HIV/AIDS HANDOUT.
Topic: Objectives
Topic Objectives
By end of this topic, you should be able to:
Describe the basic concepts of HIV and AIDS
Appreciate the global and national HIV statistics and epidemiology
Explain HIV combination prevention intervention
Describe HIV positive living
Topic 1: Objectives
By the end of the session the participant will be able
1. To list the modes of HIV transmission
2. To discuss the parthenogenesis and life cycle of HIV
3. To describe the progression of HIV
Topic 1: Modes of HIV transmission and Key Risk Factors
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Modes of transmission
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In Africa mainly heterosexual (males-female)
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Include homosexual (men having sex with men) as well
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Non consensual sexual exposures (assault)
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Parenteral
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Transfusion of infected blood or blood products
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Exposure to infected blood or body fluids through contaminated sharps- IDU
through needle sharing or need stick accidents
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Donated organs
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Traditional procedure
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Perinatal/Vertical
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Trans placental, during labor/delivery and breastfeeding
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HIV is not transmitted by casual contact, surface contact, or from insect bites
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Biological factors influencing HIV transmission
Disease status of source patient
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Related to degree of immunosuppression and viral load.
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High risk during primary infection and late disease when viral load is very high
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Higher or the lower the CD4 count independent of viral load
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Presence of untreated STI in source and person at risk.
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Both ulcerative and non-ulcerative STIs important cofactors
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Related to high viral load in genital secretions during STIs and the disturbance of
genital mucosa
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A major reason for high prevalence in SSA
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Circumcision status
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Uncircumcised men four times as likely to acquire HIV infection than circumcised
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Gender differences in susceptibility
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Female genital anatomy presents a larger surface area with more of the target
cells that HIV require to gain entry
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Socio-economic factors facilitating HIV Transmission
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Social Mobility
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Global economy
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HIV/AIDS follows route of commerce
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Partners living apart
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Stigma and denial
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Denial and silence is the norm
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Stigma prevents acknowledgement and care seeking
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People in conflict
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Context of war and struggle for power spreads HIV
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Cultural factors
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Traditions, beliefs, and practices affect understanding of health and disease and
acceptance of conventional medical treatment Gender
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In many cultures it is accepted for men to have many sexual relationships
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Women suffer gender inequalities
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Many women unable to negotiate condom use
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Poverty
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Lack of information needed to understand and prevent HIV
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Drug use and alcohol consumption
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Impaired judgment
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Sharing of needles and equipment
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Behavioral factors
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Multiple sexual partners
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Unprotected sexual intercourse
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Large age difference
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Factors not associated with risk of transmission
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Insect bites
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Saliva (kissing)
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Sneezing or coughing
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Skin contact (e.g. hugging)
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Shared use of facilities (e.g. toilets)
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Key populations (KP)
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KP are those groups who, due to specific higher-risk behaviours, are at increased
risk of HIV irrespective of the epidemic type or local context.
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They often have legal and social issues related to their behaviours that increase
their vulnerability to HIV
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HTS should be routinely offered to all key populations (every 3 months).
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Retesting at least annually is recommended for all clients of key populations.
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More frequent voluntary retesting may be beneficial, depending on risk
behaviours
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Vulnerable populations:
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These are persons who due to situation or circumstances beyond their control,
they are at high risk of getting infected or transmitting, accessing vital HIV services etc.
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Where applicable these persons should also be encouraged to be tested with
their sex partners. These include;
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Widows and widowers
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Orphans and vulnerable Children (OVCs)
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Families and children living on the streets
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Young women aged 15-24 years
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Service men and women, and their families
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Refugees, displaced persons and migrants
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People who abuse alcohol
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Vulnerable populations:
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These are persons who due to situation or circumstances beyond their control,
they are at high risk of getting infected or transmitting, accessing vital HIV services etc.
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Where applicable these persons should also be encouraged to be tested with
their sex partners. These include;
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Widows and widowers
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Orphans and vulnerable Children (OVCs)
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Families and children living on the streets
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Young women aged 15-24 years
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Service men and women, and their families
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Refugees, displaced persons and migrants
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People who abuse alcohol
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Survivors of sexual and gender based violence
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Clients who report sexual violence should receive HTS at the first contact.
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They should immediately be referred for clinical evaluation, documentation and
treatment, trauma counselling and initiation of post exposure prophylaxis (PEP).
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Survivors who test negative should be re-tested after 4 weeks and if still negative
or in a discordant relationship, retesting should be done at 12 weeks.
Topic 2: objectives
1. Discus the organization of the immune system
2. Define terms commonly used in immune responses
3. Describe how immune system works
Topic 2: The Immune System
IMMUNE SYSTEM AND AIDS
Definition of terms
The immune system: a system of special cells (lymphocytes, monocytes), proteins (antibodies),
tissues and organs that defend the body against foreign substances (antigens= germs,
microorganisms, HIV)
Antigen
A foreign substance which when introduced into the body will stimulate the immune system to
respond by producing antibodies
Antibody
A protein substance produced by lymphocytes, and deposited in blood, and they bind to specific
antigens
Introduction to Immune system
This is the body’s protective mechanisms and response to infections
Organisation:Immune system responses is organized into Innate, cellular and humoral
Further:
•The immune system is organized into organs, tissues and cells
•The organs involved in the immune system are categorized into;
1. Primary and 2. secondary organs
Introduction to Immune system
Primary and secondary organs of the immune system
1. Primary Lymphoid Organs:
Thymus and
bone marrow
2. Secondary Lymphoid Organs:
Lymph nodes and
spleen
1. Primary Lymphoid Organs
Primary (central) lymphoid tissues
Serve to generate mature lymphocytes from immature cells
provide a place of ‘training’ for lymphocytes
2.Secondary Lymphoid Organs:
•Secondary (peripheral) lymphoid tissues
Lymphocytes interaction with antigen
Expansion/production of more cells
Its also provide a home for lymphocytes, where they can be available when they are needed
1. Cellular Responses to HIV infection
Once HIV enters the body, anti-HIV antibodies and cytotoxic T cell production is initiated
Macrophages and dendritic cells bind virus and present it to the CD4 cells
T-cells are the prime target for HIV attack due to CD4 receptor.
Other cells with CD4 receptor are macrophages, glial cells, langerhans cells, chromaffin cells.
Cellular Responses to HIV infection
The other very important cell in HIV infection is CD8+ T cells
CD8+ cytotoxic cell lyse HIV infected cells and secrete cytokines, and chemokines that inhibit
virus replication and block viral entry into CD4+ T cells.
Development of CD8+ T cells is crucial for control of HIV replication
Why are CD4+ T cells depleted by HIV?
CD4 T Lymphocyte is the main target of HIV
HIV infection leads to low levels of CD4+ T cells through three main mechanisms:
Direct viral killing of infected cells
Increased rates of apoptosis (self programmed death) in infected cells
Killing of infected CD4+ T cells by CD8 cytotoxic lymphocytes that recognize infected cells.
2.Humoral response to HIV
The humoral immune response involves production of specific antibodies in response in HIV
infection
Non-neutralising antibodies to HIV structural proteins (i.e. P17 and P24) and neutralizing
antibodies specific to proteins are produced target:
The variable region of gp120
CD4 binding sites and chemokine receptors
The transmembrane protein gp41
3.Cellular and Humoral response
In HIV infection both cellular and humoral immune responses combined play important role
Initially cellular responses are initiated followed by Antibody responses four to eight weeks after
infection
B Cells play the major role in production of antibodies
Mutations within the HIV glycoproteins render antibodies ineffective
Topic 2: The Immune System
Why are CD4+ T cells depleted by HIV?
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CD4 T Lymphocyte is the main target of HIV
HIV infection leads to low levels of CD4+ T cells through three main
mechanisms:
Direct viral killing of infected cells
Increased rates of apoptosis (self programmed death) in infected cells
Killing of infected CD4+ T cells by CD8 cytotoxic lymphocytes that recognize
infected cells
2.Humoral response to HIV
The humoral immune response involves production of specific antibodies in response in
HIV infection
Non-neutralising antibodies to HIV structural proteins (i.e. P17 and P24) and
neutralizing antibodies specific to proteins are produced target:
The variable region of gp120
CD4 binding sites and chemokine receptors
The transmembrane protein gp41
3.Cellular and Humoral response
In HIV infection both cellular and humoral immune responses combined play important
role
Initially cellular responses are initiated followed by Antibody responses four to eight
weeks after infection
B Cells play the major role in production of antibodies
Mutations within the HIV glycoproteins render antibodies ineffective
Topic 3: Objectives
•By the end of the session the participant will be able
To describe the progression of HIV
Topic 3: HIV progression
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•Transient symptomatic illness
•Affects 40-90% of HIV+ individuals
•Ranges from mild, non-specific illness to severe illness that can result in
hospitalisation
Assembly: The HIV proteins together with copies of HIV's RNA genetic material
are assembled into new viruses
The newly assembled virus "buds“ out from the host
Maturation: The new virus budding out mature into viruses that can now infect
nearby CD4 cells
Click here to access Unit Three Content..
Topic : Objectives
At the end of the session, participants will be able to:
1.Describe nutrition in relation to HIV/AIDS
2.Describe food and Nutrition implications of HIV
Describe the interactions between foods
Topic 1: Nutrition in relation to HIV/AIDS
•HIV and frequent infections increase the body’s energy and nutrient requirements.
•HIV destroys the body’s immune response and the body’s ability to resist diseases which leaves the
body vulnerable to frequent opportunistic infections.
HIV and opportunistic infections may also interfere with food intake and the way nutrients are absorbed
and used in the body
•If the increased energy and nutrients needs are not met a person infected with HIV may lose weight or
become malnourished.
If a person has a compromised nutritional status his/her body’s immune response may be weakened
even further making him/her more vulnerable to infections and hastening the progression to AIDS
THE CYCLE BETWEEN NUTRITION AND HIV
A range of drugs are used to manage the symptoms of HIV infection, opportunistic infections
and other common infections.
Conventional pharmacological drugs, herbal remedies or other combinations are used
in Kenya.
A range of drugs are used to manage the symptoms of HIV infection, opportunistic infections
and other common infections.
Conventional pharmacological drugs, herbal remedies or other combinations are used in Kenya
The effectiveness and tolerability of some drugs
nutritional stores.
can be affected by the body’s
The overall bioavailability of and efficacy of a drug, particularly a highly protein bound
drug can be influenced by an individual’s plasma protein concentration and by the
drugs volume of distribution.
Both factors are affected by nutritional status
The effectiveness and tolerability of some drugs
nutritional stores.
can be affected by the body’s
The overall bioavailability of and efficacy of a
drug, particularly a highly protein bound
drug can be influenced by an individual’s plasma protein concentration and by the
drugs volume of distribution.
Both factors are affected by nutritional status
INTERACTIONS BETWEEN ARV’S AND FOOD
•ARV drugs must be taken according to the dosage and schedule recommended by the Doctor.
•ARV’S may alter the absorption and utilization of nutrients in the body.
•Some ARV’S should be taken with food, others should not be and others have specific food restrictions.
A check with the health care provider about specific instructions related to your individual drug regimen
is important.
•Some ARV’S create side effects that reduce food intake and absorption. simple changes to dietary habit
can alleviate the severity of common side effects.
•Some foods may interfere with the absorption and use of some ARVs. -e.g. garlic reduces the efficacy
of Efavirenz & Sequinavir
•Alcohol should be avoided when taking ARV’S.
•Some traditional therapies/herbs may reduce the effectiveness of drugs (or ARV’S) that one is taking.
Topic 1: Summary
topic : Objectives
1. Describe Nutrition related side effects of ARV's.
2. Explain food and non-ART drug interactions
3. Recommend appropriate foods in relation to possible side effects from common
medication use
Topic 2: ARV and Nutrition
How ART and Nutrition inter-relate
ART affects nutrition:
Drugs can decrease appetite (decrease food intake)
Drugs can cause metabolic changes
Drugs can cause vitamin disturbances
Nutrition affects ART:
Food can hinder or help drug absorption
Certain minerals can hinder drug absorption
Certain vitamins can help minimize drug side effects
Types of Drug- Food interactions
Alcohol can exacerbate side effects of drugs
•Food enhances or inhibits drug efficacy.
•Food may decrease drug absorption
e.g. Aspirin, Isoniazid, Rifampin ,Indinavir
High fat diets and indinavir, Zidovudine
Food may increase drug absorption
e.g. high fat diets increase absorption of Tenofovir
•Drugs enhance or inhibit nutrient absorption and metabolism. For example;
•Increased nutrient intake is needed for
- Isoniazid + vitamin B6
- Rifampin + vitamin D
• Many protease inhibitors may cause changes in lipid levels and insulin resistance.
- Reduce intake of saturated fats and sugar.
•Side effects e.g. nausea, taste changes, bloating affect food intake and absorption.
Types of Medication – Food interactions
•Drugs enhance or inhibit nutrient absorption and metabolism. For example;
•Increased nutrient intake is needed for
- Isoniazid + vitamin B6
- Rifampin + vitamin D
•Side effects of drugs can affect nutrient metabolism
e.g. protease inhibitors may cause bone disorders or osteoporosis therefore
increased calcium intake is required.
protease inhibitors may also cause fat mal-absorption
• Many protease inhibitors may cause changes in lipid levels and insulin resistance.
- Reduce intake of saturated fats and sugar.
Side effects e.g. nausea, taste changes, bloating affect food intake and absorption
Nutrition and ARVs Interactions
•ARV's contribute to improved nutritional status, but like other medicines, they have side effects
•ARV side effects and drug–food interactions may lead to poor adherence to drug regimens,
especially during the early stages of HAART.
Topic 2: Summary
Nutrition and ARVs Interactions
•ARV's contribute to improved nutritional status, but like other medicines, they have side effects
ARV side effects and drug–food interactions may lead to poor adherence to drug regimens,
especially during the early stages of HAART
Topic : Objectives
1. Explain the role of herbal remedies
2. Describe the role of dietary supplementation
3. Apply the knowledge of Nutritional Support in a drug-food plan for a PLHIV on ARV's
Topic 3: ROLE OF HERBAL REMEDIES
•Herbals
although beneficial, some of this herbs may interfere with prescribed medicine and may have
negative effects on the body or they may restrict food intake
•Where the ingredients are known the interactions (drug and food) should be addressed.
•Thus it is important to know the herbs and spices the PLHIV is taking so as to help the client
maximize the benefits and minimize the negative side effects of the herbs.
•Ensure that they are used as supplements and not as replacements to standard therapy.
•Of special concern is the use of St. John’s wort, which is used in the management of
depression, which interferes with the absorption and utilization of most ARVs.
•Its side effects include-photosensitivity, bloating, gas, and allergic reactions.
•Garlic should also be used in moderation especially when taking Efavirenz and Sequinavir as it
reduces their efficacy in the body. it also causes gastrointestinal disturbances.
ROLE OF DIETARY SUPPLEMENTS
–Build self efficacy by starting with simple, achievable tasks
–Provide reinforcement for task accomplishment
–Express confidence in the person’s ability and provide sincere encouragement.
–Identify some similar people who have accomplished the task
Teach specific skills to overcome problem areas
•Anti-oxidant preparations help the immune system. they include vitamin A, C, E, and Selenium
•It may thus be useful to take a vitamin supplement with added minerals daily, rather than
several pills containing different vitamins and minerals.
•The single dosing of specific vitamins or mineral should only be done if there are laboratory
results showing low blood levels of a certain vitamin/mineral e.g. iron levels below normal
values or if there are signs and symptoms of a deficiency of either of them or if the treatment
schedule requires it-TB therapy and vitamin B6 supplementation.
•However consumers are likely to be on several of this formulations at the same time. this has
the increased risk of overload (toxicity) and side effects.
•The risk with fat soluble vitamins is greater than with water soluble vitamins because they are
stored in the liver.
DRUG-FOOD PLAN FOR PLHIV ON ARVs
Most first line ARV’S in Kenya do not have strict food restrictions though some
(Zidovudine, Efavirenz) should not be taken with a high fat meal.
All drugs need to be taken as recommended by the health worker
Reasons for non adherence
Side effects or fear of side effects.
stigma
Forgetting to take drugs or misplacing of drugs.
Inability to make follow up visits to get drugs on time.
When does one need a drug food plan
•One needs a drug food plan to:
– Reduce the severity of the side effects of some of the drugs.
– Support nutritional needs of the client
–Manage food restrictions
– Improve drug adherence
COMPONENTS OF A DRUG-
FOOD PLAN
1.Medications currently being taken and timing of the drugs
2.Food implications of the drugs
3.Dietary patterns and preferences of the client
4.Food types/quantities accessible to the family
Any symptoms that may affect food intake or preferences-allergies & intolerances
6. The plan should be feasible, acceptable, given the clients daily schedule
7. Information on what foods to avoid or moderate e.g. alcohol, traditional herbs etc
drug-food plan should include
•Date column
•Medication column
•Special instruction column
•Symptoms column
•Morning, mid-morning, lunch, mid-afternoon, evening/night
Discuss with the client the need to change eating patterns to promote effectiveness of
ARV’s
Topic 3: Summary
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Topic : Objectives
Objectives
By the end of this session learners should be able to
•To classify an HIV-infected patient according to the WHO clinical staging
Topic 1:WHO Clinical Staging Of HIV
WHO Clinical Staging
•WHO Clinical Staging 1
•Asymptomatic
•Persistent generalised lymphadenopathy (PGL)
•Painless enlarged lymph nodes >1 cm
•In two or more non-contiguous sites (excluding inguinal), in absence of known cause and
•Persisting for 3 months
WHO Clinical Staging 2
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§Unexplained moderate weight loss
body weight)
§Recurrent respiratory tract infections
(sinusitis, tonsillitis, otitis media, pharyngitis)
Herpes zoster
Angular cheilitis
Recurrent oral ulceration
Papular pruritic eruptions (PPE)
Seborrhoeic dermatitis
Fungal nail infections
(<10% of presumed or measured
WHO Clinical Staging 3
§Unexplained severe weight loss
weight)
(>10% of presumed or measured body
§Unexplained chronic diarrhoea for longer than one month
§Unexplained persistent fever (above 37.5oC intermittent or constant for longer than one month)
§Persistent oral candidiasis
§Oral hairy leukoplakia (OHL)
§Pulmonary tuberculosis
WHO Clinical Staging 3
Severe bacterial infections (e.g. pneumonia, empyema, pyomyositis, bone or joint infection,
meningitis, bacteraemia)
Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis
Unexplained
Anaemia (<8 g/dl)
§Neutropenia (<0.5 x 109 /L) and or
§Chronic thrombocytopenia (<50 X 109 /L)
WHO Clinical Staging 4
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Disseminated mycosis (extra pulmonary histoplasmosis, coccidiomycosis)
Recurrent septicaemia (including non-typhoidal salmonella)
Lymphoma (cerebral or B cell non-Hodgkin)
Invasive cervical carcinoma
Atypical disseminated leishmaniasis
Symptomatic HIV associated nephropathy or Symptomatic HIV associated
cardiomyopathy
•Describe the lesion
•What are the differential diagnosis?
Clinical staging
Which WHO staging is this?
Topic : Objectives
Objectives
By the
•List the major classes of ARVs with examples
•Describe the mechanism of action for each major class of ARVs
•Define ARVs and state their major indications
Topic 2: Classes of ARVs and their side effects
Antiretroviral Drugs
•Reduce the number of circulating HIV (Virological goal)
•Prevent the HIV from making copies of itself
•Ensure there’s reduced damage on the immune systems leading to improve immune functioning and delay
in onset of AIDS (Immunological goal)
•Enhance quality of life & reduce emergence of opportunistic infection (Therapeutic goal)
•Reduces the impact of HIV Transmission in the community
Indications for ARVs
Antiretroviral therapy
•Treatment of infected persons meeting treatment criteria
Prevention of mother to child transmission ( PMTCT)
Post exposure prophylaxis (PEP)
•Prevention of infection in exposed uninfected person e.g. Needle stick injury, sexual assault
Pre Exposure Prophylaxis (PrEP)
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Major classes of ARVs
vReverse Transcriptase Inhibitors (RTIs)
•Nucleoside Reverse Transcriptase Inhibitors (NRTIs)
•Nucleotide Reverse Transcriptase Inhibitors NtRTIs)
•Non nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
vProtease Inhibitors (PIs)
vOthers:
•Fusion Inhibitors
•Integrase Inhibitors
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Reverse Transcriptase Inhibitors
•NRTIs inhibit reverse transcription by competitively blocking reverse transcriptase
enzyme activity due to their resemblance in structure to the viral nucleosides i.e. it sits
on the active site of the enzyme receptor
–Form back bone of the ART regimen
•NtRTIs work in the same way as the NRTIs but differ in chemical structure
–NtRTIs already has a phosphate group but NRTIs get phosphorylated in the
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Protease Inhibitor
•Inhibits the cutting down of the core multi-protein molecule to functional viral protein
molecules essential for HIV replication
–Enzymes
–Core proteins
–Envelop proteins
–Regulatory proteins
•Enzymes and building block proteins are needed to make complete copies of the virus
which can infect the cells
Topic 2: Classes of ARVs and their side effects
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Fusion Inhibitors
•Prevent HIV from entering healthy CD4 cells
•The only drug marketed in this category is ENFUVIRTIDE
•Is provided as a powder to be reconstituted before subcutaneous injection
once daily. Not feasible for public health use
•Very expensive. Used as salvage therapy
A new fusion inhibitor is MARAVIROC
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Integrase Inhibitor
•Inhibit the Integrase enzyme which is responsible for integration of the virus
DNA
•RALTEGRAVIR and Dolutegravir- recently approved for use by FDA and
registered in Kenya by PPB
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Gold standard for ART
•HAART (Highly Active Antiretroviral Therapy) is the Gold standard
•It is the combination of three or more ARVs in the treatment of HIV infection:
–Ensures maximal effect on suppressing the virus
–Ensures prolonged effect
–Delays emergence of drug resistance
•These ARVs work in different ways to prevent the HIV from multiplying and
infecting new cells
Drug combinations from different classes:
•2 NRTIs/NtRTI + 1 NNRTI
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•2 NRTIs/NtRTI + 1 PI
•2 NRTIs/NtRTI + 2PIs
3 NRTIs ( One drug must be ABC
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What are the benefits of ART?
•Allows CD4 cells to increase and strengthen the immune system
•Prevents multiplication of virus
•Reduces incidences of opportunistic infections
•Improves quality of life
•Decreases morbidity and mortality
Guidelines for Antiretroviral Drug Therapy in Kenya
•The guidelines cover the following:
•HIV diagnosis and initiation of ART
•Monitoring and changing therapy
•Information of the available ARVs
•Use of ARVs for Pediatrics and PMTCT
•Post Exposure prophylaxis
FIVE GOALS OF ART
Topic : Objectives
Objectives
By the
•List the major classes of ARVs with examples
•Describe the mechanism of action for each major class of ARVs
•Define ARVs and state their major indications
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◄ Unit Three: Handout
Topic 3: Side Effects Of ARVs
Definitions
•Side effects:
–This refers to unwanted but natural and anticipated consequences of taking a particular
medication.
–Such effects result from action on normal or healthy cells, tissues or organ systems other than
the one for which the drug was prescribed
–Eg lactic acidosis due to blockage of enzyime in mitochondria, hair loss in anticancer drugs
•Adverse effect:
–Adverse reactions are rare and unforeseen bodily responses to a drug. Eg allergic reaction
(NVP rash).
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•Toxicity:
–This refers to the systemic effects of a drug that are related to the overall level of the
medication in the bloodstream.
Drug toxicitymay occur with overdosage of a medication, accumulation of the drug in the body
over time or the inability of the patients body to eliminate
Why is it important to identify toxicity effects of ARVs
•Toxicity can decrease adherence, counselling is extremely important
•
•Disfiguring e.g after Steven Johnson Syndrome, Lipodystrophy
•
•Death
Scenario 1
•Nabatanzi is a 7 month old girl who was started on triomune baby tablets 6 days ago.
•
•Her grandmother returns today to see you because Nabatanzi has developed an itchy rash on
her neck and back last evening.
•She is worried that it appears to be spreading even other parts of her body.
She has no fever, and the rash has not formed any blisters. Her neighbour, who also has a child
with HIV, has told her the rash is a sign that the drugs make the child sicker and asked her to
•Which drug do you think caused the rash?
Nevirapine
•What would you tell the grandmother?
Reassure her that while the reaction may be
bothersome, it does not require change of therapy.
Remind her to continue monitoring the child and to
report immediately if the rash gets worse and
develops blistering.
Mild NVP rash
•Nevirapine is the commonest ARV causing skin rash as a side effect.
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•The rash usually appears in the first 6 weeks of starting treatment
•To prevent nevirapine associated rash, NVP is initially given at half the full dose for the first two
weeks as the health worker monitors for skin rash and signs of acute liver toxicity such as
yellow eyes, abdominal pain, vomiting and lethargy
•Reassure the child and caregiver that while the reaction may be bothersome, it does not
require change of therapy.
•Give symptomatic treatment.
•mother should continue monitoring the child and to report immediately if the rash gets worse
and develops blistering
Scenario 2
•Mbabazi is a 5 year old child who has been on Combivir, and Nevirapine for 10 days now.
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•His concerned mother brings him to see you because he has developed peeling and ulceration
of his skin and mucous membranes.
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•His mother says his condition began as a rash all over the body and has steadily gotten worse
over the last 2 days.
•She denies he has been burned.
•Which drug do you think is responsible for
this clinical picture?
Nevirapine
•How would you manage the child?
Immediately discontinue all ARV drugs, manage
the child as for burns
Ensure the child has adequate hydration & nutrition
Keep in a sterile environment, cover with antibiotics,
and give pain killers.
Monitor the child’s vital sign closely
Steven Johnson Syndrome
•This is a severe hypersensitivity reaction affecting the skin and the mucous membranes
•
•Can be caused by any drug. NVP is the most common ARV causing SJS, but can also be
caused cotrimoxazole
•Immediately discontinue all ARV drugs, manage the child as for burns.
•Ensure the child has adequate hydration and nutrition.
•Keep in a sterile environment, cover with antibiotics, and give pain killers.
•Monitor the child’s vital sign closely.
Refer patient or consult with a doctor about re-introducing ARV drugs
Topic 3: Summary
Summary on Drug Interactions
•NVP and antiTB drugs (Rifampicin):
Rifampicin reduces the serum levels of NVP to near
sub therapeutic levels.
Avoid using NVP and Rifampicin together, or increase the dose of NVP
•PI and antiTB drugs:
Rifampicin reduces the serum levels of PI to near sub therapeutic levels.
Avoid using them together
•Never use AZT and d4T together.
They antagonize each other
Topic :Objectives
Objectives.
•Explain the principles of home & community-based care .
•Discuss the components of home & community-based care.
Topic 1 :Concepts of Home based Care
VISION OF HCBC:
To integrate HCBC into other health services so as to provide a holistic, sustainable,
stigma-free and high quality continuum of care that is accessible to all those in need
and supported by motivated community and health facility care providers
Home & community based care (HCBC) concept
•HBC is an integral part of community based care.
•Community-based care is the care that
–the consumer can access nearest to home
–which encourages participation by people
–responds to the needs of people
–encourages traditional community life and
–creates responsibilities.
HCBC concept ct….
•HCBC calls upon the resources, skills, time, energy and funds of communities and
governments.
•It is implicit that “health” is the outcome of the overall social and economic development of the
community.
•Therefore, no single entity is able to meet the total requirements and challenges of home/
community-based care.
A collaborative effort is fundamental to success
•Care in the community must become care by the community
–HCBC calls upon the resources, skills, time, energy and funds of communities and
governments.
HCBC goals
•To shift the emphasis of care to the beneficiaries – the community
•To ensure access to care and follow-up through a functional referral system.
•To integrate a comprehensive care plan into the informal, non-formal and formal health system.
•To empower the family/community to take care of their own health.
•To empower the client, the care giver (s) and the community through appropriate targeted
education and training.
•To reduce unnecessary visits and admissions to health facilities.
•To eliminate duplication of activities and enhance cost-effective planning and delivering of
services.
•Be pro-active in approach National guideline on home-base care / community-based care
Rationale for HCBC
In most countries of Africa the rationale for HBC is based on;
•Shortage of hospital beds.
•Inadequate number of medical, nursing and allied
•health professionals in the public sector.
•Lack of resources for treatment and drugs.
•Increasing demands of curable conditions on existing institutional care.
•Hospitals, which are crowded and over-stretched, are often unsuitable for managing patients
with terminal or long-term diseases.
•Cost of institutional care.
•HC should provide back-up for people, who need extended care, not necessarily hospital care
or patients that are discharged early from hospital.
•However, HBC is not intended to be “second class care” or “cheap care” for those who cannot
afford hospital care.
•Commonly occurring diseases/conditions can be effectively managed at home Institutionalized
care is not the most appropriate care for many problems.
Principles of HCBC
•Helping clients to help themselves by providing them with the skills and opportunities to
develop their potential and continuously improve their health
•Working together with patients/ clients, collaborators and beneficiaries of HCBC to achieve
more sustainable and efficient outcomes
•Harnessing the benefits of synergy to enhance performance and provide learning and
development opportunities.
•Ensuring that we fully understand and meet the patient/client needs, with the understanding
that quality of care is the responsibility of every care provider
•Using the HIV act of the GOK to uphold the rights of all those who are infected and affected by
HIV. ( cap14 of the laws of Kenya, 2006).
•Defining complementary gender roles and responsibilities, promoting women's’ empowerment,
addressing traditional inequitable gender-related cultural practices, and addressing gender
imbalance in HCBC and service delivery.
Components of home-based care
Clinical Care:
•Clinical care aims to reduce suffering by treatment and preventing opportunistic infection .
•It is desirable that treatment of opportunistic infection be integrated into the primary health care
sector .This will allow better access to treatment and early diagnosis of infections.
Nursing care
•Nursing care involves attending to the personal needs and maintaining dignity of the patient,
preventing transmission of infection .
•Administering prescribed Medication to ensure adherence.
•Nursing care also takes into consideration patients comfort and nutritional needs
•The Home Care Kit
•The home care kit comprises the basic requirements for nursing the HIV-positive patient
outside of the health facility.
•Levels
–Community Health worker/volunteer kit
–Patient primary kit
Community Health Worker / Volunteer kit
•Gloves (latex, non sterile)
•Soap
•Toilet paper
•Scissors (small)
•Razor blades
•Waste disposal bags
•Jik
•Surgical spirit
•Plastic apron
•Plastic sheeting
•Condoms
Medications:
• Aspirin/paracetamol
• Anti-malaria tabs (Fansidar)
• Alberdazol
• Multi-vitamins
• Piriton
• Iron tablets
•
Reference materials:
• Handbook
Reference material
Topic 1 :Concepts of Home based Care
Palliative care, Pain relief and symptom management:
•This involves active and compassionate long term therapies intended to comfort and support
individuals and families living with a chronic life- threatening illness.
Symptom management runs from interventions for reducing fever and relieving pain, to treating
diarrhoea, vomiting and cough
Counselling and emotional support:
•The main aim of counselling is to reduce psychological stress and to provide the client with the
information and support necessary to make decisions. Counselling as a professional skill, can be
provided through individual, family and group therapy approaches. Group counselling affords an
opportunity for people with similar needs to share their experiences on how they have coped.
Psycho-social support:
•Social support involves improving the ability of people living with and affected by HIV/AIDS to cope
with, participate in, and be accepted by their communities.
•People infected and affected by HIV/AIDS require assistance to cope with the impact of the infection.
•Some CBOS/NGOS and social services organization sometimes provide material support
Spiritual care:
•Spiritual care may need the presence of religious leaders where applicable
This care is an effective means of helping patients cope with the concerns of impending death
Life skills development:
•PLWH should be encouraged to adopt positive life styles to strengthen skills that enhance them to
effectively prevent further infection. Involvement in community groups gives them a sense of belonging,
hence promotes responsible behaviour and sustainable positive lifestyles.
Family care and support:
•Should take into account the inter-relationships among family members and family roles in providing
care and support.
•Should include- planning for the children’s future, bereavement counseling, use of memory book etc.
ovc care and support should encompass the children's’ act (cap 586 of 2001) and the Kenya national ovc
guidelines.
•Children must be regarded as key players and not just beneficiaries of care and service delivery
especially in matters related to inheritance.
Food and nutrition:
•This should be should be short term- food prescription to meet immediate urgent food needs, medium
term- palatability issues and consumption for recuperation and recovery and long term- to ensure food
security (Kenya national food and nutrition guidelines for details)
Prevention of HIV transmission:
•Through advocacy for – VCT, PITC, PMTCT
•Training care givers on infection prevention
Topic 1: Concepts of Home Based Care
Linkage, coordination, referral and networking:
•Define roles and responsibilities of service providers at all levels
•Identify, map and harmonize a database of services in line with the comprehensive care services
•Through the support supervision structures of of the PHMTs and DHMTs, equitable distribution of
services and gaps in service provision will be identified and addressed.
Community rehabilitation:
•Through embracing community physical therapies and massage
Beneficiaries of HCBC
People who need basic support services to continue to live and/or die in their community and
without which they would have been either prematurely, inappropriately or unavoidably moved
to institutional care.
•Terminally ill persons e.g. cancer patients.
•Persons living with HIV/AIDS.
•Persons with debilitating disease and/or conditions e.g. mental Illness, substance abusers
•Any other disadvantaged group/person in need of such care e.g. people in crisis
•Frail older persons
•At risk people with moderate to severe functional disabilities.
People recovering from illness, in need of assistance e.g. post deliveries or after specific treatment
Needs of the Patients/Clients
Physical Needs
•Drugs for treatment.
•Clinical care including medication and regular check-ups in case of onset of new symptoms to ensure
immediate management.
•Clothing, housing, food, fuel/energy, water, education for children and income.
•General nursing care including attention to toilet needs, observation of vital signs, care of wounds,
personal and oral hygiene and comfort.
•Nutritional needs, that is, provision of an affordable and locally available balanced diet.
Physical therapies, exercise, massage
•Information, education and communication (IEC), including up-to-date, accurate information on
HIV/AIDS and safer sexual behaviour, on writing a will and on preparing for the eventuality of death.
•IEC on how to take prescribed drugs, prevention and care of the clients’ illness
Spiritual/Pastoral Needs
Strengthening existing faith and helping the patient/client in spiritual growth boosts the spiritual aspect
of life. This plays a great part in encouraging the person to have a positive view of life and to forgive
others and self for any misconceptions and liabilities
•Have reassurance that God accepts them;
•Allow religious groups to offer support;
•Have freedom of worship according to faith, which should be respected by the health worker and the
care providers;
•Call a religious leader of choice for sacraments and fulfilment of other needs.
Social Needs
•The patient/client and especially PLWHAs need company and association without stigma or
discrimination. Family and community members should facilitate recreation and exercise at
clubs/groups of their choice. PLWHAs need to be considered as people of value and having rights to be
respected. They should not be cut off from activities they enjoy e.g. political rally,
church/mosque/temple and spiritual gatherings.
•The social needs of PLWHAs/client include:
•Respect;
•Love and acceptance from others;
•Company of those around them;
•Source of income/income-generating activity;
•Right to own, inherit and bequeath property;
•Confidentiality regarding their condition by all who know about it;
Help with the activities of daily living
Psychological Needs
•Love, encouragement, warmth, appreciation, reassurance and help in coping with the disease are the
most important psychological needs. Religious groups, volunteer groups and other related support
groups can all play a part in meeting these psychological and counselling needs. They can:
•Instil hope so that the patient/client can continue with their daily activities as long as possible;
•Maintain confidentiality and unconditional acceptance and love;
•Provide supportive counselling to live positively.
In short, we can say that home-based care must be Holistic, encompassing all the aspects of human
living
Needs of the Family and Caregivers
•Families and caregivers too, have physical, psychological and social/spiritual needs that must be met in
order to maintain family solidarity and well-being.
Physical Needs
The physical needs of the family are more or less the same as those of the client except for personal
needs that are specific to the PLWHAs/clients condition. Family members of PLWHAs will need proper
STD/HIV/AIDS education and demonstrations on the care they will be expected to provide. Because the
burden of caring for someone who is very ill or dying is constant and heavy, the family may also need
help with household, farm or other chores
HCBC care giver team
A full home based care team comprise of the following
–Family members
–Health facility NGO/CBO as the coordinating centre
–Nurses
–Counselor
–Social worker
–Clinical officer
–Spiritual advisor
–IEC specialist
–The government
Role of various key players
Role of the patient
•The patient is one of the main players in home-based care. When the patients are not very sick, they
may provide their own care, but when they are too sick and require somebody else to care for them,
their role is to:
•Identify the primary or alternative caregiver;
•Participate in the care process, but not passively, especially in making decisions on own welfare;
•If possible, give consent on caregivers and where the care will be provided, for example, home or
hospital especially during the terminal phase of the disease
Role of Family members and care givers:
•Learn to accept and adjust to the situation, including that of the terminally ill with AIDS
•Collaborate with other care providers, e.g religious institutions, support groups, health and social
institutions
•Be able to volunteer or agree on other possible caregivers to be involved in providing the services in
the family - shared responsibility on issues of referral and networking
•Learn to consult with the clients on matters concerning them
•Involve the client in all care activities and any other family activities without discrimination
•Emphasize the need to prepare for death as inevitable and sensitise the client about the importance of
ensuring the continuing care of family members who are left behind
•Encourage and help the client to write a will
Remember that being present is a major support
Role of Home Care Team
Home care teams are under the supervision of a medical or social work professional,
works closely with a health centre or local community organization. The team is usually
led by a community health worker to:
•Manage AIDS-related and the client’s disease-related conditions
•Provide home nursing care
•Arrange voluntary HIV counselling and testing
•Provide supportive counselling
•Refer the patients for further specialized care such as treatment, radiotherapy, counselling, and
emotional/spiritual support
•Educate PLWHA/client/family on HIV/AIDS and other related diseases
•Arrange spiritual/pastoral care
•Mobilize material support
•Train the caregiver on all HBC services.
•Provide supervision of the caregiver.
•Train the clients on how to care for themselves.
Role of the Community
•Accept the situation of the PLWHA/client
•Collaborate and work with existing agencies around to meet the needs of those infected /
affected
•Prepare a Memory Book to provide their children with family history and a tangible record of
caring
•Encourage the client to write a will
•Identify own spiritual/pastoral needs
•Be open to the caregiver and share any worries
•Take personal responsibility to prevent further transmission of HIV
•Advocate for behaviour change
Role of the Government
•Create a supportive policy environment
•Develop policies and guidelines
•Develop and maintain standards
•Provide/coordinate training
•Provide drugs and commodities
•Help in the formation of support groups to lobby and advocate for the rights of the PLWHA.
Link the patient or client to the available support services right from the beginning when you
identify that the patient needs Home-based care
The process of linking patients to support services involves:
•Assisting patients and their families to identify the support that is needed.
•Identifying groups/agencies/individuals that can provide the support
•Informing patients about the existence of the individuals, agencies and the services that are
offered
Introducing the identified agencies and individuals to the patients and their families
•Helping patients to evaluate the individuals and agencies and allowing them to close those who
meet their needs.
•Helping them set up home visits and transportation if needed.
•Following up to ensure that there is coordination of services.
Challenges
•Resources
•Stigma
•Coordination of efforts
•Paradigm shift
•Volunteer burnout
•Burden of care on women.
•Confidentiality, acceptance and solidarity.
•Protection from loss of job and insurance.
•The role of traditional healing.
•Societal concept of the epidemic.
The impact of the extent and quality of support on the PLWHAs quality and quantity of life
Topic 1: Summary
At the end of the lesson participants should be able to:
•Explain the principles of home & community-based care .
•Discuss the components of home & community-based care.
•Appreciate the rationale for HCBC
•Identify the key players in HCBC
•Explain the challenges faced in HCBC
Topic : Objectives
Objectives
By the end of this Topic the participants should be able to;
• Provide Infection control and prevention
• Understand Practices necessary during provision of HIV and AIDS services
•Understand how to prevent infection in health facilities
NEXT PAGE
◄ Unit Five Handout
Topic 1: Percutaneous exposure incidents
•Percutaneous exposure incidents (PEIs)
needle stick, sharp injuries, splashes are a potential mode of
exposure to and transmission of blood-borne infectious diseases
among healthcare workers
•Blood borne pathogens have been associated with sharps injuries - hepatitis B virus
(HBV), hepatitis C virus (HCV), and HIV . This problem therefore, requires infection control
prevention and practices
Fundamentals of safety practice in regards HTS
•Staff education and continuous education- Formal training and specialized HTC
training and continuous support supervision
•Provision of safe building and equipment-Laboratory room – adequate
Laboratory floor – non polished/carpeted, Proper lighting and
ventilation, Benches – standard height and depth, Sink – free
flowing water, Drawers and cupboards
Good analytical practice
•HIV testing services require a specific
organizational structure and procedures
to perform and document HTS work for
quality of data, traceability and integrity of
data. Documentation can help find out;
•Who has done what
•How the experiment was carried out
•Which procedures have been used
•Whether there has been any problem and
if so
•How it has been solved
Hazards and occupational exposure
•Knowledge of the potential hazards and
proper management of Infection control
practices is required for the HTS service
providers
•Biological
•Chemical
•Electrical
•Physical/Mechanical
•Radiation
Classification of Hazard
Type of Hazard
Blood/ body fluids, Used needles
Biological
Any Materials contaminated with blood or Body fluids
Reagents, chemicals, strong bleach (Jik)
Chemical
Alcohol
Proper Dispo
Sharps Conta
dispose of acc
Use Spill kit
clean up spill
container
Equipment or supplies on floor
Physical/Mechanical
Make arrange
Discarded equipment left on floor and not disposed of
supplies; stor
properly
shelves out of
waste left on floor
Reorganize el
in
Electrical
Electrical cords placed across sinks, down hallways;
cords frayed and not repaired; too many equipment
plugs connected to one outlet
contact with w
Either have fr
container
Sources of Biological Hazards
•Accidental pricks/cuts
•Contamination of open cuts
•Inhalation
•Ingestion
Topic 1: Summary
Laboratory Hazards and Sources
Classification of Hazard
Type of Hazard
Blood/ body fluids, Used needles
Biological
Any Materials contaminated with blood or Body fluids
Reagents, chemicals, strong bleach (Jik)
Chemical
Alcohol
Proper Dispo
Sharps Conta
dispose of acc
Use Spill kit
clean up spill
container
Equipment or supplies on floor
Physical/Mechanical
Make arrange
Discarded equipment left on floor and not disposed of
supplies; stor
properly
shelves out of
waste left on floor
Reorganize el
in
Electrical
Electrical cords placed across sinks, down hallways;
cords frayed and not repaired; too many equipment
plugs connected to one outlet
contact with w
Either have fr
container
Topic : Objectives
Objectives
•Describe the chain of infection
•Brainstorm on various components of standard precautions
•demonstrate on proper use of various personal protective equipment (PPE)
•describe safe injections procedures and practices
•Describe significance of using PEP and scenarios where PEP is applicable
•Describe in detail how to segregate wastes and formulas used in preparing disinfectants
Topic 2: Infection Prevention Procedures
Chain of infection
•Transmission of microorganisms and
subsequent infection
•Transmission occurs when the agent in
the reservoir exits the reservoir through a
portal of exit, travels via a mode of
transmission and gains entry through a
portal of entry to a susceptible host
•Assess the risk of exposure to blood,
body fluids and non-intact skin and
identify the
Strategies that will decrease exposure risk
Assessing the risk of exposure and identify
the strategies that will decrease exposure risk
and prevent transmission of microorganisms
is based on;
•Client/patient/resident infection status
(including colonization)
•Characteristics of the
client/patient/resident
•Type of care activities to be performed
•Resources available for control
•HCW’s immune status
Risks are assessed for
•Contamination of skin or clothing by
microorganisms in the
client/patient/resident environment
•Exposure to blood, body fluids,
secretions, excretions, tissues
•Exposure to non-intact skin
•Exposure to mucous membranes
•Exposure to contaminated equipment or
surfaces
Rationale for Standard Precautions
•Standard Precautions are the minimum
infection prevention practices that apply
to all patient care
•Protect healthcare personnel (HCPs) and
prevent HCPs from spreading infections
among patients include hand hygiene use
of PPE
• Safe injection practices, safe handling of
potentially contaminated equipment or
surfaces in the patient environment,
respiratory hygiene/cough etiquette etc
Hand Hygiene : general term that applies to
either handwashing or antiseptic hand rubs
Perform hand hygiene:
•BEFORE: coming into direct contact with
patients for health-care related
procedures; putting on gloves (first make
sure hands are dry)
•AFTER: an injection session; any direct
contact with patients; removing gloves.
Personal Protective Equipment (PPE
They include gloves, gowns, facemasks,
respirators, goggles and face shields
•Equipment that protect HCPs from
exposure to or contact with infectious
agents
•Selection of PPE is based on the nature
of the patient interaction and potential for
exposure to blood, body fluids or
infectious agents
Gloves
•Must always be worn when handing
blood, body fluids, secretions, or
equipment and environmental surfaces
contaminated with the above
•Gloves are task-specific and single-use
for the task
•Hand hygiene should be done before
wearing and after removing gloves
•Order to Put On & Remove
•ON – gown, mask, gloves
•OFF – gloves, mask, gown
Apron / Gowns
•worn as a protective clothing
•procedure generates splashes or sprays
of blood, body fluids, secretions, or
excretions
•are removed immediately after use,
followed by hand hygiene to avoid transfer
of micro-organisms to other patients or
environment
•Hen contaminated decontaminate with
appropriate disnfectant
Topic 2: Infection Prevention Procedures
Safe injection practices
•A sharps injury prevention program must be in place in all settings and
include follow-up for exposure to blood-borne pathogens
•prevent injuries when handling needles, scalpels and other sharp
instruments, devices during procedures, cleaning process and disposal
•Treat all specimens as potentially infectious
•Dispose specimens in appropriate containers to prevent potential spillage
and transmission of pathogens
In event of blood or body fluid spills:
•Pour chlorine based disinfectant (e.g. sodium hypochlorite (jik) granules
or solution) over blood or body fluid spills. It should achieve 10,000ppm
chlorine.
•Wear gloves and use paper towels to clean up blood and body fluids spills
•Dispose them into a biohazard bag and mop the area with institution
recommended disinfectant
Post-HIV Exposure Prophylaxis (PEP)
In case of an accidental prick :
•Do not panic
•Inform the supervisor immediately
•Wash site with plenty of soap and water. DO NOT squeeze to promote
bleeding as this will damage the site further, increases the surface area
•Perform basic first aid (arrest bleeding)
•Record in incident/accident log book
In case of splashes:
•Do not panic
•Flood the surface with water
•Record in incident/accident log book
•Access HTS
•Assess risk of exposure (use the details recorded)
•Initiate ARV prophylaxis immediately and take for 4 weeks
Note: an initial 3 day dose of ARVs may be given before
accessing HTS
•The risk of HIV transmission from a single needle stick is 0.3%
•This can be further reduced by 80% by taking antiretroviral (post-HIV
exposure prophylaxis)
•The recipient must be HIV negative to benefit from PEP
Waste segregation and disposal
•In the process of providing HTS, waste is generated since re-use of the
materials is not recommended. Some of these wastes are contaminated
and pose potential hazards to service providers
•proper waste management should be practiced in order to further ensure
safety of the practitioners
•Procedure required include; waste segregation, disinfection and disposal
Waste is segregated into the following categories:
•Non contaminated solids- burn or incinerate
•Sharps- Put in sharps container. Sharps container must not be more than
¾ full
•Contaminated solids- place in color coded biohazard bag, burn in a
designated pit or incinerate
•Contaminated liquids- add neat bleach to the waste in the ratio 1 in 10 and
leave for at least 30min, pour down the sink and flush with plenty of water
Sharps disposal Containers
Disinfection
These are chemical solutions used to decontaminate or
sterilize working surfaces, equipment, etc.
Choice of disinfectants is based on:
•Mode of action (Cidal, Static)
•Rate of action (sensitivity to light, working concentration etc.)
•Side effects (Corrosiveness, Irritant vapors, Staining properties)
•Keeping qualities. (bleach should be prepared on a daily basis)
HIV testing services safety standards
•Strictly observe universal precautions
•Do not break, bend, re-sheath or reuse lancets, syringes or needles
•Never shake sharps containers to create space because this leads to
formation of aerosols
•Eating, drinking, smoking and applying cosmetics is prohibited
•Mouth pipetting is prohibited
•Staff must behave in a safe and responsible manner at all times
•Appropriate PPE must be worn at all times
•The HTS provision area must be kept clean, tidy and should contain items
necessary for the work carried out
•decontaminate all working surfaces at the end of each working day and
after any spillages
•wash hands when leaving the service provision area
•Avoid the formation of aerosols or the splashing of materials
•Appropriately decontaminate all contaminated waste or reusable materials
before disposal or reuse
•Report and take appropriate action all incidents and/or accidents
•All staff must be adequately trained
•Gowns should be worn and removed immediately after the task in a
manner that prevents contamination of clothing/skin and prevents agitation
of the gown
opic 2 Summary
Click here to access Unit Seven Content...
Topic :Objectives

•Explain the epidemiology of STIs
•Discuss some risk factors & complications of STIs
•Enumerate examples of STIs
•Describe Syndromic approach to STIs
•Common symptoms and signs of STIs
•Discuss the management of STIs (Syndromic)
•Prevent the spread of STIs
Topic One : SEXUALLY
TRANSMITTED
INFECTIONS

Epidemiology of STIs
•STIs are a major health problem globally and especially in developing countries
•More than a million people acquire a sexually transmitted infection (STI) every day:
•An estimated 500 million new cases of curable STIs (gonorrhoea, chlamydia, syphilis and
trichomoniasis) occur every year
•In addition, 536 million people are estimated to be living with incurable herpes simplex virus
type 2 (HSV-2) infection
•Approximately 290 million women have Human Papilloma Virus (HPV) infection at any given
time
•Risk factors of STIs
•The common risk factors include:
•Multiple sexual partners
•Alcoholism & smoking
•Drugs & substance abuse
•Youth & adolescents
•Prolonged antibiotic use
•Poor hygiene
•Ignorance about STIs and modes of spread
Complications of STIs
•The complications of STIs have a negative impact on sexual and reproductive health and
include:
•Fetal and neonatal deaths
•Syphilis in pregnancy leads to 305, 000 fetal and
•neonatal deaths, and 215, 000 infants
•Increased risk of dying from prematurity, low birth weight or congenital anomalies
•Cervical cancer: HPV infection causes an estimated
•530, 000 cases of cervical cancer and 275, 000 cervical cancer deaths each year
•Infertility: STIs such as gonorrhoea and chlamydia are an important causes of infertility; in SubSaharan Africa, untreated genital infection may be the cause of up to 85% of infertility among
women seeking infertility care
•
HIV risk: having an STI such as syphilis or HSV-2 infection increases the chances of acquiring
HIV infection by three-fold or more
Definition & Transmission of STIs
•Definition of STIs
•Infections that are commonly spread through sexual contact
•The common modes of spread are:
•Oral
•Vaginal
•Anal
•Direct skin-to-skin contact
TRANSMISSION
•For successful transmission to occur, there must be:
• - An infected person and at risk person
•
–A body fluid containing the organism
–
–Means of transferring the organism from one person to another
METHODS OF TRANSMISSION
High Risk
§Sexual Intercourse
§vaginal
§anal
§oral
§Blood-to-blood contact
§Sharing of needles or other drug administration equipment
§Tattoo or body piercing
§Infected mother to her baby
Low or Medium Risk
§Abstaining
§Hugging
§Kissing
§Holding hands
§Dancing
§Sitting on toilets
§Sharing lip stick/balm
§Practicing monogamy
§Sharing of forks, knives,
Contact sports,
BODY
Examples of body fluids that are considered infectious include:
FLUIDS
•Semen
•Vaginal fluid
•Blood
•Fluid in sores or blisters
•Saliva
•Tears
•Sweat
•Urine
•Ear wax
Examples of STIs
•Bacterial STIs include:
•Gonorrhea, Chlamydia, Syphilis, Lymphogranuloma venerium (LGV), Bacterial vaginosis (Bv),
Granuloma inguinale (GI) and Chancroid
•Most of these can be treated and cured using antibiotics
•Untreated infections can cause complications like PID, infertility & epididymitis and urethral
stricture in males
•Viral STIs include:
•HPV, HIV, Herpes genitalis, Hepatitis B and Molluscum contagiosum
•For most of these viral STIs, there is NO cure
•Medications are available to treat symptoms only
•They can be transmitted to others for long periods
•STIs from other organisms:
•Protozoal eg - Trichomonas vaginalis
•
•Fungal/yeasts eg - Candida albicans
•
•Parasitic eg - Scabies and lice (Pediculosis)
Control of STIs
•This can be achieved through:
•Integration of STI services into existing health services eg OPD services
•Advocacy to fight the stigma of STIs among the community
•Improvement of diagnostic ability
•Training for capacity building of HCWs
•Continuing research
Syndromic Approach to STIs
•This was started in early 1990s by WHO for resource limited countries without adequate
personnel & laboratory services
•
•It was aimed at improving care and control of STIs and HIV infection
•
•The antibiotic combinations were carefully selected to cover common pathogens
Components of Syndromic Approach
Case management process involves:
•History taking & Examination
•Diagnosis & Treatment
•Patient Education & Counseling
•Partner management
•Recording & compiling of data for planning & development
Advantages of Syndromic Management
•Patients are treated at first encounter
•
•Is convenient and faster since one doesn’t wait for laboratory tests and results
•
•Does not require highly trained care givers
•
•Use of treatment protocols or algorithms for standardization
Topic One : SEXUALLY
TRANSMITTED
INFECTIONS

Types of STIs Syndromes
•The STIs are subdivided based on a set of common signs & symptoms:
•I. Urethral discharges – male urethral & female vaginal caused by GC, Chlamydia,
Trichomoniasis, B.V. & Candidiasis
•II. Genital ulcer disease – Chancroid, Syphilis & Herpes genitalis
•
•III. Inguinal bubo syndrome – LGV and GI.
•IV. Scrotal swelling – caused by orchitis, epididymitis and hydrocoele
•V. Chronic Lower Abdominal Pain – in women due to PID, Oophoritis, salpingitis, etc
•VI. Ophthalmia Neonatorum – due to neonatal conjunctivitis
•VII. Others – present with rashes, itching, growths, etc. Examples include: scabies, genital
warts, molluscum contagiosum and lice
Case management process
•The 7Cs for case management are:
•Client selection
•Chemotherapy treatment
•Compliance with treatment
•Condom use promotion
•Counseling & education
•Contact tracing & treatment
•Coming back for review
Strategies for STI prevention
•Integration of STI services into existing health services eg OPD
•Syndromic case management
•
•Advocacy to fight the stigma of STIs in the community
•
•Surveillance of STIs to monitor trends and
•Biomedical interventions – include, Voluntary Medical Male Circumcision (VMMC) not only
reduce the risk of heterosexual HIV acquisition but also STIs
•
•Use of rapid diagnostic tests that are affordable, quick and reliable
The 4Cs of STI prevention
•Counseling and advocacy for behaviour change
•
•2. Contact-tracing and treatment
•
•3. Condom use promotion for all groups at risk
•
•4. Compliance- No self medication, Take full course of medications & Follow up visits
•Future strategies
•Vaccines and other biomedical interventions
•HPV vaccines are safe and very efficacious against HPV types causing 70% of cervical
cancers;
•A new vaccine also prevents genital warts
Specific STIs
•These are discussed based on their aetiology and presentation
•Diagnosis is confirmed using various laboratory tests as follows:
Specific STIs - Bacterial
•We shall discuss the ones below:
•Chlamydia
•Lymphogranuloma venerium (LGV)
•Granuloma inguinale
•Syphilis
•Gonorrhoea
•Bacterial vaginosis
•Chancroid
Chlamydia
•This is one of the most common bacterial STIs
•The majority of infections occur in people aged 15 to 25 years, the sexually active age group
•
•If untreated, it can spread to affect the cervix and urethra, and occasionally the rectum, throat
and the eye
•
•Causative organism – Chlamydia trachomatis
•Many patients have NO symptoms – in both men and women
•In men - only half (50%) of infected men have some symptoms – white or cloudy watery
discharge on tip of penis
•Burning sensation on micturition
•Painful, tender testicles
•Can be treated with antibiotics
Chlamydia in Males and Female
Topic One : SEXUALLY
TRANSMITTED
INFECTIONS

Lympho-granuloma Venerium (LGV)
•Is a chronic infection of the lymphatic system caused by – Chlamydia trachomatis (3 Serotypes
– L1, 2 & 3)
•It was discovered by Durand-Nicolas- Favre and was called Poradenitis Inguinale
•Incubation period – 2-6 weeks
Clinical Features
A primary lesion or sore occurs – on the genitals plus large swollen lymphnodes
(Buboes)
General symptoms like – Fever, chills, anorexia, joint pains and weakness, Painful
micturiton
Other features are:
§ Pain when opening bowels
§ Rectal bleeding
§ Abdominal pains
§ Constipation
§ Bloody diarrhoea
GONORRHEA
•The 2nd most common bacterial STI
•Most common in people aged 15 to 35 years
•Can affect other areas - cervix, urethra, rectum, throat, and occasionally the eyes
•Can be treated with antibiotics
•
•In most patients is asymptomatic or they delay to occur especially in females
•Causative organism – Neisseria gonorrhoeae, a Gram negative dipococcus which is
intracellular
•
•It infects warm moist areas of the body including – the mouth, eyes, anus and throat
GONORRHEA:
Signs & Symptoms
•In Female
–Increased vaginal discharge
–Painful urination
–Lower abdominal pain
–Bleeding after sex and between periods
–Pain during sex
–Bartholin’s abscess
•In Male
–Thick, yellowish-green discharge from penis or urethra
–Painful urination
–Testicular pain or swelling
–Rectal pain, discharge or itching
Complications of GC include
•Salpingitis
•Oophoritis
•Cervicitis
•PID
•Ectopic pregnancy
•Infertility
•Arthritis
•Meningitis
Gonorrhea in Male
Granuloma Inguinale (GI)
•Also called Donovanosis
•Is caused by Calymmatobacterium granulomatis (Donovan’s organism)
nA gram-negative rod that is related to Klebsiella
n
•It begins as a small subcutaneous nodule in the genital area that breaks through to the surface
Diagnosis – is confirmed by:
1. Smear of fluid or discharge
2. Histopathology: mononuclear cells, PMN, no giant cells,
Donovan bodies
Treatment:
– Doxycycline 100 mg PO bd x 4 weeks
–Co -trimoxazole - II (or 1DS) PO bd x several weeks, until lesions
heal
Wound care
SYPHILIS
•A bacterial infection that progresses in stages if not diagnosed and treated early
•It is a chronic multi-systemic diseases caused by a spirochaete called Treponema pallidum
1. Primary: (3 days – 3 months) starts as a small, painless sore called a chancre; that
heal on it’s own
–The sore is usually firm, round and painless
–It may be one or many
–Areas involved include the genitals – vagina, prepuce, anus or other hidden places
Signs & symptoms
2. Secondary: (2 – 12 weeks) hyper-pigmented (dark) circular rash on the body, palms
of hands & soles of feet, hair loss & general weakness
–The rashes are non-itchy and non painful
–
–There could be flu-like symptoms plus swelling of glands
–
–The patient may loose weight plus muscle pains
•
. Latent & late stage:
In latent stage there may be no symptoms or signs for several weeks or months
nThe lesions or rashes can recur
nTumors, blindness and paralysis of muscles may occur
Diagnosis – can be confirmed by laboratory tests – Screening eg VDRL, Khan test and
Dark ground illumination test
nOthers – eg FTA, TPHA, TPI, etc
SYPHILIS - Complications
•Untreated syphilis may lead to complications ie 4. tertiary syphilis - which can involve:
–The cardiovascular system (heart & blood vessels)
–The neurological system – Neurosyphilis (headache, behavior change & gait problems
–Other organs of the body – eyes, liver, bones and joints
–Complications may lead to deformities and death
Specific STIs - Viral
•The common examples of viral diseases are:
•Genital herpes
•Human papilloma virus (Genital warts)
•Molluscum contagiosum
•Hepatitis B infection
Genital Herpes
(Herpes Simplex Virus - HSV)
•Two types: HSV-1, causing cold sores, and HSV-2, causing genital herpes
•It is a viral infection causing outbreaks of painful sores and blisters
•Spread through direct vaginal, oral or anal sexual contact with an infected partner
•Also transmitted through having oral sex with a partner with a history of cold sores
•Symptoms: can be treated with antiviral medications, but NO CURE. This reduces the duration
& reccurences
b
Topic One : SEXUALLY
TRANSMITTED
INFECTIONS

Genital Herpes – Signs & Symptoms
•Prior to appearance of lesions, the person may feel a tingling or burning sensation
where the virus first entered the skin
•Painful sores or grouped blisters (external or internal)
•Inflammation and redness
•Fever
•Muscular
pain
Genital Herpes
•Tender lymph nodes
Hepatitis B (HBV)
•Virus that infects the liver
•Most infected people (90%) naturally produce antibodies to fight the disease, but some
develop chronic HBV and will carry the virus for the rest of their life
•Chronic infection can lead to liver damage, cirrhosis, and cancer
•There is NO CURE, but vaccination can prevent infection, what is the vaccine called?
Hepatitis B
A patient suffering from liver cancer caused by HBV
HPV – Signs & Symptoms
•Many people with low-risk types have no symptoms
•Other HPV types may cause:
–Warts on vulva, cervix, penis, scrotum, anus or in the urethra
–Itchiness
–Discomfort and bleeding during sex
Molluscum contagiosum
•A bit rare viral (Pox virus) infection that can also be transmitted sexually
•Is common in all age groups
•Presents with discrete or isolated papules that are umbilicated on the face and genitals,
anal, thighs or buttocks
•Lesions are flesh colored, grey-white, yellow or pink
Complications of M.C.
•These include:
•
•Eczematization
•Bacterial infection
•Ulceration & scarring
•Conjunctivitis
Bacterial vaginosis
•This is an infection of the genital tract caused by overgrowth of some atypical bacteria
including, Garnerella vaginalis, Lactobacilli, Bacteroides and Fusobacteria
•
•It causes much discomfort due to foul fishy smell, discharge and intense ithing
Clinical Features
•It is fairly less serious but causes much discomfort due to foul fishy smell, discharge
and intense itching
•Occasionally some patients experience pain during coitus and soreness
•Possible complications during pregnancy
•Include: - premature labour, abortions & PID
•Diagnosis – is confirmed by “Whiff test” in which drops of KOH are put onto discharge
and a fishy odor is produced
inical features
Parasitic infections considered as STIs
•These infections caused by parasitic infestations - Pubic Lice & Scabies
•1. Lice (Phthiriasis) – Involves the pubis, scalp and eye brows
•Pubic lice: also called crab-lice are small insect like parasite that forms nits in pubic
hair & bite their host to feed on blood then go back
•Treatment: - 1% Permethrin Cream or powder plus Shaving of
hairs
Pubic Lice
Scabies
•Scabies is caused by a mite called Sarcoptes scabiei, that burrow under the surface of
the skin to lay their eggs
•Can survive for 1 – 3 days on beddings, towels and clothing
•
•Treatment - Use medicated creams & lotions – BBE, Gamabenzene hexachloride
lotions
STI Prevention
•Abstinence from sexual intercourse (only method that is 100% effective)
•Don’t share injection needles or other drug-use equipment
•Have only 1 mutually faithful, uninfected sexual partner
•Get tested for STI’s before having sex
•Use of condoms & spermicidal gels
•Avoid alcohol & other drugs used by the youth
•Health education
•NB: Above are summarized under ABC strategy
Where to go for advice
•Health Worker or Educator
•STI Unit/Special Clinics in Health Facilities
•Family Doctor or Clinical Practitioner
•CCC in Hospitals
•Hospital Chest or Skin Clinics
•Youth Friendly Clinics
•VCT Centres in various places
Topic Summary

•What have we covered in this lesson?
•Epidemiology of STIs, risk factors & complications of STIs, examples of STIs, the
Syndromic approach to STIs, symptoms and signs of STIs and the management of STIs
(Syndromic) plus
•prevention of STIs
•
• Any Questions & Contributions?
•
THANK YOU
Click here to access Unit Eight Content.
Topic : Objectives
Objectives
At the end of the session,participants will be able to:
•Explore the the purpose of communication.
•Discuss the principles of communication.
•Develop skills in communication so as to enhance effective interaction with clients and the caregivers.
Apply the the principles of communication in differing helping relationships with clients/patients
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◄ Unit Seven Disucssion Forums
Topic 1: Concepts of Behaviour Change Communication
Details about BCC
•Promoting positive behaviour change is a complex process
requiring a thorough understanding of what motivates
BCC strategies are designed to impart knowledge and skills
and provide psychosocial support that is needed to initiate
and sustain change people to adopt or resist new
behaviours.
Behaviour change communication (BCC) approaches
recognise that presenting facts alone does not guarantee
behaviour change
BCC Messages
Address
Care & Support
•ART
•Adherence
•PMTCT
•STIs
•Positive Living
•Stigma
Prevention
•ABC (D)
•Addressing Stigma
•Focus on Youth
–Delay sexual debut
–Peer Education
•Be targeted at an identified group
•Involve people from that group
•Develop appropriate messages
•Use many sources to convey the message
•TV
•Radio
•Newspaper
•Magazine ie Straight Talk (also Parent, Teacher, Young Talk)
•Posters
dramas
•Involve the target group in leadership and implementation
•Pilot intervention
•Plan for M & E (both during and at end)
•Sex can wait, my future can’t”
•
“We respect each other, we are abstaining until marriage
Principles of effective Communication
•Think of a time when you were confronted by a difficult situation.
•What help did you need?
•From whom did you get help?
•Why did you decide to approach this particular person?
Purpose of communication
•To be heard
•To be understood
•To be accepted
•To get action
•To change behaviour
•To gain trust
Non-Verbal Communication
Gestures:
•Touch: amount, type, who, where and when
•Body postures: Arms and legs
•
•Hands to face gestures
•Eye contact: Mirror of the soul
•
•Clothes
Tools used in Non-Verbal Communication based on available information:
•Observation
•Interpretation/perception
•Conclusion
Principles of communication
•Empathy
•Respect
•Genuineness
•Honesty
•Listening
•Openness
•Touch
Principles that characterise effective communication
•Ensures that there is an interaction rather than direct transmission of messages
•Demonstrates dynamism- there is flexibility as different individuals needs and contexts change
continually
•Follows a helical model where what one says influences the other in a spiral manner
•Requires planning and thinking in terms of intended outcomes
•Dealing with ones own issues- self awareness
Skills for effective communication
•Listening- this involves hearing and understanding even silence
•Attending-provides a basis for listening
•Probing
•Questioning
•Reflecting (paraphrasing, restating and summarising).
•Reflecting (paraphrasing, restating and summarising).
Principles that characterise effective communication
•Ensures that there is an interaction rather than direct transmission of messages
•Demonstrates dynamism- there is flexibility as different individuals needs and contexts change
continually
•Follows a helical model where what one says influences the other in a spiral manner
•Requires planning and thinking in terms of intended outcomes
•Dealing with ones own issues- self awareness
Skills for effective communication
•Listening- this involves hearing and understanding even silence
•Attending-provides a basis for listening
•Probing
•Questioning
•Reflecting (paraphrasing, restating and summarising).
•Reflecting (paraphrasing, restating and summarising).
Issues in Communication
Communication is influenced by one’s:
•Age
•Social class
•Culture
•Milieu (social environment)
•Marital status
•Gender
•Attitudes
•Emotions
•Feedback
•Educational background
Culture & Communication
Culture Deficit approach:
•Assumes that the rules, values and behaviours of the ‘dominant’ culture are normal and that
any variations observed are deficits.
Culture sensitive approach:
•Helpers show respect for cultural differences and
may emphasise the positive features of cultural
variation.
Encouraging & Discouraging Vocal & Bodily Communication
•Leans back Look alert
•Pick nose Smiles when greeting you
•Calm manner Sits higher than you
•Head very close
to yours Half closes eyes
•Tugs to ears High pitched voice
•Looks towards you Leans lightly towards you
•Sits on the same
level as you Look clean
Topic 2: Objectives
By the end of this lesson learners should be able to:
1.Demonstrate understanding of condom as a method of HIV Prevention.
2.Demonstrate understanding of proper use of male condoms.
Demonstrate understanding of proper use of female condoms
Topic 2:Condom Use Demonstration
Condom as a Method of HIV Prevention
–A condom is a sheath-shaped barrier device used during sexual intercourse to reduce the
probability of pregnancy or a sexually transmitted infection
–Condoms are physical barriers that can reduce the risk of a sexual exposure to HIV
–There are both male and female condoms
How effective are condoms in preventing HIV
•Effectiveness of condoms in preventing HIV transmission is estimated to be 95-99%( WHO
2015)
•
•consistent condom users are 10 to 20 times less likely to become infected when exposed to the
virus than those are inconsistent or non-users(USAID 2015)
•
•Effectiveness is achieved when condom is used consistently
What are condoms made of
•Condoms are usually made of latex or polyurethane.
•Latex condoms are readily available & can only be used with water based lubricants, not oil
based lubricants
•such as Vaseline as they break down the latex.
•
Condom Use Demostration
Topic 2: Summary
•Between male and female condoms which one would be most preferable to use?
•Despite Knowledge that condoms prevents HIV by 99%why do you think only 2% of the
people in kenya use condoms?
•
•Why many reported cases on condom bursts?