1. Module 3 Counselling, Testing, Social Issues & Safety and Supportive Care in the Work Setting

2. Kenya National PMTCT Training Curriculum Module 3 - June 2005 2 Module 3 Objectives Unit 1- Counselling Describe the importance of effective communication and counselling skills when working in HIV settings. Discuss the integration of HIV counselling and testing and into RH settings. Discuss the HCW’s role in maintaining confidentiality. Provide information to pregnant women about HIV testing.

3. Kenya National PMTCT Training Curriculum Module 3 - June 2005 3 Module 3 Objectives Unit 2 - Testing Describe HIV testing processes. Perform a rapid test correctly. Unit 3 - Safety and Supportive Care in the Work Setting & Care for the Caregiver Describe strategies for preventing HIV transmission in the healthcare setting.

4. Kenya National PMTCT Training Curriculum Module 3 - June 2005 4 Module 3 Objectives Unit 3 (continued) Define universal precautions (UP) in the context of the prevention of mother-to child HIV transmission (PMTCT). Unit 4 - Social and Community Issues Define and identify HIV-related stigma and discrimination issues.

5. Kenya National PMTCT Training Curriculum Module 3 - June 2005 5 Module 3 Objectives Unit 4 - Safety and Supportive Care in the Work Setting & Care for the Caregiver Describe the management of occupational exposure to HIV. Identify measures to minimise stress and support healthcare workers and caregivers.

6. Kenya National PMTCT Training Curriculum Module 3 - June 2005 6 HIV counseling The PMTCT scenario will be used to demonstrate the process of HIV counseling and testing In integration of RH/FP/HIV the aim is to encourage the RH/FP client to have HIV testing

7. Counselling, Testing, Social Issues & Safety and Supportive Care in the Work Setting Unit 1 Counselling

8. Kenya National PMTCT Training Curriculum Module 3 - June 2005 8 Counseling and Testing Services Play a vital role in identifying women who are HIV-positive Provide an entry point to comprehensive HIV/AIDS treatment, care, and support Help clients identify and take steps to reduce behaviours that increase risk of HIV infection or transmission.

9. Kenya National PMTCT Training Curriculum Module 3 - June 2005 9 Counselling and Testing Services Need to be available to all women of childbearing age, especially those who are pregnant. Need to be available to male partners. Offer clients the right to decline HIV testing.

10. Kenya National PMTCT Training Curriculum Module 3 - June 2005 10 Role of the HCW Listen to the client. Understand the choices that need to be made. Help the client make decisions and explore his/her options and circumstances. Help the client develop self-confidence to enable him/her to carry out the decision made.

11. Kenya National PMTCT Training Curriculum Module 3 - June 2005 11 Stages of Counselling Exploration stage Understanding stage Action stage

12. Kenya National PMTCT Training Curriculum Module 3 - June 2005 12 Basic Counselling Skills Self-awareness Communication (verbal and non-verbal) –Active listening –Attending skills –Paraphrasing –Reflecting feelings –Questioning –Clarifying –Summarising

13. Kenya National PMTCT Training Curriculum Module 3 - June 2005 13 Communication Skills Non-Verbal Skills Listening, attending, and observing S O L E R S- SIT facing client O- adopt OPEN posture L- LEAN forward to listen E- maintain EYE contact R- stay RELAXED

14. Kenya National PMTCT Training Curriculum Module 3 - June 2005 14 Communication Skills Non-Verbal communication Use the five senses: –Touch –Sight –Hearing –Speech –Smell

15. Kenya National PMTCT Training Curriculum Module 3 - June 2005 15 Communication Skills Observe the following: –Eye contact –Facial expression –Gestures –Posture and gait –Tone of voice –Affect

16. Kenya National PMTCT Training Curriculum Module 3 - June 2005 16 HIV Counselling and Testing All pregnant women in ANC should receive information about Basics of HIV/AIDS Safer sex practices Prevention and treatment of STIs HIV testing, post-test counselling and follow-up services Prevention of HIV in infants and young children including PMTCT interventions

17. Kenya National PMTCT Training Curriculum Module 3 - June 2005 17 HIV Counselling and Testing Guiding Principles for C & T in PMTCT Confidentiality Informed consent Post-test support and services

18. Kenya National PMTCT Training Curriculum Module 3 - June 2005 18 Approaches to HIV Testing in PMTCT Routine or Opt-Out Strategy Testing routinely offered Opportunity to decline

19. Kenya National PMTCT Training Curriculum Module 3 - June 2005 19 Kenya Preferred Strategy Opt-Out Normalises HIV testing by integrating it into ANC care Increases the number of women who receive testing and PMTCT interventions Adheres to principles of informed consent, confidentiality and post-test support services

20. Kenya National PMTCT Training Curriculum Module 3 - June 2005 20 Pretest Information Counselling Dialogue between client and caregiver to discuss HIV test, implications of knowing one’s HIV status Offered in individual or group settings

21. Kenya National PMTCT Training Curriculum Module 3 - June 2005 21 Couples Counselling Opportunity to encourage men to practice safer sex Encourages male responsibility to protect health of partner and family Reduces “blaming” the woman Identifies discordant couples Improves the couple’s ability to cope with breastfeeding decisions

22. Kenya National PMTCT Training Curriculum Module 3 - June 2005 22 Couples Counselling Discordance One partner tests HIV-positive while the other is HIV-negative. Discuss safer sex options. Refer the couple for treatment, care and support.

23. Kenya National PMTCT Training Curriculum Module 3 - June 2005 23 Considerations in Counselling couples Assure them of confidentiality and support. Create a trusting relationship. Contract with both. Each one’s opinion is important. Observe both verbal and non-verbal communication. Encourage the silent one to share feelings.

24. Kenya National PMTCT Training Curriculum Module 3 - June 2005 24 Post-Test Information Provide test result. Help the woman understand the test result. Provide appropriate PMTCT essential messages. Offer support, information, and referral. Encourage risk-reducing behaviors. Explore and encourage disclosure and partner testing, if safe and appropriate. Encourage follow-up visits.

25. Kenya National PMTCT Training Curriculum Module 3 - June 2005 25 Post-Test Counselling HIV-negative result Prevent future infection. Discuss family planning. Explain issue of discordance. Explore and encourage partner testing, if safe and appropriate.

26. Kenya National PMTCT Training Curriculum Module 3 - June 2005 26 Post-Test Counselling HIV-positive result Clarify understanding. Acknowledge feelings. Review benefits of knowing HIV status. Address immediate concerns. Schedule follow-up visit. Provide name and number of clinic and contact person.

27. Kenya National PMTCT Training Curriculum Module 3 - June 2005 27 Disclosure of HIV Status Disclosure may facilitate Partner testing, if safe and appropriate Prevention of HIV transmission to the partner(s) Access to PMTCT interventions Linkages to partner, family, and community support

28. Kenya National PMTCT Training Curriculum Module 3 - June 2005 28 HIV Testing for Women with Unknown HIV Status in Labour Early labour (Opt-Out) –Provide information on HIV. –Test, unless woman declines. –Offer nevirapine (NVP) prophylaxis. Late labour: –Defer testing until after delivery and before discharge. –Provide information on HIV. –Test unless woman declines. –Offer NVP prophylaxis for baby after delivery and, when appropriate, AZT for infant for 7 days, where available.

29. Kenya National PMTCT Training Curriculum Module 3 - June 2005 29 Key Points Pre-test information, HIV testing and post-test counselling should be available to all pregnant women on a routine (opt-out) basis as recommended by Kenya national guidelines. Healthcare providers and the facility must maintain confidentiality of HIV status. Exploration of partner testing and couples counselling is encouraged. Post-test counselling is important for all women. Emphasise that one partner may be HIV-positive and the other HIV-negative.

30. Counselling, Testing, Social Issues & Safety and Supportive Care in the Work Setting Unit 2 Laboratory Diagnosis of HIV/AIDS

31. Kenya National PMTCT Training Curriculum Module 3 - June 2005 31 HIV Testing Detects antibodies or antigens associated with HIV in whole blood, saliva, or urine Blood sampling most common mode of testing Results of different test can be combined to confirm HIV test results When properly administered, HIV tests offer a high degree of accuracy Proper training critical to ensure accuracy

32. Kenya National PMTCT Training Curriculum Module 3 - June 2005 32 Five Main Steps in HIV Testing 1.Obtain test sample. Blood, saliva, urine 2.Process sample. On site or through lab 3.Obtain results. Keep confidential, method determined by clinic protocols and client 4.Provide results to clients. 5.Provide post-test counselling, support, and referral.

33. Kenya National PMTCT Training Curriculum Module 3 - June 2005 33 Types of Antibody Tests Rapid HIV tests and ELISA are most commonly used HIV tests in ANC setting. Rapid tests commonly used in Kenya and time for obtaining results are: Determine™ – 15 minutes UniGold™ – 10 minutes Instantquick – 30 seconds (used as tiebreaker)

34. Kenya National PMTCT Training Curriculum Module 3 - June 2005 34 Parallel and Serial Testing for HIV Kenya guidelines recommend parallel testing. Parallel testing occurs when two different tests are performed at the same time on the same sample. Serial testing occurs when positive test is confirmed using a different test on the same sample.

35. Kenya National PMTCT Training Curriculum Module 3 - June 2005 35 Antibody Tests: ELISA Identifies antibodies to HIV: indirect measure Blood sample drawn from vein in arm Limitations –Laboratories, trained lab technicians required –Tests done in batches of 40–90 specimens –Reporting may take several days or weeks –Positive results must be confirmed with either another ELISA or with Western blot –Test sensitive to temperature; reagents require refrigeration

36. Kenya National PMTCT Training Curriculum Module 3 - June 2005 36 Viral Tests or Assays Directly detects presence of HIV in blood P24 antigen tests measure one of the proteins found in HIV. PCR (polymerase chain reaction) tests measure viral load by detecting DNA or RNA. –Used to diagnose infants <18 months Cultures seldom done but can be used in HIV diagnosis. Limitations –Require more time than antibody tests –Must be done in lab by skilled personnel

37. Kenya National PMTCT Training Curriculum Module 3 - June 2005 37 Interpreting HIV Antibody Test Positive result Antibodies to HIV present Person infected with the virus Negative result Person not infected OR Person in “window period:” 4 to 6 weeks, up to 3 months after exposure antibodies appear, indicating infection

38. Kenya National PMTCT Training Curriculum Module 3 - June 2005 38 HIV Testing Procedures In HIV testing, proper handling of test devices is important. Infection control and Universal Precautions Proper labeling Proper sample collection procedures Using required sample volume per test

39. Kenya National PMTCT Training Curriculum Module 3 - June 2005 39 HIV Testing Procedures Use proper buffer solution per test Correct timing per test Interpretation of results Proper record-keeping Proper disposal procedures

40. Kenya National PMTCT Training Curriculum Module 3 - June 2005 40 Key Points Rapid HIV testing offers a high degree of accuracy. Three groups of tests for HIV diagnosis –Antibody-detecting assays –Antigen and viral tests, or assays –Viral cultures Serial testing occurs when a positive test is confirmed by repeat testing using a different test. Parallel testing occurs when two different tests are performed at the same time on the same sample.

41. Kenya National PMTCT Training Curriculum Module 3 - June 2005 41 Unit 3 Safety and Supportive Care in the Work Setting & Care for the Caregiver

42. Kenya National PMTCT Training Curriculum Module 3 - June 2005 42 Basic Concepts of HIV Transmission Primary source of HIV infection in the healthcare setting –Blood or body fluids in direct contact with an open wound, or by needle or sharp stick –High-risk MCH settings Obstetric procedures Labour and delivery Immediate care of the infant

43. Kenya National PMTCT Training Curriculum Module 3 - June 2005 43 Bloodborne Pathogens In addition to HIV, bloodborne pathogens include: –Hepatitis B and C viruses –Syphilis –Brucellosis

44. Kenya National PMTCT Training Curriculum Module 3 - June 2005 44 Prevention of HIV Transmission Apply Universal Precautions. –Healthcare worker to patient –Patient to healthcare worker Prevent patient-to-patient transmission. –Sterilise contaminated equipment and devices.

45. Kenya National PMTCT Training Curriculum Module 3 - June 2005 45 Universal Precautions Wash hands. Decontaminate equipment and devices. Use and dispose of needles and sharps safely (avoid recapping, especially two-handed). Wear protective items. Promptly clean up blood and body fluid spills. Use safe disposal systems for waste collection and disposal.

46. Kenya National PMTCT Training Curriculum Module 3 - June 2005 46 Universal Precautions Definition A simple set of effective practices designed to protect health workers and patients from infection with a range of pathogens including bloodborne viruses. These practices are used when caring for all patients regardless of diagnosis.

47. Kenya National PMTCT Training Curriculum Module 3 - June 2005 47 Infection Control Measures Universal Precautions Management of the work environment Ongoing education of employees in all aspects of infection prevention

48. Kenya National PMTCT Training Curriculum Module 3 - June 2005 48 Promoting a Safe Work Environment Implement, monitor, and evaluate use of Universal Precautions. Develop procedures for reporting, and treating occupational exposure to HIV infection. Attain and maintain appropriate staffing levels Provide protective equipment and materials.

49. Kenya National PMTCT Training Curriculum Module 3 - June 2005 49 Education in Infection Prevention Make all staff aware of established infection control policies. Provide ongoing training to build skills in safe handling of equipment and materials. Supervise and evaluate practices to remedy deficiencies.

50. Kenya National PMTCT Training Curriculum Module 3 - June 2005 50 Handling of Equipment and Materials Risk reduction strategies Assess condition of protective equipment. Safely dispose of waste materials. Make available appropriate cleaning and disinfecting agents. Decontaminate instruments and equipment. Monitor skin integrity.

51. Kenya National PMTCT Training Curriculum Module 3 - June 2005 51 Handling and Disposal of Sharps Use syringe or needle once only. Avoid recapping, bending, or breaking needles. Use puncture-proof container for disposal. Clearly label container—“SHARPS.” Never overfill or reuse sharps containers. Dispose of sharps according to local protocol.

52. Kenya National PMTCT Training Curriculum Module 3 - June 2005 52 High-Level Disinfect Boil Steam Chemical Instrument Processing Sterilise Chemical High pressure steam Dry heat Dry/Cool and Store Decontaminate Clean

53. Kenya National PMTCT Training Curriculum Module 3 - June 2005 53 Handling Needles and Sharps Use a puncture-proof container for storage and/or disposal. Do not recap a needle before disposal unless using one-hand technique.

54. Kenya National PMTCT Training Curriculum Module 3 - June 2005 54 Hand Hygiene Recommended practice Wash hands with soap and water using friction under running water for at least 2 minutes. Use alcohol-based hand rubs (or antimicrobial soap) and water for routine decontamination.

55. Kenya National PMTCT Training Curriculum Module 3 - June 2005 55 Personal Protective Equipment Basic personal protective equipment Gloves—correct size Aprons—as a waterproof barrier Eyewear—to avoid accidental splash Footwear—rubber boots or clean leather shoes

56. Kenya National PMTCT Training Curriculum Module 3 - June 2005 56 Safe Work Practices To reduce occupational risks Assess high-risk situations and areas. Develop safety standards and protocols. Institute measures to reduce occupational stress. Orient new staff to protocols. Provide ongoing staff education, supervision. Develop protocols for post-exposure prophylaxis (PEP).

57. Kenya National PMTCT Training Curriculum Module 3 - June 2005 57 Post-Exposure Prophylaxis (PEP) Immediate steps post-exposure –Wash exposed wound or skin with soap and water. –For needle or sharp injury, allow to bleed for a few seconds before washing. –Inform supervisor of type of exposure, and actions taken. –Assure confidentiality, support, and referral for treatment. Short-course of ARV drugs is recommended to reduce likelihood of infection.

58. Kenya National PMTCT Training Curriculum Module 3 - June 2005 58 Guidelines for PEP It is best to begin PEP within 2–4 hours of exposure and no later than 72 hours after exposure. If patient is not infected with HIV, discontinue PEP and retest at 6 weeks, 3 months, 6 months. If patient is infected with HIV, counsel, support, and refer healthcare worker for continued treatment.

59. Kenya National PMTCT Training Curriculum Module 3 - June 2005 59 Guidelines for PEP Currently there is no single approved PEP regimen. Dual or triple drug therapy is recommended and believed to be more effective than a single agent. Follow approved PEP regimen.

60. Kenya National PMTCT Training Curriculum Module 3 - June 2005 60 Compassion Fatigue Behavioural –Frequent mood changes –Eating too much/too little –Drinking/smoking too much –“Accident prone Cognitive –Indecisive –Forgetful –Sensitive to criticism Physical –High blood pressure –Palpitations, trembling –Dry mouth, sweating –Stomach upset Occupational –Taking days off –Arguing with co-workers –Working more hours/getting less done –Low energy/low motivation Signs and Symptoms of Burnout

61. Kenya National PMTCT Training Curriculum Module 3 - June 2005 61 Managing Burnout Peer support group Mentor for confidential support Access resources on coping with stress Refresher courses Structured breaks Time for self and family Exercise, eat properly and rest

62. Kenya National PMTCT Training Curriculum Module 3 - June 2005 62 Key Points Universal Precautions apply to all patients, regardless of diagnosis. Key components include: –Safe disposal of infectious waste materials –Safe environmental practices –Safe handling and disposal of sharps –Handwashing –Use of personal protective equipment –Decontamination of equipment

63. Kenya National PMTCT Training Curriculum Module 3 - June 2005 63 Key Points Infection control measures include: –Universal Precautions –Management of the work environment –Ongoing education of employees in all aspects of infection prevention Post-exposure prophylaxis (PEP) is short- term ART that reduces the risk of HIV infection after occupational exposure.

64. Kenya National PMTCT Training Curriculum Module 3 - June 2005 64 Key Points Compassion fatigue/burnout is related to intense, prolonged job stress but can be managed by individual and organisational supports.

65. Counselling, Testing, Social Issues & Safety and Supportive Care in the Work Setting Unit 4 Social and Community Issues

66. Kenya National PMTCT Training Curriculum Module 3 - June 2005 66 HIV/AIDS in Women Number of women who are HIV-infected worldwide is increasing. Women are more vulnerable to AIDS. Fear of social stigma, abandonment, and feelings of isolation can prevent access to services.

67. Kenya National PMTCT Training Curriculum Module 3 - June 2005 67 Stigma and Discrimination HIV/AIDS-related stigma is increasingly recognised as the single greatest challenge to slowing the spread of HIV/AIDS. Most effective responses to HIV/AIDS are those that prevent stigma and protect the rights of PLWHA.

68. Kenya National PMTCT Training Curriculum Module 3 - June 2005 68 Definition of Stigma Stigma refers to unfavourable attitudes and beliefs directed toward someone or something.

69. Kenya National PMTCT Training Curriculum Module 3 - June 2005 69 Themes Related to Stigma Attitude and actions are stigmatising. Choice of language may express stigma. Lack of knowledge and fear foster stigma.

70. Kenya National PMTCT Training Curriculum Module 3 - June 2005 70 Themes Related to Stigma Shame and blame are associated with stigma and HIV. Stigma makes disclosure more difficult. Stigma can exist, even in a caring environment.

71. Kenya National PMTCT Training Curriculum Module 3 - June 2005 71 Consequences of Stigma in PMTCT Programmes Discourages women from accessing ANC services Prevents access to HIV CT and PMTCT services Discourages disclosure of HIV test results Discourages acceptance of PMTCT interventions Discourages use of recommended PMTCT safer infant-feeding practices

72. Kenya National PMTCT Training Curriculum Module 3 - June 2005 72 PMTCT Programme Level Intervention Maintain policies against discriminatory recruitment and employment practices. Support workers who are HIV-infected. Offer flexible hours and access to healthcare services.

73. Kenya National PMTCT Training Curriculum Module 3 - June 2005 73 PMTCT Programme Level Intervention Establish policies that guarantee all clients equal treatment regardless of status. Ensure procedures for reporting discrimination and protocols for disciplining staff. Promote programme policies to staff and clients.

74. Kenya National PMTCT Training Curriculum Module 3 - June 2005 74 Key Points While stigma reflects an attitude, discrimination is an act or behaviour. Stigma and discrimination are interlinked. Stigmatising thoughts can lead to discrimination. PMTCT programme staff have a responsibility to respect the rights of all women and men, irrespective of HIV status.

75. Kenya National PMTCT Training Curriculum Module 3 - June 2005 75 Key Points HIV-related stigmatisation and discrimination may discourage PLWHA from accessing key HIV services. Encourage PMTCT staff to serve as role models by treating PLWHA just as they would treat clients assumed to be HIV-negative.