapy (ART). John Snow (for the US Agency for International
Development): Boston, MA.
International Perinatal HIV Group. 1999. The mode of delivery and the risk of vertical
transmission of human immunodeficiency virus type 1: A meta-analysis of 15
prospective cohort studies. N Engl J Med 340(13): 977–987.
Ioannidis et al. 2001. Perinatal transmission of human immunodeficiency virus type 1 by

pregnant women with RNA virus loads <1000 copies/ml. J Infect Dis 183: 539–545.
Israel E and M Kroeger. 2003. Integrating prevention of mother-to-child HIV

transmission into existing maternal, child, and reproductive health programs.
Pathfinder International Technical Guidance Series, No. 3. Pathfinder International:
Watertown, MA. Retrieved 30 July 2004, from
http://www.pathfind.org/site/DocServer/
Technical_Guidance_Series_3_PMTCTweb_01.pdf?docID=242

Resources
Jackson JB et al. 2003. Intrapartum and neonatal single-dose nevirapine compared with
zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala,
Uganda: 18-month follow-up of the HIVNET 012 randomised trial. Lancet
2003.362(9387): 859–868.
Kourtis A et al. 2001. Understanding the timing of HIV transmission from mother to
infant. JAMA 285(6): 709–712.
Kroeger M. 2002. ARV Prophylaxis for Prevention of MTCT of HIV in a Resource Poor
Setting. Linkages Project, Academy for Educational Development: Washington, DC.
Lindgren S, C Ottenbald and A Bohlin. 1998. Pregnancy in HIV-infected women.
counseling and care—12 years’ experiences and results. Acta Obstet Gynecol
Scand 77: 532–541.
Malonza I et al. 2003. The effect of rapid HIV testing on uptake of perinatal HIV-1
interventions: A randomized clinical trial. AIDS 17: 113–118.
McIntyre J and G Gray. 2002. What can we do to reduce mother to child transmission of
HIV? BMJ 324: 218–221.
Mofenson LM. 2003. Advances in the prevention of vertical transmission of human

immunodeficiency virus. Sem Pediatr Infect Dis 14: 295–308.
Mofenson L and P Munderi. 2002. Safety of antiretroviral prophylaxis of perinatal

transmission for HIV-infected pregnant women and their infants. J Acq Immune
Defic Syndr 30(2): 200–215.
Moodley D et al. 2003. A multicenter randomized controlled trial of nevirapine versus a
combination of zidovudine and lamivudine to reduce intrapartum and early
postpartum mother-to-child transmission of human immunodeficiency virus type 1.
J Infect Dis 187: 725–735.
Peiperl L. 2002. Antiretroviral treatments to reduce mother-to-child transmission of HIV.
Unpublished. Retrieved 30 July 2004, from
http://www.hivinsite.com/InSite.jsp?page=kbr-07-02-03&doc=3098.0098
Petra Study Team. 2002. Efficacy of three short-course regimens of zidovudine and
lamivudine in preventing early and late transmission of HIV-1 from mother-to-child in
Tanzania, South Africa and Uganda (Petra Study): A randomized double-blind,
placebo-controlled trial. Lancet 359: 1178–1186.
Preble EA, D Huber, and E Piwoz. 2003. Family Planning and the Prevention of Mother-
to-Child Transmission of HIV: Technical and Programmatic Issues. Advance Africa:
Washington DC.
Shaffer N and R Chuachoowong et al. 1999. Short-course zidovudine for perinatal HIV-
1 transmission in Bangkok, Thailand: a randomised controlled trial. Bangkok
Collaborative Perinatal HIV Transmission Study Group. Lancet 353: 773–780.
UNAIDS. 2003. A conceptual framework and basis for action: HIV/AIDS stigma and
discrimination. World AIDS Campaign 2002–2003, UNAIDS Best Practice Collection.
Joint United Nations Programme on HIV/AIDS: Geneva.
UNICEF. 2002. Mother-to-child transmission of HIV: A UNICEF FACT Sheet. UNICEF:

New York.
Resources–10
Resources
USAID/Synergy. 2004. Women's Experiences with HIV Serodisclosure in Africa:
Implications for VCT and PMTCT. Meeting Report. Washington, DC, 2 April 2003.
USAID: Washington, DC. March Retrieved 30 July 2004, from
http://www.synergyaids.com/documents/VCTDisclosureReport.pdf
Wiktor SZ and E Ekpini et al. 1999. Short-course oral zidovudine for prevention of
mother-to-child transmission of HIV-1 in Abidjan, Côte d'Ivoire: a randomised trial
[electronic version]. Lancet 353(9155): 781–5.

guidelines for a public health approach. [2003 Revision]. WHO: Geneva. Retrieved
30 July 2004, from http://www.who.int/hiv/pub/prev_care/en/arvrevision2003en.pdf
WHO and UNAIDS. Provisional WHO/UNAIDS secretariat recommendations on the use

of cotrimoxazole prophylaxis in adults and children living with HIV/AIDS in Africa.
UNAIDS and WHO Press Release 7/00. Retrieved 30 July 2004, from
http://hivinsite.ucsf.edu/InSite?page=md-01-01&doc=3098.0061
MODULE 4—Infant Feeding in the Context of HIV Infection
Key Resources
Nduati R et al. 2000. Effect of breast feeding and formula feeding on transmission of
HIV-1: A randomized clinical trial. JAMA 283: 1167–1174.
WHO, UNICEF, and USAID. 2004. HIV and infant feeding counselling tools.
Currently in print, to be available in late 2004 from http://www.who.int/child-
adolescent-health/NUTRITION/HIV_infant.htm
WHO. 2000. New Data on the Prevention of Mother-to-Child Transmission of HIV

and Their Policy Implications. WHO Technical consultation on behalf of the
UNFPA/UNICEF/WHO/UNAIDS Inter-Agency Task Team on Mother-to-Child
Transmission of HIV.11–13 October 2000, Geneva. WHO: Geneva. Retrieved 30
July 2004, from http://www.who.int/child-adolescent-
health/New_Publications/CHILD_HEALTH/ MTCT_Consultation.htm
WHO 2000. HIV and Infant Feeding Counselling: A Training Course. Participant’s
Manual. WHO: Geneva. Retrieved 30 July 2004, from http://www.who.int/child-
adolescent-health/New_Publications/
NUTRITION/HIV_Inf_Feeding/Participants_Manual.pdf
Black R and C Victora. 2002. Optimal duration of exclusive breastfeeding in low income
countries. BMJ 325: 1252–1253.
Coutsoudis A and N Rollins. 2003. Breast-feeding and HIV transmission: The jury is still
out. J Pediatr Gastroenterol Nutr 36(4): 434–442.
Coutsoudis A et al. 2001. Method of feeding and transmission of HIV-1 from mothers to
children by 15 months of age: Prospective cohort study from Durban, South Africa.
AIDS 15: 379–387.

Resources
Coutsoudis A et al. 1999. Influence of infant-feeding patterns on early mother-to-child

transmission of HIV-1 in Durban, South Africa: A prospective cohort study. South
African Vitamin A Study Group. Lancet 354: 471–476.
Ezzati M et al. and the Comparative Risk Assessment Collaborating Group. 2002.
Selected major risk factors and global and regional burden of disease. Lancet 360:
1347–1360.
Fawzi W et al. 2002. Transmission of HIV-1 through breastfeeding among women in Dar
es Salaam, Tanzania. J Acq Immune Defic Syndr 31: 331–338.
Fowler M and M Newell. 2002. Breast-feeding and HIV-1 transmission in resource-

limited settings. J Acq Immune Defic Syndr 30(2): 230–239.
Mbori-Ngacha D et al. 2001. Morbidity and mortality in breastfed and formula-fed infants
of HIV-1 infected women: A randomized clinical trial. JAMA 286(19): 2413–2420.
Regional Centre for Quality of Health Care (RCQHC) and the USAID. 2003.
Counselling Mothers on Infant Feeding for the Prevention of Mother to Child
Transmission of HIV: A Job-Aid for Primary Health Care Workers. RCQHC: Kampala,
Uganda.
Rousseau CM et al. 2003. Longitudinal analysis of human immunodeficiency virus type

1 RNA in breast milk and of its relationship to infant infection and maternal disease.
J Infect Dis 187 (5): 741–747.
Shapiro, RL et al. 2003. Low adherence to recommended infant feeding strategies
among HIV-infected women: results from the pilot phase of a randomized trial to
prevent mother-to-child transmission in Botswana. AIDS Education and Prevention
15 (3): 221–230. The Guilford Press.
Taha TE et al. 2003. Short postexposure prophylaxis in newborn babies to reduce
mother-to-child transmission of HIV-1: NVAZ randomized trial. Lancet 362:
1171–1177.
WHO Secretariat, Fifty-Fifth World Health Assembly. 2002. Infant and Young Child
Nutrition: Global Strategy on Infant and Young Child Feeding. Retrieved 30 July
2004, from http://www.who.int/gb/ebwha/pdf_files/WHA55/ea5515.pdf
WHO. 2001. The optimal duration of exclusive breastfeeding. Report of an Expert

Consultation, 28–30 March 2001, Geneva, Switzerland. WHO Department of
Nutrition for Health Development/Department of Child and Adolescent Health and
Development: Geneva. Retrieved 26 September 2003, from
http://www.who.int/nut/documents/optimal_duration_of_exc_bfeeding_report_eng.pdf
WHO. 2000. HIV and Infant Feeding Counselling: A Training Course. Trainer’s Guide.
WHO: Geneva. Retrieved 30 July 2004, from http://www.who.int/child-adolescent-
health/New_Publications/NUTRITION/ HIV_Inf_Feeding/Trainers%20_Guide.pdf
WHO and UNAIDS. 2003. HIV and infant feeding: Guidelines for decision-makers,
Retrieved 30 July 2004, from http://www.who.int/child-adolescent-
health/New_Publications/NUTRITION/HIV_IF_DM.pdf
WHO and UNAIDS. 2003. HIV and infant feeding: Guidelines for health care managers
and supervisors. Retrieved 30 July 2004, from http://www.who.int/child-adolescent-
health/New_Publications/NUTRITION/HIV_IF_MS.pdf
Resources–12
Resources
WHO, CDD Programme, and UNICEF 2002. Breastfeeding Counselling: A Training
Course. Director’s Guide. Unpublished. Retrieved 30 July 2004, from
http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/
Breastfeeding/Directors_Guide.pdf
WHO, CDD Programme, and UNICEF 2002. Breastfeeding Counselling: A Training

Course. Trainer’s Guide. Parts 1–4. Unpublished. Retrieved 30 July 2004, from
http://www.who.int/child-adolescent-health/publications/NUTRITION/BFC.htm
WHO, CDD Programme, and UNICEF. 2002. Breastfeeding Counselling: A Training

Course. Participant’s Manual. Parts 1–4. Unpublished. Retrieved 30 July 2004, from
http://www.who.int/child-adolescent-health/publications/NUTRITION/BFC.htm
WHO 2001. Breastfeeding and Replacement Feeding Practices in the Context of

Mother-To-Child Transmission of HIV: An Assessment Tool for Research.
Unpublished. Retrieved 30 July 2004, from http://www.who.int/child-adolescent-
health/New_Publications/NUTRITION/ Tool-breast_feeding.htm
MODULE 5—Stigma and Discrimination Related to MTCT
Key Resources
CDC. 2000. HIV-related knowledge and stigma. Retrieved 30 July 2004, from
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4947a2.htm
Mukasa S et al. 2001. Uganda: HIV and AIDS-related discrimination, stigmatization

and denial, in UNAIDS Best Practice Collection. Retrieved 30 July 2004, from
http://www.unaids.org/en/other/functionalities/
ViewDocument.asp?href=http%3a%2f%2fgva-doc-
owl%2fWEBcontent%2fDocuments%2fpub%2fPublications%2fIRC-
pub02%2fJC590-Uganda_en%26%2346%3bpdf
Aggleton P. 2001. Comparative analysis: Research studies from India and Uganda.
HIV and AIDS-related discrimination, stigmatization and denial, in
UNAIDS Best Practice Collection. Retrieved 30 July 2004, from
http://www.unaids.org/en/other/functionalities/ViewDocument.asp?href=http%3a%2f
%2fgva-doc-owl%2fWEBcontent%2fDocuments%2fpub%2fPublications%2fIRC-
pub02%2fJC650-CompAnal_en%26%2346%3bpdf
Bharat S. 2001. India: HIV and AIDS-related discrimination, stigmatization and denial, in
UNAIDS Best Practice Collection. Retrieved 30 July 2004, from
http://www.unaids.org/en/other/functionalities/ViewDocument.asp?href=http%3a%2f
%2fgva-doc-owl%2fWEBcontent%2fDocuments%2fpub%2fPublications%2fIRC-
pub02%2fJC587-India_en%26%2346%3bpdf
Busza J. 1999. Literature review: Challenging HIV-related stigma and discrimination in

Southeast Asia: Past successes and future priorities, in Horizons Global Operations
Research on HIV/AIDS/STI Prevention and Care. The Population Council: New York.
Gilbert L and L Walker. 2002. Treading the path of least resistance: HIV/AIDS and social
inequalities. A South African case study. Soc Sci Med 54: 1093–1110.

Resources
Gilmore N and M Somerville. 1994. Stigmatisation, scapegoating and discrimination in

sexually transmitted diseases: Overcoming ‘them’ and ‘us.’ Soc Sci Med 39(9):
1339–1358.
Health Resources and Services Administration, US Department of Health and Human

Services, 2003. Stigma and HIV/AIDS: A review of the literature—introduction:
Rockville, MD. Retrieved 30 July 2004, from
http://hab.hrsa.gov:80/publications/stigma/introduction.htm
International Center for Research on Women (ICRW). 2002. Addressing HIV-related

stigma and resulting discrimination in Africa: a three-country study in Ethiopia,
Tanzania, and Zambia [Information Bulletin]. Retrieved 30 July 2004, from
http://www.icrw.org/docs/Stigma_Africa_InfoBulletin_302.pdf
International Center for Research on Women (ICRW). 2002. Understanding HIV-related

stigma and resulting discrimination in sub-Saharan Africa. Emerging themes from
early data collection in Ethiopia, Tanzania and Zambia [Research Update]. Retrieved
30 July 2004, from http://www.icrw.org/docs/Stigma_ResearchUpdate_062502.pdf
Kidd R. 2003. Anti-Stigma toolkit: A research-based adult education curriculum to

address stigma and discrimination against PLWHAs. The CHANGE Project,
Academy for Educational Development/The Manoff Group: Washington, DC.
Malcolm A et al. 1998. HIV and AIDS-related stigmatisation and discrimination: Its form
and contexts. Critical Public Health 8(4): 347–370.
Moore M. 2003. A behavior change perspective on integrating PMTCT and safe

motherhood programs: A discussion paper. The CHANGE Project: Washington, DC.
Panos Institute. 2001. Stigma, HIV/AIDS and prevention of mother-to-child transmission:
Women, children, and HIV. Resources for prevention and treatment CD ROM, in
HIV InSite and Global Strategies for HIV Prevention, 2nd ed. Panos Institute:
Washington, DC.
Parker R and P Aggleton. 2003. HIV and AIDS-related stigma and discrimination: A
conceptual framework and implications for action. Soc Sci Med 57(1): 13–24.
Parker R and P Aggleton with K Attawell, J Pulerwitz, and L Brown. 2002. HIV/AIDS-
related stigma and discrimination: A conceptual framework and an agenda for
action. Horizons Program, The Population Council, Inc.: New York.
Rutenberg N, ML Field-Nguer, and L Nyblade. 2001. Community involvement in the
prevention of mother-to-child transmission of HIV: Insights and recommendations.
The Population Council, ICRW, Glaxo: New York.
Seaton R (ed). 2003. HIV/AIDS stigma in HRSA care action. US Department of Health
and Human Services Health Resources & Services Administration, HIV/AIDS
Bureau: Rockville, MD.
UNAIDS. An overview of HIV/AIDS-related stigma and discrimination [Fact Sheet].

Retrieved 30 July 2004, from http://www.unaids.org/html/pub/Publications/Fact-
Sheets02/FSstigma_en_doc.htm
UNAIDS/IPU. 1999. Handbook for legislators on HIV/AIDS, law and human rights:
Action to combat HIV/AIDS in view of its devastating human, economic and social
impact. UNAIDS/IPU: Geneva. Retrieved 30 July 2004, from
http://www.unaids.org/html/pub/publications/irc-pub01/jc259-ipu_en_pdf.pdf
Resources–14
Resources
UNAIDS, OHCHR. 2002. HIV/AIDS and human rights, international guidelines: Third
international consultation on HIV/AIDS and human rights [Guideline 6]. Geneva,
25–26 July, 2002. Retrieved 30 July 2004, from
http://www.unaids.org/html/pub/Publications/IRC-pub02/JC905-
Guideline6_en_pdf.pdf
UNAIDS. 1993. Stigma and discrimination. Fact sheet. Retrieved 30 July 2004, from
http://www.unaids.org/html/pub/publications/fact-
sheets03/fs_stigma_discrimination_en_pdf.pdf
UNAIDS and WHO. Fighting HIV-related intolerance: Exposing the links between
racism, stigma and discrimination. (Prepared in consultation with the Office of the
High Commission for Human Rights). Retrieved 30 July 2004, from
http://www.unaids.org/html/pub/Publications/IRC-pub03/BPracism_en_doc.htm
Valdiserri R. 2002. HIV/AIDS stigma: An impediment to public health. Am J Public

Health 92: 341–342.
Weiss MG and J Ramakrishna. 2001. Interventions: Research on reducing stigma.
Presented at Stigma and Global Health: Developing a Research Agenda. Bethesda,
MD. Retrieved 30 July 2004, from
http://www.stigmaconference.nih.gov/WeissPaper.htm
World Bank. 2000. Confronting AIDS. Oxford University Press: New York.
WHO. HIV/AIDS World AIDS Campaign 2002–2003, Live and Let Live. Retrieved 30
July 2004, from http://www.who.int/hiv/events/wad2003/dec1/en/
MODULE 6—HIV Testing and Counselling for PMTCT
Key Resources
WHO and CDC. 2004. Rapid HIV Tests: Guidelines for Use in HIV Testing and
Counselling Services in Resource-Constrained Settings. Retrieved 30 July 2004,
from http://www.who.int/hiv/pub/vct/en/rapidhivtestsen.pdf
WHO. 2003. The right to know. New approaches to HIV testing and counselling.
WHO: Geneva. Retrieved 30 July 2004, from
http://www.who.int/hiv/pub/vct/pub34/en/print.html
CDC. 2001. Revised guidelines for HIV counseling, testing, and referral and revised
recommendations for HIV screening pregnant women. MMWR Morb Mortal Wkly
Rep 50(RR-19).
Commonwealth Regional Health Community Secretariat (CRHCS). 2002. HIV/AIDS
voluntary counselling and testing: review of policies, programmes and guidance in
East, Central and Southern Africa. CRHCS: Arusha, Tanzania.
Family Health International. 2004. Preparedness of voluntary counseling and testing
centers in Kenya to provide family planning. Retrieved 30 July 2004, from
http://www.fhi.org/en/RH/Pubs/Briefs/KenyaVCT.htm

Resources
Family Health International. 2003. HIV voluntary counseling and testing: A reference
guide for counselors and trainers. Family Health International: Research Triangle
Park, NC.
Family Health International. 2003. Models of HIV voluntary counselling and testing
(VCT) service delivery. Retrieved 30 July 2004, from
http://www.fhi.org/en/HIVAIDS/Publications/FactSheets/vctmodels.htm
Kankasa C et al. 2002. Why do women accept VCT during antenatal care? The
experience from the prevention of mother-to-child transmission of HIV program in
Zambia. Horizons Project, The Population Council: Washington, DC.
Pronyk PM et al. 2002. The introduction of voluntary counselling and rapid testing for
HIV in rural South Africa: From theory to practice. AIDS Care 14(6): 859–865.
UNAIDS. 2001. Counselling and voluntary HIV testing for pregnant women in high HIV
prevalence countries: Elements and issues. UNAIDS: Geneva. Retrieved 30 July
2004, from http://www.unaids.org/html/pub/publications/irc-pub01/jc245-
couns&test_en_pdf.pdf
MODULE 7—Linkages to Treatment, Care, and Support for

Mothers and Families with HIV Infection
Key Resources
Food & Agriculture Organization of the United Nations (FAO) and WHO. 2002.
Living well with HIV/AIDS: a manual on nutritional care and support for people
living with HIV/AIDS. Available online at:
http://www.fao.org/DOCREP/005/Y4168E/Y4168E00.HTM
Rutenberg N, ML Field-Nguer, and L Nyblade. Undated. Community involvement in

initiatives to prevent mother-to-child transmission of HIV. The Population Council
and the International Center for Research on Women. Retrieved 30 July 2004,
from http://www.popcouncil.org/pdfs/mtct.pdf
Demarco R, M Lynch, and R Board. 2002. Mothers who silence themselves: A concept
with clinical implications for women living with HIV/AIDS and their children. J Pediatr
Nurs 17(2): 89–95.
Kitahata M et al. 2002. Comprehensive health care for people infected with HIV in
developing countries. BMJ 325: 954–957.
Resources–16
Resources
Mbori-Ngacha D and O Ogutu. 2002. Integrating the prevention of mother-to-child
transmission of HIV into existing maternal and child health services in PMTCT
training curriculum. Horizons, Kenya PMTCT Project.
Moss WJ, CJ Clements, and N Halsey. 2003. Immunization of children at risk of
infection with human immunodeficiency virus. Bulletin of the World Health
Organization 81:61–70. Retrieved 30 July 2004, from
http://www.who.int/docstore/bulletin/pdf/2003/bul-1-E-2003/81(1)61-70.pdf
Woods, MN: 1999. Dietary recommendations for the HIV/AIDS patient. In: Nutritional
Aspects of HIV Infection, ed. T. Miller and SL. Gorbach, Arnold Press, London. pp
191–203
Working Group on Antiretroviral Therapy and Medical Management of HIV-Infected

Children. 2004. Guidelines for the use of antiretroviral agents in pediatric HIV
infection. Retrieved 30 July 2004, from
http://aidsinfo.nih.gov/guidelines/pediatric/PED_012004.pdf
WHO. 2004. Scaling up antiretroviral therapy in resource-limited settings:

Recommendations for initiating antiretroviral therapy in adults and adolescents
withdocumented HIV infection. Retrieved 30 July 2004, from
http://www.who.int/hiv/pub/prev_care/en/arvrevision2003en.pdf
WHO. July 2003. A reference guide on HIV-related care, treatment and support of HIV
infected women and their children in resource-constrained settings [Draft]. Retrieved
30 July 2004, from www.ahfgi.org/global_pdf/refguide_toc.doc
WHO. 2003. Emergency scale up of antiretroviral therapy in resource limited settings:

Technical and operational recommendations to achieve 3 by 5. Retrieved 30 July
2004, from http://www.who.int/3by5/publications/
documents/en/zambia_doc_final.pdf
WHO and Child and Adolescent Health and Development. 2002. Integrated
management of childhood illness [IMCI] guidelines. Retrieved 30 July 2004, from
http://www.who.int/child-adolescent-health/integr.htm
WHO, Department of Vaccines and Biologicals. 2001. Introduction of hepatitis B vaccine

into childhood immunization services. Management guidelines, including information
for health workers and parents. Retrieved 30 July 2004, from www.who.int/vaccines-
documents/DocsPDF01/www613.pdf
WHO, Regional Office for Africa, IMCI Unit, Division for Prevention. 2001. Report on the
workshop on adaptation of IMCI guidelines to include HIV/AIDS, Harare, 18 to 23
June 2001: Draft. Retrieved 30 July 2004,from http://www.who.int/child-adolescent-
health/New_Publications/HIV/report_HIV_Harare.htm
WHO, Department of Vaccines and Biologicals. 2000. Introduction of haemophilus

influenzae type B vaccine into immunization programmes: Management guidelines,
including information for health workers and parents. Retrieved 30 July 2004, from
http://www.who.int/vaccines-documents/DocsPDF99/www9940.pdf
WHO, UNAIDS. 2000. Provisional WHO/UNAIDS secretariat recommendations on the

use of cotrimoxazole prophylaxis in adults and children living with HIV/AIDS in
Africa. Retrieved 30 July 2004, from http://www.unaids.org/html/pub/publications/irc-
pub04/recommendation_en_pdf.pdf

Resources
MODULE 8—Safety and Supportive Care in the Work

Environment
Key Resources
CDC. 2001. Updated US public health service guidelines for the management of
occupational exposure to HBV, HCV and HIV and recommendations for
postexposure prophylaxis. MMWR Morb Mortal Wkly Rep 50(No. RR-11): 1–42.
Retrieved 30 July 2004, from http://www.cdc.gov/mmwr/PDF/rr/rr5011.pdf
WHO. 2004. Post-exposure prophylaxis. Retrieved 30 July 2004, from

http://www.who.int/hiv/topics/prophylaxis/en/index.html
WHO. 2003. His life and her trust are in your hands. [electronic version]. Retrieved
30 July 2004, from http://www.injectionsafety.org
WHO. 2003. Secretariat of the Safe Injection Global Network. Health care worker
safety. Aide-memoire. Retrieved 30 July 2004, from
http://www.who.int/injection_safety/toolbox/en/AM_HCW_Safety_EN.pdf
CDC. 1996. Exposure to blood—what health-care workers need to know. Retrieved 30

July 2004, from http://www.cdc.gov/ncidod/hip/blood/exp_blood.htm
CDC. 1989. Guidelines for transmission of human immunodeficiency virus and hepatitis
B virus to health care and public-safety workers. MMWR Morb Mortal Wkly Rep
38(S-6).
Israel E and M Kroeger. 2003. Integrating prevention of mother-to-child transmission

into existing maternal, child, and reproductive health programs. Pathfinder
International: Watertown, MA, pp 9–11. Retrieved 30 July 2004, from
http://www.pathfind.org
Mountain Plains AIDS Education & Training Center in Consultation with the National
Clinicians’ Postexposure Prophylaxis (PEP) Hotline. 2002. PEP steps: A quick guide
to postexposure prophylaxis in the health care setting. Retrieved 30 July 2004, from
http://www.uchsc.edu/mpaetc/images/PEP%20web.pdf
Tietjen L, D Bossemeyer, and N McIntosh. 2003. Prevention: Guidelines for Healthcare

Facilities with Limited Resources. [electronic version]. JHPIEGO Corporation,
Baltimore. MD. Retrieved 30 July 2004, from
http://www.reproline.jhu.edu/english/4morerh/4ip/IP_manual/ipmanual.htm
UCSF Center for AIDS Prevention Studies. Fact sheet: What is post-exposure
prevention (PEP)? [electronic version] Retrieved 30 July 2004, from
http://www.caps.ucsf.edu/PEP.html
WHO. 2003. Post exposure prophylaxis. Retrieved 30 July 2004, from

http://www.who.int/hiv/topics/prophylaxis/en/print.html
WHO. 2001. Best infection control practices for skin-piercing intradermal, subcutaneous,
and intramuscular needle injections. Retrieved 30 July 2004, from
http://www.who.int/injection_safety/toolbox/en/LeafletBestPracticesPrinter.pdf
Resources–18
Resources
MODULE 9—PMTCT Programme Monitoring
Key Resources
Family Health International and The Elizabeth Glaser Pediatric AIDS Foundation.
2003. Baseline assessment tools for preventing mother-to-child transmission
(PMTCT) of HIV. Retrieved 30 July 2004, from
http://www.fhi.org/NR/rdonlyres/ejkelmgqgkbumgmsmuzbeaiys3rjpgbnzed5jtygb2
6iny2vhlk4naexoprcwoy6u6e5vnsfcd4yga/PMTCTreportcorrectedFINAL.pdf
Preble EA and EG Piwoz. 2001. Prevention of mother-to-child transmission of HIV in

Africa: Practical guidance for programs. Support for Analysis and Research in
Africa (SARA) Project, Academy for Educational Development: Washington, DC.
http://www.aed.org/publications/healthpublications/mtctjuly17.pdf
UNICEF, UNAIDS, WHO and Children's Fund Organisation. September 2001. Local
monitoring and evaluation of the integrated prevention of mother to child
transmission in low-income countries. [electronic version] Draft. Retrieved 30
July 2004, from http://www.unaids.org/html/pub/Publications/IRC-
pub03/ME2001_en_doc.htm
Health Communication Partnership. 2003. The new p-process, steps in strategic

communication. Retrieved 30 July 2004,
fromhttp://www.hcpartnership.org/Publications/P-Process.pdf
Kanshana S and R Simonds. 2002. National program for preventing mother-child HIV
transmission in Thailand: Successful implementation and lessons learned. AIDS
16(7):953–959.
McCoy D et al. 2002. Interim findings on the national PMTCT pilot sites: Lessons and
recommendations. Health Systems Trust, Department of Health: South Africa.
Preble EA and EG Piwoz. 2002. Prevention of mother-to-child transmission of HIV in

Asia: Practical guidance for programs. Linkages Project. Retrieved 30 July 2004,
from http://www.aed.org/publications/AsiaPMTCT.pdf
Rutenberg N, S Kalibala, C Baek and J Rosen. 2003. Programme Recommendations

for the Prevention of Mother-to-Child Transmission of HIV: A Guide for Managers.
UNICEF. Retrieved 30 July 2004, from http://www.popcouncil.org/pdfs/horizons/
pmtctunicefevalprogmgr.pdf
Rutenberg N, S Kalibala, and C Mwai. 2002. Integrating HIV Prevention and Care into
Maternal and Child Health Care Settings: Lessons Learned from Horizon Studies.
The Population Council: New York.
Stringer EM et al. 2003. Prevention of mother-to-child transmission of HIV in Africa:

Successes and challenges in scaling-up a nevirapine based program in Lusaka,
Zambia. AIDS 17(9): 1377–1382.

Resources
Synergy Project. 2003. APDIME toolkit resources for HIV/AIDS program managers [CD-
ROM]. Retrieved 30 July 2004, from http://www.synergyaids.com/
USAID. 2003. Meeting discusses effective programs for preventing mother-to-child HIV
transmission. [electronic version] Washington, DC, 16 December 2003. The
Population Council: Washington, DC USA. Retrieved 30 July 2004, from
http://www.popcouncil.org/horizons/mtgs/dcmtct03.html
Wilson D. 2001. HIV/AIDS rapid assessment guide. [electronic version]. Family Health
International: Research Triangle Park, NC. Retrieved 30 July 2004, from
http://www.dec.org/pdf_docs/PNACP112.pdf
UNAIDS and World Health Organization. 2004. National Guide to Monitoring and
Evaluating Programmes for the Prevention of HIV in Infants and Young Children.
http://www.who.int/hiv/pub/prev_care/en/nationalguideyoungchildren.pdf
Resources–20
Resources
Notes

Resources
Notes
Resources–22
Resources
For further information, please contact:
World Health Organization

Department of HIV/AIDS
20, Avenue Appia, CH-1211 Geneva 27, Switzerland
E-mail: [email protected]
http://www.who.int/hiv/en
ISBN 92 4 159204 4

PMTCT-Trainer Manual

Uploaded by

Copyright:

Available Formats

PMTCT-Trainer Manual

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

PMTCT-Trainer Manual

Uploaded by

Copyright:

Available Formats

Module 1 Introduction to HIV/AIDS

SESSION 1 Scope of the HIV/AIDS Pandemic

If available, HIV prevalence

SESSION 2 Natural History and Transmission of HIV

Also have available the following:

PMTCT—Generic Training Package Trainer Manual Module 1–1

Module 1–2 Introduction to HIV/AIDS

Begin by reviewing the module objectives listed below.

After completing the module, the participant will be able to:

Discuss the scope of the global HIV/AIDS pandemic.

Make These Points

PMTCT—Generic Training Package Trainer Manual Module 1–3

Explain the effects of HIV/AIDS on children.

HIV in children, 2003

! 40 million people worldwide were living with HIV/AIDS.

Make These Points

Module 1–4 Introduction to HIV/AIDS

! About 6,000 each day were among persons 15 to 24 years old

Table 1.1 Regional HIV/AIDS statistics and features, through 2003

Sub-Saharan Africa 25.0–28.2 million 3.0–3.4 million 7.5–8.5 2.2–2.4 million

North Africa and

Latin America 1.3–1.9 million 120,000–180,000 0.5–0.7 49,000–70,000

Caribbean 350,000–590,000 45,000–80,000 1.9–3.1 30,000–50,000

Western Europe 520,000–680,000 30,000–40,000 0.3–0.3 2,600–3,400

North America 790,000–1.2 million 36,000–54,000 0.5–0.7 12,000–18,000

Australia and New

PMTCT—Generic Training Package Trainer Manual Module 1–5

Figure 1.2 HIV prevalence: Pregnant women in South Africa, 1991–2002

HIV prevelance among pregnant women at antenatal

Module 1–6 Introduction to HIV/AIDS

Make These Points

! HIV/AIDS affects every region of the world.

Global impact of HIV

Effects of the HIV/AIDS pandemic on individuals include the following:

PMTCT—Generic Training Package Trainer Manual Module 1–7

Exercise 1.1 Hope exercise: group discussion

Introduction Explain to participants that this activity is intended to introduce

Activities Ask participants to share their ideas about positive responses

Debriefing Summarise the session by noting the following points:

Module 1–8 Introduction to HIV/AIDS

Overview of HIV and AIDS

Refer to Pocket Guide

Definitions of HIV and AIDS

A: Acquired, (not inherited) to differentiate from a genetic or inherited condition that

I: Immuno-, because it attacks the immune system and increases susceptibility to

D: Deficiency of certain white blood cells in the immune system

PMTCT—Generic Training Package Trainer Manual Module 1–9

! Emphasise the differences between HIV and AIDS.

Differences between HIV, HIV infection, and AIDS

Differences between HIV-1 and HIV-2

A discussion of preventing mother-to-child-transmission (PMTCT) from women who are

Make These Points

Module 1–10 Introduction to HIV/AIDS

Total Session Time: 90 minutes

Make These Points

PMTCT—Generic Training Package Trainer Manual Module 1–11

Background information on CD4 count and viral load

Infection Clinical Latency AIDS

HIV RNA copies per ml plasma