Malawi PMTCT Trainer Manual
Module 8 Referral for Treatment, Care and Support
Services
Total Module Time: 75 minutes
After completing the module, the participant will be able to:
 Describe the difference between linkages and referrals.
 Describe why linkages are essential to ensuring clients have access to the full
continuum of services.
 Explain the referral process.
 Discuss the goals of PMTCT community outreach.
 Describe strategies that will encourage community participation in PMTCT
interventions.
 Discuss the importance of male involvement in PMTCT interventions.
 Discuss barriers to male involvement in PMTCT interventions.
UNIT 1
Linkages and Referrals Supporting PMTCT Services
Activity/Method
Time
Interactive lecture
15 minutes
Exercise 8.1 Community linkages: small group discussion
20 minutes
Questions and answers
5 minutes
TOTAL UNIT TIME 40 minutes
UNIT 2
Community Education, Outreach and Mobilization
Activity/Method
Time
Interactive lecture
15 minutes
Exercise 8.2 The “male friendly” PMTCT service: large group discussion
15 minutes
Questions and answers
5 minutes
TOTAL UNIT TIME 35 minutes
Trainer Instructions
Slides 1-3
Begin by reviewing the module objectives listed above.
Module 8 Referral for Treatment, Care and Support Services
8-1
Malawi PMTCT Trainer Manual
UNIT 1
Linkages and Referrals Supporting PMTCT
Services
Advance Preparation
The day before: Preparation for Exercise 8.1
The trainer should review Exercise 8.1 Community linkages: small group
discussion. The trainer should organize the small groups for the exercise,
explain the exercise and instruct participants to complete as much of the
worksheet as possible for the next day’s discussion.
Total Unit Time: 40 minutes
Trainer Instructions
Slides 4-5
Introduce the unit and review objectives.
After completing the unit, the participant will be able to:
 Describe the difference between linkages and referrals.
 Describe why linkages are essential to ensuring clients have access to the full
continuum of services.
 Explain the referral process.
Trainer Instructions
Slides 6-18
Introduce linkages, the importance of community as well as governmental linkages, and
why linkages should be family centred. It may be helpful to illustrate the advantages of
helpful linkages by contrasting them with the Consequences of Poor Linkages.
Make These Points




8-2
Linkages are between agencies whereas referrals are between a service provider and
the client.
Linkages and referrals should be centred on the needs of the woman, her children and
family.
Women access the continuum of care, treatment and support services through
linkages and referrals; their access to the referral network is through their HCW.
HCWs need to be familiar with locally available services.
Malawi PMTCT Trainer Manual
Introduction to linkages and referrals
Because HIV can be a debilitating and life-threatening illness, and the diagnosis of HIV
infection a life-altering event, women testing HIV-positive will need support services. In
addition, women who test negative may also need referrals to local services. Although
many of these services are available at the site where PMTCT services are offered, many
other necessary interventions are provided outside of PMTCT services. To offer truly
comprehensive care, health facilities must partner or establish linkages with
governmental organizations, non-governmental organizations (NGOs), faith-based
organizations (FBOs), and similar agencies that provide treatment, care and support
services for mothers who are HIV-infected and their family members.
What are linkages?
Linkages are formal networks of organizations and/or agencies and the community,
which facilitate the referral of the client and her family for needed services. Linkages also
facilitate referring clients from the community to PMTCT services. The aim of
coordinating services by establishing linkages is to provide access for clients to a
"seamless" continuum of services, which are delivered efficiently and conveniently, as
though there was one well-organized deliverer of care.
PMTCT services, which are based on a seamless flow of patients between ANC,
obstetric, and postnatal care, should also have linkages with:
 Tertiary referral hospitals, district hospitals, peripheral health facilities
 Intersectoral linkages within the district (i.e., with education, agriculture and local
government sectors, etc.)
 The communities they serve
 NGOs and FBOs
Community linkages
Linkages to community-based organizations can provide the resources, such as support
groups and social activities, to help women who are HIV-infected and their families cope
with the isolation, social stigma, and emotional pressures that often accompany a
diagnosis of HIV. Community-based organizations such as women’s groups also may
provide women infected with HIV a way to become involved in voluntary or paid HIVrelated work in community development projects. Participating in these projects may help
their families by meeting specific needs, such as housing, transportation, food assistance,
and legal assistance and advice. Many religious leaders have recently received HIVstigma training and have the potential to be powerful allies for counselling and supporting
HIV-affected families.
HCWs can facilitate a connection with community-based organizations by networking
with supportive community agencies, and by identifying key partners and preferred
methods of contact and communication. Where no such organizations exist, HCWs can
foster their development through community mobilization.
Module 8 Referral for Treatment, Care and Support Services
8-3
Malawi PMTCT Trainer Manual
Suggested linkages and referrals
For all women and their families:
 Nutritional rehabilitation and
supplementary feeding services for the
child plus nutrition care and support for
the mother
 Routine well-baby or well-child care,
including immunisations
 HIV testing and counselling sites
(partner and family member testing)



Family planning and other reproductive
health services, including the provision
of condoms and safer sex advice
Infant feeding counsellor
Treatment and support for drug and/or
alcohol abuse
Additional services for HIV-infected women and their families:
 Treatment, care and support for HIV Organizations providing supportive
exposed infants
counselling including support groups
 Infant and/or young child HIV testing
and infected mothers’ clubs
 HIV treatment, care, prevention and
 Community-based HIV support groups
support, including treatment for HIV Faith-based and community
related conditions and ARV therapy
organizations that offer services such as
 Infant feeding counsellor or
psychosocial care, housing,
replacement feeding counsellor
transportation, food assistance, legal
 Community/home-based services
assistance, and income-generation
 HIV-related clinics
 Laboratory services
 Sexually transmitted infection (STIs)
treatment programmes
Linkages should be family-centred. Important elements of family-centred HIV care and
treatment are
 Recognition of all persons who are family members, as identified by the person living
with HIV. These may be blood relations, in-laws, or friends.
 Inclusion of these family members in decisions about care, treatment and support of
the HIV-infected and affected members of the family unit.
Although it is essential that PMTCT services foster a wide range of linkages, those
between MCH and HIV services are essential:
 PMTCT services integrated into MCH are entry points for the treatment, care and
support of women who are HIV-infected, their infants, and family members.
 Caring for and treating families affected by HIV is a shared responsibility.
 Children born to women who are HIV-infected require close follow-up and
appropriate care.
 Community health workers may be encouraged to provide information on health
promotion and disease prevention, as well as care and support services, to women
with HIV infection and their families.
 Specialists in HIV who care for women and children may provide consultation,
antiretroviral treatment, and help with the ongoing management of HIV infection.
 The Health Education Unit can assist with outreach by organizing special mass media
education programmes to support MCH and HIV services.
8-4
Malawi PMTCT Trainer Manual
Linkage enablers
A number of factors facilitate the building of strong linkages:
 A formal organizational structure that creates a single entity of a district health
service
 Informal personal relationships
 Communication
 Transport systems
 Integration of management and support functions such as planning, education and
training, supplies and maintenance
The advantages of linkages include:
 Better access for people living with HIV to key HIV, reproductive health, and MCH
services tailored to their needs
 Promotion of PMTCT activities and PMTCT messages amongst service providers
 Reduced HIV-related stigma and discrimination
 Improved coverage of underserved and marginalized populations
 Improved quality of care
 Enhanced programme effectiveness and efficiency
Not only do linkages provide clients with the range of services they need, but linkages
also enable the development of a sense of joint purpose and shared achievement. They
enable staff to feel part of the broader strategy to improve the health of the community
and, as such, increase staff motivation and satisfaction: the PMTCT clinicians and
community healthcare workers (HCWs) do not feel they are battling HIV unsupported,
and district hospitals do not feel as though they are a “dumping ground”.
Consequences of poor linkages
When linkages are ineffective, a number of problems may occur:
 Lack of access to services for clients
 Gaps in service
 Duplication of services
 Inappropriate division of tasks. Clinics may take on tasks they are not well-equipped
to do or that could have been handled more efficiently at another level. Or, patients
who could have been treated locally may be treated at the district hospital at higher
expense than necessary.
Trainer Instructions
Slides 19-23
Introduce referrals as well as the criteria for making a referral, and the referral process.
As an introduction to Exercise 8.1, discuss how participants can develop a referral
network to support the clients who receive PMTCT services.
Module 8 Referral for Treatment, Care and Support Services
8-5
Malawi PMTCT Trainer Manual
Make These Points



When introducing the concept of referral monitoring, consider asking participants
why they think monitoring of referrals is important from both a patient and a system
perspective.
Discuss mechanisms that participants can establish in their own localities to facilitate
the development of formal referral networks.
RH and MCH programmes can expand the services they offer by establishing a
referral network.
What are referrals?
Criteria for referral
Definition
A referral is made when a healthcare
or social service worker guides a
client to obtain services that will meet
the client’s need for continuity of
care.
The client can be referred to another service
under the following circumstances:
 Client has unmet needs
 Services are unavailable or inaccessible at
the facility where PMTCT services were
offered
 Client request
The referral process
The referral process should include:
 Assessment of client’s needs: clients will have individual care, treatment and support
needs based on the status of their HIV infection and their individual circumstances.
 Documentation of the referral, including date, to whom client was referred, and any
additional information provided to facilitate the referral.
 Issues of confidentiality and privacy should be made clear to the client as well as staff
at partner organizations.
 Feedback from medical referral should always be provided at all levels, while
feedback for non-medical interventions is optional, depending on client wishes.
Monitoring referrals
Feedback from referrals is important as a quality assurance mechanism:
 The organization making the referral can assess the success and appropriateness of
their referrals.
 The organization receiving the referred client can review the records to determine if a
provider who is making referrals needs additional technical support or training.
See Appendix 8-A: Service strategies to facilitate referrals.
Developing a referral network
Functioning referral networks require that HCWs be fully versed in the range of clinics,
departments, units and organizations that provide services to clients with HIV, their
partners and families.
8-6
Malawi PMTCT Trainer Manual
Referral networks take time and commitment to create and maintain. The first step in
creating a network is to list all possible referral resources and create a directory of these
services. A referral network can include the following components:
 A lead organization to coordinate the referral system.
 Regular meetings of network providers or another way for providers to communicate
regularly (eg, e-mail, telephone, newsletter).
 A designated person at each of the organizations, who will be the first contact for
people referred. This person will handle any paperwork involved in processing
referrals and attend network meetings.
 A standard referral form that all network members give to clients and use for
managing referrals.
 A system that tracks referrals and lets network members know when a referral has
been successfully completed and when it has not.
If the PMTCT service has a community coordinator, this person could play a key role in
meeting with community partners and participating in the referral network.
Trainer Instructions
Slide 24
Introduce information on the global impact of HIV and AIDS by reviewing Figure 1.1 To
maximize the benefits of this exercise, ask participants to complete the “Community
Resource Information Worksheet” the day before this unit is taught.
Lead the small group discussion in Exercise 8.1 on community linkages.
Exercise 8.1 Community linkages: small group discussion
Purpose
Duration
Introduction
Activities


Identify the range of services available to people living with HIV
Encourage interagency networking and linkages and facilitate
client referrals to community services.
20 minutes
Once a HCW recognizes that a client meets the criteria for referral,
the next step is to identify the agencies to which the client should be
referred. This exercise will provide participants with a chance to
share information on the continuum of HIV-related services offered
in their community. By the end of this exercise, participants will have
compiled a list of potential HIV-related resources.
 Divide participants into 4-5 small groups based on geographic
location or by association with a particular facility.
 Ask participants to refer to the “Community Resource
Information Worksheet” in their manuals.
 Using this Worksheet as a guide, ask each small group to identify
available community resources and record them on the
Worksheet.
 Ask them to read each category of community resources in the
left-hand column and answer the following questions:
 Are they familiar with a resource for each listing? For
Module 8 Referral for Treatment, Care and Support Services
8-7
Malawi PMTCT Trainer Manual
Exercise 8.1 Community linkages: small group discussion
Debriefing
8-8
example, do they know of a local support group or club for
people living with HIV?
 If so, are they aware of the address and hours of operation?
 For each resource listed, do they know of a contact person for
networking and referral?
 Are there resources missing in their list?
 Are there any other resources that are not included?
 Can key community members be identified to help expand the
resource list?
 Ask each group to assign a spokesperson who can report on the
group’s findings.
 List the services on a flipchart or blackboard as each group
spokesperson provides information.
 Allow up to 10 minutes per group for this process. Depending
upon their list of resources; some groups will finish sooner than
others.
 Request that participants take the opportunity during this training
to secure missing information such as addresses, phone numbers,
contact persons, and hours of operation, and report back to the
group.
Remind participants that establishing linkages requires interagency
teamwork. HCWs need to become familiar with local services,
including the physical location and hours of operation of each agency
or organization, the specific services provided, and a contact name
and telephone number for referrals.
Malawi PMTCT Trainer Manual
Community resource information Worksheet
Use this form to list the contact information for agencies that provide services to women
and families living with HIV.
Community Resources that Support PMTCT Services
Worksheet
Resource Category
We Have
We Need
Testing and counselling
for partners
Health care
(for STIs, reproductive
health, TB treatment,
etc.)
ART clinic
Nutritional support
Support group or club
Community-based HIV
service and faith-based
organizations
Module 8 Referral for Treatment, Care and Support Services
8-9
Malawi PMTCT Trainer Manual
UNIT 2
Community Education, Outreach and Mobilization
Advance Preparation
No additional advance preparation is required.
Total Unit Time: 35 minutes
Trainer Instructions
Slides 25-26
Introduce the unit and review objectives.
After completing the unit, the participant will be able to:
 Discuss the goals of PMTCT community outreach.
 Describe strategies that will encourage community participation in PMTCT
interventions.
 Discuss the importance of male involvement in PMTCT interventions.
 Discuss barriers to male involvement in PMTCT interventions.
Trainer Instructions
Slides 27-34
Before covering the material on community education, outreach and mobilization, invite
participants to share their experiences outreaching to their communities.
Make This Point

Outreach to the community in which your clients live is important for securing
community support. Without the support of formal and informal community leaders,
even a well-managed PMTCT service with sufficient resources is likely to fall short
of its goals.
Community education
A community is a group of people with shared resources, a common interest, shared
goals, or shared tradition and culture. A community can be defined by its geographical
location, its social interactions or social organization.
8-10
Malawi PMTCT Trainer Manual
Lack of communication with communities has hurt the uptake of PMTCT services in
many areas. One of the roles of HCWs is to inform communities of new health problems
such as MTCT, to share information on the practices that can address these problems, and
to help the community adopt new practices and behaviours.
It is recommended that PMTCT services are developed in tandem with PMTCT
communication initiatives so that when the facility is ready to provide PMTCT services,
the community is ready and willing to receive them. These communication initiatives
should not be one-time occurrences, but rather a series of regularly scheduled ongoing
events to support the PMTCT service.
Community outreach
The goals of PMTCT community outreach
include:
 Create awareness and increase knowledge about
Community outreach is a formal
PMTCT and HIV, including the benefits of
attempt to increase public
knowing one’s HIV status.
awareness and support for a
 Create demand for PMTCT services.
service. Outreach work may also
 Influence attitudes, norms, values and behaviour
aim to bring tailored health
regarding PMTCT issues, including infant
education to specific populations,
feeding and community care and support of
with the aim of changing
HIV-affected families.
knowledge and behaviours.
 Fight HIV-related stigma and discrimination to
create a supportive environment for PMTCT
clients and families affected by HIV.
 Provide education and services to people in remote areas with poor access to health
care.
Definition
Community outreach is usually done through health education talks in communities,
musical performances with PMTCT messages, theatrical performances and role-plays,
brochures and pamphlets, posters, pre-counselling informational videos, and radio and
television messages. See Appendix 8-B on how to conduct a PMTCT health education
session.
Messages
A central message of behaviour change communication is that mothers and fathers should
use PMTCT services to:
 Give their babies the chance to be healthy and HIV-free
 Receive HIV care and treatment for themselves and their families if needed
Communication initiatives must also clearly convey that PMTCT interventions are not
100% effective, so that women do not feel they were misinformed if their children are
infected despite adherence to PMTCT interventions.
HCWs should ensure that the messages they use in their communication with the
community are consistent with those in the national guidelines. The messages
communicated by agencies and HCWs should be developed with input from community
organizations, community members, people living with HIV and PMTCT clients.
Module 8 Referral for Treatment, Care and Support Services
8-11
Malawi PMTCT Trainer Manual
Audience
Communication messages should target many audiences. While women of reproductive
age may be the primary audience for PMTCT messages, the messages should also be
created for members of the wider community (e.g., other HCWs outside of the RH and
MCH settings, members of civil society groups, community leaders). The messages may
be different, depending on the audiences. Importantly, specific communication messages
should be created for men, and they should be delivered in venues where men congregate
such as sports stadiums, markets, places of worship and taxi stands. If possible,
influential leaders for men, and leaders of social groups should be brought into the
mobilization process.
Community mobilization
The goal in community mobilization is to ensure that the community participates in:
 Identifying its health problems and the causes of these problems
 Developing possible solutions to these problems
 Identifying the resources necessary to carry out these solutions.
Community mobilization is different from health education and outreach. While
education aims to inform community members to encourage them to pursue a course of
action, mobilization aims to empower community members to name their own problems
and to find their own solutions using their own resources. Community mobilization is
usually a long-term process involving intensive, participatory work with community
members. Health education and outreach is used to get people to participate in existing
HIV initiatives; community mobilization is often used as a tool for getting community
members to explore the values and norms that may underlie the stigmatizing of people
living with HIV, and to motivate community members to initiate projects and activities
that support people living with HIV.
Implementing community outreach and mobilization
Health education activities are a normal part of the duties of many HCWs in Malawi.
Several health facilities have interdisciplinary teams of nurses and public health workers
who are responsible for health education in the community. Busy HCWs may not have
the skills and/or the time to conduct these activities. For this reason, HCWs may want to
consider partnering with governmental and non-governmental organizations that
specialize in community mobilization and health communication, and to work with them
on the larger, more complex communication initiatives.
HCWs who wish to conduct community mobilization activities should receive detailed
training in participatory development communication. For conducting more basic
outreach activities, detailed guidelines on providing health education talks are provided in
the Appendix 8-B, Conducting a PMTCT Health Education Session.
Strategies to increase community participation

8-12
Integrating information, education and communication (IEC) interventions with
PMTCT messages. These interventions may include community meetings, drama,
theatre performances, posters, etc
Malawi PMTCT Trainer Manual



Involving existing community-based committees and support groups (e.g. village
health committees, Edzi Toto clubs, community based organizations, etc), in
implementing grassroots PMTCT activities
Involving community members in PMTCT education, e.g. inviting people who have
used PMTCT services — both women and men — to give motivational talks
Planning and implementing PMTCT activities together with community
representatives, e.g. chiefs, religious leaders
Trainer Instructions
Slides 35-38
Use the slides and information below to facilitate a discussion about the role of men in
PMTCT. Participants may find this section controversial. Feel free to encourage
comments from participants, but do bring the group back to the outline if they go off
topic.
Make These Points


There are culturally-defined male risk-taking behaviours, as well as impediments to
safer sex. These provide a rationale for involving men in PMTCT services.
Men are involved in almost every case of sexual transmission in Malawi, and almost
always have the power to protect themselves and their partners.
Rationale for male involvement
Approximately 14% of adults in Malawi are infected with HIV. Although some of the
transmission may be due to sex between men, by far the primary mode of transmission
amongst adults is heterosexual intercourse. Heterosexual transmission of HIV has an
impact beyond the couple: A large percentage of all cases of HIV in Malawi are infants
and children infected through MTCT. The reality is that men are involved in almost every
case of HIV in this country.
Routine HIV testing in PMTCT services has meant that pregnant women tend to be the
first ones in the home to be tested for HIV. Proactive PMTCT services that involve men
and have educated the community about HIV risk and transmission can prevent women
from being blamed and even punished for bringing HIV infection into the family. Blame
and punishment are all too common, despite the fact that in the majority of cases, women
were infected by their partners.
Men and HIV risk
Risk-taking behaviours increase men’s chances of contracting and transmitting HIV:
 Women are exposed to an increased risk because men are more likely to have more
sex partners, consecutive and concurrent, while women are more likely to be faithful.
 Men who migrate for work and live apart from their families may adopt risky
behaviours (such as paying for sex and using drugs such as alcohol that may
contribute to risk taking) to cope with the stress and loneliness of living far from
home.
Module 8 Referral for Treatment, Care and Support Services
8-13
Malawi PMTCT Trainer Manual



High risk situations involving sexual and drug taking behaviour are supported by
cultural beliefs and expectations about “manhood”.
Men are expected to be strong and daring, to provide food and shelter, to defend
themselves and their families.
Virility is defined by frequent penetration, with young men pressured into having sex
by the need to “prove themselves”.
Sex and power
Studies have shown that in Malawi, men initiate sex in 92% of relationships and
women feel powerless to refuse sex or negotiate safe sex. 55% of women said they
had been raped or forced into sex. Another study in 1999 suggested that men are
socialized to believe that it is not normal for women to actively agree to sexual
intercourse and that coercion is necessary. (Source: Malawi Sexual Assault and Rape
Guidelines).
Impediments to safer sex







Men believe they are invincible and not liable to become infected; “real men don’t get
sick.”
Men visit commercial sex workers presumably for health reasons, mistakenly
believing that going without sex is bad for one’s health.
Condom use is discouraged by concerns that they break easily, are clumsy, reduce
sexual pleasure, and are appropriate only for sex outside marriage.
A belief that contraception is a woman’s responsibility frees men from having to use
condoms.
The perception that women or girls who ask their partners to use condoms are
promiscuous or unfaithful causes women and girls not to push men to use condoms,
for fear of reprisals, including violence and/or a damaged reputation.
The fear of violence makes it more difficult for women to refuse unsafe sex or
negotiate for condom use.
Domestic violence, rape and sexual abuse are not only violations of human rights but
also opportunities for HIV transmission.
Trainer Instructions
Slides 39-41
Re-frame the social and cultural role of men just described to include men as part of the
solution to prevent MTCT.
The inclusion of men as an “opportunity” rather than a “threat” is the surest way to
change the course of the epidemic.
Discuss the role of PMTCT services in taking the lead to change societal attitude and
customs.
8-14
Malawi PMTCT Trainer Manual
Evolving role of men
PMTCT services can help to start changing attitudes by providing community education
that emphasizes that the role of a “good husband and father” is to protect himself, his
partners and his family from becoming infected with HIV.






Men have an important role in prioritizing optimal reproductive health for both
themselves and their wives.
Men have much to offer as fathers, husbands, brothers, and sons when they assume a
greater role in caring for family members with HIV-related illnesses.
Men who contribute more time and money towards family household bills (including
food and rent) not only ease the unfair burden on women, but also actually improve
the health and happiness of their children.
Some men have had to step in and parent the children left behind after losing their
wives and sisters to AIDS. However, the prevailing societal and cultural attitudes
have not made it easy for men to expand their roles.
Men are role models:
 Boys who observe fathers and other men being violent towards women or treating
women as sex objects may believe that this is “normal male behaviour.” and may
act the same way in their relationships with women.
 Observing their families, boys may believe that domestic tasks and taking care of
others is “women’s work”.
 To “learn to become responsible and caring men,” boys must be able to interact
with male adults who reinforce alternative gender roles and fully respect women.
Men can be good communicators:
 Encourage men to talk about their feelings, including communicating about
sexuality, and to openly discuss these with their partners.
 Encourage men to listen to the concerns of their partners. Men are much more
likely to support their partners and address their partners’ concerns when they are
aware of those concerns.
Benefits of involving men in PMTCT
The advantages of involving men in PMTCT services include the following:
 Facilitates understanding of HIV test results
 Reduces blame, domestic violence, harmful cultural practices, and stigma
 Provides men with first-hand information
 Promotes shared decision making and partner support (for family planning, condom
use, infant feeding method)
 Improves adherence to HAART
 Reduces risky sexual behaviour and HIV transmission
Barriers to male involvement



Health system has not yet adapted to male involvement.
Lack of policies enabling men to participate in PMTCT services.
Culture discourages men’s participation in reproductive health programmes.
Module 8 Referral for Treatment, Care and Support Services
8-15
Malawi PMTCT Trainer Manual
Strategies to increase male involvement in PMTCT
Men need to take responsibility for their actions and to understand their role as being part
of the solution. Special effort should be made to:
 Make services more “male friendly”: if men are to be encouraged to participate in
HIV education, counselling and/or testing as part of ANC, then they must be made to
feel welcome by the health staff.
 Further encourage men’s participation in ANC clinics: accommodate men’s work
schedule by considering more flexible working hours at the clinic.
 Emphasize the valued role of men in ensuring that their partners receive the level of
care and support required to have a healthy baby.
 Offer couple counselling to facilitate joint discussion of HIV prevention measures and
risk-reduction behaviours, taking into consideration the concerns of both members of
the couple.
 Treat all cases of STIs: untreated STIs can increase the risk of HIV infection. Make
sure that men with an STI recommend their female partners to go for treatment, since
women may show no symptoms.
 Address gender based violence and empowerment during counselling and health
education sessions. These issues play an important role in HIV-prevention for
women.
 Stress the importance of condoms for preventing STIs and unwanted pregnancy.
Men have a responsibility to:






Respect the rights of women
Protect women’s health including their access to reproductive health services
Prevent unwanted pregnancies
Prevent the transmission of HIV and other STIs
Share household and child rearing responsibilities
Promote the elimination of sexual and physical violence against women
Trainer Instructions
Slide 42
Facilitate Exercise 8.2: large group discussion.
Exercise 8.2 The “male friendly” PMTCT service: large group discussion
Purpose
Duration
Introduction
8-16
To identify ways that PMTCT services can be made more userfriendly for men
15 minutes
It is well accepted that if male partners hear the ANC HIV
counselling messages and PMTCT educational messages they will be
more likely to support the service and their partner’s participation in
it. Participants should think about their own clinic settings and
consider what organizational, environmental or policy changes need
to be made inside and outside of the facility to encourage more men
Malawi PMTCT Trainer Manual
Exercise 8.2 The “male friendly” PMTCT service: large group discussion
Activities
Debriefing
to attend ANC services with their partners.
Participants should remain in the large group. Trainer should lead
the discussion inviting all participants to contribute. The following
questions may be used to guide the discussion:
 How often do your female clients attend ANC or PMTCT
services with their male partners?
 How likely are the men to support their partner’s decision to test
for HIV?
 Will the partner support her decision to take ARVs if she is HIVpositive? How about her decision to practise safer infant feeding
(i.e., exclusive breastfeeding or replacement feeding)?
 Is it common in your area for women to experience negative
repercussions (e.g., violence or abandonment) if they test HIVpositive?
 What can be done to encourage the community’s support of
PMTCT interventions so that all of ANC clients test for HIV and
all those testing HIV-positive accept PMTCT interventions?
 How important is it to involve men in ANC and in PMTCT
interventions?
 What can you do at your clinic to encourage men to attend?
 What organization changes should be made (e.g., longer
hours, open on weekends)?
 Which policy changes need to be made?
 How about changes in services (eg providing on-site couple
counselling)?
 What can we do to change the assumption that ANC clinics
are “female only” venues? (e.g., ads in newspapers, signs on
shop walls, hosting discussion groups at churches)?
Summarize the discussion noting the male-friendliness of our
PMTCT services currently as well as the major changes that we can
implement upon return to work.
Trainer Instructions
Slides 43-46
Conclude this module by summarizing the key points listed below.
Module 8 Key Points


Linkages are formal networks between organizations or agencies and the community.
Making and supporting linkages facilitates the referral of the client and her family for
needed services. Linkages also facilitate the referral of clients from the community
into PMTCT services. The aim of coordinating services through linkages is to give
clients access to a "seamless" continuum of care delivered efficiently and
conveniently as though there was one well-organized deliverer of care.
A referral is made when a healthcare or social service worker guides a client to obtain
services that will meet the client’s need for specific services provided outside the
Module 8 Referral for Treatment, Care and Support Services
8-17
Malawi PMTCT Trainer Manual




8-18
clinic.
Referral networks take time and commitment to create and maintain. The first step is
to list all possible referral resources and create a directory of these services.
Community outreach is a formal attempt to increase public awareness and support for
a healthcare programme. Outreach work may also aim to bring tailored health
education to specific populations with the aim of changing knowledge and
behaviours.
Many women are at an increased risk of HIV infection because of the current or past
behaviour of their partners. In general, men are more likely to have more sex partners,
consecutive and concurrent, while women are more likely to be faithful.
Additionally, there are a number of social and cultural impediments to practising safer
sex, which exacerbate men’s risk of acquiring and transmitting HIV.
It is the responsibility of PMTCT staff, through education and outreach, to initiate the
cultural and social changes necessary to support men to take responsibility for their
actions and to understand their role as part of the solution. PMTCT services may need
to undergo changes to ensure a more inviting atmosphere for men.
Malawi PMTCT Trainer Manual
APPENDIX 8-A Service Strategies to Facilitate Referrals
1) Carry out individual and home needs assessments.
2) Register pregnant and lactating women and orphans.
3) Build the capacity of healthcare workers and social workers to make referrals.
4) Build the capacity of Community Based Home Care (CBHC) services.
a) Expand the number of CBHC workers.
b) Train the HBC volunteers to achieve the following objectives:
i) Discuss facts about HIV, including cultural factors involved in the prevention
of HIV.
ii) Manage HIV-related conditions at home.
iii) Provide advice on nutrition and diet to patients and young children at home.
iv) Explain and demonstrate effective condom use for HIV prevention.
v) Demonstrate good communication and counselling skills.
vi) Facilitate linkages with other care providers to ensure effective care.
vii) Correctly use the monitoring and reporting system.
c) Train family care givers and foster parents.
i) Assist family care givers to provide quality care to clients.
ii) Reduce stigma in the family by providing education on HIV including
infection prevention
iii) Facilitate appropriate linkages with other care provider to ensure effective care
that includes social support.
d) Establish linkages with any other social support systems operating in the
community such as support groups, health facilities, NGOs, and social welfare
committees, etc.
Module 8 Referral for Treatment, Care and Support Services
8-19
Malawi PMTCT Trainer Manual
APPENDIX 8-B Conducting a PMTCT Health Education Session
Basic Steps
Prepare the location for the health talk:
 Set up the seating so that everyone in the audience can see
 Ensure adequate ventilation and light
 Prepare all visual aids
 Prepare the lesson plan
Prepare the audience:
 Greet the audience politely
 Give the audience an outline of what the session will entail
 Ask if everybody is present and ready for the session
 Introduce yourself and others in your team
Present the session:
 Introduce the topic
 Address the key messages on PMTCT
 Elaborate each key point using visual aids as necessary
 Allow questions and answer them factually
 Make the session as participatory as possible: solicit audience thoughts and questions,
include role-plays or other interactive exercises, and allow audience members to
attempt to answer each others questions.
Close the session:
 Summarize key points
 Ask questions to evaluate audience understanding
 Summarize key conversation points and discuss any next steps
 Distribute any educational material or brochures that you would like the audience to
keep.
 Tell the audience that the session is over and thank them for their participation
8-20
Malawi PMTCT Trainer Manual
APPENDIX 8-B Conducting a PMTCT Health Education Session
(continued)
Content
Key content to be included in community education sessions include discussions of the
following:
 Basic HIV information (e.g., how HIV is spread, difference between HIV and AIDS)
 Impact of HIV on communities
 Misconception and myths about HIV
 Psychosocial issues/factors related to HIV
 Interventions to prevent mother-to-child transmission of HIV
 Testing and counselling services
 Improved ANC and modified obstetric care
 Use of ARVs
 Modified infant feeding
 Family planning
 Importance of male involvement
 Care and treatment
Basic health education skills
Use adult learning methods.
It is widely acknowledged that adults absorb new information best when they:
 Are actively involved in the process of learning
 Can share their knowledge and experiences and learn from other participants
 Can apply the new information to their everyday life
 Are thought in a safe, respectful and comfortable atmosphere
Giving effective health talks therefore requires many of the facilitation skills needed for
individual counselling. Presenters and trainers need to be able to make participants feel
comfortable, encourage them to share their thoughts and experiences, and clarify their
statements in non-judgemental ways.
Preparation
Facilitating presentations requires detailed preparation.
 The presenter must know the subject matter well and feel comfortable talking about it
in public. A period of internal reflection may help them develop the self awareness
necessary to feel comfortable discussing the subject matter.
 The presentation script should be prepared well in advance of the presentation and
should be reviewed to make sure that it is written at a level that is linguistically
appropriate for the audience and logically and clearly organized.
 If they will be used, an adequate number of handouts and brochures should be
obtained
 All presentation tools such as flip charts, posters, videos, visual aids and equipment
should be arranged and checked before the session starts.
 The presentation room should be arranged so that there is adequate seating and that all
participants will be able to see.
Module 8 Referral for Treatment, Care and Support Services
8-21
Malawi PMTCT Trainer Manual
APPENDIX 8-B Conducting a PMTCT Health Education Session
(continued)
When giving a speaking in front of a group healthcare workers should
keep the following guidelines in mind:
Movement
 Make sure that the group can see you clearly; do not stay in a corner or behind a desk.
 Move around the room when presenting. Approaching group participants will help



you get your participant’s attention and allow them to respond to your questions
easily.
Face the group when speaking.
Make appropriate eye contact with people in all sections of the group.
Use natural gestures and facial expressions in your presentation. The goal is to appear
relaxed and confident.
Speaking
 Speak slowly, clearly and in a voice loud enough for the group to hear. This is



particularly important if you are giving your talk in a language many in your audience
do not speak as their native language.
Use simple and appropriate language in your presentation.
If you must use new or difficult words, pronounce and explain them clearly.
Try to speak in an enthusiastic, natural voice. Vary the tone of your voice from time
to time—try not to give the entire talk in the same tone as this will become tiring to
the listeners.
Content
 Follow your presentation guide or plan closely, making sure that all important points




are covered.
Use stories and analogies to explain complex concepts.
Encourage participation by inviting questions and comments.
Keep to time. Try not to rush or spend too much time with an early part of the session.
Reiterate key “take home” messages at the end of the session.
Facilitation Skills
One of the health care worker’s main responsibilities is to ensure that everyone in the
group has an opportunity to participate in the session. Effective facilitators promote
discussion among group members and encourage sharing and learning among
participants. In particular, good facilitators should:
 Use open-ended questions to encourage participants to give detailed answers and
interact
 Pay close attention to what participants say and question them carefully to show that
their contributions are valued
 Adopt a non-judgemental attitude toward group members who have cultural,
religious, and medical that are different from your own. This does not mean that you
need to agree with what they say but only that you should moderate your reaction to
their statements
8-22
Malawi PMTCT Trainer Manual
APPENDIX 8-B Conducting a PMTCT Health Education Session
(continued)

The facilitator will have to learn techniques that will increase participation in order to:
Manage talkative participants and those who dominate the group
Ensure that all participants, including quiet or shy group members, have an
opportunity to participate
 Make the group session interactive and participatory rather than a simple lecture
Instead of talking for the entire session, combine talking with times when participants
are asked questions. Make sure to direct questions to different participants.
When asking questions, allow the group sufficient time to answer. Do not supply the
answer too quickly. Do not answer the question yourself every time. If possible, have
participants answer each other’s questions. You can do this by asking: Say, “Can
anyone answer to that question?”
Give encouraging responses to all participant answers. Be polite when correcting
wrong answers
Steer participants’ conversations back to the main discussion when they drift off the
point.
Try to involve all participants in discussions. When a few people have been
dominating the discussion, ask the group if anyone else has an opinion on the topic, or
if everyone agrees with the points that participant has just made.
Use open-ended questions to encourage participants to share their concerns and
knowledge. When participants respond with short “Yes” or “No,” answers ask them
to explain their answers more fully. For example ask “Why do you say that?”
Maintain an open body language that encourages group members to participate. Don’t
cross your arms, frown, or shake your head when participants are speaking.
If you do not know the answer to a question, be honest and say so.










Module 8 Referral for Treatment, Care and Support Services
8-23
Malawi PMTCT Trainer Manual
References
Malawi Ministry of Health. January 2006. Sexual Assault and Rape Guidelines.
Resources
Key Resources:
FAO and WHO. 2002. Living well with HIV/AIDS: A manual on nutritional care and support for people
living with HIV/AIDS. FAO, WHO: Rome, Italy. Retrieved 16 February 2006 from
ftp://ftp.fao.org/docrep/fao/005/y4168E/y4168E00.pdf.
Rutenberg, N, M Field-Nguer, et al. Undated. Community Involvement in the Prevention of Mother-to-Child
Transmission of HIV: Insights and Recommendations. The Population Council and the
International Center for Research on Women: Washington D.C. Retrieved 15 February 2006 from
http://www.popcouncil.org/pdfs/mtct.pdf
Gupta, G, D Whelan and K Allendorf. 2003. Integrating Gender into HIV/AIDS Programmes. International
Center for Research on Women for WHO: Geneva. Retrieved 1 March 2006 from
http://www.who.int/gender/hiv_aids/en/
WHO. July 2003. A reference guide on HIV-related care, treatment and support of HIV infected women
and their children in resource-constrained settings [Draft]. WHO: Geneva. Retrieved 14 February
2006 from www.ahfgi.org/global_pdf/refguide_toc.doc.
8-24