Microsoft word - introductory course copaap, booklet main - updated 07-.doc
Chapter 1 5 National Structural Organisation
Chapter 7 19 Mother To Child Transmission of HIV 27
Feeding of infants of HIV positive mothers
Immunisation of infants living with HIV/AIDS
'In the face of the grave threat posed by HIV and AIDS, we have to rise above our differences and combine our efforts to save our
people. History will judge us harshly if we fail to do so now, and right
Community HIV-AIDS workers (CAW's) play a very important part in
COPAAP’s strategy to help organised village /rural communities take charge of the fight against the HIV-AIDS pandemic amongst their
people. Where the area of jurisdiction of a Local AIDS Control
committee (LACC) coincides with that of an organised village, the CAW's would naturally emanate from, or be responsible to the LACC. Where an organised village/rural community area covers that of more than one LACC, such a community will need to have a Community AIDS control committee (CACC) to integrate the efforts of the more than one LACC. In such a situation CAW's may be responsible directly to LACC’s, or to both LACC’s and CACC's, depending on the existing support infrastructures in the area. The important objectives in COPAAP’s strategy are that organised communities be made; to feel directly responsible for the fight against HIV-AIDS in their communities, to organise themselves to carry out the fight, and to seek help and guidance from others; (the Government, and NGO’s) as partners only. COPAAP has been very encouraged by the enthusiasm with which organised communities, represented by their Development and Cultural Associations have embraced our ideas. A COPAAP seminar intended for Cultural and Development Associations (CUDA's) of organised communities on the theme “The war against the HIV-AIDS; the First priority development project” was held in November 2002. The seminar was very heavily attended. Pilot projects based on the COPAAP strategy are going on in three different villages at the moment. These projects begin first with sensitisation of a CUDA of a particular village to the potential role it can play in assuming the responsibility of fighting HIV-AIDS in its
community, the way it traditionally does for all the other problems of the village, followed by guiding it to draw up a comprehensive, self-
reliant anti HIV-AIDS programme, and helping co-ordination of its implementation with other partners involved in the war on HIV-AIDS. In
one of such projects implementation has gone from the establishment
of the village/community HIV-AIDS control committee (CACC), the establishment of a village anti HIV-AIDS solidarity fund, mass village
education on preventive measures, mass pre-test counselling, mass
free voluntary screening for HIV, post-test counselling, and is presently in the process of organising village subsidised ART for the needy.
The village community HIV-AIDS worker will help sustain education on prevention in the village, provide continuous counselling and support
for those infected or affected by the HIV problem, help in ART
distribution and compliance. The CAW shall be the HIV-AIDS resource person for the village residents, as well as the link between the village
and specialised centres for the management of HIV-AIDS matters. This
introductory course which main points are summarised in this booklet aims at giving the Caws the knowledge base and basic skills
necessary for them to begin their work. It is expected that their training
will continue on the job, influenced by the feedbacks and results of close monitoring of their performance by COPAAP (see appendix 3;
1. Cipla, HIV/AIDS, a clinician’s guide, 2000.
2. Evian, Clive, Dr., Primary AIDS Care, a practical guide for primary
In Cameroon the following national structural organisations for the fight against HIV/AIDS have been put in place:
health care personnel in the clinical and supportive care of
3. IPPF, Counselling for STI/HIV prevention in sexual and reproductive
4. Lawlor, K., Education for Life, a Behaviour Process, Masaka,
5. USAID and RCQHC[ Regional Centre for Quality of Health Care],
Counselling Mothers on Infant Feeding for the Prevention of
Mother to Child Transmission of HIV- a job-aid for Primary Health
6. Peace Corps Center for Field Assistance and Applied Research,
Life Skills Manual, Washington DC, July 2000.
7. PMSC, Bledsoe, S., Curriculum 110 % reglo et 100% jeune, October
8. PTG, North West Province, data on HIV/AIDS prevalence, 2003
9. RCQHC (Regional Centre for Quality of Health Care) &USAID,
Community-AIDS-Workers (CAW’s) (COPAAP addition)
Counseling mothers on infant feeding for the prevention of mother
to child transmission of HIV, march 2003.
10. UNAIDS/WHO, AIDS epidemic update, December, 2003.
HELP THE MOTHER DECIDE HOW TO FEED HER INFANT AS
1) Breastfeed exclusively for 3 months or less.
2) Protect herself from sexually transmitted
HIV stands for Human Immune deficiency Virus; it was discovered to
be the cause of AIDS (Acquired Immune Deficiency Syndrome) in
1983. It is unclear where the virus came from and why it appeared.
3) Stop breast milk abruptly at 3 months or
4) Feed only with animal milk or commercial
The difference between HIV and AIDS is that you can have HIV
infant formula from 3 months (or earlier) to 6
without being sick. When the virus multiplies it weakens your protection
against illness (this is your immune system). If your protection is weak
5) Feed with animal milk or commercial infant formula and give complementary food from 6
you can not protect your body against illnesses and you get AIDS. This
can go fast within a few months or it can go slow and take up to 7
years before somebody with HIV gets AIDS.
1) Use commercial infant formula or animal
In the world there where 40 million people infected by the end of
2) Use infant formula or animal milk and give
2003, 70 % of these people are living in Africa (UNAIDS).
complementary foods from 6 to 24 months.
In Cameroon there were in 1987: 0,5% of the people living with
HIV/AIDS and in 2002 this has raised to 12%.
1) Breastfeed exclusively for only 6 months or
This means that 600 Cameroonians are being infected every day.
less (no other food or drink, except prescribed
Out of every five positive people three are women.
One third of the positive people are between 15 and 34 years old
2) Stop breastfeeding abruptly at 6 months.
3) Give only complementary foods from 6 to
4) Protect herself from sexually transmitted
Somebody with HIV and a weak immune system can get
‘opportunistic infections’. These are infections that the body is
normally protected against; they take opportunity of the weak immune system. Some of the common infections are:
From Counselling mothers on infant feeding [ref 5]
Tuberculoses (coughing up blood, coughing for > 2 weeks, fever,
Candida (fungus in the mouth, throat or vagina)
If somebody’s immune system is weak he or she will often have fever,
diarrhoea, cough that is difficult to treat and is always coming back.
Facts: Vegetable oil, Palm oil, Butter,
Foods rich in fats: Fatty meat, Coconut, Pear.
The virus can be found in all body fluids, but is only enough to infect
Blood, semen [not sperm]],vaginal fluids and breast milk.
Saliva, tears, sweat, urine or faeces are not believed to have enough
Cheap Source for lasting energy.
This means HIV can be transmitted through:
1. Sexual intercourse (even if there is no blood involved)
90% of the people are infected through sex
Cassava, Irish, Sweet potatoes, Gari, Bananas, Plantains.
Sharing of unsterilised needles, syringes or blades
Sharing toothbrushes and razors (small risk)
An infected mother has about 33 % chance of passing the
o Protect Your Body
If she breast-feeds her baby ,there is an additional risk [ see
A spell or curse- so there is no witchcraft that can cure it.
Especially Red Fruits and Vegetables are
Sharing combs, sheets, towels or clothes
Adapted from Helping Health Workers Learn [ref 10]
Mosquitoes, bedbugs or any insect or animal
Most of the HIV-tests do not detect the virus but are looking for antibodies made by the body to fight the virus.
There are different HIV-tests. Some are rapid tests and some take
longer. The names and order of the tests used in Mezam Polyclinic are:
I, having willingly volunteered to be trained and to work as a
Abbott Determine, this test is done with blood and is a rapid test
That all the information I may come across about individuals,
Oral Quick, this test is done with saliva and is also used as a first test
patients, and families as a result of my work may be given only to
the Medical Doctors or Counsellors approved by the Community’s
Immunocomb. 2, this test is done with blood
AIDS Control Committee to which I hereby pledge my obedience
Elisa, this test also done with blood and is used as a confirmation.
These tests always have to be performed by a trained lab technician
That my motivation for the work I do shall be the welfare of my
patients or persons that need my care or advice and not personal
The test result can be negative, indeterminate or positive.
That I shall be satisfied with any financial compensation the
A negative test result: If the first test is negative we consider the person negative, if there was
Community’s AIDS Control Committee may be able to offer me.
no risk of infection during the three months before the test. The time
between infection and when a person develops enough antibodies to show up positive is called the window-period. This can take up to
three months. For this reason some people have to repeat the test
after three months to be sure they are not infected. But if there has been no risk in the last three months, the person is considered
An unclear or indeterminate test result: This means that the test result can not be read well or is not clear. If
the first test is indeterminate a second test has to be done. If this second test shows positive a third one can be done or the test should
be repeated after three months A positive test result:
If two different tests show positive we consider the person positive. But more about results in the chapter on Counselling later .
The CD-4 is one of your white blood cells. The white blood cells
protect your body from becoming sick. The CD-4 cell is the ’captain’
of the white blood cells and tells his ‘ soldiers’(CD-8 cells) to fight the
‘invader’ infection [bacteria or virus]. If these cells are not there your
immune system is not working as it supposed to and can not protect
you against infections. The HIV is particularly dangerous as it multiplies
inside these CD-4 cells and destroys them. This means that with time
the number of CD-4 cells will become low to a point where the body is
is a blood test that measures the number of CD4 cells. and is the next
stage after two positive HIV-tests. It will show if it is the right moment for
somebody to start taking Anti-retro Viral Therapy (ART).
The CD-4 count is normally between 500 and 1600 cells/mm3. If the
CD-4 count is below 200 cells/mm3 the protection against
opportunistic infection is weak and suggests that the person needs
But every person has to consult a doctor in order to know if it really
necessary and possible to start with the medicine.
The CD-4 count is also a good test to see if the medicine is working. If
the CD-4 count goes down the ART is not working well and the
[For current prices of CD4 Count please contact Mezam Polyclinic]
Set aside the time so that you will not be rushed.
Find a private place where you will not be interrupted.
When counselling, you must be totally trustworthy. This means you must
never talk to anyone else about what a person has told you during
counselling except another colleague when no names are mentioned
Ask general questions about how he or she is doing
[ see end section about meetings with colleagues]. This is called
Ask questions that encourage the person to give an answer more than
obeying the code of confidentiality .If a person knows that he or she
can trust you ,he/she will feel better about discussing his personal
(e.g. ‘how is your marriage’ instead of ‘is your marriage good?’)
Avoid judging the person which means trying to accept the person for
If you listen actively you will hear what he/she is feeling and what his or her main problems are. Spend more time listening then speaking.
the way he/she is. If the person feels you are judging him, he / she
Allow somebody to express his or her feelings,
may not feel confident about talking to you about feelings and
Crying, sobbing, angry outbursts are ways for people to express feelings
concerns. Everyone is different and that is ok!
Counselling skills are tools you can use to communicate with people
and help them to find their own solutions to problems.
During counselling ,an important skill is listening so that you can try to
understand the problem as the person sees it. Also it is an important to
think about your body language AND that of the person being
counselled. It is not only important what you or the person says but
If the problem is complex it can help to divide the problem in smaller problems and then explore each sub-problem.
how each of you behave in the counselling session.
Not all problems are solvable, but remember often just talking about the
In counselling there is not one way that is the best way because
problem, sharing fears, worries, concerns helps somebody to cope.
everyone is different and every situation is different. But there are
Try not to give information or advice too quickly
counselling skills which you use in every counselling session and can
Try first to really understand the situation.
be used in many other situations ,not only for HIV/AIDS. [See
Praise him or her for the good things he/she is doing.
attachment 1 for some ‘good counselling skills’]
Re-assure him/her when there are concerns and respond to those
So with HIV/ AIDS you can use counselling-skills to help in prevention
such as helping people to change risky behaviour and practises. Also
Ask him/her to repeat instructions you have given[ if there are any,] to be
counselling can provide support to those affected by the pandemic
Show your support for his/her decisions
And give the possibility for follow-up or further counselling.
Together make a short-term plan of action,
This can help some people to cope with difficult situations.
People can change their behaviour if helped
The further spread of AIDS can be prevented
Those with HIV infection can live positively
As a Community-AIDS-Worker it is very important to share your
If the mother is not sick [not on ART] or having opportunistic infections,
experiences with other CAW’s. You should meet one time per month
the risk of transmitting HIV to her infant is small.
to discuss and learn from each other being careful about
confidentiality .Often counselling sessions can be emotionally difficult
Breastfeeding and Bottle feeding should not be given to the infant at
for you. So knowing you can share these feelings in confidence with
the same time as this makes the risk of transmission higher
Her personal situation should be assessed and be given information to
allow her to make a decision for herself and baby.
[See APPENDIX 5 for Infant Feeding Options]
Doing an HIV-test is an important decision in somebody's life, and
should always be accompanied by pre-test counselling.
To help someone to make an informed choice whether or not to
do the HIV-test[ that he/she understands all aspects of how the
To find out what someone knows about HIV/AIDS and provide the
To assess somebody’s risk on HIV-infection through past or present
To encourage people to reduce their risk of contracting or
To help people to prepare themselves for the result, whether
To help people prepare themselves for changes in their life after
To help young people to understand that the risks of promiscuity
are particularly high within their own peer group.
The information should be given in a way that is easy to understand
This means the person needs to know things about: the test-
procedure, the window-period, the difference between HIV and AIDS,
risk-reduction, treatment, and partner notification.
MOTHER TO CHILD
Counselling after an HIV-test will depend on the result; the result can
Because it is often difficult for somebody to accept and believe a
If a mother is HIV-positive, the chance that the virus will pass to the
test-result. Counselling is often needed to convince somebody
child, without medicine, is around 25-30 %. This means that 70-75% of
the children will not get the HIV from their mothers.
To make sure the person understands the meaning of the result.
The HIV transmission can take place during pregnancy, childbirth or
To help the person to cope with the result, especially in the days or
To make a plan for the ongoing care if somebody is positive.
All new pregnant women should be advised to have HIV screening as
To explain the need to do another test is somebody might be in
the window period or the result is not clear.
If she is HIV positive ,precautions need to made to prevent
To make sure that the person knows about the dangers of
spreading HIV if the result is positive (and the risk of getting
1. To reduce the chance of a different strain of HIV infecting the
mother and increasing the risk to the unborn child, mothers should
To make sure that the person knows how to prevent infection if the
insist on condom use and have any infection treated promptly.
2. To reduce the chance of HIV-infection during birth special
To give information on safer sex (abstinence, fidelity, condoms).
precautions have to be taken by the midwife to avoid
unnecessary injury to the infant. ART is given and the treatment
Nevirapine tablet given to the mother at the start of labour and
Nevirapine syrup given to the baby within 72 hours after birth.
If there has been some risk of infection within the last three months,
3. Some women have already started taking ART before pregnancy .
counselling will help the person avoid further risk by practising safe or
These pregnant women should always be advised to consult the
safer sex particularly over the next three months until a second test.
doctor, early in the pregnancy, to discuss their treatment.
This second test will confirm his/her HIV status if it is again
At this point there should be discussed how the person can stay
negative. If the partner is not tested this should be discussed with
Before birth discuss with the mother her preferred method of feeding.
advice to the person to discuss the risk of HIV infection with his or her
There is a risk of passing HIV through breast milk but it is the best food
partner. Careful counselling will help him/her plan whether and how
for babies in the first few weeks. A liquid produced from the breast in
the first hours after delivery has strong properties to protect the baby
If the result confirms a negative status, this counselling session will give
from other infections which can weaken the infant and encourage
the counsellor the opportunity to reinforce messages of safe or safer
HIV to develop. This liquid is called Clostridium. Breast milk itself carries
This person will be advised to repeat the test, if the result is still
Some of the ART react with other drugs for treating opportunistic
indeterminate or positive the test has to be repeated after three
infections, for example with medicine to treat Tuberculosis.[ The doctor
months. This may mean yet another [3rd] test as there has to be two
similar results before a definite result given. For behaviour during this
three month period [see window period above]. As with the negative
Side effects differ with each drug. The commonly used ARTs can
result , he or she should be counselled about informing the
cause toxic effects on organs in the body s.] That is why it is important
partner/partners. This can be a period of great uncertainty for him/her
to do ‘base- line’ laboratory tests before starting treatment Patients
and requires very sensitive counselling to make sure he/she
may complain to you of skin rashes or a numb or tingling feeling in the
understands the potential risk of transmission to others.
feet or hands['peripheral neuropathy']. Other side effects are:,
diarrhoea, nausea, tiredness and headache. The nausea, diarrhoea
If the test result is positive the person needs to do a second test to
and tiredness often become less after the first few days or weeks.
confirm the test result. If two test show the same result the person is
All side effects should be recorded and the patient referred to a
This result should be told as soon as possible and the first discussion
STOCRIN can make people feel drowsy or irritable for this reason
should be private and confidential and then the person should have
time to absorb the news. This is not the moment to give a lot of
information unless the person asks for it.
The patient should be able to afford the ART for an indefinite period of
During this period it is important to pay attention to the person's
time and the medicine should always be available.
emotions and talk about his or her feelings. As a counsellor you are there to provide support and encourage hope. Hope for achievable
HIV/AIDS patients must be seen by the Doctor immediately whether they are on ART or not if they complain of any or all of the
solutions for practical and personal problems. In a difficult situation like
this everybody responds differently and needs different support.
Severe skin itching (either patches or all of the skin) or swelling.
Some of the feelings that might occur are fear, loss, grief, guilt,
Face swelling or legs swelling.
depression, denial, anxiety, anger and suicidal thoughts.
Eyes yellow, or urine too yellow.
After some time the person might have more questions about health and treatment.
Coughing of blood, coughing for more then two weeks or
Concerning health ,it is important to look at the well being of the whole person this means: the general, physical, psychological, social
and spiritual well being (See appendix 2).
There are a lot of things that somebody who is positive can do to stay
All patients taking ART should repeat CD4 and organ tests at 3 months,
healthy, for example: get a lot of rest, eat a variety of nutritious food,
9 months and 18 months and so on to see how effectively ART works
avoid alcohol, try to avoid stress, do not have unprotected sex, talk
and to identify any severe side effects. [ please contact Mezam
with others about your worries, take the correct medicine etc. About
all these subjects the counsellor can talk with the person and give
[See Appendix 4 ‘ Enjoy a variety of foods’ ]
Triomune (= Lamivudine, Stavudine & Nevirapine)
If the CD4 count shows that the person is at risk to get other infections
The most common ART used in Cameroon is TRIOMUNE, This is a tablet
[opportunistic infections],ART is considered.
that consists of three different Anti-retro Virals: Lamivudine, Stavudine
Any infection or complaint must be diagnosed and treated. This may
delay the start of ART. Then, when ART is started ,it is able to work more
Before starting TRIOMUNE , patients have to take a lead-in dose for 14
effectively. In some patients , a check on the CD4 after treating an
days because Nevirapine in the TRIOMUNE can cause a severe skin
illness, can show an improvement so great that ART is not necessary at
rash [side effect] Even though this happens with very few people
this time.[ the body has become strong enough without the help of
everybody has to start with a separate dosage of Nevirapine.
Some people with HIV/AIDS believe that herbs help against some of
Lamivir-S [Lamivudine & Stavudine] 2 each day
the opportunistic illnesses such as itching and coughing. It is important
that they discuss all types of treatment with a doctor to decide what
If no reaction , TRIOMUNE is commenced (one tablet in the morning,
A Treatment File is started and contains information on the whole
All of these medicines have to be prescribed by a doctor and the
dosage and combinations do not always have to be the same
Socio-economic status includes: whether the person is married
(monogamous or polygamous), divorced, widow or single; age; sex; number and age of children, whether the partner and children have
Always remind doctors to write clearly and avoid abbreviations.
Clinical data contains information about the person’s health, if the
Do not give out or advise on prescriptions unless you can read
person was sick in the past, the health at this moment, and clinical
and understand the prescription with certainty.
Always ask the doctor whenever in doubt.
Therapeutic data: contains information on Anti-retro Viral Treatment and other treatment for opportunistic infections.
Laboratory data where all the results of the lab tests are recorded.
Problems that people might have when taking ART:
There are different tests that need to be done before ART is
This means taking the medicine regularly. People might forget to take
Abbott Determine and ImmununoCombi 11[ the tests which
the medicine and some ART are difficult to take like Crixivan. For some
confirm HIV and the CD4 count as already mentioned]
people it might be difficult taking the medicine if they do not have
If the CD-4 count and the health of the person are indicating that the
any health-problem. And it can also be psychological difficult to
1. Organ Tests are blood tests to see how the different organs in
the body are functioning (like the liver, kidneys and pancreas).
These tests help the doctor to decide which type of Anti-retro
Viral Treatment [ART]can be used. Some of the medicines
have effect on these organs and can make the health
2. The doctor might decide that other tests are necessary such as
a lung-photo[Chest X-ray] and sputum examination [AFB test]
Treatment for somebody with HIV/AIDS consists of different things:
treatment and prophylaxis (prevention) of opportunistic infections
Here the person is assessed whether he/she can afford ART and the
Anti Retro viral Therapy to reduce the virus
CD4 tests in the foreseeable future and includes
(See also again appendix 2 for a treatment plan for the whole
Signed Engagement form which is signed by the patient, relative
or benefactor. It is important that the patient does not stop
Somebody who is HIV positive is not yet sick,[ that is not a patient.] It
treatment[ unless advised by his doctor] So a secure source of
may take 3 to 7 years or even more before he or she gets sick.
payment must be assured before the treatment begins The type of
Because the HIV develops different with each person the follow-up is
ART prescribed is partly decided by the amount of money
pledged per month.[For further information about the effects of
If the engagement form is signed by someone other than the patient,
he or she has no right to read the patient’s file.
It is important to know that ART is not a cure but a treatment. It
Proposition: the ART recommended by the person’s doctor
reduces the virus so that the person stays healthy.
Decision by the Therapeutic Committee to start somebody on ART.
The moment to start ART is important, It is not good to start too early
Prescription form with details of ART prescribed.
and not good to start too late. If somebody’s immune system is still
very strong the medicine will do more harm than good because they
The completed file is presented to a panel of professional people ,
For this reason a doctor should always be the one to decide if
Therapeutic Committee, who decide on the best possible treatment
for the patient[a person who is taking medical treatment].
Besides this it is very important that the patient is involved in the
decision and is well counselled on what it means to take the medicine
everyday for an indefinite period of time.
Once started ART should not be stopped [ unless by the patient’s doctor] This will allow the HIV to multiply and change its character. So it may become resistant to the ART when restarted and a different ART needed to control the disease. ART always consists of a combination of three basic drugs
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