Basic education programme

Mzake ndi mzake
Prevention Treatment Care Support Prevent Treat Care Support Preventing Treating Caring Supporting Prevent Treat Care Support Prevent Treating Caring Supporting Prevent Treat Care Support Care Prevention Treatment Sourcebook for HIV and AIDS peer group education

1

2

Basic education programme

Mzake ndi mzake
Prevention Treatment Care Support Prevent Treat Care Support Preventing Treating Caring Supporting Prevent Treat Care Support Prevent Treating Caring Supporting Prevent Treat Care Support Care Prevention Treatment
Edited by Andy V Byers

Sourcebook for HIV and AIDS peer group education
3

Published by GTZ Basic Education Programme, P O Box 31131, Lilongwe 3, Malawi © GTZ 2009 The choice, presentation of facts contained and opinions expressed in this manual are responsibility of the editor and the conributors and do not necessarily represent the views of GTZ. Any part of the manual including illustrations may be duplicated, photocopied, reproduced or adapted for non-profit purposes without permission from GTZ, as long as sources are acknowledged.

4

Dedication
This manual is dedicated to the thousands of Malawians, who have participated as peer leaders and group members, in the Mzake ndi mzake peer group education for HIV and AIDS prevention project. We have included hundreds of their observations and quotations. Their contributions have greatly enriched this publication.

Acknowledgements
This book is a complete revision and expansion of the first edition of Mzake ndi mzake and it would be impossible to name the hundreds of people who have helped to create it, but we must single out a few for special recognition. We give thanks to the creators of the first edition of Mzake ndi Mzake which was developed from the work of Kathleen and James Norr and Chrissie Kaponda, with the assistance of the health professionals of the Kamuzu College of Nursing. The Mzake ndi mzake peer groups contributed ideas and suggestions for this edition: • Lilongwe Primary Teacher Training College • Blantyre Primary Teacher Training College • Karonga Primary Teacher Training College • Kasungu Primary Teacher Training College • St Joseph Primary Teacher Training College • Maria Tsvere, GTZ consultant and lecturer in HIV and AIDS at Chinoyi University, Zimbabwe led the first revision workshop. • Venencia Kabwila, formerly manager of the GTZ HIV and AIDS programme. • Sindisiwe Kabwila, former GTZ HIV and AIDS mainstreaming advisor, planned and directed and the revision. • Lillian Muyunda Byers, Acting Country Director, International HIV/AIDS Alliance, Lusaka, Zambia contributed scores of activities and observations. • Andy V Byers, GTZ consultant, redesigned and expanded the original draft of Mzake ndi mzake by including activities drawn from his publications Exploring Religion and Morality (Oxford University Press) and The Science Teachers Handbook (Heinemann). He illustrated this edition with his own drawings and those of Isaiah Mphande, Paul Ndunguru, Madalitso Chauluka and Rawlings Demba. • Wilfried Goertler, former GTZ Team leader who initiated and encouraged the revision process. • Georg Mades, Malawi GTZ Team leader, whose quiet determination and unflinching support brought this book into being.

5

Contents
Introduction ............................................................................................ What it means to be a peer educator ..................................................... How to use the manual .......................................................................... How to conduct a session ....................................................................... 11 12 13 14

Unit 1 The Importance of HIV and AIDS Prevention..................... 16
1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 1.10 1.11 1.12 1.13 1.14 1.15 Meeting for the first time .............................................................. 16 Fears and hopes about Mzake ndi Mzake .................................... 16 What are the aims of Mzake ndi Mzake ........................................ 17 Deciding on expected group norms .............................................. 17 How much do you know about HIV and AIDS? .......................... 18 What is difference between HIV and AIDS? .................................. 19 How does HIV weaken the immune system? ............................... 19 Research to stop HIV with different drugs ................................... 20 HIV and AIDS worldwide .............................................................. 21 HIV and AIDS in Malawi ............................................................... 22 Why is HIV/AIDS prevention important to our community?...... 22 What is the impact of HIV/AIDS on the individual? .................... 23 What is the impact of HIV/AIDS on the family? .......................... 23 What is the impact of HIV/AIDS on the community and nation? 23 What is the impact of HIV/AIDS on school-age children ............. 24

Unit 2
2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22 2.23 2.24

Preparing for behaviour change ......................................... 25
Assignment review .......................................................................... What are the most important things in your life? ......................... What are the most important things in life for your group? ........ How can I build high self-esteem? ................................................. Everyone is unique and special ...................................................... How can we develop empathy? ..................................................... What is happening in Malawi today ? ........................................... Which negative behaviours in our society need changing? .......... Why should we discuss values, virtues and vices? ........................ What is a good person? .................................................................. What are the major virtues and vices in society? ........................... Do different people need different virtues? ................................... The human values in The Millenium Development Goals ........... How are virtues and vices developed ? ........................................ Why do we behave as we do? ........................................................ Rights and responsibilities ............................................................ How to make the right decision .................................................... Is there a struggle going on within me? ........................................ When free will clashes with the golden rule .................................. How do I lose self-control or self-discipline? ................................. How do I develop and nurture self-control? ................................. How can I change negative behaviour into positive behaviour? Groups can unite and divide us .................................................... How do prejudice, stigma and discrimination divide people?...... 25 25 26 27 28 28 29 30 31 32 33 33 34 35 36 37 37 38 38 39 39 40 41 42

6

Unit 3 Relationships and human sexuality .................................... 43
3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10 3.11 3.12 3.13 Assignment review ......................................................................... What is love?................................................................................... Sex and sexuality ............................................................................ Elements of human sexuality ........................................................ Sexual development ....................................................................... Sex, love and behaviour change..................................................... The external features of the female reproductive system ............. The internal features of the female reproductive system .............. The features of the male reproductive system .............................. What should we call the male and female reproductive parts? .... Over 30 reasons why people have sexual relationships .............. Frequently asked questions about sex .......................................... Assignment...................................................................................... 43 43 44 44 45 46 47 47 48 48 49 50 53

Unit 4 Ways of preventing the transmission of STIs .................. 54
4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 4.18 4.19 4.20 4.21 Assignment review ......................................................................... Which body fluids contain the HIV? ............................................. How do people get infected with HIV? ......................................... How to prevent HIV infection through blood contact .................. How is HIV/AIDS not transmitted? .............................................. What are some signs or symptoms of an STI ?.............................. Complications of sexually transmitted infections ........................ Are there other ways for people to get STIs? ................................ What would you do if you got an STI? ......................................... How can STIs increase our chances of HIV infection? ................. How many people will Cecilia share body fluids with? ............... How many people have you shared body fluids with? ................ What is the ABC of safe sex? ......................................................... What is safer sex ? ......................................................................... Thinking about sex without a condom? ....................................... How fast does HIV spread ? .......................................................... What factors put men at risk of STIs and HIV infection? ............ What factors put women at risk of STIs and HIV infection? ...... Why are young girls vulnerable to HIV infection? ...................... Why are young people at high risk of HIV infection? .................. Assignment .................................................................................. 54 54 55 56 57 57 58 59 59 59 60 60 62 62 63 63 64 65 66 67 67 68 68 69 69 69 70 70 70 71 71

Unit 5
5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9

Condoms .................................................................................... Assignment review ......................................................................... If a man can carry a condom why can’t a woman?....................... How strong is a condom?............................................................... Don’t condoms have holes in them that allow HIV through? ..... Condoms are not romantic ............................................................ Sex with a condom is like eating a sweet inside the wrapper ...... Can condoms come off and remain inside a woman? ................. But we never use condoms don’t you trust me?........................... But I love you, why use a condom? .............................................
7

5.10 5.11 5.12 5.13 5.14 5.15 5.16 5.17 5.18 5.19 5.20 5.21 5.22 5.23 5.24

Condoms can cause impotence, cancer and TB! ........................... Semen is necessary to help a baby develop properly ................... Condoms are only used by prostitutes and the unfaithful ........... Doesn’t promoting condom use encourages promiscuity? .......... Can I wash the condom and use it again? ..................................... Preparing to demonstrate how to use condoms ........................... How to select and store condoms .................................................. How to use a male condom correctly ............................................ The female condom ...................................................................... How to use the female condom correctly ..................................... The lifeboat game: values and condoms ....................................... Role play: Advising a friend about safer sex ................................. Role play: Talking about prevention of STIs ................................ Role play: Dispelling false beliefs about condoms ........................ Assignment: Discussing condoms with a partner or friend ........

71 71 72 72 72 73 73 74 75 76 77 78 78 79 79

Unit 6
6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 6.10 6.11 6.12 6.13

Talking with your partner about HIV .................................. Assignment review ......................................................................... Barriers to communication about safer sex ................................... What is needed to change risky behaviour? .................................. Communicating with your partner about safer sex ..................... How does an aggressive partner behave? ..................................... How does a passive partner behave? ............................................ How does an assertive partner behave? ........................................ Responding to an aggressive partner ............................................ Finding a mutually acceptable solution ......................................... Can condoms be an enjoyable part of your love life? ................... Role play: Talking about safe sex with a new partner ................... Alcohol drinking or drug use and sexuality ................................. Assignment .....................................................................................

80 80 80 82 82 83 83 83 84 85 86 87 88 89

Unit 7 HIV and AIDS testing and ARV drug treatment ............. 90
7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 7.9 Assignment review ......................................................................... What happens when you go for VCT? .......................................... What are some reasons for not going through VCT? ................... What are the advantages of going through VCT? ........................ Why is counselling an important part of VCT? .......................... What is the clinical approach to diagnosing AIDS? ..................... What is the laboratory test approach? .......................................... What are the advantages of finding out you are HIV negative? .. What are the advantages of testing with your partner if you learn that both of you are HIV positive? ................................ 7.10 What are the advantages of testing with your partner if you learn that one of you is HIV positive and the other one is not? ... 7.11 Where can I go for a free VCT? ..................................................... 7.12 What are ARVs ? ............................................................................ 90 91 91 91 92 93 93 94 94 95 95 96

8

7.13 What are the four groups of ARV drugs and why do we need to use four of them? ....................................................................... 7.14 What must we know about ARVs if we want to use them? ......... 7.15 When should a person start taking ARVs? .................................... 7.16 What happens before someone starts taking ARVs? .................... 7.17 Where can people get ARVs? ........................................................ 7.18 What is HIV resistance to ARVs? .................................................. 7.19 How can we reduce the rate of resistance to ARVs? ..................... 7.20 What challenges are faced by people taking ARVs? .....................

96 97 98 98 98 99 99 100

Unit 8 Things we can do to fight the spread of HIV.................. 101
8.1 8.2 8.3 8.4 8.5 8.6 8.7 8.8 8.9 8.10 8.11 8.12 8.13 8.14 8.15 8.16 8.17 8.18 8.19 8.20 8.21 8.22 8.23 8.24 8.25 8.26 8.27 8.28 8.29 8.30 8.31 8.32 Assignment review......................................................................... How to carry out a risk assessment .............................................. Ways to protect groups who are at risk of HIV infection ............ Which factors in our society encourage the spread of HIV?........ Cultural practices that increase the risk of HIV infection ............ Do Malawian laws allow nkhanza? ............................................... Malawi’s National HIV/AIDS policy ............................................. Revising: stigma and discrimination? ........................................... Revising: causes of stigma and discrimination ............................. Identifying stigma and discrimination in our communities......... How can we stop discrimination in our communities ................. Role play: Helping to reduce stigma about HIV and AIDS ........ Do humorous cartoons help in the fight against HIV .................. Ways to protect widows from HIV infection ................................ Ways to protect young girls from HIV infection .......................... What can we do to reduce early sexual activity in children? ....... Ways to protect young children from HIV infection .................... Ways to protect women and men from HIV infection ................ More ways a community can protect itself from HIV infection... Teacher networks to fight HIV : T’LIPO ....................................... Networks to fight HIV: MANET ................................................... Malawi’s sex industry and the spread of HIV/AIDS .................... Is there an Education-vaccine against HIV? ................................... Does staying silent on homosexuality help spread HIV/AIDS ?.. Looking closely at a global approach to HIV prevention.............. How are people who spend time in prison put at risk?................ How does trafficking for sexploitation spread HIV and AIDS? .... How does HIV/AIDS affect the elderly? ....................................... Talking to children about sexual and reproductive health........... Role play: Discussing sex education for young children .............. Role play: Talking to a child about sex and HIV/AIDS................. Keeping children safe from sexual abuse and HIV ...................... 101 102 103 103 104 105 106 107 107 108 109 110 110 111 111 112 113 114 115 116 117 118 120 121 122 123 124 125 126 127 128 128

Unit 9

Living positively with HIV/AIDS ........................................ 129

9.1 Assignment review ....................................................................... 129 9.2 How do different people react when learning they are HIV+?..... 129 9.3 What causes stress for people living positively with HIV?............ 130

9

9.4 9.5 9.6 9.7 9.8 9.9 9.10 9.11 9.12 9.13 9.14 9.15 9.16 9.17 9.18 9.19

Living positively with HIV and AIDS ........................................... HIV and nutrition: Eating positively ............................................ Which food groups should be used by PLWHA? ........................ Which medicinal plants can b used by PLWHA?......................... How can foods relieve common symptoms of HIV/AIDS? ......... Which recipes can be used to alleviate diarrhoea?........................ HIV and hygiene: positively clean ................................................ Does spirituality strengthen the immune system?....................... Deep breathing and quiet time ..................................................... Role play: Talking about living positively with HIV and AIDS ... Succession planning ...................................................................... What things should you put in your own will? ........................... What things should you put in your own memory book? .......... What things should you put in your own memory box? ........... Why is home-based care so important? ........................................ When should a family start home-based care for PLWHA?.........

131 132 133 134 135 136 137 138 139 139 140 141 141 141 142 142

Unit 10 Educating caregivers about HIV and AIDS.................... 143
10.1 10.2 10.3 10.4 10.5 10.6 10.7 10.8 Assignment review: Concerns of PLWHA and their caregivers... Practical ways of preventing HIVcross-infection........................... What is the role of counselling in home based care? ................... What forms of counselling can a person access in Malawi? ........ How can we reduce opportunistic infections? ............................. How can health workers help families with PLWA? .................... What can care givers do in the fight against HIV and AIDS? ..... Living positively: Further ideas for role plays ............................. 143 144 145 145 146 146 147 147

Unit 11 Preventing Mother-To-Child Transmission (PMTCT).... 148
11.1 11.2 11.3 11.4 11.5 11.6 Assignment review: What is mother-to-child transmission?........ During pregnancy: preventing mother-to-child transmission .... During childbirth: preventing mother-to-child transmission ..... During breatfeeding: preventing mother-to-child transmission . Why is it dangerous for a mother to mix feed a baby? .............. . Role play: Partners talking about having an HIV free baby ........ 148 148 149 150 151 152

Appendix ................................................................................................... 153
The A to Z against HIV: it’s much more than just ABC .............................. Facilitation techniques ................................................................................. Planning for your new Mzake ndi mzake peer group ................................. The TALULAR Challenge ............................................................................ More Talular ideas ....................................................................................... Evaluating peer group activities .................................................................. Glossary of terms ......................................................................................... References and further reading ................................................................... Certificate ................................................................................................... 153 158 159 160 162 166 168 170 172

10

Introduction

Welcome to Mzake ndi mzake, the peer group HIV and AIDS education project. Although this book is aimed at peer educators, we hope that it will also serve as a useful sourcebook for others interested in educating themselves and others. Today, people’s health is threatened by HIV and AIDS. Worldwide, just 1 in every 5 people at risk of being infected with HIV, has access to basic prevention services. This book has been produced to equip peer educators, with knowledge and skills to enable them to disseminate information on STIs, HIV and AIDS. This will help them to develop the attitudes needed to encourage positive behaviour change. We hope it will assist in going further than the basic messages of ABC for HIV prevention. It is essential to go ‘beyond the ABC of HIV’, because a present many people still don’t abstain from unprotected sex, they aren’t faithful to their partners and rarely if ever use a condom. After going through the activities, it is hoped that you will be able to: • explain the basic facts about human sexuality, STIs, HIV and AIDS • protect yourself and others from HIV and AIDS by changing any behaviours that put people at risk • help yourself and others in your community to avoid getting infected by STIs, HIV and developing AIDS • describe how a wide variety of social factors influence the spread of HIV and AIDS • encourage yourself and others in your community, to live positively with or without HIV and AIDS When working in small groups of friends, people feel more comfortable about sensitive and personal concerns. Many people also trust information that is suggested by their friends. They often develop a sense of responsibility and ownership when carrying out an action planned and developed by their peers. It is often easier to contemplate and support successful behaviour change within such a group. Please remember, that this manual is not a substitute for professional medical advice. Peer group members and the community members they reach, should regularly consult their doctors or qualified medical health practitioners in matters relating to their health, particularly in respect to symptoms and treatment which require diagnosis or medical attention. It is essential that people who have been exposed to the risk of HIV, and their sexual partners, seek professional medical diagnosis and treatment.

11

How to use the book
This book has been described as creative mix of ideas contributed by innumerable people. Many authors have written or suggested activities, so you will find a wide variety of styles and a certain amount of repetition. We hope that this variety adds to your appreciation of the many hands that have so generously worked to make this book possible. There are over 200 activities in the eleven units, which you can combine and cover in whatever order your group decides. But, we suggest you follow the general order in the book unless you have important reasons not to do so. The first unit looks at the importance of HIV and AIDS prevention, and unit two looks at preparing for behaviour change. Topics in these two units reappear throughout the book, so you should become familiar with the contents, and refer back to them if or when necessary. All of the activities are listed in the contents pages, so you are strongly advised to keep the checklist up-to-date, in order to record the activities you have covered. Each unit ends with an evaluation activity that the peer group completes. Use the evaluation questions to help you assess your accomplishments, challenges, including how many meetings are held and how many people participate.

What is a peer educator
Peers are people who share similar interests and may live or work in the same place. Peer education is a process of sharing information amongst peers at a place where they feel safe and comfortable. Peer education provides a means of delivering culturally sensitive messages from within. Mzake ndi mzake peer groups are informal gatherings of people who share a common desire to protect themselves and their loved ones from HIV. Mzake ndi mzake peer educators are group members who have learnt how to facilitate on the themes of HIV/AIDS prevention, treatment, care and support. Peer educators are concerned about their peers and regard themselves as responsible opinion leaders. The role of a peer educator is to: • convene meetings and facilitate the activities suggested in the book • act as a role model in the community and influence behaviour change • lead group discussions to identify the activities to be covered in each session • encourage group members to identify activities that they would like to cover • encourage members to keep a record of the activities covered • motivate peers to share experiences and support each other • counsel those who wish to confide in you and those who need your help • distribute condoms and be ready to openly discuss proper use of condoms • manage time wisely, be assertive, remain focused and avoid discussing off topic • evaluate the meetings using the evaluation questions on page 166

12

You will learn how to become a peer educator by working through the book. By using it as a guide, you will practice conducting peer group sessions. Finally, when you have completed the training, you will be awarded a certificate of recognition as a qualified peer educator. After certification, you will be able to work with groups of interested people in your institution, workplace or community.

How to conduct a session
Always remember that the main aim is to get people to practice safe sex and safer sex. The following suggestions have been made by peer group members and we hope that you find them helpful. You do not have to use all of the ideas, but we suggest you discuss the points with other peer group members. • • • • • • • • • • • • • • • • • • • • • • Mzake ndi mazake peer groups should be small enough so that everyone can participate fully in the chosen activities A meeting could last from one to two hours You do not have to finish a whole unit in one session and are free to run more shorter sessions if you wish Facilitation is not lecturing and peer educators need to learn how to assist the group without taking it over At the beginning it is helpful to work together with another peer educator and co-lead the activities If necessary ask fellow peer educators questions or for support As you become more experienced, you will gain confidence and be more selfreliant. Talking about sexual behaviour may not be easy, because it is a very private subject and people often do things they would not like to reveal to others. Help the group find a way to talk honestly and openly about sexual and other important matters. Make everyone feel comfortable and free to talk about personal feelings Be friendly helpful and approachable then your peers will feel free to open up if you are open and non-judgmental You need to become self confident and dependable Show empathy and understanding to group members and they will seek counselling and talk about sensitive issues Participants will learn more from you if you are patient and a good communicator Be mature in the way you handle the individual group members Encourage members to be supportive of each other Stop or discourage any judgmental behaviour or laughing at what others say Respond forcefully to statements that belittle or stigmatise others Create a climate of trust and openness within the group Familiarise yourself with the activities via the contents pages of the book Guide the group to work together to choose a unit or a selection of activities Check and familiarise yourself with any background information, points for discussion or specific resources required

13

• • • • • • • • • • • • • • • •

• •

• • • • • •

Collect the resources you will require and organise other related logistics. If you are going to use a resource persons make sure they are available Decide on a simple introduction to the session. Introductions can be in the form of a song, dance, poem, quotation (point to ponder), poster or another art form When are you going to work individually, in pairs or larger groups? How big will your working groups be and where will they sit? Consider using an ice breaker to keep groups alive and reduce any tension. Let group members discuss what they already know about the topic or activity before reading the list of peers’ suggestions One of the most satisfying parts of being in a peer group is when one, or more, people in the group can accurately explain a topic or answer the question, so never read the points for discussion before ‘opening the floor’ to your group Some activities later in the book, do not have a statement asking you to discuss a topic, this is because it is assumed that the group will decide what to do next Check all the bullet points mentioned in an activity Bullet points for discussion are listed to help you make sure that a great variety of ideas are considered You may not agree with all the points suggested Hundreds of points were suggested by previous peer group members and that is why you will notice that they often read as if spoken by different people Admit when you are not sure of something that you may be asked about If you are not sure of an answer you can say something like, Does anybody in the group know an answer? then say, Iam not sure about that, but we should try to find out before the next session. Avoid imposing your own views or beliefs on the group, no matter how valued they may be If peer group members have a heated argument on a topic and cannot agree on something, and this is holding up the session, then say something like, Well, let’s agree to differ on this particular point and move on. Alright? Some discussions are private and sensitive and you may feel uncomfortable at times Move and talk in a way that makes you feel comfortable. Some things you will talk about in peer group meetings are confidential so people’s names and certain topics should never be discussed outside of the meetings When asking questions, pause long enough to allow people to think, before you yourself give answers or continue talking Collect feedback on the session by using the evaluation questions. Before ending a session, ensure that members are clear about the place and starting time of the next session.

14

The following list of suggestions were considered very important.
TIMING ACTIVITIES: Read through each activity in advance of the meeting. This will help the group to decide the amount of time that they will spend on each activity. Groups can combine activities, so that more time is available to cover the issues that the whole group considers particularly important.

More than the ABC of HIV: You are familiar with the ABC message for HIV prevention. By the end of the course you will have created your own A-Z of HIV prevention, treatment, care and support. See page 157 for ideas for your A-Z of HIV. Create and include messages about protecting vulnerable groups from HIV. Groups such as pregnant women, unborn babies, new-born babies and the impoverished. See page 103 for a full list of groups that are at risk and need assistance.

PICK-AND-MIX ACTIVITIES: Some peer group members will know a great deal about HIV and AIDS, while others may not. As a group or as individuals, you can cover the units or activities in any order. The manual is designed so that, if you wish to, you can ‘pick-and-mix’ activities that may deal with related topics, which are of particular relevance to you or your group. Keep track of your individual and group progress. Whenever you complete an activity put a tick in the box on the contents page. USE A VARIETY OF TEACHING/FACILITATING TECHNIQUES: Discussions are important, but many activities can be covered by using debate, games, drama, drawing, song, dance, story and poetry. See page 162 for more ideas. TALULAR IDEAS: Adding TALULAR (Teaching And Learning Using Locally Available Resources) ideas to group activities will enrich the experiences of perticipants. See page 164 for an introduction to TALULAR. PRIVATE STUDY & ASSIGNMENTS: The whole group may decide to select some activities as assignments or for private study, to be carried out between the meetings. This will mean that more of the group time is available to cover the issues that are considered particularly important. Points to ponder.... Messages..... Log book... Can you work out why certain suggestions are marked with a while others are marked with a cross

15

Unit 1 The Importance of HIV and AIDS prevention
Introduction
Tens of thousands of Malawians have died from AIDS, probably a million people are infected with HIV and all of us have been affected in one way or another by the disease. We have over 800,000 children orphaned by AIDS and it is also killing hundreds of teachers and other government workers every year. If we do not organise effective HIV and AIDS prevention training things will get even more difficult. This training is important because it could save your life and the lives of many others close to us.

Learning outcomes
By the end of this unit, you will be able to: • state a few facts about each other • briefly explain the extent of the HIV and AIDS pandemic • describe the impact of HIV and AIDS • explain the importance of HIV and AIDS prevention • assess your level of knowledge of basic information about HIV and AIDS

Activity 1.1 Meeting for the first time
Divide the group into pairs. If there is an odd number of people, one person should be added to another pair to make a group of three. Ask them to find out the following: 1 Your partner’s name 2 Three interesting facts about your partner 3 Why your partner wishes to join the Mzake ndi Mzake peer education group 4 If they know the meaning of the terms HIV and AIDS • After a few minutes the group should come together again • Each person should introduce and describe their partner to the group • Summarise (on the chalk board) why people joined the peer group

Activity 1.2 Fears and hopes about Mzake ndi Mzake
This activity should provide you with an opportunity to voice fears and hopes (or expectations) of the Mzake ndi mzake programme. What to do next: • divide a piece of A4 paper into four • explain that no names should be put on the papers which will be displayed later in the session • think about what you expect or hope to learn from the Mzake ndi mzake programme • write down two things you hope will not happen during the programme (each answer should be written on a separate paper) • write down two things you hope will happen during the programme (each answer should be written on a separate paper) • ask volunteers to give the meanings of the terms HIV and AIDS • write the meanings on the board (HIV means Human Immmuneodeficiency Virus and AIDS means Acquired Immune Deficiency Syndrome)

16

• After everyone has finished, ask participants to put their papers in two bags or boxes. One bag labelled for hopes or expectations and one labelled for fears. • Ask one or two participants to post the fears and another one or two to post the hopes or expectations. They may also be grouped lying flat on a table top if agreed. Let the participants view the two sets of papers and talk casually about their observations.

Activity 1.3 What are the aims of Mzake-ndi-mzake?
When all the participants are seated, review the hopes or expectations expressed on the papers on display. Briefly go through them and explain those likely to be met by the training and those which may need further research during or after the course. Write the aims of Mzake ndi mzake on the board and read them out. The training programme is designed to enable you to: • explain the basic facts about human sexuality, STIs and HIV and AIDS • carry out a personal risk assessment to discover if your behaviour puts you at risk of HIV infection • protect yourself from STIs especially HIV and AIDS by changing any behaviours that put you at risk • promoting positive behaviour change and so help yourself and others in your community to avoid HIV and AIDS • encourage and support those in the community infected with HIV to live positively with HIV and/or AIDS

Activity 1.4 Deciding on expected group norms
Discuss what ground rules the group will use during meetings. It is up to the you and the group, to modify them and add more rules as you may see fit.’ Points for discussion - bring up only if not mentioned - add ideas you discover What have peer group members suggested? • Stay on schedule • One person speaks at a time • Any question asked is a good question • Everyone has a right to change his or her opinion both during and after a session • Everyone is allowed to express his or her opinion • Respect opinions of everyone • Enjoy the discussions • We are all learners but all of us have something to teach others • If a member of the group consistently breaks group rules then the whole group will meet to decide what should happen Point to ponder I know why I would make an excellent group leader, it’s because I have an unshakeable confidence in my own ability to always make correct decisions. Discuss.

17

Activity 1. 5 How much do you know about HIV and AIDS?
This ball game gives everyone an opportunity to assess their level of knowledge on basic information about HIV and AIDS. It is also an ice-breaker to break the tension amongst everyone. Many people are confused about what HIV and AIDS is and how it is spread. This game gives everyone a chance to review some of the things people say about HIV and AIDS. Some of the things you will hear are true while others are false. How to play the game • Move your chairs into a circle • Ask everyone to stand up • Throw the ball to any participant • As soon as the catch is made the leader should asks one of the 20 questions shown below • The person catching the ball should respond by saying whether the statement is true or false. • If the catcher gets the question wrong, they sit down in their chair and miss a turn • The catcher then throws the ball to another participants and the leader asks another question • Throw the statements randomly at least twice • The reasons for some answers will become clearer as we go through the training Choose the statements from the following list 1 HIV is the same as AIDS 2 A person only gets AIDS when HIV destroys the immune system 3 A person will know right away if they have been infected with HIV 4 A blood test will always show that you are infected with HIV 5 You can always tell just by looking whether a person has HIV or AIDS 6 There are many symptoms of AIDS 7 Antiretroviral drugs cure AIDS 8 Faith healing cures AIDS 9 All people who look well are HIV negative 10 People who test HIV negative do not have the virus in their body 11 Some people get HIV from mosquito bites 12 Women are less likely to get HIV than men because their monthly menstruation washes the virus from their bodies 13 You can get infected with HIV when you donate blood 14 If I have sex with somebody it means I love that person 15 The partner who first shows symptoms of an STI is the one who brought the infection into the relationship 16 It is easier for a woman to contract STIs and HIV than a man 17 Circumcised men are not infected by STIs or HIV 18 Women who are HIV positive can deliver babies that are HIV negative 19 People living with HIV/AIDS can live a long time if they take ARVs 20 Eating a good balance diet helps to boost immune system

False True False False False True False False False False False False False False False True False True True True

18

Activity 1.6

What is difference between HIV and AIDS?

HIV is the virus that causes AIDS. AIDS is not a virus nor a disease. A person only has AIDS, when HIV has damaged their immune system so much, that their body is too weak to fight off even ordinary diseases. So, what is HIV? Here is one description. The

Human Immuno-deficiency (=body’s ability to fight infections gets weak) Virus
The diagrams show the outside of an HIV (left) and the cross-section through an HIV (right)

Activity 1.7

How does HIV weaken the immune system?

Special white blood cells, called CD4 T cells, help to protect our body against infection

When germs enter our body the CD4 T cells fight and usually kill them

CD 4T cells help to kill the germs and keep our bodies strong and healthy

HIV is powerful. When it gets into our body it searches for the CD4 T cells and attacks them. It enters the CD4 T cells and can now control them.

The CD4 T cells are then changed into HIV copying factories. When the new HIV copies escape into the blood, they search for more healthy CD4 T cells to attack

If HIV keeps killing every CD4 T cell it enters, eventually our body is too weak to fight off even ordinary germs and it shows symptoms of many diseases

19

Acquired = it enters from outside your body and Immune = your body’s ability to fight infection Deficiency = gets too weak and Syndrome = you show symptoms of having not
just one illness but many Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? • The immune system is a collection of cells which defend our body against infection • When we are HIV free the body’s immune system can cope with most infections • Part of our immune system are the white blood cells, which have the ability to identify and work together in order to fight off most harmful viruses or bacteria • There are two important types of white blood cells, B-Cells and T-Cells. One type of T cells called CD4 T cells is important in the fight against HIV. They are often called helper T cells • When HIV enters the blood, our CD4 T cells make HIV antibodies (chemicals), to fight the infection • Being HIV-positive means that the HIV antibodies are present in your body • There is no way to remove HIV from a body or to kill HIV • Unfortunately the HIV antibodies cannot successfully fight and kill the HIV • A person could be HIV+ for over 10 years before their body starts to weaken and become unable to fight off most diseases • When HIV gets into the blood of a person, it attacks white blood cells, but it is especially attracted to CD4 T cells, which it attacks and enters, then it reproduces by making many copies of itself. When the HIV copies leave the cell they spread round the body attacking and taking over more CD4 T cells • It is like a defending army losing soldiers while the attacking HIV army is growing • Some HIV infected CD4 T cells are identified as dangerous and killed by B cells • Without enough CD4 T cells, the body is unable to defend itself • As the viral load (the number of HIV copies) increases, the CD4 T cell count decreases • The two types of HIV are called HIV-1 and HIV-2 (Malawi has mainly HIV-1) • Both types cause AIDS although HIV-2 is less virolent than HIV-1 • HIV can mutate (change) when it reproduces and it now has at least 9 subtypes • A CD4 (T-cell) count below 350 to 400 cells mm3 marks the onset of opportunistic infections

Activity 1.8 Research to stop HIV with different drugs
Scientists know that any drug that can kill HIV will probably be far too strong for our own human body cells. So, they are developing many different drugs to prevent HIV from spreading. They are looking for drugs to stop HIV in at least six ways. Drugs to stop HIV from searching, sticking-to and attacking T cells. Other drugs are to stop HIV from entering T cells, while others stop HIV reproducing inside the cells. The last group of drugs stop the HIV copies getting out of the cells. Each ARV drug stops HIV from doing only one of these activities. There is no single drug that can stop all of these HIV activities by itself. That’s why people take more than one pill when they are on ARVs.

20

• Read the following facts about HIV and AIDS • Discuss the implications of the information for HIV prevention, treatment, support and care • Share you ideas The term epidemic is the rapid spread of a disease among many people in the same place. A pandemic means it occurs over a whole continent or the whole world. AIDS is a pandemic. Points for your discussion, debate, drawing, song, story, play, poem, poster etc • Since the start of the HIV/AIDS pandemic over 25 million people have died due to AIDS related illnesses. • Sexual transmission accounts for over 85% of all HIV/AIDS infections. • Over 4 million new infections were reported last year with over 2 million of those in sub-saharan Africa. • Almost 40 million people in the world are living with HIV and over 25 million of those live in Sub-Sahara Africa. • Africa has over 12 million children who have been orphaned by AIDS. Anti-retroviral treatment (ART) is prolonging the lives of millions of people who are HIV+, but not everyone who needs them can get them.

Activity 1.9

HIV and AIDS Worldwide

Problems encountered collecting data on HIV and AIDS from around the world • Data collected about HIV and AIDS can give us part of the picture, but may be inaccurate. • Research shows that many cases of HIV infection are not reported because many infected people do not go for HIV tests. • An increase in the number of diagnosed cases of HIV in Malawi, does not necessarily mean that more people are getting infected with HIV. It might mean that more people are going for HIV tests, because they have become more available, or that stigmatisation of people who are living with HIV has declined, or more people are willing to get tested. • Figures based on gender and age may reflect a group that is more willing to be tested than an other. For example more women than men in Malawi undergo Voluntary Counselling and Testing (VCT).

21

Activity 1.10

HIV and AIDS in Malawi

Ask the group to review the following information. • Over 11 million Malawians are not infected with HIV. The prevalence rate is just over 14% this means about 86 out of every 100 Malawians are HIV negative. • Nearly 1,000,000 persons who are infected with HIV, but still look and feel healthy, 850 000 are adults above 15 years and over 500 000 of these are women. • Because HIV infection is spread mostly through sexual activity, people between 15 and 49 years of age are the most infected. • Malawi has almost 800,000 orphans. • Infection rates are higher in urban areas, where 1 of 5 adults may be infected. • Only 34% female and 41% male adults are aware of how they can prevent themselves from HIV infection. • In 2008, AIDS -related deaths have dropped by when compared to 2003. • Out of 159,111 people who went onto ARVs in 2004, 106,547 are still alive. • Peer group members should note any new statistics appearing in the media.

Activity 1.11 Why is HIV/AIDS prevention important to our community?
• Draw a Life tree with chalk ( on a board/table) and label the parts of the tree • Just as a tree, every human being has different parts to his or her life. • Study the diagram and notes. Roots: family background, who influenced us as we grew up etc. Trunk and branches: the structure of our life, things like job, family, training, and groups we belong to etc. Leaves: What inspires us. Just as stem and leaves feed the trees. Things like love, compassion, friendship, faith etc. Fallen leaves: struggles and problems encountered. These could be illness and death of family and friends. Money used for funerals and hospital visits. Not enough food for family; money for school fees etc. Fruits: achievements in life. Your children could be branches or fruits. Now reflect on your life and complete your Life Tree by examining how HIV and AIDS has affected your life. Share your life tree with the group and summarise under the following headings: individual, family and community. Adapt this activity for different audiences.

22

Activity 1.12 What is the impact of HIV/AIDS on the individual?
Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? • Shock, stress even anger • Feel betrayed or depressed • Feel unable to cope with life • Lack of income and resources • Sad and pessimistic about the future • Loss of job or school place • Broken relationships • Self-esteem lowered • Decide to live positively with HIV/AIDS • Join support or action group and works to fight HIV • Add any other key points to your list

Activity 1.13 What is the impact of HIV/AIDS on the family?
Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? • Loss of financial resources leading to family stress • Harder to pay any education fees • It is difficult to care for people living with HIV and AIDS (PLWHA) • Income lost to medical and funeral expenses • Stress due to loss of loved ones (parents, children etc) • Extended family disruption or disintegration • High dependency ratio of children to adults • People have to seek out the best ways to protect family members from HIV and encourage and assist members living with HIV to live positively

Activity 1.14 What is the impact of HIV/AIDS on communities and nation?
Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? • Increase in hospital bed occupancy • Increase in health expenditure straining national budget • Lower productivity • Pessimistic mood in communities where some see no future • Loss of skilled workforce • People need training to replace the sick and the dead • Reduced national income • National development slows • Possible social unrest • Citizens speak out openly about sexual matters that were once taboos • Communities are pro-active by educating all citizens on HIV and AIDS

23

Activity 1.15

What is the impact of HIV/AIDS on school-age children?

Discuss which of the issues mentioned in activitites 1.12, 1.13 and 1.14, are particularly relevant to school-age children. Points for your discussion, debate, drawing, song, story, play, poem, poster etc What points have peer group members suggested? • Orphaned by AIDS or infected with HIV/AIDS • Often need to care for sick parents or siblings • Trauma related to illness and death of family member • The traditional extended family support system is being over-stretched • Lower motivation due to loss of support from a disintegrating extended family • Need for children to work • Discrimination and stigma they can suffer in school due to infection of themselves or death of family members • Early marriage in the case of girl children • Child-headed family and caring for younger siblings • Child is the bread-winner

Activity 1.16 Assignment: HIV and AIDS and the future
The assignments are designed to give you an opportunity to share some of the knowledge and skills from the activities you have just completed. They also give participants an opportunity to carry out research and make preparations connected with the activities in the next unit or session. 1 Talk to a friend, neighbour or relative about HIV and AIDS in Malawi. a How concerned are they about HIV and AIDS? b How many people do they think are already infected? c Let them talk freely about issues that arise. d Tell them that most people in Malawi are HIV negative.

Preparing for behaviour change Read through the point to ponder and discuss it with friends and family. Point to ponder: If the word development means good change, what changes do you want to see in your personal life, family life, community life and national life that will help.

Evaluation
Evaluations can be carried out after each session or at the end of each unit. Use the evaluation questions on page 166 and record the results in an exercise book or on plain paper for filing. Be sure to indicate the date, unit number, number of members, and your name in the record. Remember to mention which activities were carried out and your own feelings about the unit.

24

Unit 2
Introduction

Preparing for behaviour change

Why is behaviour change an important part of HIV prevention, treatment, support and care? It is because HIV and AIDS is destroying the things we value most in life. Our extended families are breaking down. Sickness and funerals are robbing us of loved ones, hard earned wealth and our traditional lifestyle. Children are orphaned, out of school and many are on the streets. Families and communities are struggling to keep going. This is why it is important for each one of us to identify what we consider the most valuable things in our lives and do everything we can to protect them. The activities look at the life skills necessary for a person to identify risky behaviours which need changing, successfully change the behaviour or support others in the community who are trying to do so.

Learning outcomes
By the end of this unit, you will be able to: • list the most important things in your life • identify negative behaviours in society that need changing • explain why a person’s values play an important part in behaviour change • describe the character qualities you most value in a good person • describe how values are acquired and developed • explain how people make choices in life • describe the different stages of behaviour change • explain why making some decisions are not easy • explain how a person can build their self esteem • explain how a person can develop self-control • state the importance of empathy in behaviour change • describe how group identities can unite and divide societies • define and differentiate between a person’s rights and their responsibilities

Activity 2.1 Assignment review
Carry out a review of the assignment by discussing your findings.

Activity 2.2 What are the most important things in your life?
If we asked people around the world this question, what do you think they would say? Here are some of their suggestions: • You’re only young once. So, you should go out and have fun, fun, and more fun! • I want my share of the good things in life. I want a big car, big house and money! • I want to get to heaven, so my life is lived in order to earn my place in paradise • Seeing my grandchildren growing up and succeeding • Babies. I want to have children, then my life will mean something • I will use any means possible to feed, clothe, shelter and educate my children • I really don’t know, I haven’t thought about it much. I am sure I will think about this question when I am older • I want to learn absolutely everything I can about this amazing thing called ‘life’ • I just don’t care about questions like that, I just need a few drinks

25

What are the most important things in your life? When we asked groups of people that question, we got a long list of ideas. Here is the list we compiled. The items are listed in no particular order of importance. The most important things in life are: • Marriage • Children • Family • Religion • Own house • Own car • Love • Friends • Enjoyment • Money • Sex • Studying • Being happy • Staying healthy • Career success • Boyfriend or girlfriend • Democracy and freedom • Fashionable clothes • Football and other sports • Travelling abroad • Peace (no conflict or war) • Doing what I want to do • Doing good • My community • My country • The Earth (our environment) .................................................................. • Work by yourself • Write the heading The most important things in my life, and then choose the ten things that you think are the most important in your life • Put a number 1 next to the one you think is the most important • Put a number 2 next to your second choice • Number your other choices until you have put a number next to all of them

Activity 2.3 What are the most important things in life for your group?
• Choose someone to read out the list shown above • Write the list on the board before the voting starts • As each item on the list is read out, you should silently raise your hand if that item is in your top ten • The vote counters should add up the numbers of hands raised for each item and write the scores on the chalk board • After the whole list of things has been read out, the counters will announce which are the most important things in life according to the class opinion poll • What are the five most important headings? Points to ponder • Owning more and more things will never make you completely happy • Sometimes you have to do things that you don’t enjoy • The most enjoyable things that you want to do can damage your body, mind and spirit • We need to develop the strength to make the right choices and stick to them

26

Activity 2.4 How can I build high self-esteem?
A person who has high self-esteem feels: unique connected empowered What does it mean to be unique, connected and empowered? Points for your discussion, debate, drawing, song, story, play, poem, poster etc

I am unique (eg. ‘I feel special’)
No two people are the same. Never in the history of the world, has there ever been anyone exactly like you To develop high self-esteem you must think of yourself as special or unique You must love yourself, not with an arrogant selfishness, but with the same sort of love you would give a child or partner

I am connected (eg. ‘I feel as if I belong’)
To be connected, you must make an effort to form and maintain good relationships Relationships can be of many different types We should try to form, build and maintain relationships within family, school, community, tribe, nation and/or internationally At school or work we belong to different classes, departments, teams and clubs When you are connected, you have a sense of belonging. This makes you feel good about yourself Members of groups live or meet together to share this sense of belonging Worship also helps us to stay connected to God Traditional beliefs say that the community is made up of living people, ancestors, other spirits, animals and plants, air, water, rocks, infact the whole planet and universe! God is at the centre of his community and gives everything life Traditional believers respect the interaction of everything in the environment and worship in ways that maintain the relationships Traditionally, if people work together, and look after living things, the ancestors and the environment, this strengthens and protects life’s relationships (mwambo wa umunthu or mwambo wa umoyo) Muslims and Chrisians believe that every good deed is an act of worship. Good deeds therefore strengthen relationships between people and with God When believers meet together for worship or in community service this strengthens the connections between all of their believers Non-believers also value relationships but do not consider a God is part of them

I am empowered (eg. ‘I feel that I have talents and can achieve things’)
Things that make us feel good about ourselves, can build our self-esteem and empowers us Every person is born with an special variety of talents, as they develop these talents and enjoy the feeling of success, this builds self-esteem If we leave some talents underdeveloped or unused we can feel depressed and this lowers self-esteem

27

Activity 2.5

Everyone is unique and special

Now we are going to look at ways of strengthening our relationships or connections with other people. Malawi’s main religions teach that everyone is unique and special, but we only become fully human when we mix and interact with other human beings. How far do you think that people with no religious beliefs share this viewpoint? Points for your discussion, debate, drawing, song, story, play, poem, poster etc Here are some suggestions: If I want to be treated as unique and special I must learn to treat other people as unique and special too Unfortunately, we humans can find it very difficult to live peacefully together for a long time If we are to enjoy good relationships we must always consider the thoughts and feelings of others

Activity 2.6

How can we develop empathy?

Empathy is the ability to imagine what another person is feeling and thinking. If you can imagine what a person is feeling or thinking you might understand why they behave as they do. Points for your discussion, debate, drawing, song, story, play, poem, poster etc Here are some suggestions: One of the best ways to develop empathy is to imagine that you are standing in someone else’s shoes or walking a mile in someone’s shoes By developing empathy we can try to share other people’s feelings such as fear, sadness, joy and happiness If we learn how to empathise it may help us to become more compassionate towards other people Christianity, Islam and Traditional Religion consider compassion to be one of the most important virtues Like other virtues empathy to others does not develop straight away and may need to be practicedbefore it becomes a habit You may wish to combine this activity with activity 2.25 on page 42.

28

Activity 2.7

What is happening in Malawi today?

We love to call our country the warm heart of Africa. As a nation we value the idea of a kind and generous heart. Many foreign visitors comment on how much they enjoy being in the country. Many names that we give children reflect the traditional values we would like to see in our children.

But some of the good things that made us the warm heart of Africa are changing. Points for your discussion, debate, drawing, song, story, play, poem, poster etc Look at what some people are saying about Malawi today: People are forgetting our traditional values that’s why things are going wrong HIV and AIDS are destroying family and community life HIV is harming our efforts to develop into a 21st century nation HIV is spreading because of a decay Malawi’s moral standards Corruption is playing a part in keeping thousands of Malawians in poverty AIDS is not just about abstinence, faithfulness and condoms. Poverty and gender inequalities are complicating our fight against HIV and AIDS Children are not getting the right sexual reproductive health lessons they need a new sort which includes moral education Teachers, preachers and politicians are not the role models they used to be • • • • Which statements do you agree with? Which ones do you disagree with? Which ones are you not sure about? Discuss your answers with the group

Source: Times

29

Activity 2.8 Which negative behaviours in our society need changing?

Source: Headline in The Malawi News, August 9-15, 2008.

Before we look at behaviour change for action against HIV infection, we need to look at behaviour in general. How would you define the terms good behaviour and bad behaviour. Here are two suggestions: Good behaviours are the actions that we believe to be right, just, fair, positive, constructive and true. Bad behaviours are the actions that we believe to be wrong, unjust, unfair, negative, destructive and false Describe some of the bad behaviours in our society that you would like to change. Points for your discussion, debate, drawing, song, story, play, poem, poster etc Alcoholism and drink induced negative behaviour Illicit sexual activities like pre-marital sex, adultery, under age sex and spousal rape Smoking chamba and taking drugs leading to addiction Prejudice and discrimination against minority groups (eg people with disabilities) Using power and position to influence employment interviews, school places etc Over-eating to the point of being overweight or obese, even though many people in the country go hungry and are under-nourished Petty stealing of small things from the work place Not being polite to someone because you believe you have more status Not speaking out or taking action when a neighbour (male or female) is subjected to gender based violence Allowing boys to play while girls fetch water, wash, cook and clean the house Favouring a son or boy child over a daughter or girl child Lying about where you have been and what you have been doing Telling someone you love them when what you want is sexual intercourse Avoiding doing a very important job by doing a less important task Accepting bribes in the form of money, gifts or favours Overspending on luxuries when orphans and street children are struggling nearby Going to worship regularly, but not living a truly religious lifestyle Staying silent about girls being sold or given as child brides Exam leakage Points to ponder What we think and believe greatly influences how we behave. • Why do some people behave in a negative way, even though they know and want to do the right thing? • Think about how all sorts of negative behaviours can affect the spread of HIV.

30

Activity 2.9 Why should we discuss values, virtues and vices?
Our values greatly influence our behaviour and may therefore put us at risk of HIV and other dangers. Values also influence how we interact with others in our society. What are values and what is the difference between virtues and vices? Points for your discussion, debate, drawing, song, story, play, poem, poster etc Here are some suggestions: • Values are the human character qualities that a person or a group considers valuable • Most societies consider virtues to be the most important character qualities (values) • Virtues are the types of feelings, thoughts and behaviour that a society calls right or good • Virtues are important and useful in building and sustaining a community • Virtues are called good habits, because they can be practiced over and over again • Vices are the types of feelings, thoughts and behaviours that society calls bad or wrong • Vices are considered dangerous and destructive to development of a community • Vices are called bad habits, because they can be repeated over and over again • Some vices are considered so bad that they may be called evil or wicked • Many people have vices, bad habits, that they think they cannot stop • When a person’s values contain serious vices, we say they have poor moral standards or that their personal values are wrong • How we feel and think seriously affects the way we speak and act • All of Malawi’s major religions, teach that few human beings are perfect and that we all have a mixture of virtues and vices • Strengthening virtues and fighting vices will make us better people and our families and communities more safe, peaceful, prosperous and happy • Traditional rules of behaviour (mwambo) help a person to become umunthu (a complete human being) and as the Tumbuka say, this helps towards the creating and sustaining muzi uweme (good village or village of goodness) • Christians use Jesus as the perfect role model, individuals work to behave as Jesus would, so that the local and worldwide church is a living example of Christlike behaviour • The Muslim Hadith describes what Muhammed, said, did or approved of. It says that the most perfect Muslim, has the best character and that virtue leads to paradise. They use the examples of prophets they consider to be perfect role models, such as Isa (Jesus), Yusuf (Joseph), and especially Muhammed • Good Muslim behaviour is seen to strengthen the jummah (the local community) as well as the ummah, the world wide community of Muslims Points to ponder What would Jesus, Muhammed or a genuine umunthu (ancestor or living) say and do if faced with some of the negative situations found in Malawi today? Discuss

31

Activity 2.10 What is your idea of a good person?

Here is a list of good character qualities or virtues found in communities all over the world. Some words have similar or overlapping meanings. Look through the words, choose your own top ten virtues, the ones that a person like yourself should display. Points for your discussion, debate, drawing, song, story, play, poem, poster etc I am a good person if I am: 1 Caring: show affection and concern for other people 2 Chaste: do not have sex except with the person to whom I am married 3 Compassionate: feel or share the suffering of others and want to help them 4 Courteous: show good manners 5 Courageous: ready to face and endure great difficulties, danger, pain or suffering 6 Forgiving: ready and willing to forgive 7 Generous: ready to give freely or share 8 Gentle: kind; careful; not rough or violent 9 Hard working: works hard to improve personal, family and community life 10 Honest and truthful: ready to tell the truth, not lying, cheating or stealing 11 Hopeful: confident of future success 12 Humble or modest: not openly proud or boastful 13 Just: behave in a fair and correct way 14 Kind: show concern for the feelings of others in a gentle and friendly way 15 Loyal or faithful: true to my religion, partner, family, friends and people 16 Loving: feel and show love to one or more (partner, children, family, God etc) 17 Merciful: show a forgiving attitude towards someone that I could hurt 18 Obedient: obey fair rules and laws 19 Patient: accept annoyance, suffering and delays without anger 20 Prudent: act wisely or carefully when planning for the future, especially money 21 Resourceful: good at finding ways out of difficulties or creative ways to do things 22 Respectful: show respect and admiration 23 Responsible: reliable or sensible when carrying out a duty or task 24 Temperate or self-controlled: able to control excessive behaviour, especially anger and the amount I eat and drink, drinking little or no alcohol 25 Tolerant: accept that people have the right to hold different beliefs to my own 26 Trustworthy: able to be trusted, reliable Which of these values do you think are important in traditional African culture?

32

Activity 2.11 What are the major virtues and vices in society?
Compare your findings from the last activity with the lists shown below. Christian virtues The seven Christian virtues are: 1 Justice. You treat all people fairly 2 Courage. You are ready to face and endure pain, suffering and trouble 3 Prudence. You plan carefully and wisely for the future 4 Temperance. You control your desires 5 Faith. You are true to your religion 6 Hope. You are confident of future success 7 Love. Christians consider this the greatest virtue of all Islamic virtues Ιslam values all of the above virtues, but believes that only by practicing the 5 pillars of Islam can a believer develop the right attitude of mind, body and soul inorder to face any moral choice. The five pillar of Islam are: 1 Faith. Declare that there is no God but Allah and that Muhammed is his prophet 2 Prayer. Pray five times daily 3 Charity. Every year Muslims gives at least 2½% of their savings to the poor 4 Fasting during the month of Ramadan 5 Pilgrimage to Makkah once in a life time if circumstances allow The seven deadly sins (vices) The seven deadly sins were identified by Christians as the most serious threats to society and the chances of a individual getting a place in heaven. For religious believers, a sin is anything that goes against God’s teachings. The 7 deadly sins are: 1 Pride. Arrogance; having an inflated opinion of yourself; being big-headed 2 Anger. Strong feeling of displeasure which may lead to loud or violent behaviour 3 Envy. Jealousy; wanting what someone else has or to be like someone else 4 Lust. Greed for sex; sexual desire, but with no love involved 5 Gluttony. Greed for food and drink 6 Avarice. Greed for power and wealth 7 Laziness. Finding excuses and ways to avoid doing important work

Activity 2.12 Do different people need different virtues ?
List some of the character • good friend • good mother • good religious leader qualities that you think the following people should show: • good teacher • good nurse • good street child • good father • good parent living in poverty • good sex worker

Point to ponder Our streets are now filled with street kids... smoking, taking drugs, stealing, sleeping in tunnels and eating dirty food... it is breeding a generation that will be uncontrollable... they will have no human heart and will be prepared to kill to get what they want! Discuss.

33

Activity 2.13 The major values in the UN Millenium Development Goals
The United Nations has made a statement about the values shared by over 200 of its member states. Read through the following quotation from the United Nations, which outlines the major values in the UN’s Millenium Development Goals. Discuss whether the list fits in with your own thoughts or those of the group as a whole. ‘’We consider certain fundamental values to be essential to international relations in the twenty-first century. These include: • Freedom. Men and women have the right to live their lives and raise their children in dignity, free from hunger and from the fear of violence, oppression or injustice. Democratic and participatory governance based on the will of the people best assures these rights. • Equality. No individual and no nation must be denied the opportunity to benefit from development. The equal rights and opportunities of women and men must be assured. • Solidarity. Global challenges must be managed in a way that distributes the costs and burdens fairly in accordance with basic principles of equity and social justice. Those who suffer or who benefit least deserve help from those who benefit most. • Tolerance. Human beings must respect one other, in all their diversity of belief, culture and language. Differences within and between societies should be neither feared nor repressed, but cherished as a precious asset of humanity. A culture of peace and dialogue among all civilizations should be actively promoted. • Respect for nature. Prudence must be shown in the management of all living species and natural resources, in accordance with the precepts of sustainable development. Only in this way can the immeasurable riches provided to us by nature be preserved and passed on to our descendants. The current unsustainable patterns of production and consumption must be changed in the interest of our future welfare and that of our descendants. • Shared responsibility. Responsibility for managing worldwide economic and social development, as well as threats to international peace and security, must be shared among the nations of the world and should be exercised multilaterally. As the most universal and most representative organization in the world, the United Nations must play the central role. It is important for us to appreciate that the six UN values mentioned here will keep reappearing in the national media and within our local communities. Later, we will get another opportunity to discuss how far the shared values of the UN may influence efforts to reduce the prevalence of HIV around the world and mores especially in Malawi. Point to ponder It is wrong to assume that the whole world could share the same basic values. Discuss

34

Activity 2.14 How are virtues and vices developed ?

Points for your discussion, debate, drawing, song, story, play, poem, poster etc Here are some suggestions: Giving people a list of rules to follow works only so far, if other members of a community openly break society’s rules in full view of others In traditional life, umunthu, is the person showing moyo wangwiro (good spiritual health) or moyo wabwino (good living) Traditionally, the ancestors are considered role models and are rememebered because of their good lives, and there is no real afterlife for badly the behaved People develop virtues and vices and turn them into habits, by following the example of role models around them. Not only what these role models say but more especially what they do Teaching by examples which stress responsibility and self-control (discipline) People, especially children, copy or imitate the actions of older community members Muslims consider Muhammed to be the best role model (Uswatun Hasanah) Christians say that people can see the character of Jesus in the loving actions of good Christians and the young should model this sort of behaviour You may want to possess a virtue but it can only be made a full part of your life through practice, practice and more practice If you wish to be brave you must practice being brave, starting with small acts of bravery and building up to greater acts by making bravery part of your character How could you help a child to learn to be kind and generous? Try to become wise by making good decisions based on knowledge and experience It is said that if you want to become wise you must examine your emotions, thoughts and behaviours in order to discover your personal virtues and vices Point to ponder a) Whoever is granted wisdom has indeed been granted wealth abundant (The Quran) b) Wisdom is more valuable than jewels (The Bible)

35

Activity 2.15 Why do we behave as we do?

When we decide what we think is right and what we think is wrong, we have made a moral decision. As we grow up and then grow older, we learn that life is all about making the right choices or decisions. Every choice we make has one or more consequences. Some choices may be very easy to make, while others are very hard. Points for your discussion, debate, drawing, song, story, play, poem, poster etc People all over the world use the same methods when making choices. Here are some of the different ways in which people decide what is the right thing to do: 1 I obey God’s laws. Most religions have a set of rules and laws that are believed to have come from God. Believers are expected to obey the laws of their religion. One rule appears in all the major world religions. Compare the following versions of what is called the golden rule. Christianity - Treat other people as you would like them to treat you Traditional - Do for others what you want them to do for you Islam - Nobody truly believes, until he wishes for his brother what he wishes for himself Buddhism - Act towards other people as you would act towards yourself Sikhism - What you consider for yourself, so consider for others Hinduism - Do nothing to others, which would cause pain when done to you 2 I am not religious, but I always follow the golden rule 3 I am a good citizen and always obey all laws 4 I will do anything to avoid punishment or pain 5 I follow cultural tradition 6 I think about myself first, my pleasure, possessions and position 7 I do whatever will please my peers, constitutants and tribe 8 I copy older members of my family and community 9 I only help those who can help me 10 I do it because it feels like the right thing to do 11 I rebel, against a society where I am poor, marginalised, without hope • Discuss whether you use one or more of these reasons when deciding what to do • Can you list any reasons why people find it hard to follow the golden rule?

36

Activity 2.16 Rights and responsibilities
Today, people are talking a lot about human rights. Malawi’s religions and the constitution say that as well as human rights you also have human reponsibilities. What is the difference between a human right and a human responsibility? Human rights are things you are free to do or the things your family, community or nation should do for you. Human responsibilities are the good things you should do to help other people such as your family, community or nation. To also have a responsibility not to do things that might be harmful to yourself and others. What are my responsibilities? There are two types of responsibility: Legal responsibility - something the law says that you should or should not do. Moral responsibility- somethings that your personal code of conduct (code of behaviour) say that you should or should not do. This is also called a moral duty or moral obligation. For example there is no law that says that Malawians have to care for their parents when they get old. But most Malawians say they have a moral responsibility to do it.

Activity 2.17 How to make the right decision
In activity 2.15, we looked at some of the reasons why people behave as they do. In activity 2.16 we looked at rights and responsibilities. In life we face millions of choices and our choices change the world in millions of different ways. Our choices create our own lives and alter the lives of others. Here is a seven step method, that many people have used to help them make the right choices in life. If 1 2 3 4 5 6 7 you have a decision to make, go through the seven steps before you act. What is the problem that you are facing? List all of the different ways in which you could solve the problem List the consequences for each of the different choices Do the choices and consequences match up to your personal values? What will be the impact on other people of each choice? What is the best alternative? Act on your decision

37

Activity 2.18 Is there a struggle going on within me?
All the major world ideologies, teach that the strength and goodness of a community, depends upon the decisions that individual community members make. If individuals behaves in positive or constructive ways, the community is strengthened. But, if an individual chooses to behave in a negative or destructive way the community is weakened. When we try to decide what to think or do, it can feel as if there’s struggle goig on inside us. Some people say that it is as if I am wrestling with my conscience. They mean that choosing between good and bad thoughts and actions can make you feel uneasy inside. Points for your discussion, debate, drawing, song, story, play, poem, poster etc Here are a few more comments about the feelings and making the right choices. Which of the quotes do you feel expresses your own feelings? • My vices and virtues are competing with each other deep in my head and heart! • It seems as if an angel is whispering in one ear and a devil is whispering in the other • My good side is arguing with my bad side • Sometimes I get some really bad thoughts

and I am glad people can’t read my mind! • I have to fight my selfish thoughts and urges all the time! Sometimes it’s so very hard to behave in a good, fair and kind way
• A vice will stay a living, breathing, ugly part of you until you yourself destroy it! Have you ever had the same sort of thoughts and feelings? Describe one occasion when you struggled to make a decision.

Activity 2.19 When free will clashes with the golden rule
The major religions in Malawi say that God has given human beings free will. Nonrelgious people often believe that they have free will, but it is not a gift from anyone. Points for your discussion, debate, drawing, song, story, play, poem, poster etc If I have free will it means that I am the one who has to choose between good and b a d thoughts, words and deeds I am the only one who can control my feelings, thoughts, words and actions You have freedom of choice. In a one-party state or dictatorship choice may be limited, in a developing democracy more and more choices become available A selfish or self-centred person might say something like, I do what I want to do, my feelings and needs are the priority. Are there any times when selfishness would be justified? If I am selfless I think more of other people’s feelings and needs than my own The golden rule reminds us that, even if we have to care for others, we must love and care for ourselves as well, because if we don’t love and care for ourselves we will not be able to care effectively for others!

38

Activity 2.20 How do I lose self-control or self-discipline?
If you have self-control, you have the ability to control your feelings, thoughts and behaviours. So, how do we lose self-control? Points for your discussion, debate, drawing, song, story, play, poster etc Here are some suggestions: • Religions often describe the struggle for self-control as a war! • It is better to win control over yourself than over whole cities (Bible) • The greatest jihad is against the self (Hadith) • You lose self-control when you give in to, or surrender to your vices • The serious vices are the seven deadly sins of pride, anger, envy, lust, gluttony, avarice and laziness, because they can make you act very selfishly • When you give in to your vices, you may feel uncomfortable inside, have a guilty conscience and this lowers your self-esteem • ..wrong doing is that which wavers in your soul and which you dislike people finding out about (Qur’an) • Many Malawians, believe that good and evil forces are at work in the world. These forces can influence and destroy a person’s self-control • Satan said, I had no power over you except that I called you and you obeyed me. So do not blame me, but blame yourself (Quran) • Jesus was tempted and had to forcefully repulse his negative thoughts • Many believe evil spirits (mfiti), sorcery and magic are some of the things that can weaken a person’s self-control Point to ponder Alcohol and other drugs make us feel, think and act differently. We can be excited and depressed it can really influence or destroy our self-control. Discuss.

Activity 2.21 How do I develop and nurture self-control?
How do we develop and then nurture the life skill of self-control or self-discipline? Points for your discussion, debate, drawing, song, story, play, poem, poster etc Here are some suggestions, can you think of any others? All forms of worship try to keep humans connected to God, so that they can ask for help when they need it Muslims believe that life is a test which they must pass inorder to go to paradise The five pillars of Islam help Muslims to maintain self-discipline on a daily basis Christians say that the Holy Spirit advises and strengthens self-control Tradional believers appeal to azimu for help with prayers like, mzimu ndirinde (Take my hand my ancestral spirits) Positive thinking, as it always helps to look on the bright side of life Don’t continue arguing say, I see your point but think differently Don’t continue arguing say, I think we should agree to disagree Point to ponder It is so hard to resist temptation! No matter how much I try I seem to be drawn back to behaving badly. What can I do? Discuss.

39

Activity 2.22 How can I change my negative and risky behaviour?
How have other people changed their lives around? How can someone change their negative or destructive behaviour into positive and constructive actions? Well, behaviour change involves knowledge, attitudes as well as actions. Your knowledge and attitudes will probably need to change before anything else. Inorder to successfully stop negative behaviour a person needs to go through various stages of change. The 6 stages of behaviour change are : 1) Not thinking about changing 2) Thinking about changing 3) Preparing to change 4) Changing 5) Making the change a habit 6) Trying not to slip back to old habits Points for your discussion, debate, drawing, song, story, play, poem, poster etc The stages of behaviour change in more detail are: 1 Pre-contemplation....... I am not thinking about changing my behaviour. I am in denial, because I don’t think I have a problem... I don’t have a problem! 2 Contemplation............. I accept that I have a problem and I have identified it! I am thinking about changing my negative behaviour. But, something has to happen to motivate me to change an event or person. The root of behaviour change is in the mind and usually requires a complete change of our attitude to something. 3 Preparation ................. I am planning and getting ready to change my attitude and then to change my behaviour. I have gathered information, learned how to change, decided when to change, know what the impact will be of my change, I am now determined to change! I am developing an action plan that I will use to make change disciplined and easier. 4 Action ........................... I have stopped my negative behaviour by changing to positive actions or avoiding certain risky situations. I am putting my action plan into operation (using all previous information, plans, new skills, experience, decision making). 5 Maintenance ................ I am practicing my behaviour so it becomes a positive habit that I can call upon when necessary. I have ways to reinforce this new behaviour, ways to support and sustain my positive living. 6 Relapse (Start-over).... I have slipped back into my old behaviour to one of the other stages. People tend to move back-and-forth between stages, and a relapse to a prior stage is always possible. In fact, people can relapse to any stage, but a return to pre-contemplation is least likely. It is important to remember that changing your behaviours, especially intimate and private behaviours, is a complex process.

Points to ponder
Individuals, couples, groups, institutions, communities and governments all can and do use this process to promote development, which is positive change. Discuss. Pick out some of today’s key issues and discuss how behaviour change has been successfully promoted. Some issues could be gender, democracy, crime, orphans and vulnerable children, malaria, primary education and of course HIV and AIDS.

40

Activity 2.23 Groups can unite and divide us
People all over the world are born into groups like families, tribes and nations. We have no choice about some of the groups we belong to, this is because we do not choose things like our sex, colour of skin or whether our parents are rich or poor. On the other hand, we can choose whether or not we want to join some other groups like religions, political parties, sports or social clubs.

Points for your discussion, debate, drawing, song, story, play, poem, poster etc What are some of the things that can be used to unite or divide people? • • • • • • • • • • Age: between old and young HIV: between HIV+ and HIV free Gender: between male and female Colour: between black and white Lifestyle: between rich and poor Education: between educated and uneducated Tribe: between your tribe and mine Region: between north and south Politics: between UDF and DPP Religion: between your religion and mine • Nationality: between Malawians and other nationalities • Laws: between criminals and their victims • Sport: between fans of different teams • Disability: between able-bodied and disabled • Music: between rap and gospel • Fashion: between traditional and modern • Beauty: between those who are thought beautiful and those who are not

Points to ponder
It is not the obvious things that divide human beings. It is not colour nor race nor religion, it is our envyof those who have more than us and our fear of anyone who is different. Discuss. I just don’t like them, I have never liked them. In fact my father and grandfather hated them as well and warned me about them on numerous occasions. Discuss.

41

Activity 2.24 How do prejudice, stigma and discrimination divide people? Point to ponder
It is often easier to blame our problems on outsiders like foreigners and the underclass than see that the solution is in our own hands. Discuss.

Prejudice

• We are prejudiced if we prejudge before we know all the facts • We can prejudge individual people and groups of people • Prejudice happens in our minds and involves our feelings and our thoughts

Stigma

• In olden times, in different parts of the world, slaves and criminals were often marked on the skin with a tatoo or branded with a hot iron • The Greeks called this mark stigma. It was like a label that the slave or criminal carried everywhere and could be seen by everyone they came into contact with. The mark showed they were different, it made them outsiders from society • When we stigmatise, we are now acting on our prejudice • When we stigmatise ,we are pointing the first finger of our prejudices • When we stigmatise, we are labelling someone as being different to ourselves and we make them outsiders • Stigmatizing involves feelings, thoughts and behaviour. • Stigmatizing can develop into a serious form of negative discrimination

Negative discrimination is often the end result of stigmatizing
Discrimination is when we put our thoughts and feelings into action. We treat some people in different ways than we treat others. Favouritism is a form of positive discrimination. The next activity will look at how discrimination may affect others.

Activity 2.25 Assignment: Standing in someone else’s shoes During a typical day we meet all sorts of people at markets, in shops, on the road and at work. It is often easy for people to discriminate against others they meet,
especially in a situation where a dangerous disease is preading in our community. • Observe the different types of people you meet or pass by • Imagine what it would be like to live as some of the people you meet • Choose four people from the list shown and write short notes, a poem or a song describing the life of each of your choices • You can start each description with the words, What would my life be like if I was a • refugee or displaced person • rich person • person of the opposite sex • male street child • prisoner • female street child • poor student needing school fees • unemployed single mother • person of a different race or colour • president of Malawi

Evauation. Use the questions on page 166 and enter the results in your log book. 42

Unit 3

Relationships and human sexuality

HIV +

Introduction
The drawing above is adapted from a well known cartoon. What point do you think it is trying to communicate? The drawing is pointing out that sex and love can make people feel, think and act in ways that could be described as crazy. If HIV is now a danger to people forming sexual relationships, then it affects billions of men and women all over the world - including ourselves and our children - and it is essential to study it in greater detail. In order to recognise our feelings, thoughts and actions concerning sex and affection, we must understand the relationship between love, sex and sexuality. This will help us to respect our own feelings as well as the feelings of others which may influence how humans behave.

Learning outcomes
By the end of this unit you should be able to: • explain the terms sex and sexuality • describe elements of human sexuality • describe factors that influence sexuality • discuss some of the physical and psychological changes which take place during adolescence • explain how sexuality can affect behaviour • describe the features of the female reproductive system • describe the features of the male reproductive system • list some of the reasons why people have sexual relationships • answer some of the most frequently asked questions about sex and sexuality

Activity 3.1 Activity 3.2

Assignment review What is love?

Carry out a review of the assignment by discussing your findings.

As you work through this unit on sex and sexuality, remember that love is considered to be a significant part of most sexual relationships. Look at the types of love mentioned below and discuss how they may relate to discussions on sex and sexuality. • Love of objects and experiences - I love eating chicken; I love drinking beer; I love dancing • Love of family and friends - I love my grandmother; I love my old friend so much • Love of husband/wife (partner) - My wife/husband has always been my one true love • Love which is unconditional - I try to love other human beings without conditions

43

Activity 3.3 Sex and sexuality
Sex is a condition of being either male or female. This aspect is genetically and biologically determined and cannot be changed. On the other hand, sexuality deals with the biological, psychological, socio-cultural as well as ethical aspects of human sexual behaviour. Biological aspects of sexuality refer to issues of reproductive organs, hormones, nerves and brain centres. The knowledge about biological aspects help us to understand how the body responds to sexual stimulation. However, it is important to note how people view themselves as males or females constitutes the psychological aspects of their sexuality. Therefore, sexuality is associated with all the feelings, thoughts and behaviours of a person in relation to issues such as love, attractiveness and sexual intimacy. • Discuss the relationship between sex and sexuality • Discuss the importance of learning about sex and sexuality

Activity 3.4 Elements of human sexuality
Human sexuality is a broad concept which includes the following elements: sex, sexuality, sexualisation, sexual intimacy and self-identity. Points for your discussion, debate, drawing, song, story, play, poem, poster etc • Discuss the terms sexuality, sexualisation, sexual intimacy and sexual-identity • Discuss the importance of self-identity in relation to sex and sexuality

Sex is the condition of being male or female.
Sexuality refers to those aspects of gender identity that relates to sex. These include sexual desires, sexual behaviours and sexual orientations. You need to understand human sexuality, so you can learn how to protect yourself. Sex is frequently secret and emotional, so many people have a lot of trouble talking about sex. Sexualisation is using sex or sexuality to manipulate or control other people. It is manifested through such behaviour as flirting, seducing, withholding sex from a partner in order to punish or to get money. Sexual intimacy is the ability and need to be emotionally close to another human being and have that closeness returned. Sharing intimacy is what makes personal relationships rich. While sensuality is about physical closeness, sexual intimacy focuses on deeper emotions too. Sexual identity is a person’s understanding of who she/he is sexually. This includes the sense of being male or female (sexual orientation). Sexual identity can be seen as three inter-linked factors. These are gender identity; gender role and sexual orientation.

44

Activity 3.5 Sexual development
During sexual development children experience many changes in their bodies as they gradually become sexually mature. Sexual development usually starts some time between ages 9 and 16. Most girls start their sexual development earlier than most boys. Ask the group to study the diagrams below. Discuss what aspects mentioned in the diagams are the most significant aspects of male and female sexual development.

45

Activity 3.6 Sex, love and behaviour change in adolescents and adults
As children grow into teenagers and towards adulthood, parents, relatives, community leaders, teachers and others become concerned that the young will work hard, stay out of trouble and grow into successful members of society. The issue of sex before marriage worries adults, and they often sternly warn both boys and particularly girls, against sex that can bring unwanted pregnancy and HIV into the family home and the shame that would result. In many societies around the world, this has meant that sex has often been given a bad name, labelled as dirty or something whispered about, but never freely talked about in any great detail. Here are some things that people have said about sex and love, that might influence our view of sex, our sexual behaviour and any possible behaviour change to be made by ourselves or others. Read the statements through and think about whether you share the view or disagree with it. Spend only ten minutes or so on the activity and resist the temptation to impose your own ideas on others, agree to differ and move on. 1 2 Sex is beautiful, special and essential for human survival They way I love my wife is completely different to the way I love my children, the way I love God is so different to the way I love football andeating chicken with nsima. It so gets confusing, having one word for so many feelings! Sex without love is animal lust, rats do it, pigs do it even cockroaches do it Sex between two people can be wonderful, exciting and enjoyable experience, but they don’t need to be married or even love each other Sex is just for making babies Love making is to make babies from love Sex is about giving and sharing rather than taking or having Sex should bring loving partners closer together Sex should be love-making and love is always more than just sex-making Sex should make both partners smile and feel happy Sex is to be enjoyed by both men and women Sex education films which show enjoyable ways to make love are useful to a society Sex in pornographic films is a corrupting influence on society Boys talk of love when what they want is sex, while girls use sex because what they really want is love If parents really love their children they would talk to them about sex and not leave them find out fromtheir possibly misinformed peers

3 4 5 6 7 8 9 10 11 12 13 14 15

Did you find that this activity created a lot of heated discussion and debate? Well, anything that creates such energy is useful, especially if we can focus efforts on the fight against HIV.

Points to ponder. HIV is passed on by sex, and sex and love are also the most powerful tools we have to use in HIV prevention, treatment, care and support. Discuss When I make love for the very first time, I want it to be a very special event. I want to remember it for the rest of my life. Or is that too much to ask for? Discuss 46

Activity 3.7 The external features of the female reproductive system
The group may split into male and female groups for this activity. Study the diagrams of the female reproductive organs. Locate the clitoris, labia, urethral opening, vagina and anus. Drawing of a woman’s external genitalia The clitoris is a small firm organ at the top of the inner vaginal lips. The clitoris is a very sensitive part of a women. It provides many pleasurable feelings during sexual activity. The labia or vaginal lips cover the delicate area where the openings of the urinary tract and the vagina are located. The urethral opening is where urine comes out. The vaginal opening is below the urethral opening. This is the outlet for a baby during child birth and through which a penis penetrates into the vagina during sexual intercourse. The anus is the opening where faeces (waste products) come out.

Activity 3.8 The internal features of the female reproductive system
Study the diagram and locate the ovaries, uterus, and vagina. The ovaries usually produce one egg every month. The egg travels down a narrow fallopian tube and is fertilised and then moves down to the uterus. The man’s sperm travels from the vagina up the uterus to the tube. If the sperm meets the egg, the egg is fertilized and the woman becomes pregnant. The uterus is the place where a fertilised egg grows during pregnancy. Each month if she is not pregnant, a woman menstruates: she sheds the blood-rich lining of the uterus. Usually the uterus is only about as big as a fist. It expands during pregnancy. The vagina is the passage from the uterus to outside the woman’s body. It produces vaginal fluid and act as a passage for menstrual flow. During sexual relations, the man’s penis goes inside the vagina and releases sperms. Points to ponder In female circumcision the clitoris is cut out, usually with a sharp knife, and the vaginal lips are stitched closer together to make the vaginal opening smaller. During her first sexual intercourse the young woman is very vulnerable to medical problems. Discuss In male circumcision the loose skin (foreskin) which folds over the head of the penis is cut off. This reduces the chances of being infected with HIV, but may reduce pleasure because the movement of the skin at the base of the penis head. Discuss

47

Activity 3.9 The features of the male reproductive system
Look at the diagram of the male sexual anatomy and locate the scrotum and testes, urethra and penis. The scrotum is a sack, which contains the two testes and protects them against damage or injury. It controls the temperature around the testes The testes produce the sperm that can fertilize a woman’s egg. Testes produce a hormone called testosterone. During sexual activity, the sperms travel through tubes in the testes and the penis and then they are expelled from the penis. Seminal vesicles are pocket like structures lying around the spermatic cord. Seminal vesicles produce seminal fluid which is important for the survival of sperms. The urethra is the small tube that carries urine or the semen, down the penis to the outside the body. During ejaculation, a special valve closes off the bladder so no urine can mix with the semen and sperm When a man is sexually excited, the penis becomes erect (larger and firmer). It is at this time that he can push his penis into his partner’s vagina. Semen containing sperms comes out with force when the man has a climax or comes. Not having sex or an ejaculation does not cause any health problems, because sperms are re-absorbed into the body. The anus is the opening where faeces (waste products) come out.

Activity 3.10 What should we call the male and female reproductive parts?
This activity contains terms that may be offensive to some people, or be censored from mainstream media. In order for peer groups to be effective they have to discuss what terms are use for male and female genitalia (private parts). • What names do you use to for the male and female private parts? • When do people use the scientific names? • List all the different names you can think of, that are used for the male and female genitalia - see page 169 • Discuss which terms could be used with different peer group audiences • What words would you use with children?

48

Activity 3.11 Over thirty reasons why people have sexual relationships
There are many reasons why people form sexual relationships. • Read the list of reasons why men and women form sexual relationships. If you are in a group circle let each person read a line each until you finish the list • Decide which of the reasons are good and make you feel happy and which are bad reasons which make you feel sad or angry? Points for your discussion, debate, drawing, song, story, play, poem, poster etc I have this sexual relationship because I want to: 1 give and receive love in a very special way 2 get special treatment and promotion (eg. workplace, school, college, services) 3 have a baby 4 discover the ’fireworks’ that go with sex that’s in hollywood films and in other media 5 fulfil one of God’s purposes for marriage 6 obey my husband who says that my duty is to have sex with him whenever he wishes 7 prove my manhood (or womanhood) 8 get money, fashion clothes and gifts 9 get a fresh experience, my wife (or husband) is not as tasty as she was when we met 10 show my husband (or wife) that if he can be unfaithful so can I 11 please my teacher so he gives me good marks 12 get or keep my job 13 make good friends with this person who could give me a much better quality of life 14 prove my independence and sample what this sex thing is all about 15 be released from this police station cell without being charged 16 get this influential person to help me afterwards 17 release the tensions in my body 18 be cleansed after my husbands death (kupita kufa) 19 be initiated into womanhood (kuchotsa fumbi) 20 have a temporay husband replacement (mbulo) 21 have a change of wife (chimwanamaye) 22 have a baby and my husband cannot give us one (fisi) 23 get accepted...feel loved...become more popular...cure my loneliness and depression 24 stay alive after these men have finished raping me 25 fulfil my loving same-sex relationship in a special way like mixed-sex couples do 26 feed my family, because I am unemployed at the moment 27 to be cured from AIDS and I have been told this child virgin will cure me 28 have two wives, polygamy is allowed in our culture 29 stay in my uncle’s house where he feeds and clothes me because I am an orphan 30 hold on to my partner 31 be protected from violent people in this prison 32 be protected from the other street children who frighten me 33 show this person I am the boss and I have the power! Point to ponder A sexual relationship may have little to do with love and affection, but be more about establishing power within the relationship. It can be almost impossible for some people to say, ‘No!’ Discuss.

49

Activity 3.12 Frequently asked questions about sex
Discuss the following questions. They are written from a health professional’s viewpoint. 1 What exactly is a virgin? The term virgin is used for a woman or man who has never had sexual intercourse at any time during their life. By sexual intercourse we mean the penetration of the penis into the vargina. 2 What is a virginity test? A female virgin has a hymen, a thin membrane of skin in the vagina, which is broken when she has sexual intercourse. It tears as soon as it is poked with anything stiff, such as a finger or a penis. But a few women are born without this membrane and some membranes are easily torn during physical exercise, such as riding a bike or climbing a steep hill or heavy farmwork. The hymen can also tear during a medical examination or treatment of the sex organs. So, the existence or non-existence of this membrane is not a good indicator of virginity. The only way to identify a virgin is to know whether the person has or has not had sex. If a woman has had sexual intercourse she has lost her virginity and there is no way to get it back. 3 Is it important to be a virgin before marriage? Many people believe that sexual intercourse is a very special gift from God and should be shared only with the person you marry. Others believe it is important for young people to remain virgins until marriage, because it is the very best way to protect them, from unwanted pregnancies, sexually transmitted diseases which may affect fertility and more especially from HIV. 4 Do adults have to have sex to be completely healthy? If you abstain from sex completely or for a long time, it causes no health problems. No harm will be done to either your private parts or any other part of your body. When people who have been celibate (abstained for a long time) have sex they will feel excitement and enjoyment. Abstaining from sex for a long time, does not cause pimples on the face or private parts or psychological problems. The causes of these conditions have their roots elsewhere. 5 Why does a man’s penis become erect when he sees parts of a woman’s body? In Africa, tradition says that men find the hips (thighs) and buttocks of women attractive and they get sexually excited. In other countries of the world it may be a woman’s breasts, neck or legs. These are natural, male sexual feelings and just thinking about a woman is often enough to cause the penis to become erect. 6 How often can a person have sexual intercourse? As often as both they and their partner wishes. Having regular, daily sexual relations will not harm a person as long as they are not being forced against their will, which would be a form of sexual abuse or spousal rape. Obviously, as a physical activity it uses energy and can make people tired. Often men need more time to recover and become excited between ejaculations than women do.

50

7 Who has more enjoyment when having sex, the man or the woman It is not easy to say who has more enjoyment when having sex, because the extent of enjoyment a man or woman has depends on both of the people involved. The most important thing about having sex is that both the man and woman try to satisfy each other to the maximum extent. If both seriously try to satisfy their partner, both will get a lot of enjoyment from having sex. In earlier times, many men thought that it is only the women’s task to satisfy the man’s desire, and often women did not get much enjoyment from having sex. This is not how it should be. Nowadays things have changed, because men have started to realise that having sex is more enjoyable if both partners try to satisfy each other. This is why sexual intercourse is called making love. 8 Do women have orgasms? Yes, women also have orgasms when having sex. A woman reaching an orgasm when having sex feels a very special excitement and well-being in her body. Men usually ejaculate when they reach their orgasm. Women can have one or more orgasm while having sex. Some women experience multiple orgasms which do not need to be caused by intercourse, but can be stimulated by stroking and touching parts of her body especially the clitoris and vagina. 9 What is the easiest way for a man or woman to have an orgasm? The most important things is that both partners are ready to have sex. This means that they love and respect each other, and that they are physically and mentally ready to make love. Not being ready to have sex, for example if you fear pregnancy, or STIs, may hinder you from reaching an orgasm. If both partners are ready, whether or not you reach an orgasm depends on the way you go about having sex. You should make sure that you have agreed together upon ways of having sex, which bring the most enjoyment and satisfaction to both of you. Indeed, millions of people around the world enjoy foreplay which involves cuddling and touching before full penetrative sex. Every woman and every man has certain parts of the body, which are very sensitive to touching. Foreplay can increase the chances of reaching an orgasm for both women and men. 10 What can be done if someone cannot have an erection or an orgasm? Sometimes a man cannot get an erection or ejaculate when having sex. This can be for different reasons. To have an erection and ejaculate requires energy, therefore anything which reduces the physical energy of a man, such as stress, sickness, alcohol abuse, drug abuse, smoking or feeling hungry can hinder the man ejaculating properly. Action to reverse these conditions should be taken. Other important reasons could be not being ready to have sex or not really being in love. Gentle, loving, sexual foreplay can help bring about an erection for the man and assist both partners to an orgasm. 11 Can a penis get stuck when penetrating a vagina? No, because the vagina is made from very elastic skin. The vagina can expand sufficiently for giving birth to a child, where it may expand as much as ten to twelve centimetres in diameter. So, even if you have a big penis, it cannot get stuck in a vagina.

51

12 Should a woman’s vagina be dry during sexual intercourse? No, a woman’s body naturally produces lubrication during fore-play. This lubrication makes intercourse easier and there is less risk of damaging the delicate membranes. Traditional medicines or herbs should never be put into the vagina to make it dry, because they can damage the tissues and increase the risk of HIV infection. 13 Why do men usually take the initiative towards having sex? Studies have shown that in many places in the world, boys and men take the initiative to have sex, this is said to be because of social and biological factors. Men are often the leaders in the family and community, they are bigger and stronger and they can get sexually excited very quickly. It is commonly accepted that men often have an orgasm before women do. Today, it is becoming more acceptable for women to take the initiative as well as men. The cartoon shows Taxina drawn by late Vic Kasinja.

14 How soon can a couple have sexual relations after a woman has a baby? Usually 4-6 weeks. A woman can have sexual relations as soon as she has no pain or discomfort and feels ready to do so. Some women have little desire for sexual relations just after giving birth. It is not harmful to the baby’s health to have sexual relations while the baby is still nursing. Some local beliefs are the traditional ways of making sure women do not get pregnant too soon. Sexual intercourse has no harmful effects on a woman’s milk. 15 Is it all right to have sexual intercourse during menstruation? Yes, but it is advisable to use a condom. A woman cannot get pregnant during menstruation even if a condom is not used. Sexual relations during menstruation can be messy, but it is not physically harmful for either men or women, unless one or more partners is infected with an STI. However, some people find the idea unacceptable. 16 What is masturbation and is it wrong? Orgasms can be achieved through masturbation. For example the man can rub his penis, or the woman can rub her clitoris to reach an orgasm. Masturbation is a safe way of satisfying the feeling of wanting to have sex. It has no negative health consequences. It will not cause a person to have future problems having sex with a partner and it does not cause blindness nor weaken the sexual organs. Remember, religions often have clear teachings on whether masturbation is acceptable or not, check with your religious leaders if in doubt.

52

17 Does a woman need semen to improve her health and beauty? Some people believe that women require semen for their health, especially so they will have beautiful skin. If you look at the diagram of a woman’s body, you will see that semen goes only into the vagina. It has no way to reach the skin. So putting on lotion will give smooth soft skin, but sexual intercourse cannot affect the skin. This question is still being debated by scientists. 18 What are the consequences of anal sexual intercourse? The main problem with having anal sex is that there is an even higher risk of infecting one another with STIs and HIV/AIDS. To have anal sex is dangerous, because their are no fluids to lubricate penetration and the skin in vulnerable. Therefore it is very easy to get small injuries, which do not cause pain but which also enhance the chance of transmitting diseases. If you decide to have anal sex use a condom. Homosexually is illegal in Malawi and against the teachings of the main faiths. 19 What is oral sex and is it safe? Oral sex is using your mouth to stimulate your partners genitalia. Oral sex on male genitalia is called falatio. Oral sex on female genitalia is called cunnilingus. If partners have no STIs, especially HIV, there is no health hazard. While some women enjoy falatio, others do not like receiving sperm in the mouth, others find it unpleasant. Religions often have clear teachings on whether oral sex is acceptable or not and you should check with your religious leader if you are concerned. 20 Why should men take on greater responsibility in reducing HIV infection? Men are slow in seeking health care and do not easily cope with illness in the way women often do. They take greater risks regarding alcohol abuse and casual sexual intercourse. Men need to take greater responsibility to protect themselves, their partners, and future children.

Activity 4.12 Assignment: Talking about sexuality
• Interview a friend, neighbour or relative about how you each learned about sexuality and what they would like to know more about • How do you and your friend think young people should learn about sexuality? • How old should a child be when you first introduce the concept of sex to them? • Find out how much they know about the way HIV is transmitted • What sexual practices would they wish to change in order to reduce spread of HIV and STIs in Malawi? • Collect any interesting or important stories about HIV transmission

Evaluation. Evaluate the unit or your chosen selecton of activities by using the
questions on page 166.

53

Unit 4 Preventing transmission of HIV
Introduction
An STI is a Sexually Transmitted Infection. STIs are also known as STDs or Sexually Transmitted Diseases. There are many STIs which can be passed from one person to another through sexual activity. In this unit you will study how STIs get into the body, what they can do to the body, how they should be treated and ways to protect the body from future infection. HIV is the most dangerous STI so the unit begins by looking at transmission of HIV.

Learning outcomes
By the end of this unit you should be able to: • identify which body fluids contain the HIV • describe how people get infected with HIV • describe how to prevent HIV infection • explain how HIV/AIDS not transmitted • describe some signs or symptoms of STIs • describe some of the complications resulting from sexually transmitted infections • describe what you would do if you got an STI • explain how infection by other STIs can increase our chances of HIV infection • calculate how many people you may have shared sexual body fluids with • explain the ABC of HIV prevention • define the terms safe sex and safer sex • list the factors that put men at risk of STIs and especially HIV infection • list the factors that put women at risk of STIs and especially HIV infection • describe why young girls may be vulnerable to HIV infection

Activity 4.1 Assignment review
Review the assignment as preparation for the activities in this unit.

Activity 4.2 Which human body fluids may contain HIV?
Which human body fluids do you think are the most dangerous? Points for your discussion, debate, drawing etc The following fluids may contain HIV: • Seminal fluid, vaginal fluids, and blood pose the highest risk • 75% of men secrete a clear fluid called precum from the penis before they ejaculate and pecum can contain HIV if the man is HIV+ • Breast milk poses a risk of infecting children, but in Malawi, breast milk is recommended as the only food for the first 6 months of a baby’s life • Sweat and tears have very low risk of HIV • Amniotic fluid poses less risk than vomit, faeces, urine and saliva, although all these have low chances of causing HIV infection

54

Activity 4.3 How do people get HIV?
We will now look in greater detail at the ways in which HIV is spread. Facts about HIV • Is a parasitic virus which needs to live inside another living thing (a host) in order to survive • Uses human body cells to reproduce inside • Cannot live and reproduce outside the body • Cannot survive unless it is in human body fluids like blood, semen, urine etc • Can stay alive and dangerous in body fluids such as drops of blood etc • Dies when outside the body when a liquid completely dries up! • Has no brain, cannot think and it does not plan where it will reproduce next • Has millions of humans to help find new bodies for it to reproduce in • Would find it almost impossible to reproduce and survive if humans stopped moving it to new places • Prevention, treatment, care and support programmes work to stop humans from passing the virus to new bodies where it can successfully reproduce People get the HIV virus through 1 Sexual contact 2 Mother-To-Child-Transmission (MTCT) 3 Other ways of body fluid cross-infection Points for your discussion, debate, drawing, song, story, play, poem, poster etc The most common way is sexual contact through unprotected sexual intercourse with an HIV infected person. Why are the vagina, the inside of the foreskin and anus the most vulnerable routes? 1 Vagina: the vagina lining is thin especially in young girls and the vagina has little mucus. The vagina also contains HIV targets such as white blood cells, which may be there as a result of some inflammations not caused by HIV. Young women are biologically more vulnerable to HIV infection. After sex semen remains in the vagina at body temperature long enough for infection, whereas vaginal fluid may dry and stay for a shorter time on a penis 2 Foreskin: The male foreskin easily allows HIV to penetrate the skin and it is liable to tears and ulcerations. Circumcision is recommended for sexually active men and can reduce HIV risk by about 60% in men. 3 Anus: Male and female anus linings are extremely thin. Unprotected anal sex poses a very great risk. Mother-to-child-transmission. An HIV infected mother can pass on HIV to her baby during pregnancy, delivery or breast feeding. Doctors recommend that Malawian women breast feed exclusively for six months. Which means giving the baby no other liquids or feeds, not even traditional medicines like dwale. Unit 11 deals with this important topic in greater detail. Other ways of body fluid cross-infection. See the activity 4.4. You may wish to combine activities 4.3 and 4.4.

55

Activity 4.4 How to prevent HIV infection through body fluid contact
What strategies would you use to prevent yourself from becoming HIV infected via contact with blood and other fluids? We have marked the peer group members suggestions with symbols ( & ) and we hope that this will help to show the things that are dangerous and the things that are safe to do. Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? The HIV virus can live for only a very brief time outside the human body, so the risk is quite small. But if any HIV contaminated fluids like blood, come into contact with the blood in your body you are at risk Sharp objects, like needles for injections or razor blades, that have been used by a person with HIV can transmit the virus, because a small amount of blood may remain on the blade or point To prevent the risk of HIV infection from sharp objects, use only new needles and razor blades or be sure they have been properly sterilized. Health clinics use disposable needles or sterilize them so that injections at the clinic and hospitals are safe Ear piercing, tattoos, traditional medical cutting, ritual procedures such as circumcision and self-injecting drug abuse, should be with new or properly sterilized equipment for each person Sharing a toothbrush can also put you at risk, especially if there are cuts, sores or gum bleeds in the mouth During violent gender-based disputes there is a danger of HIV infection if both people involved have open wounds or are bleeding Violent contact sports like boxing and wrestling if blood mixes through open cuts Traditional birth attendants, mothers and babies are at risk if one has cuts or sores There is a risk when the same cloth is used to wipe both bodies after sexual intercourse, this is because both vaginal fluids, semen and possibly blood may be on the cloth There are risks when caring for a person living with AIDS (PLWA) because of open wounds, bleeding and open bowel issues - we will deal with these issues in greater detail in unit 9 which starts on page 129 The risk of getting HIV from unprotected sexual relations is much greater than the risk of getting HIV while caring for a person living with HIV You may be at risk of contracting other diseases such as tuberculosis (TB) from a PLWHA If the person has TB, check with a doctor or clinic about protecting yourself and family because TB can be treated effectively In an accident or emergency, where a person has been cut a plastic bag can be used as a substitute for medical gloves. The risk is not great unless you yourself have open wounds on your body. Blood transfusions are unlikely to give you HIV, because blood is tested before use

56

Activity 4.5 How is HIV/AIDS not transmitted?
HIV cannot live for long outside the human body and it cannot travel through the air by itself. This is why there are no anti-HIV sprays to kill it in the air. So, can you work out how HIV is not transmitted? Points for your discussion, debate, drawing, song, story, play, poem, poster etc You cannot get HIV from the following activities: Handshaking or hugging Kissing (provided people have no mouth sores) Visiting PLWA’s homes and hospitals Sharing beds and furntiture Preparing food and eating together Swimming pools or public showers Using items previously used by a person with HIV, such as books, clothing or the toilet, telephone, hand washing basins, unless the PLWHA has open wounds or sores Donating or giving blood. When you donate blood you do not get some from someone else. The equipment used is always sterilised Being bitten by mosquitoes or other insect bites. This cannot happen because the mosquito mouthparts cannot transmit it. If mosquitoes transmitted HIV, then almost all people in malaria-prone areas like Salima would be HIV+ by now Caring properly for people living with HIV and AIDS.

Activity 4.6 What are some signs or symptoms of an STI ?
HIV does not have any significant symptoms in the early stages of infection, but a person may have slight flu symptoms in the first two weeks or so. But, HIV gradually weakens a person’s immunity to other infections such as STIs, colds etc. You may wish to combined this activity with 4.7. Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? Having an STI can seriously increase someone’s risk of getting HIV Sometimes people have painful symptoms, but sometimes there are no symptoms For some STIs, women are more likely to be infected without showing any symptoms Here are some symptoms that may show that a person has an STI and some people may have one or more of these symptoms: Sores or blisters near sex organs or in and around the mouth Burning pain when passing urine Ιtching feeling on private parts Swelling around the sexual organs Discharge from eyes of new born baby Rashes (spots) on the body Pain during sexual intercourse Pain in lower belly area or in the vagina or testes Bleeding from the vagina other than regular periods Unusual pus discharge from penis or vagina, that can be very smelly

57

Activity 4.7 Complications from sexually transmitted infections
Here are some of the complications that can occur if a person has an untreated STI. Which complications would you personally be most afraid of? Points for your discussion, debate, drawing, song, story, play, poem, poster etc Some STIs cause serious and permanent damage to a the body if left untreated. Increased risk of getting infected with HIV, because the skin in your private parts may be damaged by STI infection.

Disease
Gonorrhea

Cause
a bacterium called Gonococcus

Symptoms in Men
• • • • • • • • discharge from the penis pain when urinating genital itching urethra constriction

Symptoms in Women
• • • • • • • • • • • • • • • • • • • • • • bad (foul) smell vaginal discharge pain when urinating lower abdominal pain due to pelvic inflamation itching of the vulva infectious genital ulcer fever itching in the vagina swollen lymph glands bleeding from vagina pain in pelvic area profuse vaginal discharge vaginal pain vaginal itching bad smell painful sexual intercourse vaginal discharge vulva irritation reddened vulva vaginal swelling vaginal sores vaginal discharges

Syphilis

a bacteria called Treporema palladium

infectious genital ulcer fever bumps on penis swollen lymph glands

Trichomonisasis

Micro-organism called chlamydia trichomontis

• • •

no visible signs that lead to problem called urethritis increased itching sores and itching of penis

Candidacies

Fungus

Chancroid (mabomu)

A bacterium Haemophilus ducreyi

• •

genital sores genital swelling

Points for your discussion, debate, drawing, song, story, play, poem, poster etc Brain damage which may lead to madness or insanity Infertility in both men and women. Miscarriages by pregnant women Death of babies, before, during or after birth Blindness in infants if not treated well in pregnancy Pelvic Inflammatory Disease (PID) in women - Mbulu Nearly all STIs are treatable by clinics, rather than by traditional healers, who often treat only the symptom and not the cause of the infection

58

Activity 4.8 Are there other ways for people get STIs?
Like HIV, some of these diseases are also spread by ways other than sexual contact. Look at the list of STIs on the last page and discuss how they could be transmitted. Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? STIs are caused by different micro-organisms and have different signs and symptoms Newly born babies can be infected whilst in the womb or during birth or during breast-feeding by their HIV positive mothers Kissing, sharing a toilet, razors, bath cloths and towels can transmit some STIs Open sores on the genitals and around the mouth are often very highly infectious So, it is imperative that people with STIs get immediate treatment and do not pass the disease on to others

Activity 4.9

What would you do if you got an STI?

STIs do not go away on their own, they must be treated by medical professionals. You can easily spread the STI to others. If you though you had an STI what would you do? Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? Go to the clinic if you or your partner has any of these symptoms, even if the symptoms seem to have gone away Do not stop your treatment early even if the symptoms seem to have gone Until both of you finish your treatment, you need to abstain or use condoms during sex If either of you has had sex with another partner now or recently, that person also needs to be treated Attend all follow up medical sessions Be very hygienically clean and careful so that you do not pass on the STI

Activity 4.10 How can other STIs increase our chances of HIV infection?
Review this topic by discussings what you have already learned. Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? If a person already has another STI, especially an open sore in the genital area, that person can more easily get infected with HIV To become infected, the HIV virus must enter your bloodstream, if there is an open sore or cut in the genital area, this is more likely to happen. If one gets infected with HIV, some STIs (genital herpes and warts) becomes more frequent, some STIs become aggressive and respond poorly to treatment. STIs like genital herpes and syphilis, depress the immune system making it easier for HIV to attack a person with STI at a single encounter. Prevention of STI infection therefore reduces the spread of HIV in a community To reduce the chance of getting HIV have all STIs treated as soon as possible Encourage others in the community to get tested for STIs and treated

59

Activity 4.11 How many people will Cecilia share body fluids with?
People sometimes forget that a new partner may have had a previous partner. Discuss the diagram on page 61. Read the following case study and make a list of the people mentioned. Then create a diagram to work out a possible chain of infection. How many people may put Cecilia at risk of HIV infection? Today is Cecilia’s wedding day. She is a very religious, young woman who is marrying George, her first serious boyfriend. She is a virgin who has saved herself for her future husband. George attends the same place of worship as Cecilia and has had only one serious sexual relationship with Monica. He has never been tested for HIV, because he knows Monica is not promiscuous. This is because Monica has had sex with just one other man, Kondwani. Kondwani, is very good looking and is very attractive to girls and older women. Last year, at school he was seduced by Mrs Mwape, his teacher. They did not use a condom. Mrs Mwape had never done this sort of thing before, she was a virgin when she had married her husband. Mr Mwape, an accountant, is regularly called to workshops by the lake. He enjoys the pleasures of sex workers. Mr Mwape and his friends at the bar, often joke that he must have played around with over thirty of the sex workers in the ten years in his job. Mary, one of the prostitutes, had been forced into sex work by her violent husband. She had started three years ago, just after her marriage. Like the other prostitutes Mary could have sex with up to ten men a day, with local men, workshop attenders and foreign tourists. Mary’s husband has never stayed faithful to her for long. He drinks and when drunk he has sex with young and old sexworkers. Locals make fun of him because he often has sex with Chikondi, a kind hearted prostitute who is well over 50 years old. When Cecilia and George begin a sexual relationship how many people may be involved?

Activity 4.12 How many people have you shared body fluids with?
This is a private activity you may do as an assignment. Look at the picture on the next page. Could you represent your sex life in the same way by using simple little drawings? This is one way of assessing your risk of HIV infection. • Select a drawing or shape, to represent people that you have had sex with • You may wish to use boxes or bubbles • Use only initials and dates if you prefer • Put a if you think that person was an HIV risk to you for any reason • Put a ☺ if you think that person was not an HIV risk to you for any reason • Finally consider your behaviour and decide if you should change it at all • Go for VCT if you are at all concerned!

60

Point to ponder

Only one person had HIV to start with, but how many could be infected now? Discuss 61

Activity 4.13 What is the ABC of safe sex?
The ABC of safe sex, or staying safe from HIV is the most popular prevention message in the world. It calls on people to stick to one or more of the methods, depending upon their beliefs and the situations they find themselves in:

A = abstain from sexual intercourse B = be faithful to one uninfected life-long partner C = use condoms correctly and consistently
Activity 4.14 What is safer sex?
The term safe sex and safer sex mean different things to different people. Safer sex is said to involve physical contacts, which do not allow the penetration of the penis into the vagina. There are many ways in which people can have an enjoyable, sexual relationship and stay safer from both HIV and an unwanted pregnancy. Read through the statements below and decide whether the advice may work for you and your partner or other people. They are all sexual activities with no contact with semen, vaginal fluids or other body fluids. Points for your discussion, debate, drawing, song, story, play, poem, poster etc 1 The safest sex is no sex at all, until after both VCT and marriage 2 I play with my partners hair slowly moving my fingers gently over his scalp 3 When his fingers move up and down my arms, barely touching my body hairs it sends ripples of excitement all over me...then our fingers play together 4 My fingers trace patterns on his forehead, cheeks and gently explore his ears, followed by the eyebrows and then I start kissing him starting with his hands 5 We like to touch skin with different things like a flower, a feather, our hair, small stones, coins, drops of water, slices of fruits and sweets...it’s very sexual 6 We keep our clothes on and enjoy touching and stroking through our clothes, because it’s safe and we have barriers up against temptation...we hold hands and hug a a lot 7 We keep our clothes on but can press our private areas together and move...it’s safe sex 8 We allow ourselves to be naked above the waist, but remove nothing else, apart from shoes and socks. We can kiss and touch only uncovered places, nowhere else 9 I really enjoy doing a strip dance for him. I never remove my pants...I move sensually and peal off my clothes...I enjoy him looking at my body, but no intercourse until VCT! 10 We can stand, sit or lie down in all sorts of different ways...we take turns removing clothes down to our underwear 11 I do masturbate to an orgasm and I think it helps control my behaviour 12 I wear shorts and she wears a swimsuit or underwear, which we never take off... ...touching the private parts for long time... I suppose it’s mutual masturbation 13 We tell each other sexy stories, including all the exciting details of what is happening 14 We shouldn’t talk about this sort of issue as it may encourage people to experiment Points to ponder Safe sex involves making rules and trust. Trusting that both partners will keep to those rules. There is sexual freedom up to a limit, but a limit not to be crossed. Discuss Both safe sex and unsafe sex begin in the mind and that is the best place to stop them both until after both VCT and marriage. Discuss

62

Activity 4.15

Thinking about sex without a condom

After carefully considering the consequences, a couple should consider the following points before having a full sexual relationship. • Your safety depends on both your behaviour and your partner’s behaviour • Βefore having sexual intercourse without a condom, you need to: 1) Use condoms for three months 2) both get treatment for any STDs 3) both have a blood test that shows you are HIV free 4) be completely faithful to each other or use condoms in any outside relationship You may combine this introduction with Activity 4.14.

Activity 4.16

How fast does HIV spread?

You may wish to combine this activity with others. This is a very good ice-breaker or introductory activity. You will need • Cups which represent the human body • Water which represents healthy human body fluids • Starch solution which represents infected body fluids containing HIV • Iodine solution which represents an HIV test • Behaviour cards. These are small pieces of paper with the following five letters on A (abstain) B (always be faithful) U (unfaithful partner) S (sexually active )

Suggested method • Explain what sort of behaviour each letter represents • Ask each participant to pick a paper at random • Give one or two participants a quarter cup of weak starch solution (HIV+) • Give all others a quarter cup of plain water • Ask participants to mix the contents of their cups according to the behaviour shown on the paper • To mixing represents sexual intercourse between two people, which mixes body fluids • To represent sexual intercourse pour the contents of one cup into the another, mix and then divide the contents equally between the two cups • Stop the activity when most of the participants have mixed body fluids with others • Represent the HIV test, by putting a few drops of iodine solution into each cup. • If the solution goes dark then it means starch (HIV) is present in the cup • How could you develop this idea further?

63

Activity 4.17 What factors put men at risk of STIs and HIV infection?
What factors put men at risk of STIs and HIV infection? Ask the group to think about the behaviour of men in their community. The best male role models in a society, who hold firm views about correct behaviour are at lower risk than the poor role models. Points for your discussion, debate, drawing, song, story, play, poem, poster etc We have marked the peer group members’ suggestions with the symbol because this activity concentrates on identifying dangerous behaviours that can be changed. Which dangerous behaviours put men at risk? Wanting to prove their manhood Belief that girls and young women don’t have HIV Not abstaining when a sexual partner is menstruating or is in latter period of pregnancy Men who abstain from having sex with their wife during her menstruation, believes it is culturally acceptable to go out with other women. Unfaithfulness by wives Casual sex with multiple partners Homosexual relationships Wanting to show off wealth through sex Using sex as source of power If accused of being impotent, men have sex with other women to prove or disprove the allegations. Looking for sex to gain experience Traditional view of women as sex objects to be used and then discarded Performing widow cleansing ritual with a late relative’s widow Men selected to act as fisi during girl-child initiation Infection by blood on an unclean blade during the circumcision of a boy-child

The late Brian Hara’s cartoons often used humour to carry important messages

Showing off to peers, by bragging about manhood and conquests Drinking alcohol in a bar frequented by sex workers

64

Activity 4.18 What factors put women at risk of STIs and HIV infection?
What biological and social factors put women at risk of HIV and AIDS? Points for your discussion, debate, drawing, song, story, play, poem, poster etc We have marked the peer group members’ suggestions with the symbol because this activity concentrates on identifying dangerous behaviours that can be changed. What have peer group members suggested? Early marriage of primary school-age girls puts them at risk, because their reproductive organs are not fully developed and smaller than a grown woman There is a lot of pressure on woman to have sex with boyfriends to prove their faithfulness Older men with money (sugar-daddies) tempt young girls to exchange sex for gifts or money Poverty can force women to become sex workers in order to support their families. Employers can pressure women employees to give them sexual favours Some women use sexual favours to rise in an organisation Sex within marriage is considered as simply a duty and a condition for having children, instead of as a source of mutual pleasure and bonding Some men are sexually unfaithful, they can bring HIV and AIDS into a marriage Women put herbs and other agents in the vagina to cause dryness, heat and tightness. These substances may cause inflammation and open sores in the vagina making it easier for HIV to mix with body fluids Women are the primary care-givers at homes with people living with HIV and AIDS. This puts them at risk of infection from blood and other body fluids Wife inheritance, where a relative inherits a dead relative’s wife When an impotent man hires fisi to have sex with his wife Widow cleansing through sexual intercourse Proverbs like Mamuna ndi mwana, which means that a man is a child, so he has an excuse for any sexual infidelity Men say they love a woman when what they really want is sex, a woman will often have sex with a man when what she really wants is his love Women are vulnerable to HIV infection because of gender inequalities and lack of power within sexual relationships

65

Activity 4.19 Why are young girls vulnerable to HIV infection?
We have just discussed the factors which make women vulnerable to HIV. Now, we will look at factors that make young girls particularly vulnerable to HIV infection. Read the article from the Malawi Daily News.

School girls - their friends being sold for cows (Source: Nation May 31, 07)

Points for your discussion, debate, drawing, song, story, play, poem, poster etc How widespread in your area, are events similar to those described in the article? Peer group members suggested that the following points were very important. Men often choose younger women as sexual partners and it’s not easy for a young woman to talk assertively with an older man. Early marriage, where the older husband controls the sex life of the couple due to the respect and expected unquestioning obedience of his younger wife You can combine this activity with the next one if you wish, but group members have suggested that school age girls are particularly vulnerable.

66

Activity 4.20

Why are young people at high risk of HIV infection?

What are the factors that put young people at particular risk of HIV infection? We have marked the peer group members’ suggestions with the symbol because this activity concentrates on identifying dangerous behaviours that can be changed. Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? Young people can experience rapid mood changes and become very emotional, this can lead to stress, depression, aggression and wild behaviour Research shows that youth interaction between mental health and HIV/AIDS increases the risk of them developing mental disorders Elders who carry out the initiation may not be well informed about how young people can prevent HIV and AIDS, STIs and early pregnancy Anxiety disorders in youths can lead to reckless sexual behaviour during which they are exposed to HIV Youths often don’t want to listen to lectures on behaviour from adults. They experience new strong sexual urges and attraction to the opposite sex They may have day dreams or sexual fantasies which they want to act out They need more independence from their parents and this can lead them into unsafe situations Negative peer pressure can influence them act in dangerous ways and do things just to impress the group Influenced by negative role models they see on TV or in films They want to try new things and take risks and this can lead to infection, injury or death Drinking alcohol and smoking chamba Early unsafe sexual relationships In some parts of Malawi, young people start having sex at a very young ages Half of all women have sex before the age 15 and half of all men before 16 Unemployment and the lack of community activities that interest them can leave youths with lots of time on their hands Lack of accurate information Lack of communication with parents or caregivers. Parents may not feel comfortable talking to their children about sex

Activity 4.21 Assignment : Peer pressure
Carry out research into the power of peer pressure in your community. Look at both negative pressure and positive pressure within different peer groups. How do you think that peer pressure could be used to encourage people to work to halt the HIV pandemic?

Evaluation. Evaluate the unit or
your chosen activities by using the questions on page 166.

67

Unit 5

Condoms

Introduction
Many doctors and health workers see condoms as a key weapon in fighting the pandemic of HIV and AIDS. Other people view the situation in a completely different way. Some religious leaders are openly opposed to the use of condoms as they blame them for encouraging promiscuous behaviour. Others say that condoms interfer with the natural process of conception. In your peer group you will probably have conflicting views, but we believe it is valuable for all students and teachers to know more about condoms. Discussing condom use does not mean that a person is going to use one.

Learning outcomes
At the end of this unit, you should be able to: • explain how condoms protect against HIV and STIs • correctly use and dispose of a female and a male condom. • be comfortable when discussing and teaching others about importance of using condoms

Assignment 5.1 Assignment review
Encourage group members to share their experiences about the assignment from the last unit.

Assignment 5.2 If a man can carry a condom why can’t a woman carry one?
What message do you think the cartoon is sending out? Points for your discussion Study the picture and consider the following questions. • What is happening in this picture? • Does this happen in Malawi? • Why do you think that the man is surprised? • What do you think of the woman’s statement? • Discuss the situation in pairs and then as a full peer group • Some peer group members believe that the woman is perfectly correct in carrying a condom, because she is protecting both herself and her husband. Do you agree? • Some peer group members believe that the both partners are correct in carrying condoms, because they are protecting each other. Do you agree? • Many activities in this unit will deal with the practical, social and moral issues related to condom use.

68

Activity 5.3 How strong is a condom?
What can we say to people who say that condoms can break during sex and therefore do not protect us. In Malawi standards experts would say, Condoms are tested for tensile strength; freedom from holes; dimensions such as length, width and thickness; air inflation for bursting pressure and volume; package seal integrity before they are distributed. Demonstration Choose one of the two demonstrations below. Say, Let me show you that condoms are very strong. 1 Blow up a condom like a balloon until it breaks. In preparation, before the session open and lightly wash the lubrication from a condom. 2 Fill a condom with water and show that it does not break. You can even play a game of catch with it, but be careful people don’t get wet! What causes condoms to break? Sharp fingernails; exposure to heat and sunlight for a long time; unrolling condoms before putting them on makes it harder to put on without stretching. Don’t put oilbased lubricants such as petroleum jelly, baby oil or lotions on a condom. Point to ponder People say that condoms sometimes fail, but in our community condoms may be the best chance, because abstinence has failed and being faithful has failed us as well! Discuss.

Activity 5.4 Don’t condoms have tiny holes which allow the HIV through?
Peer group members have suggested that you could say: Condoms, like everything else, do have pores and holes but they are too tiny to see Research shows that these pores are too tiny to let the HIV virus go through Under normal use there is no leakage In scientific stress tests, condoms have been filled with over a bucket full of water before showing any signs of leaking - that is a considerably larger volume than the average penis - some condom critics fail to mention the fact that scientific testers often fill condoms with over 4 litres of water More importantly, there are many couples where one partner is known to be infected and the other is not infected. Studies show that the HIV negative partner did not contract HIV or other STIs when those couples used condoms consistently. But if couples did not use condoms at all or used them inconsistently, many of the partners who were HIV negative became infected. Condoms do not offer 100% protection, but they offer over 98% protection and this greatly reduces the risk of HIV infection by sexual contact. Points to ponder a) If you can’t abstain or be faithful, use a condom to save the life of your partner and future children. Do not kill your own partner by unsafe sex. Discuss b) If condoms give 98% protection against HIV infection that is better than the 0% protection if you don’t wear one. Discuss

69

Activity 5.5 Condoms are not romantic
Peer group members have suggested that you could say: Worrying about HIVand AIDS or STIs is not romantic...with condoms we don’t need to worry...we can relax and enjoy our love Let’s try to make it safe and romantic If we keep the condom close by under the pillow it will be less stressful Let’s open a packet and examine a condom together...it is not just the man’s job to put it on. Many couples find that they enjoy sexual relations even more when they use a condom, once they get used to using condoms and make condoms a part of their activities...they are more relaxed, because they are not worrying about getting pregnant and infected with HIV or other STIs. For many men condoms help them last longer before ejaculation, which is something both the man and his partner appreciate Romantic men always hold their partner after making love...they become very experienced at carefully and quietly, removing the condom and putting a knot near the open end, which seals the semen inside. Keeping a fresh tissue near at hand can also make it easier. Learning how to remove, knot and carefully hide the used condom for later disposal, is more romantic than a noisy performance.

Activity 5.6 Sex with a condom is like eating a sweet inside the wrapper
Your partner says, ‘Sex with a condom is no good because there is no skin-to-skin contact, it’s like eating a sweet inside the wrapper or wearing a raincoat in the shower?’ Peer group members have suggested that you could say: If two people have sex without a condom they risk sharing a lot more than a good time...how can we enjoy sex when we are worried about AIDS? We can have sex without a condom someday, if we both get tested and find out that we are both HIV negative and we agree to be completely faithful I don’t think its time to have a baby right now

Activity 5.7 Can condoms come off and can remain inside the woman?
Peer group members have suggested that you could say: The condom will not usually come off if the man withdraws his penis carefully, holding the top of the condom right after climax so the penis is still erect People all over the world have used condoms safely for over 100 years Condoms are the safest of all family planning methods for both the man and the woman If a condom did come off during intercourse, the woman would be able to reach it with her finger, and take it out of her vagina. This is because, at the top of a woman’s vagina, there is only a very tiny opening to her uterus (womb). A condom cannot enter the womb. When a woman is in labour, this opening gets bigger to let the baby out. But when a woman is not in labour, this opening is always tiny, a condom could not possibly get through it.

70

Activity 5.8

But we’ve never used condoms before, don’t you trust me?

Peer group members have suggested that you could say: It is not a matter of trust, it is a matter of health. Condoms are important for our health, until we both get tested It is important that we are both protected. Maybe we should be more careful, because we haven’t been for VCT yet We can still prevent infection or re-infection, because if one of us is HIV positive, getting more viruses can weaken the person more I want to protect myself from pregnancy We should start using condoms now so that we won’t be at any risk

Activity 5.9 But I love you, why should we use a condom?
Peer group members have suggested that you could say: Show me that you love me and care about my future by using a condom. Being in love cannot protect us against HIV and AIDS. Careful, sound, scientific research shows that condoms are effective. If 100 couples use condoms or a year consistently and correctly, only about two or three will experience a pregnancy. Unless people know they are both faithful, condoms are a safer way for sexually active individuals to reduce the risk that they might give HIV or STIs to a partner or receive HIV and STIs from a partner

Activity 5.10 Condoms can cause impotence, TB and cancer
Peer group members have suggested that you could say: This is not true, condom use does not lead to impotence Diseases like cancer and TB are not passed on by condoms A few people are allergic to the latex or natural rubber in condoms - those people can use a condom made of polyurethane Very rarely, a person may be allergic to the lubricant on a condom, and will get a mild rash or itching - that person can use an unlubricated condom, or try a different brand that they may not be allergic to

Activity 5.11 Semen is necessary to help a baby develop properly
Peer group members have suggested that you could say: Condoms protect the baby by protecting the woman from HIV or other STIs - this is very important for the baby’s health. The baby gets all it needs to develop from the single sperm and egg that unite to form life and then from its mother. Women whose partners are away during the rest of their pregnancy deliver healthy, fully developed babies.

71

Activity 5.12 Condoms are only used by prostitutes and the unfaithful
Peer group members have suggested that you could say: Condoms protect from pregnancy and HIV or other STIs. Your regular partner or spouse deserves this sort of protection too Many religious people around the world use condoms, but many do not Prostitutes are fellow human beings - if they consider condoms essential for their wellbeing then others should consider the idea Abstaining from sexual activity is the only way to be absolutely safe from getting HIV through sexual contact Point to ponder Everytime a prostitute uses a condom she is acting not only to protect herself, but she also protects her client, his family, his community and the economy of the nation! Discuss

Activity 5.13

Doesn’t promoting condom use encourage promiscuity?

Peer group members have suggested that you could say: If two HIV negative people are both completely faithful they can have unprotected sex, but the reality in Malawi today is that sadly many of us cannot depend on abstinence or faithfulness Condoms do not promote sex outside marriage. Condoms are not widely used in Malawi, but HIV and AIDS continue to spread. Many people do not use condoms, but they also do not abstain before marriage, nor do they remain faithful People can control their own behaviour but they cannot control their partner’s behaviour, nor change their own or their partner’s past behaviours. So they should be able to use condoms to protect their future health Most partners have not been tested and many people have had risky relationships in the past Many people who say condoms should not be used do consider using them In a democracy, people should have full information about family planning The HIV and AIDS epidemic is so serious that we need to encourage the use of condoms as a public health and development issue Point to ponder I am not prepared to take the risk with my daughter’s life. I shall educate her about condoms and how to use them properly. She will not die from ignorance! Discuss

Activity 5.14

Can I wash the condom and re-use it?

What have peer group members suggested? No, only use the condom once, 1 round 1 condom, 3 rounds 3 condoms Point to ponder If you are sitting on the bed with your love, it is may be too late to ask where you can buy a condoms. Discuss

72

Activity 5.15 Preparing to demonstrate how to use condoms
Remind people that learning how to put on a condom does not mean they have to use one. A religious person in an earlier Mzake ndi mzake group said, The sin does not lie with the condom, its just a piece of rubber! What do you think? There are 3 parts to the demonstration: • selection and storage • demonstration • practice 1 Show a condom in its packet to the group and talk about how to select and store condoms (see activity 5.16 below) 2 Show how to put on a condom correctly - use a penis model, a small cucumber, a banana or a maize cob inner pith for the demonstration 3 Divide the group into pairs and have one person demonstrate how to use the condom - then the other person should do so 4 Be sure everyone in the group has an opportunity to putting on a condom. 5 Occasionally, you will encounter a person who is not willing to do this. Let this person just observe, and make sure that they do not discourage others in the group from trying the condom demonstration. Remind people that learning how to put on a condom does not mean they have to use one.

Activity 5.16 How to select and store condoms
Hold up a packet of condoms or a condom in its wrapper. What have peer group members suggested? Check the expiry date before buying and using a condom Always remember that even an old condom is safer than no condom Store condoms in a cool and dry place near the bed away from sunlight Do not store in a hot place like in the glove compartment or boot of your car Don’t keep condoms in a warm pocket for too many days it can get very warm Some condom lubricants contain a spermicide (Nonoxyl-9) for added protection The spermicide kills sperm and kills the HIV virus Use latex male condoms unless either partner is allergic to latex Before using check to see if your condom feels hard and decayed or looks dried out or discoloured or damaged - if the condom has any of these defects, throw it away Many people keep at least two condoms nearby even when they only intend to use one - this is in case you spoil or get one dirty, which is easy to do if excited Point to ponder I have kept the same condom safely in my inside jacket pocket for six month now. Discuss

73

Activity 5.17 How to use a male condom correctly
Condoms offer very good protection if used properly. But, they must be put on and used correctly. Pass out packaged condoms and point out the expiration date. Allow participants to familiarise themselves with the packaging of the condom before opening it. Check to see if there are diagrams on the inside cover of the packaging - if there are compare the diagrams and instructions with those shown below. Read the following while putting the condom on the model • Choose a penis model, a small cucumber, a banana or a maize cob inner pith or similar shape for this practical • Open condom package carefully - be sure you do not puncture the condom with your fingernails • Hold the top ring of the condom tightly as you remove it - do not let it unroll yet • Do not test the condom before use - the manufacturer has already tested it • Do not use two condoms at once - 2 condoms rubbing against each other makes them more likely to break • A condom should not be unrolled until the penis iserect and hard • A condom is rolled over the penis starting at the tip • Roll the condom over the erect penis while squeezing the bubble at the tip to keep out air • Roll it all the way down to the base of the penis and be careful to leave the bubble at the end - this provides room for the semen and helps prevent breakage • Most condoms are pre-lubricated today - never lubricate the condom with vaseline, oil or lotion • Lubricants and vaginal foam with Nonoxyl-9 can be used in addition to a condom for extra protection Nonxyl-9 kills the HIV and AIDS virus • Soon after ejaculation the penis should be withdrawn and the condom carefully removed - hold index finger and thumb around the condom at the base of the penis so that it cannot slip off during withdrawal • Wrap the condom in a tissue if available, and dispose of it in an appropriate way - if you can learn how to knot the condom it may be easier to carry before disposal Never wash and reuse a condom Do not use the male and female condom together - they will rub against each other and that sort of friction can damage them both Point to ponder I learned to use a condom correctly by practicing putting it on in the privacy of my own room. At first I made mistakes, but like most things, pratice did make perfect. Discuss

74

Activity 5.18 The female condom
Although many people have seen a male condom, fewer have seen a female condom. Do the following • Pass a female condom (that is still in the packet) and around the group • Encourage participants to examine the packet and any writing on it • Open the packet and hold up the condom • Read and discuss some of the following information before the group examine it • Pass the condom around - if someone does not wish to hold it do not press them What is the female Condom? The female condom is a plastic pouch that covers the cervix, the vagina, and part of the external genitals. A woman uses the female condom during sexual intercourse to prevent pregnancy and STI/HIV infection. Research is still being conducted to determine the effectiveness of this new product. Malawi has two types of female condoms. The first generation female condom (FC) Care condom and the New generation condom (FC2). The FC condom is made of polyurethane, a colourless and ordourless material that transmits heat better than latex. Polyurethane can produce noise during sex. The FC2 is made of nitrite, which is thinner and almost noiseless. Both condoms are lubricated with silicon based non-spermicidal lubricant and expire after 5 years. Advantages of using a female condom What have peer group members suggested? Is safe and effective in protecting against STIs, HIV and pregnancy Does not require a prescription or medical examination Can be inserted up to 8 hours before sexual intercourse Can be used by women who were afraid of using or relying on the male condom Is female controlled Excellent option for someone who does not need ongoing contraception It can be used with oil-based lubricants like vaseline Does not alter the vaginal flow and reduces the chances of irritation from allergic reactions Disadvantages of using a female condom What have peer group members suggested? Costs more than the male condom Has a slight noise Sometimes negatively associated with sex workers Is female initiated but requires skills to use properly and to negotiate its use with a partner Can be difficult to insert - needs practice Like the male condom it can occasionally break or slip out during intercourse Most women experience no side effects - rarely, someone may experience an allergic reaction or irritation Point to ponder It took me some time to get used to using the female condom, but now it takes just a few seconds to put it in place. Discuss

75

Activity 5.19 How to use the female condom correctly
This may be very difficult to demonstrate unless you have a model, but it is well worth the effort. • • 1 2 3 4 5 6 7 8 9 Check the expiration date on the condom package - shelf life is usually 5 years Find a comfortable position - try standing with one foot on a chair or sit with knees apart or squat down Open the package carefully so that the condom does not get damaged Find the inner ring which is at the closed end of the condom Squeeze the inner ring together Put the inner ring into the vagina Push it up into the vagina with a finger, the outer ring stays outside the vagina During sex, guide the penis through the outer ring, keeping the ring outside and against the labia (outer lips) Hold the ring as the penis is withdrawn - then remove the condom immediately after sex, before you stand Squeeze and twist the outer ring to keep the sperm inside the pouch and pull the pouch out gently Burn, bury the condom or put into pit latrine, do not flush it down the toilet

1

2

3

4

5

6

9 7 8

76

Activity 5.20

The lifeboat game: values and condoms

Conduct the life saving boat game. This will let participants critically examine the options they could adopt to save their life and the lives of others.

If I am to stay safe from HIV, I may have to get into a different lifeboat Do the following • Use chalk to draw three boats and label them as abstinence, be faithful and use a condom • Ask peers to assume different roles - professional sex workers, truck drivers, professionals like doctors, newly weds, army personnel, office secretaries, church believer, experimenting youth, a person who drinks, two lovers who have just met on the ship, a church elder etc Read the following to the participants • Imagine your character is in a ship which is sinking • There are three life saving boats at your disposal the abstinence boat, the be faithful boat and the use a condom boat • Move into the boat that you would prefer to save your character’s life - act quickly before the ship sinks. • Give time for the participants to move into the boats of their choice • Let the participants in each boat defend their choices • Summarise the findings from the game • Adapt or improve the game for different audiences Point to ponder Look at the advert for condoms on the right. It was used in the United States. Do you think such a message would work in Malawi? Give at least one reason for your decision Points to Ponder Is a person who knows that they are HIV+ but refuses to wear a condom guilty of premeditated murder? Discuss What would you say to a religious person who is HIV+ but refuses to wear a condom? Discuss

77

Activity 5.21 Role play: Advising a friend about condom use
Introduce the role play by studying the cartoon and reading the brief background. You can add additional ideas or change the scene if you wish.

Background Two good friends, George and Kondwani, have known each other since primary school days. They meet at the bus stop and start to talk. They were out at a bar, drinking together last night. George had to study for his examinations and returned home early. Kondwani stayed on and got very drunk leaving the bar with a woman who is known to have had many partners. George wants to help Kondwani avoid getting HIV through this behaviour. Continue the conversation between George and Kondwani. After the role play. The people who play George and Kondwani should stay in role during the discussion. • What other ways could you develop this role play?

Activity 5.22 Role play: Talking about prevention of STIs
Introduce the role play reading the brief background. You can add additional ideas or adapt the scene if you wish. Background Taona and Nora are two young women who work at the same place. They are sitting together and talking over lunch break. Nora is looking sad and Taona asks her what is wrong. Nora says she has a smelly discharge and pain when she urinates. Yesterday, she went to the clinic because she thought she might have an STI. The nurse told her she should change the way she practices birth control. That birth control pills or injections do not protect against HIV or other STIs. She has just returned from the clinic with the results. Nora: You’ll never guess what I learned at the clinic yesterday. Taona: What did you learn? After the role play Discussion points - bring up if not mentioned - add new ideas you discover • What are the advantages of using condoms even if you are already using shots or the pill to prevent pregnancy? • What should a woman or a couple do if they have already had unprotected sex? • What should Taona and Nora do next? • What other ways could you develop this role play?

78

Activity 5.23 Role play: Dispelling false beliefs about condoms
In this activity you will be able to chose from a selection of roleplay topics. They are based around myths and false beliefs about condoms. Choose from one of the following 1 Sipho and Jane share the same room in the college. One morning as she is cleaning, Sipho discovers a packet of condoms under Jane’s bed. Sipho has never used a condom before. She starts to think about the different things that people say about condoms. She’s worried, because she cannot seem to get answers to the key questions and decides to ask Jane when she comes in the evening. 2 Yoanus and Charley, unmarried college students are discussing their girlfriends. Yoanus says that he’s upset because his girlfriend, Yamikani, is refusing to have sex with him. She insists that if they have sex she will become pregnant or get STIs. 3 Yamikani is in Yoanus’ room, they are alone and it is getting late. Yoanus has decided to raise the issue of protection with Yamikani. She wishes he would be less bossy when they discuss the issue. After the role play Discussion points - bring up if not mentioned - add new ideas you discover• • What are the advantages of using condoms, even if you are already using shots or pills to prevent pregnancy? • What should a person or a couple do if they have already had unprotected sex? • Is it still beneficial to start using condoms or start abstaining and being faithful? • Please bring up differing points of view in a respectful way, so that everyone is aware of the differing faith views in our society.

Activity 5.24 Assignment

• Review the stages of behaviour change from page 40 • Find out what things may stop your peers/friends from talking about safe sex and condom use with a friend or a partner • Identify the stages of behaviour change that a person would pass through in order to reach the point of using

condoms consistently during a sexual relationship • Find out what aspects related to alcohol use could hinder consistent behaviour change • Prepare to share your findings with the group at the next meeting Evaluation. Use the questions on page 166 to evaluate the activities from this unit.
Point to ponder It takes courage for couples to actually discuss using a condom. The condom and the discussion are the easy parts, the barrier is that we are not yet brave enough! Discuss

79

Unit 6
Introduction

Talking with your partner about HIV

Millions of people know what they can do to keep from getting infected wth HIV, yet many do not practice abstinence or safer sex. This unit looks at the issues surrounding communication between partners on HIV. It will consider some of the barriers to effective communication and the ways in which these barriers can be removed.

Learning outcomes
By the end of this unit you should be able to: • explain the different stages that people may need to go through in order to use condoms consistently during sexual relationships • identify the barriers to communicating about safer sex • describe how gender affects discussions on preventing thE spread of STIs • identify what is needed to make people change their behaviour • practice ways to communicate with a partner about safer sex, sexuality, HIV and AIDS • explain how condoms may become an enjoyable part of sexual relationship • identify the issues raised by alcohol, drug use and sexuality

Activity 6.1 Assignment review: In order to change your behaviour and begin using condoms consistently, the following stages may be used:
1 Pre-contemplation - You have not considered that you are at risk and need to use condoms 2 Contemplation You become aware of the risk and subsequent need to use condoms 3 Preparation You begin to think about using condoms in the next few months 4 Action You use condoms consistently for fewer than six months 5 Maintenance You use condoms consistently for six months or more 6 Relapse You may begin to use condoms less consistently or stop

Activity 6.2 Barriers to communicating about safer sex
You may wish to combine this activity with 6.3 and 6.4. Remember that it is not necessary to hold a lengthy discussion on each of the points raised during this activity. Many of the key issues will be considered in greater detail later in the course. Points for your discussion, debate, drawing, song, story, play, poem, poster etc As you talk consider the reasons why people don’t practice safer sex try to group the ideas under the following three headingss • Individual reasons • Couple or relationship reasons • Social or cultural reasons

80

1

Individual reasons

What are some of the reasons an individual finds it hard to change risky behaviour? Look back at pages 64-67 to review some of the earlier activities linked to this topic. How do these reasons create barriers to communication? Points for your discussion, debate, drawing, song, story, play, poem, poster etc Which individual reasons can create barriers to communication about safer sex? Enjoy having unprotected or natural sexual relations. Want to have a baby but have not been for VCT Fear they are already infected, so there is nothing to lose Don’t wan to admit that they drink too much or use drugs so they do things they never intend to do Life is short anyway, so they do not want to lose any fun Believe they are not going to have sex, so don’t prepare Peer pressure
2 Couple or relationship reasons

Which relationship reasons can create barriers to communication about safer sex or changing risky behaviour? Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? Cannot communicate openly, especially about sexual matters Too shy to raise the matter of safe sex with a partner Talking about safer sex raises difficult issues between you and your partner Fear a partner will think they are not faithful if they talk about HIV prevention Have different goals in life, so they cannot agree on what to do - for example, a man may want to have extra partners while a woman wants him to be faithful Have unequal power relationships, so that the wife fears physical or emotional abuse Lack of respect from one partner for another - one partner may be the underdog 3 Social and cultural reasons Sexual activities are enjoyable, and many of us don’t like to change activities that give us pleasure. Many social or cultural factors affect conversationss about sexual matters. Points to ponder Two of the barriers to effective communication are the difficulty of talking openly about sex and gender inequality. Discuss If I went for VCT without telling my wife, I am not sure if I would tell her of my visit if I had been found HIV negative. Discuss If a villager’s wife started talking to her husband about using a condom he would suspect that she was having an affair. Discuss

81

Activity 6.3 What is needed to help people to change their behaviour?
It may be hard to talk a partner or friend about changing a risky behaviour, especially if it involves personal and private issues. We can however provide information, skills, and processes that might help them choose and maintain more positive behaviours. Points for your discussion, debate, drawing, song, story, play, poem, poster etc What do we need to do to help people change risky behaviour? Couples have to be brave, show courage, in order to talk about and then challenge a risky behaviour that endangers their lives Community elders should encourage couples to talk to each other about safer sex Talk openly and frankly about how you feel and let the person talk about how they feel and think about HIV prevention Tough love is the answer, where a partner rejects someone who engages in risky behaviour - this can shock them into changing their ways If a person is depressed because they cannot talk about their behaviour, they must be given hope and see a better future is possible Encourage more conversation within the family and this will make talking about sex easier Talking helps a person take more personal responsibility for managing their reproductive health Information and correct facts must be available to couples to study or talk about, before they take any action Talking together helps partners to come to an agreement not only over sexual matters but other aspects of their relationship Conversation empowers couples to fight together against any risky behaviour

Activity 6.4 Communicating with your partner about safer sex
You may wish to combine this activity with 6.5, 6.6, 6.7, 6.8 and 6.9. Communicating is more than just using the correct words, it is also our tone of voice, facial expressions and body language. In a sexual relationship partners can share personal facts about how they feel, think and would like to act. When partners share these special feelings and thoughts it often provides an opportunity to strengthen the relationship, but it can also be a worrying time for a partner who feels threatened or mis-understood. In partnerships, relationships can have different power structures. The most common attitudes/behaviours found within relationships are aggresive, submissive and assertive. Points for discussion - bring up if not mentioned • If both partners have an aggresive attitude what would you expect to happen? • If both partners have an submissive attitude what would you expect to happen? • If both partners have an assertive attitude what would you expect to happen?

82

Activity 6.5 How does an aggressive partner behave?
How would you describe the behaviour of an aggressive partner? Points for discussion - bring up if not mentioned What have peer group members suggested? Use body language that frightens or controls, likes standing stiff and erect using a loud voice and angry gestures Present their own ideas forcefully Often seem to lecturer their partner and other people Do not listen to their partner’s ideas Can be domineering by ignoring the partner or butting-in and start discussing something else

Activity 6.6

How does a passive partner behave?

How would you describe the behaviour of an passive partner? Points for discussion - bring up if not mentioned What have peer group members suggested? Use body language that shows lack of confidence or fear; like slumping over; a soft voice; not making eye contact and submissive gestures Present their ideas timidly or keep silent Agree with their partner to end disagreement, even if they don’t like what their partner suggests If this happens frequently, they can feel resentful, unhappy and they lose confidence in themselves and their partner The work of a person who suffers within a relationship can be affected

Activity 6.7

How does an assertive partner behave?

How would you describe the behaviour of assertive (but respectful) partner? Points for discussion - bring up if not mentioned What have peer group members suggested? Use body language that shows respect to others Very rarely lose their temper or get angry Standing relaxed and straight, using a moderate voice, looking directly at their partner and using friendly gestures Present their own ideas and feelings confidently and clearly without shouting Listen carefully and make sure they know what their partner thinks and feels Try to find a plan that both partners can accept Identify people in national and local life who show assertiveness and use them a good examples Do you think that compromise plays an important part in a relationship involving two assertive people?

83

Activity 6.8 Responding to an aggressive partner
Whether the aggressive partner is male or female, certain characteristics are usually present in a conversation. How could you respond to an aggressive partner? Points for discussion - bring up if not mentioned - add new ideas you discover Peer group members have suggested three basic responses to aggressive behaviour. You could: 1 Delay - try to postpone this discussion to a time when you are both more relaxed - this is especially useful if your partner is drunk or becoming violent. You may need to leave or get help to protect yourself. Take your children with you if they are in any danger. 2 Bargain - try to follow a middle path that gives each of you part of what you want. Even if you don’t get all of what you want - agreeing to a bargain this time should make it easier to bargain again and again in future. 3 Refuse to go along with your partner’s demands - if your partner will not bargain and what he/she suggests is not acceptable to you, you may have to refuse. Refusing a partner can trigger anger, so if you refuse you may also need to leave and go to a safe place while your partner calms down. • Which of the stragtegies have you used (delaying, bargaining or refusing) during conversation with a partner? • Discuss different situations when each of the strategies is most likely to succeed More ideas for improving bargaining Make your own body language confident and respectful Explain how you feel about your partner’s ideas and the different ways of saying them - eg. I feel (frustrated, sad, angry, embarrassed) when you shout at me Make a clear statement of what you want If your partner interrupts, point this out and say you want to finish speaking. Ask your partner how he/she feels Points to ponder I am the man of the house and must be obeyed. My wife is breaking her marriage vows if she asserts herself too much! Discuss I always obey my husband if he is right, but feel that I have to challenge him if he is in the wrong. That’s what a good wife should do. Isn’t it? Discuss

84

Activity 6.9

Finding a mutually acceptable solution

Sometimes it can be difficult to agree when both partners feel very strongly about their opinions. How can we compromise or find a solution that is acceptable to both? Points for discussion - bring up if not mentioned - add new ideas you discover What have peer group members suggested? They can find a middle path that gives each of them some of what is important to them They can agree that they will follow one of their ideas this time, and the other person’s idea next time They could agree that one of them will make decisions about one area of life, and the other will decide about another area of life - for example, the man will decide about clothes and the woman about furnishings. But it may be better for both to be involved in both issues Even if partners do not come up with an ideal solution, knowing that they have tried and have listened to each other makes them feel glad to be together Make a list of the statements that could be used during a discussion which reaches a mutually agreed conclusion - write down the exact words that will be spoken and test them out on peer group members If you believe that you personally need to practice making these sort of statements, why not find a place where you can be alone. Then speak the words out loud - try them at home speaking into a mirror. Study the cartoon shown below and swer the following questions: a) How do you think the message relates to conversations between sexual partners about HIV and AIDS? b) How do you think its message relates to the fight against the HIV pandemic?

85

Activity 6.10 Can condoms be an enjoyable part of your love life?
In unit 5, we looked at the condom and some of the mis-conception surrounding its use. In this activity we will discuss how condoms can be made an enjoyable part of a sexual relationship. Refer back to the activities in unit 5 if you wish to revise the topic. What could you say to convince your partner to use a condom consistently? Remember, that if you decide to use condoms, you need to use them every time you have sex in order to stay safe. Points for your discussion, debate, drawing, song, story, play, poem, poster etc Group members have suggested that by using a condom I show that I care about: myself my partner my family and future generations every child being a wanted child helping to stop the spread of HIV and STIs What other statements have peer group members suggested? Take control of your life You alone are in charge of your body and only you can decide what to do with it The decision to have unprotected sex can seriously affect you and everything in your life forever! It is a modern world, and women should be able to carry a condom, especially if it will save her life and the life of many others Find a condom before sex starts, because after beginning sexual activity it may be more difficult to negotiate safe sex, if you and your partner are excited Learn how to use a condom before sex - you may need to use condoms a few times before you are really comfortable about putting them on and removing them as part of, and not an interruption to sexual activity Couples can make condoms a fun part of foreplay and by calling a condom by a nickname like Johnny break the ice a bit The woman can put Johnny on her partner in an enjoyable way Many sexually active people who say thay don’t like condoms have not tried them, or they tried them as teenagers when they were not very experienced encourage them to try condoms again or try a different brand of condom If partner does not agree, explain issues about safe sex and if s/he still does not agree, say something like, Maybe we need to wait until you care about me enough to wear one. Remember to consult your religious leader if you are in any doubt about condom use - your sexual activities should fit in with your personal moral code. Point to ponder When I wear a condom it helps me stay erect longer, so I have more time for love making, experimenting and my partner appreciates that. Discuss

86

Activity 6.11 Role play: Talking about safer sex with a new partner
Introduce the role play with the briefground brief. Different people should read the different thoughts and words of the players. Start the role play by using Chisomo and Mphatso’s words, and continue by making up your own. Background to the role play Chisomo, is a first year teacher trainee student. She meets Mphatso at a party given by a mutual friend. They have known each other since secondary school, but they haven’t met in a long time. Tonight they are really attracted to each other. They have been dancing all night and having a wonderful time talking together. Mphatso is thinking: • Chisomo is beautiful, elegant and so hot! • She smiles a lot and is still here with me • I think sex with her will be better than with both my other lady friends • I really want her tonight, but I have never used a condom and I am not really sure how to! • I want to play safe but how do I bring up the topic? • if i mention condoms she’ll think I believe she’s infected or even worse, that I sleep with every girl I date! Chisomo is thinking: • I loved being with him he’s so handsome, strong and intelligent • I don’t have a boyfriend maybe he is the one, let me find out • Men expect you to sleep with them as an appreciation of a good date, but HIV worries me, is he HIV+? • I wonder what he’d be like in bed - now Chisomo stop those thoughts right now! • Well, in Mzake ndi Mzake we learned how to put on the male condom correctly • But maybe I could convince him to use a condom • But that would make me appear cheap, wouldn’t it? • Maybe I will just abstain until I know him better The role-play begins: Chisomo: I have really enjoyed myself tonight. Mphasto, I am so glad that I have met you again after so long. Mphatso: Chisomo, this party’s breaking up. Can I walk you home, or maybe we can stop somewhere to talk some more? After the role play • Did each actor/partner communicate clearly? • What style did they use? • Did the partners succeed in developing a plan that would protect them both from STDs, HIV infection? • What else could have been said? • How could this role play be adapted?

87

Activity 6.12 Alcohol drinking or drug use and sexuality
How can taking alcohol and other drugs put people in danger from HIV infection? Points for your discussion, debate, drawing, song, story, play, poem, poster etc What concerns have peer group members raised about alcohol use and mis-use? Alcohol and other drugs like chamba, produce feelings of well-being, relaxation, pleasure or excitement Problem drinkers or drug users are people who have may have other problems in their lives Social customs tolerate and even encourage social use of alcohol, especially for men Poverty, unemployment and jobs away from home cause stress that may lead some to drink Alcohol and home brew are widely available and affordable for many people Few health services are available for people with alcohol problems How can drink put people at risk of getting HIV? What have peer group members suggested? Having sexual relations when they planned to abstain Have sexual relations with someone they don’t really know well Compromises their judgement about sexual partners and protection against HIV Argue and refuse to take No for an answer and use force to have sexual relations Serious arguments or physical fights may occur - some people may hurt their partners If a person is high on alcohol they may have trouble using a condom because they have less control over their movements than usual Why is it hard to help people who drink alcohol to change their behaviour? What have peer group members suggested? Some people who drink to excess don’t recognise that they have a big problem People who abuse alcohol and substances usually deny that they have a problem. They know that they feel better after a drink and so look forward to it Drinking with friends may be the traditional way that a person relaxes - if his friends drink and he stops he may feel like an outsider If people depend on alcohol or drugs to feel good, they rarely want to change their behaviour - it can be hard to find an enjoyable replacement activity People who rarely drink can put themselves in danger as they may refuse to acknowledge that they coul get drunk and then behave out of character There is so much advertising related to drinking alcohol that it is hard to avoid Many alcoholics would like to live sober a lifestyle but want to delay acting until the next day - reformed or recovering alcoholics may need to advise them

88

What discourages excessive drinking of alcohol? What have peer group members suggested? The first step is for the person to admit that they have such a problem - the next step is to want to change the situation Use the behaviour change ideas on page 40 to make a plan for giving up alcohol Accept that drinking alcohol is a form of selfishness where the drinker is the one who alone enjoys that drink Accept that drinking alcohol uses money that could be better spent on other things - family food, school fees, transport, pension, health issues etc Learn more about Alcoholics Anonymous (AA) a worldwide organisation helping recovering alcoholics and how you can join - stories and tips at www.aa.org Couples who are open and honest with each other find it easier to tackle a problem like alcoholism or drug addiction People who have kicked the habit of drinking can act as mentors for others Faith groups can provide confidential support for members struggling to do so Women can counsel friends - traditionally women are expected to either not drink alcohol or drink only a little on special occasions Men can help each other by spending leisure time in places where beer is not sold Taking up sports or other active leisure pursuits can replace the trip to the bar as the main social activity People living with HIV and AIDS are discouraged from drinking alcohol as it can weaken the immune system Pray both individually and in groups for the spiritual strength to beat the addiction Family and friends who will stick by you and keep encouraging you to give up Counselling the drinker of the consequences of drinking on individual, family and community Never ever stop trying to give up your addiction to alcohol - others have succeeded and so will you! Malawi Times

Activity 6.13 Assignment: Talking about safer sex with your partner
• Talk with your partner about sex and what is safe and satisfying for both of you - what each partner find particularly enjoyable? • If you do not currently have a partner, talk (or role play) with a friend or neighbour • Make a list of things that you will do to protect yourself and your partner from getting HIV and STIs

89

Unit 7

HIV and AIDS testing and ARV treatment

Introduction
A person who is living with HIV (PLWH) may look perfectly normal, before they develop AIDS. Only an HIV test can tell whether a person is carrying the virus or not. AIDS is diagnosed using mainly clinical observation or using laboratory tests along with observation. If a person knows their sero-status (whether they are HIV+ or not ) then they can plan ahead and start anti-retroviral treatment (ART) when it is appropriate. ART is proving very successful in Malawi. You may wish to look back at the diagram on page 19 before starting this unit.
IMPORTANT: Since this manual was published new drugs and new methods of testing and treatment may have been introduced. So you should always listen to the most current medical advice from your health professional.

Learning outcomes
By the end of this unit you will be able to: • describe what happens when you go for VCT • state some of the reasons why people do not go for VCT • list some of the advantages of going through VCT • explain why counselling is an important part of VCT • describe the clinical approach to diagnosing AIDS • describe the laboratory test approach • list the advantages of finding out if you are HIV negative • describe where you can go for free VCT • explain what ARVs are • list the groups of ARV drugs • describe what we must know about ARVs if we want to use them • describe what happens before someone starts taking ARVs • list places where people can get ARVs • list some of the challenges faced by people taking ARVs

Activity 7.1 Assignment review
Review the assignment and select ideas that may be useful when studying this unit.

90

Activity 7.2 What happens when you go for VCT?
VCT stands for Voluntary Counselling and Testing. Ask the group about their experiences of same-day VCT is. What does VCT involve? Points for your discussion, debate, drawing, song, story, play, poem, poster etc A counsellor explains the whole procedure and helps you think about what it will mean if you test positive or test negative. During a test, a finger prick blood sample is taken While you are waiting, the counsellor will talk to you about HIV and AIDS prevention In about an hour you will get your results - the counsellor tells you your results and talks with you about what these results mean for you. Everything is done in privacy You can go alone or you can go with your partner

Activity 7.3 What are some reasons for not going through VCT?
Discuss and list all the disadvantages there could be to being tested for HIV. Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? Not wanting to know that you have a serious disease Not wanting others to react negatively if they learn you are HIV positive Fear that if people see you going to be tested they will assume you are positive Fear of losing your partner or not having a future partner if you are HIV positive

Activity 7.4 What are the advantages of going through VCT?
What some of the advantages of being tested, whether you learn that you are HIV infected or free of infection? Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? Counselling is done before and after the test HIV test is quick, not painful and private It is your right to know your HIV status You can start making informed decisions and plan for the future You no longer have doubts or anxiety about your HIV status You can take responsibility for yourself and your partner It’s like a new start for your life Going for an HIV test protect community and country There’s no real stigma in our community around going for a VCTs Point to ponder I am so afraid of going for VCT. What if I am found to be HIV positive? I think that it is better not to know. Discuss

91

Activity 7.5

Why is counselling an important part of VCT?

Counselling before and after VCT is very important. Many people go through a mourning process when they hear they have HIV or AIDS, it is as if they are mourning for themselves. They may feel as if they had lost their beloved wife, mother, father, child or dearest friend all rolled into one. In order to reach a position of living positively with HIV a person will probably have to go through the stages of mourning shown below. The 8 stages of the mourning process are: 1 Shock .............When first hearing the news that they are HIV+, people can go into shock. Shock is an intense emotional and physical reaction to devasting news. This is similar to shock after a physical accident; feelings of hysteria, numbness, an ability to think and act clearly. They may be unable to take in any more information or to respond to counselling. 2 Denial ............ Denial is linked to shock, it is a deep seated inability or refusal to take in the information. This might continue after the initial shock has worn off. Continued denial becomes problematic as it blocks appropriate behaviour change towards coping and living positively 3 Anger ............ Feeling as if you have been singled out for this terrible situation. Wanting to blame someone else. This anger may be directed at a spouse, the opposite sex, children, God or members of the community. 4 Bargaining .. The person prays or begs supernatural powers or medical staff to change the diagnosis. This often includes pledges to change behaviour. 5 Guilt ...............The person starts to blame themself for the situation. This often greatly reduces self-esteem and concern for all those who are directly or indirectly affected. The amount of guilt the person feels may be far greater than expected. 6 Depression.. Deep sadness, helplessness, which stops many ordinary activities, with low self esteem and loss of hope. This may be linked to loss and fear: eg loss of job, loss of loving relationships, loss of having children, loss of control. Fear of stigma, rejection, loneliness and death, or leaving dependents without support. At this stage PLWHA may give up and contemplate suicide or believe they have nothing to lose if they go back to dangerous sexual behaviour. 7 Acceptance.. No longer feeling overwhelmed; recognising that the situation cannot be changed and beginning to come to terms with living with HIV. 8 Coping ......... Adjusting to the new life situation and getting back to normal as far as possible. This means rebuilding self esteem, coping with life, and planning effectively for the future by adopting appropriate behaviour change. The best form of coping is living positively with HIV, where hope for the future is continually reinforced through positive actions. If a family member or friend was in an early stage of mourning for themself what could you do? Is giving information enough? Point to ponder The families and friends of PLWHA, play a very important role in helping them through the mourning process to the coping stage. Discuss

92

Activity 7.6 What is the clinical approach to diagnosing AIDS?
How do medical staff decide if a person has AIDS? Discuss experiences of the process used to diagnose AIDs in a friend, family member or anyone else. Points for discussion - bring up if not mentioned - add new ideas you discover • It is carried out by qualified staff in medical centres • Using the clinical approach a person is diagnosed with AIDS when they have a pattern of infections that come back again and again - these infections (such as malaria, rashes, spots and TB) can be common even in people without HIV • Some opportunistic infections, like oral thrush, are unusual and rarely occur in people who are not living with HIV • A person has repeated infections only in late stages of HIV infection • Clinical observation does not help identify when infections may start, and it doesn’t allow careful monitoring of a person’s condition - however, clinical diagnosis is important because it is relatively low cost and readily available

Activity 7.7 What is the laboratory test approach?
Using the laboratory approach, a person’s blood is tested. Points for discussion - bring up if not mentioned - add new ideas you discover • The immune cell count gives a more precise indication of how well the immune system is functioning and can guide drug treatment • If the immune cell count is 200 or less, the person is considered to have AIDS • There are generally two tests which search for antibodies to HIV • The ELISA test uses colour changes to detect presence of antibodies • Elisa tests may produce false results - this occurs when newly infected person is tested for HIV • The body of a newly infected person will not have produced antibodies to HIV and they are said to be in the window period. People who are newly infected by other diseases that suppress the immune system such as malaria, TB, diabetes and other parasitic infections may test positive • Some people may be HIV positive but too ill to have enough antibodies that can be detected by a laboratory test • The Western blot and other tests is used to confirm the ELISA test • The Western blot test reacts to specific proteins of HIV antibodies • The PCR tests detect the presence of HIV in the blood Points to ponder HIV tests cannot dispel fears or myths about HIV transmission, nor do they tell where and how the person was infected. Discuss The window period can lull some people who go for VCT into a false sense of security. Discuss Why is important for every pregnant woman to know if she is HIV positive or not? Discuss

93

Activity 7.8 What are the advantages of finding out you are HIV negative?
Ask any group members who have been tested, to describe their feeling before, during and after the test. Then discuss the advantages of a couple discovering that they are both HIV free. Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? Means past partners may be safe too Feel relieved you don’t have to inform your partner if you have been unfaithful If I am HIV free this will encourage me to do careful planning for the future Helps decide to practice abstinence or safer sex in the future You can make informed decisions about marriage, pregnancy, and sexual relationships If you are both completely faithful, you can have sex without using a condom You can plan to have a baby knowing that the baby will not be infected with HIV

Activity 7.9 What are the advantages of going for VCT with your partner if you learn that both of you are HIV positive?
What are the advantages of going for VCT with your partner, especialy if you learn that both of you are HIV positive? Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? You can take good care of each other and stay healthy as long as possible Learn more about ARVs and the ART available in the community You can become a role model to other couples, showing them how to live positively with HIV and AIDS Plan to have regular tests speedy treatment for other illnesses Practice safer sex or abstinence so you will not re-infect each other Plan for the future for both of yourselves and your family eg pregnancy and succession planning which helps protect the family if you die (see page 140-1 ) Join or set up a self-help group for PLWHA

Point to ponder Knowing whether you are HIV positive or negative means that you can get on with the rest of your life and live it positively! Discuss

94

Activity 7.10 What are the advantages of testing with your partner if you learn that one of you is HIV positive and the other one is not?
If partners go for VCT together and one is positive and the other is negative, what do you think could happen? What would be the disadvantages? Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? It may cause an argument over the assumed unfaithfulness of the HIV+ partner Partners can be careful to protect the negative partner from infection Couples decide to abstain or practice only non-penetrative sex(kissing, hugging, etc) to avoid the risk of infecting the other partner Some couples continue to have sexual relations with each other using condoms - many couples have done this, and when they ALWAYS use condom, the person who is HIV negative remains negative You can be behave carefully to protect the negative partner from infectionre You can be role model and show other couples how to live positively with HIV and AIDS

Activity 7.11 Where can I go for a free VCT?
Where can people go to get free VCT or HIV counselling and testing? Ask the group to mention the different options available locally and throughout the country. Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? • The government, NGOs and private clinics are now active in providing VCT - MACRO offers free voluntary HIV counselling and testing • Invite a health professional to speak about VCT to reassure members that - testing is completely confidential but testing alone is not as helpful as testing and counselling • HIV counselling and testing is now available at district hospitals - however, the counselling in these settings may emphasize medical management and may not have a great deal of time to focus on all methods of prevention • List the local places where VCT is available and publicise its contents by posting on notice boards in schools, colleges, meeting places and shops

Point to ponder I don’t want to go for VCT at the local health centre, because people will see me going inside and then the gossip will begin. Discuss

95

Activity 7.12 What are ARVs ?
ARVs or antiretroviral drugs work to decrease the HIV viral load (the amount of HIV in the body) and improve the immune system in this process. Why do we need ARVs? Why haven’t scientists discovered a cure for HIV/AIDS? Some of the reasons given by scientists are that medicines that can cure HIV/AIDS may penetrate the brain and cause more harm. ARVs protect T cells by stopping HIV from attaching its self to, entering, reproducing inside or leaving the T cells.

Activity 7.13 What are the four groups of ARV drugs and why do we need to use four of them?
There are four groups of anti-retroviral drugs and each attacks HIV in a different way. Each of the four groups acts during a different time in the life cycle of the virus. These are the four most popular ARV drugs used at present: 1 Entry Inhibitors In order for HIV to enter the human cell, it has to attach itself the surface of the cell first and then move into the cell. This group of drugs interfere with process and prevent HIV from entering the human cell. 2 ‘Nukes’ or Nucleoside Analogue Reverse Transcriptase Inhibitors or Nukes These slow down the reproduction of the virus by blocking the action of the enzyme (reverse transcriptase) which is essential to the virus being absorbed into the host cell, where it can reproduce itself using the cell’s own genetic material - they ensure that the HIV copies are poor or faulty. 3 ‘Non-nukes’ or Non–Nucleoside Reverse Transcriptase Inhibitors Inactivates the transcription of the RNA (of the HIV) into the human cell DNA. 4 Protease Inhibitors These interfere with the enzyme (protease) needed in the final stage HIV copying by causing the production of immature viruses. These drugs are used in a combination so they: reduce HIV mutation boost the immune system by decreasing the resistance to a particular drug stop or delay the conditions favourable for the opportunistic infections The HAART combination uses the last three groups of drugs. Any one or two of them can also be used alone. If you take HAART, you need to regularly check on the effect of the treatment on your CD4 cell count and your viral load - the CD4 cell count measures how strong your immune system is

IMPORTANT: Since this manual was published new drugs and new methods of testing and treatment may have been introduced. So you should always listen to the most current medical advice from your health professional.

96

Activity 7.14 What must we know about ARVs if we want to use them?
Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? Find out if a member of the group who is on ARVs, will lead the discussion or describe their personal experiences The activity works well by using a real case study Medication should be taken exactly as prescribed You must be able to adhere to treatment regime. Change your lifestyle so you can more easily stick to the routine Missed doses should be taken as close as possible to the scheduled time, if it is not possible then the regular amount at the next scheduled time Bottles, glasses, medicine spoons should be kept separate from other medication equipment to keep uniformity of doses and avoiding accidental use by family members Drugs should be stored as prescribed - your must work out how to store and carry your drugs during the work routine or travels Find or ask for support from people who know about your HIV status or ARVs Understand the possible side effects of proposed treatment and let your friends or partners know about these

Point to ponder Your lifestyle changes when you start taking ARVs regularly. It’s as if I am in training, like an athlete, making sure my life is disciplined and focused. Discuss

97

Activity 7.15 When should a person start taking ARVs?
Try to use a real case study from the group or their family or community. What do you know about starting ART? Points for your discussion, debate, drawing, song, story, play, poem, poster etc The decision to begin ART (taking ARVs) is one that will be taken after discussion between the client and the doctor. The decision to begin taking ARVs will, among other things, depend on the following: • Your viral load • Your CD4 count (T cell count) • Your symptoms • Your willingness to adhere to drugs instructions provided by the doctor Consider the following factors when undertaking antiretroviral drug treatment: You should to start treatment before the immune system is severely damaged You should delay treatment to delay the development of resistance It is dangerous to begin HIV drug treatment without testing and continuous medical follow-up

Activity 7.16 What happens before someone starts taking ARVs?
The National AIDS Commission recommends that, after it has been agreed that a person will start taking ARVs, a clinician counsels the person and provides the following information about: • How many tablets to take • How often to take the tablets • How long to take the tablets • The need to follow instructions when taking ARVs as advised by a professional • Any signs and symptoms of side effects as a result of taking ARV • The importance of keeping fit • The importance of eating nutritious food • The importance of practising safe sex • Not to share the drugs with anyone • Visting the health centre as advised or when the need arises

Activity 7.17 Where can people get ARVs?
Do you know where ARVs can be found? ARVs are available at central hospitals, some district hospitals and private hospitals. There are now over 100 hospitals and health facilities (including all Central, District and major CHAM hospitals, Malawi Defence Force and Police hospitals) providing free ARVs while over 20 private sector health facilities are providing ARVs at asubsidised rate of K500 per patient per month. It is important that everyone realises that ARV drugs can only be safely obtained from authorised health service providers. Black-market ARVs may be very dangerous!

98

Activity 7.18 What is HIV resistance to ARVs?
Like other viruses, HIV is constantly changing. Each copy HIV makes of itself may be a little different. There are more than 8 subtypes of HIV. When two different subtypes meet they can produce a new hybrid and this may be a virus that is resistant to all known ARVs. Here are some of the ways in which the rate of HIV resistance to ARVs increases: If HIV is allowed to manufacture too many copies, eventually some mutate into different forms - the present HIV medicine (ARVs) then cannot recognise them anymore and the medicine stops working effectively Most people who are HIV positive eventually develop resistance to one set of drugs and need to have medications adapted - some people become resistant to all the available drugs When a person develops resistance, they can pass on this resistant type of HIV to someone else - the newly infected person then cannot be treated with the same ARVs As more people take anti-retroviral drugs, more viruses will mutate or develop resistance - as a result, a higher proportion of the HIV that are being transmitted from person to person will be drug-resistant Resistance is a problem for both the individual and society

Activity 7.19 How can we reduce the rate of resistance to ARVs?
What do health professionals suggest? Medicines must be taken everyday exactly as directed. Don’t miss doses. When doses are missed or medicines are taken incorrectly, HIV gets a chance to make different copies of itself. When medicines are taken correctly, most of the HIV factories stay closed, so there is less chance for HIV to make lots of different copies and for resistance to the medicine to occur. Once a person has developed resistance to a medicine, the person needs to stop taking that drug. If possible, the person can take a different drug to fight the HIV. A person may also need to stop taking the medicine if they develop severe side effects from the drug. People must have regular viral load tests One important element of treatment is regularly checking of the patient for drug resistance

Review the diagrams on page 19 and 90 99

Activity 7.20

What challenges are faced by people taking ARVs?

Ex-president of the USA, Bill Clinton has said, AIDS is no longer a death sentence for those who can get the medicines. Now it’s up to the politicians to create the comprehensive strategies to better treat the disease. • Discuss the quotation from Bill Clinton • Identify problems faced by people taking ARVs in the community. • What problems could be encountered at work, school and other places? Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have health professionals have suggested? Problems associated with treatment include: - Difficulty monitoring treatment effectively - Difficulty in distribution of drugs - Difficulty in sticking to treatment regiment - Development of resistance Some people come late to treatment because of denial - they have problems accepting they could be HIV+ Some people develop strong side effects so a drug combination is not workable Some people fail to respond to drugs due to drug resistant strains of HIV Some people cannot access regular drug treatment for HIV infection Black market drugs cannot be trusted - you cannot be sure what they are Some religious leaders try to persuade people taking ARVs to stop and look to be cured through prayer Others may feel traditional medicines are better than ARVs - if this was true the makes of these medicines would be millionaires People may hide their ARVs and take them in secret and not disclose their status Discuss other difficulties with drug treatment.

Activity 7.21 Assignment: Using and managing ARVs

• Talk to your family members or friends about what you have learnt today • Find out how much they know about anti-retroviral drugs • Make sure you tell them that since the introduction of ART, figures are changing. People still die, especially during the first few months of treatment, but when we compare the figures with those that are surviving, there are many more survivors. • Find out where people are getting ARV drugs and what challenges they are facing in using and managing the treatments • Prepare for the next session by looking at what your community is doing to fight the spread of HIV
Evaluation

Evaluate the activities in this unit by going through the questions on page 166 and record the results in your learning log.

100

Unit 8 Things we can do to fight the spread of HIV

Introduction
There is an traditional African saying, When spider webs unite, they can tie up a lion. This illustrates the special power in community action that can mobilise people and resources, which is unique. Nearly all national social initiatives rely upon some form of community action. In this unit we will look at the many different ways communities can work together to fight the spread of HIV.

Learning outcomes
By the end of this unit you should be able to: • describe how all adults have the right to protect their health either by abstaining or by having safer sex • describe ways to protect groups who are at risk of HIV infection • list the factors in our society which encourage the spread of HIV • describe cultural practices that increase the risk of HIV infection • explain why Malawian laws do not allow nkhanza • describe Malawi’s National HIV/AIDS policy • describe ways to protect widows from HIV infection • describe ways to protect young girls from HIV infection • describe ways to protect women and men from HIV infection • explain the work of teacher networks fighting HIV : T’LIPO • identify other networks fighting HIV • describe how Malawi’s sex industry can spread HIV/AIDS • explain why education is called a vaccine against HIV • explain why staying silent on homosexuality may help spread HIV/AIDS • describe one global approach to HIV prevention • explain why people who spend time in prison are at risk • explain how trafficking for sexploitation spread HIV and AIDS

Activity 8.1 Assignment review
Review the assignment.

Activity 8.2 Standing in someone else’s shoes
Look back at activity 2.25 on page 42 and spend a few minutes talking about what you learned from that activity. This should prepare you for the next block of activities which look in greater detail at how we can assist all members in our communities.

101

Activity 8.2 How to assess the risk of HIV infection
A risk assessment is a strategy used as part of the behaviour change process, but it can also be used for other purposes. Look back at Unit 4, especially from page 60 onwards, and think about the story of Cecilia and the number of people she shared body fluids with. If you feel that you have assessed your own personal risk of HIV infection then go on the activity 8.3. If you’d like to learn more or review some key points then read on. During a risk assessment, health care workers use a person’s responses to questions about their behaviours and the behaviour of their partners, in order to gauge the risk of HIV infection. Risk assessment questions focus on: • Age - Are you in an age group at greater risk of HIV infection? • Partnership status - Are you single and abstaining or married and faithful? • New sexual partners - Do you have a new sexual partner? • Multiple partners - Do you have more than one sexual partner? • Partners with multiple partners - Does your partner/s have more than one partner? • Partner who often travels - Do you or your partner travel for work or business? • History of an STI, pelvic inflammatory disease (PID), reproductive tract infection (RTI) - Do you or your partner have a medical history that increases risk of HIV? • Partner with symptoms of an STI - Have you or your partner ever had an STI? • Current symptoms or signs - Do you or your partner currently have an STI? Using a information handouts. By providing information about risks in general, and asking the participants to self-assess whether or not they are at risk. This happens without people revealing specific information. This approach is often used where it is considered culturally inappropriate to disclose more specific information about sexual practices and partnerships. Using a peer pair or peer group. This approach is likely to be more effective in assisting a peer to recognise his or her risk of HIV infection. Many people have difficulty perceiving their own risk of infection, even if they know, in general, what places a person at risk. Find a person who you trust. In private, discuss the factors which may be putting you at risk of infection. Your peer may understand your individual risks and may be able to help you apply information to your circumstances if necessary. You can arrange to meet privately on many occasions to discuss matters arising from Mzake ndi mzake. Point to ponder You are free to put your life at risk, but you don’t have the right to put other people’s lives at risk. Discuss

102

Activity 8.3 Ways to protect groups who are at risk of HIV infection
Identify the people in your community are at risk. Look at all the different members of a community and how they could be put at risk of HIV. You may want to refer to page 49, where over thirty reasons for having a sexual relationship are listed. Points for your discussion, debate, drawing, poem, poster, story, song etc Do you think the following are at higher risk? If so how would you work to protect each group from abuse and risk of HIV? • Boarding secondary school pupils and boarder at college or university • Unborn baby of an HIV+ mother • Professional at a workshop away from home • Long distance lorry driver • Sugar-daddy and sugar mummy • Cross-border trader • Health worker • Child labourers or seasonal worker • Orphan with no means of support • Orphan living with relatives • Refugee or displaced person • School child • House servant • Sex worker • Street child or youth • Police officer • Prisoner • Adolescent • Widow • Tourist

Activity 8.4 Which factors in our society encourage the spread of HIV?
The points listed below may overlap, so you can combine some of them if you wish. Which factors encourage the spread of HIV? Rank the following in order of 1st place, 2nd, 3rd, 4th, 5th to 10th: • Condoms • Prostitution • Unemployment and poverty • Homosexuality • Lack of a full primary education • Gender inequalities • Pornography • Power relationships within the family, school, workplace and community life in general • Traditional cultural practices Sunday Times, Mar 2, 2008 by Agnes Mizere • Witchcraft, sorcery or evil supernatural forces • Lack of information about HIV and AIDS • Westernisation and consumerism culture • Lack of effective moral education • Injectable drug and alcohol abuse • Lack of communication about sexual matters, between partners and between adults and children Compare your list with the lists made by other members of the group.

103

Activity 8.5 Cultural practices that increase the risk of HIV infection
You may wish to combine this activity with the next one. Review some of the cultural practices in our society which increase the risk of married couples contracting HIV.

Decisions to change any of these practices may involve the whole community or the most important leaders in the community to meet and act.
Points for your discussion, debate, song, poem etc What have peer group members suggested? Wife replacement (kusunga mwamuna) Temporary husband replacement (mbulo) Husband and wife exchange (chimwanamwayi) Widow inheritance (chokolo) Sex with the girl-child coming of age (kusasa fumbi) Sex with the boy-child coming of age Early marriage Death cleansing (kulowa/kupita kufa) Menstruation cleansing (kuthintsa mchele) Polygamy - since there is contact with a number of sexual partners within each marriage, the risk of infection if one partner becomes infected Extra-marital affairs Forced marital sex Seasonal ‘marriages’ Lack of communication on issues related to sex and HIV/AIDS Myth that sex with a virgin is safe or can cure a person from HIV and AIDS Dominant position of men in society and within all types of marriage, leaves many women powerless to negotiate safe sex even if they suspect their husband may be infected. Because men usually have control over when, where and how sex takes place, women don’t have much decision making power concerning sex

This cartoon appeared on the front page of The Sunday Times, in March 2008. The Malawi Traditional Healers Association threatened to march to parliament. The Hon. Secretary for Nutrition and HIV/AIDS had said, I have not said it’s a witchdoctor’s law. We want to protect people from healers who use albinos, people with disabilities and virgins as zizimba to treat AIDS. Read the policy on page 106.

104

Activity 8.6 Do Malawian laws allow nkhanza?
Cultural practices which go against the laws of Malawi are not allowed. Marriage is a legal relationship between people, no matter how they are married. In this activity we will look at how the legal consequences of marriage are very different from what many people believe. The laws of marriage usually outlaw nkhanza. Points for your discussion, debate, drawing, song, story, play, poem, poster etc Just because certain things happen in many marriages does not make them legal Allowing nkhanza, can increase the risks of spreading HIV both within a marriage and society Even if people are married it does not mean that they can commit illegal acts against their spouse If the law does not allow a certain practice, then it is not a lawful within a marriage and no-one can be forced to submit to it Spousal beating (including educational beatings) are a criminal offence if physical assault takes place Nkhanza can take place if a partner refuses to take care of the family (eg not buying food or clothes and a home maker not looking after the house or not cooking properly). Depending on how badly people have behaved, these could be offences under sections 164 and 165 of the penal code, which makes it an offence for any parent or guardian to desert a child under the age of 14 Marital rape, although not yet recognised as rape in Malawi, a number of crimes may be committed during this act, including assault, sexual attack or assault with intent to do grievous bodily harm Forcing a wife to have sex with another person in the customary practice of wife and husband exchange. A criminal offence (rape) if the wife does not consent Although Malawian law does not recognise witchcraft, some actions associated with the idea of witchcraft can be considered crimes - fssor example if a person confesses to using witchcraft and the potions are poisonous, they could be charged with the criminal offence of poisoning or administering dangerous substances, murder, attempted murder or manslaughter Defilement is a criminal offence

Point to ponder It will take at least a generation to get rid of nkhanza from the villages. Discuss

105

Activity 8.7 Malawi’s National HIV/AIDS policy (2004)
What is the difference between a policy and a law? A policy lays down general rules, goals and procedures on how government decisions are to be made or taken. For example, if the National Gender Policy says that girls’ attendance should be increased at university level, then government must ensure that during university selection, a set number of girls must be selected. Although not legally binding, government must try to stick to its own policies. After a policy has been made, government often drafts a law, once passed by parliament it makes the policy legally binding. Points for discussion from the national HIV/AIDS policy 2004 Discourage customary practices in marriage which may lead to HIV infection Aims to sensitise traditional leaders and their subjects on the dangers of certain customary practices such as consensual adultery for childless couples (fisi), wifeexchange and husband-exchange (chimwanamayi) and temporary husband replacement (mbulo) all of which may lead to HIV infection Calls on traditional and religious leaders to sensitise their communities to the dangers of, and discourage, customary widow- and widower-inheritance practices Aims to ensure that men and women are empowered to make independent and informed decisions and choices regarding widow- and widower-inheritance to reduce the risk of HIV transmission Encourage women and men to use condoms if they engage in customary practices that increase the risk of HIV transmission within a marriage Encourage the promotion of monogamous marriages and fidelity within marriage - monogamous marriage means being married to only one person and fidelity in marriage is when a husband and wife are both faithful to each other and do not have any other sexual partners Malawi’s national policy recommends that: All customary laws that help spread HIV or that discriminate against women in marriage relationships shall be modified or banned after consultation with traditional leaders and the people. A law should be passed to provide for the rights and obligations of men and women in any type of marriage to ensure their protection from abuse and exploitation (which can lead to HIV/AIDS) The Government of Malawi is also considering the following changes to the law that will impact on marriage and hopefully reduce the rate of infection: Make the minimum age for marriage 16 years old, by amending section 22 of the constitution - this will prevent children from marrying early and getting exposed to the HIV virus at a young age Change the law, so that having sex with a child below 16 years of age is an offence (defilement), whether the child consents or not - at the moment this is only an offence if the child is below the age of 13. Such a change will make marriage to girls younger than 16, a criminal offence as well as protect them from sexual abuse and HIV transmission There is also a proposal from civil society that marital rape should be a crime in its own right. This will help women refuse sex from a husband who they believe or know to be infected with HIV. This is being proposed in a new law which is still in draft form - the Domestic Violence Bill. A Bill is a law, that is still in draft form and, that has not been passed by Parliament

106

Activity 8.8 What are stigma and discrimination?
Look back at activities on page 41-42 which look at prejudice, stigma and discrimination. You may wish to combine this activity with 8.9. Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? • Stigma is associated with the words like shame, disgrace and dishonour. • We negatively discriminate (stigmatize) when our words and actions make people feel ashamed, disgraced or dishonourable • Say things like, She behaves like a prostitute or He got what he deserved. • Say that HIV+ people have been cursed by God • Εxclude people with HIV or AIDS and AIDS orphans from being part of our group or community discussions or decision-making

Activity 8.9 What are some of the causes of stigma and discrimination?
Why are certain people in our communities stigmatised? What causes stigmatising? Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested as causes of stigma? Lack of recognition that stigma actually exists Ignorance, lack of information on causes and modes of transmission, that leads to irrational risky behaviour Myths and fears about HIV transmission When HIV infection is viewed as punishment for immoral behaviour then nobody wishes to be associated with PLWA Self-interested people trying to create a divide between the healthy and those who are not so healthy Mass media images portraying PLWA as defenceless, weak and dying - images of thin diseased AIDS babies in adverts for charities People who are infected with HIV remind us that we are all at risk unless we practice prevention - this may scare us

Point to ponder When there is an unwanted pregnancy in your community, who usually carries most of the blame? Discuss

107

Activity 8.10 Stigma and discrimination in college and community

What forms of stigma have people experienced in colleges and communities. If you have time, group the examples to show any patterns of behaviour. Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? Stigma attached to occupation, family, tribe, race, religion, appearance or looks Treating people from different region or tribal groups badly Physical and social isolation from peers, family or community members Being left out of decision making that concerns family or even yourself Getting to hear gossip, condemnations and name calling by fellow students, family members and community members Self blaming and self isolation Refused employment, membership of benefits schemes Some insurance companies refuse to offer life insurances In the past, many people are refused proper health care, especially bed space in hospitals A whole family being isolated by community PLWA and their families suffer when people react negatively to them Being tested without consent Breaking of confidentiality (privacy) of medical records Negative reactions of others make some people afraid to get tested or to tell others if they are infected - testing helps people plan their futures and protect their loved ones from also getting HIV and AIDS Hiding HIV and AIDS from neighbours makes people less aware of the need for taking action against the HIV and AIDS epidemic in Malawi. Cause someone to feel unwanted and depressed, and contemplate commit suicide Point to ponder If stigmatizing - of any type - is allowed to continue openly in any place, it will eventually create an angry, unhappy, and unjust community. Discuss

108

Activity 8.11 How can we stop negative discrimination in colleges?
Reducing the stigma of HIV is the first step in combating HIV infection. We know that negative discrimination exists at times in our communities, but it may not be easy to identify. Make a list of what you would do or ask others to do, to stop discrimination. Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? Help educate communities about the true facts of HIV and AIDS The best defence against HIV/AIDS is tolerance and talk - partners, families, communities and nations which maintain silence on the issue hinder the fight Organise campaigns against stigmatizing and discrimination Educate parents, community and neighbours to understand conditions of people living with HIV and AIDS in order to reduce stigma Openly admit if a family member dies of AIDS Openly encourage people PLWHA to live positive lives Introduce or assist care and support groups Encourage the development of counselling services Educate PLWH and PLWA on legal rights It takes courage to stand up and speak out against something that is wrong - but take courage and assist If we want to break down prejudice and discrimination, you may have to make the same points over and over again Be a role model by making show the best side of your character - do not use negative or blaming language when discussing HIV and AIDS Politely challenging people who make negative comments, makes them aware that others do not share their negative attitudes Educating family members about HIV and AIDS prevention helps reduce the fear that leads to denial Extended family members need to create and maintain a supportive environment Care and support family and community members living with HIV and AIDS Christians should ask, What would Jesus do in this situation? Refer to The Gospel according to Luke, especially Jesus’ reaction to the outsiders of society like lepers, adulterers and prostitutes Points to ponder New government HIV legislation is waiting to be discussed in parliament and then passed into law. Among other things it legally protects PLWHA from different forms of abuse. It will also make some traditional customs which spread HIV or predispose people to HIV infection illegal. The regulations will also be used in the fight to eliminate all forms of discrimination against PLWHA and other members of vulnerable groups. A MANET+ statement declared that when this bill is passed into law it would save lives and help people crying out because of the pangs of stigma and discrimination.

109

Activity 8.12 Role-play: Helping to reduce stigma about HIV and AIDS
How do you think it feels to suffer stigma and discrimination because you are HIV+? This role play asks you to look at how we might react in a situation where someone is being stigmatized and discriminated against. Background Abigail is a student teacher from the village of Kapesi. William, is her uncle. He is a very important man in a nearby community. And a successful businessman who enjoys speaking his mind. During a visit to her village, William makes a negative remark about a family whose son died from AIDS. Abigail wants to reduce negative attitudes without quarrelling with her uncle. William Abigail William Abigail Let all these promiscuous people die from AIDS. It is their punishment for breaking our traditional codes of behaviour What do you mean uncle? After they die out, the good people will be left and we can create a new better future for this community (What could she say?)

After the role play • What did Abigail says next? • How did you feel about what was said? • What was it like to role play being the uncle? • Did Abigail manage to successfully challenge her uncle’s views in a way that will not create family quarrels?

Activity 8.13 Do humorous cartoon help in the fight against HIV?
The late Vic Kasinja’s Taxina cartoon character is an empowered woman using her beauty to help her through life, but has she helped the fight against HIV and AIDS?

Point to ponder Cartoons depicting the disappointing activities of an unfaithful husband reveal the addictive nature of extra-marital sex, but may not promote behaviour change. Discuss

110

Activity 8.14 Ways to protect widows from HIV infection?
Review the reasons why you think widows are vulnerable to HIV infection, then identify actions which would protect them from HIV. Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? Introduce alternative widow cleansing rituals which don’t involve unprotected sex Inheriting a widow is an act of enslavement - take her into your home and care for her as a loving relative Speak out against accusations of witch craft being made against widows - all over the world societies have used this as a reason to get rid of poor and vulnerable community members, but it is an abuse of fundamental human rights Actively encourage income generating activities for unemployed and widowed Husbands and wives should make wills in order to protect their spouse from abuse after a death - stopping both property grabbing and widow inheriting

Activity 8.15 Ways to protect young girls from HIV infection?
Review the reasons why young girls are particularly vulnerable to infection, then identify actions which could protect them from HIV. Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? Educate boys and men in life skills education so they see sex as being part of a loving relationship Educate and build self-esteem and assertiveness in both boys and girls, so they can just say, No to sexual advances Report all rapes to the police Encourage girls to complete a full education Educate the community about HIV to dispel local myths or urban legends about HIV Educate the community about the health risks of a grown man having sex with a childbride Discourage inappropriate relationships between very young girls and older men Run an awareness campaign against child-brides and report offenders to people who can help (eg TA, police, NGOs) Educate elders involved in the initiation of girls in human rights and HIV/AIDS Communities should modify dangerous initiation practices that can spread HIV Make sure local orphans or street children are educated and supported - girls and boys are particularly vulnerable to HIV infection through selling-sex to survive Design and implement orphan care programmes (eg care and literacy etc) Point to ponder My friend likes to go with the youngest girls working around the bar. He feels that by giving his money to them, he is probably helping to pay their school fees. Discuss

111

Activity 8.16 What can we do to reduce early sexual activity in children?
What can we do to help reduce the risk of early sexual activity and HIV infection of children? If you wish, you can link this activity with the next one and with the activities on page 126-8. Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? Adults should make sure that children are well informed about their sexual development, sexuality as well as HIV and AIDS Give children clear and truthful information they can make better decisions if they are well informed with the facts Educate elders in your community so they know what we know and educate traditional initiators of both boys and girls Keep updating your information on HIV/AIDS from newspapers and radio by writing extra notes in your copy of Mzake ndi mzake Adults should make sure they are out-standing role models displaying good sexual behaviour - they should not become involved with school-age girls and boys Report teachers who have sex with underage girls and boys Teachers should be made aware that if they drink or take drugs their pupils will eventually learn about this and try to copy - drinking excessive amounts of alcohol has been shown as one of the causes of sexual misbehaviour in adults Express disapproval of people who encourage risky behaviours, including early sex; sex with older persons; sex for money or favours and boasting about sex Help children feel good about themselves - high self-esteem helps children resist peer pressure and achieve their goals Help children stay in school, so they have a future worth waiting for - they may need encouragement and sometimes financial help Provide opportunities for youth to have success and approval to build self-esteem Encourage extra-curricular activities in school - hobbies, clubs are alternative activities which children enjoy and help them resist less desirable activities Watch for warning signs of possible trouble - being secretive, suddenly having money or new things, hanging around with questionable friends or losing interest in school Protect young people from being home alone or going to dangerous places during the hours of darkness Points to ponder If we keep children ignorant of sexual matters by treating sex as a mystery or a big secret, is it any wonder that children find it fascinating and want to experiment? Discuss Every friday, my father meets his friends in the bar of the local hotel. They chat and buy each other drinks. My mother says that it’s his way of relaxing after a hard week’s work. I really like and respect my father, and want to be just like him when I grow up. Discuss

112

Activity 8.17 Ways to protect young people from HIV infection
Review the reasons why children and youths, are vulnerable to infection then identify actions which could be used to sprotect them from HIV. Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? Give children sexual and reproductive health information before the age of initiation - talk to primary school teachers who have life skills books which include HIV education topics Help children stay in school and learn to stay safe Defend childrens’ rights and speak out against child-brides, child labourers and trafficking Life skills and health education which includes reproductive health education Parents could provide literature on sexual and reproductive health in the home Identify or create youth drop-in centres where literature and peer education is available Work to abolish sexual rituals such as the traditional behaviour of Fisi during certain ceremonies HIV is transmitted through unsafe use of cutting tools or sharing needles and piercing objects - new or boiled blades should be used for each person to prevent HIV cross-infection Many parents today have decided that HIV issues are so important that they want to talk to their children themselves - they must know where to get information Parents can ask another adult to talk with their child about sex and HIV - this adult must be someone both parents and child trust who is also well informed What is important is that children and youths can go to an adult to learn about sexuality and other issues - otherwise, they will learn from peers, books or videos Plan and provide alternative entertainment for youths and school children - such as after-school sports activities, science clubs, community action groups etc Identify or establish places in the community to be used as drop-in centres for out-of-school youth where they can also learn about HIV and AIDS Encourage faith-based groups to start youth clubs and provide HIV and AIDS education within their faith communities Parents can modify the way they speak to youths so that it is more adult-to-adult Youths-to-youth and child-to-child peer group methods can be used to pass on correct and clear information about HIV - without the need for adults to believe they should (or have to) lead all meetings Encourage bar owners to ban young children and youths from their premises All mothers in developing countries, whether HIV positive or negative, should breastfeed exclusively for the first six months - exclusively means only to give breast milk, the baby should be given no other liquids or foods for the first six months of life Point to ponder The youth can reverse the effects of HIV and AIDS by being foot soldiers and carrying the message of the disease to all parts of the country. Discuss

113

Activity 8.18

Ways to protect women and men from HIV infection

Review the reasons why women are vulnerable to infection and identify actions which could protect them from HIV. We have listed the positive steps that can be taken to protect both women and men together because they often overlap. Sometimes there is a way a man can protect himself and his partner, another time there is a way a woman can protect herself and her partner. Points for your discussion, debate, drawing, song, story, play, poem, poster etc What positive actions have peer group members suggested? Encourage girls and women to accept their equal status under the constitution this also means that boys and men should not necessarily bear the whole burden of funding and decision making in relationships Promote assertiveness rather than aggression or passivity among boys and girls Encourage community members to join or establish positive-action groups for community development Partners should be role models - observers learn more from what they see others doing, than from what they hear others tell them to do Talk to your partner about how HIV and AIDS is spread and is not spread Talk with relatives, friends and neighbours about HIV and AIDS Empower girls and women through education and counselling Speak out against spousal abuse, male-on-female and female-on-male - abused males often fail to speak out because of shame, but are at risk Report men who hit their partners to the police - it is often hard to communicate with someone who physically or sexually abuses a partner Report incidents of gender-based violence to the police or tradtional authority Campaign for or establish victim support groups in your community Eliminate gender-based violence from your community by voting in politicians who make it part of their election manifesto Things are changing fast and we have more women in positions of power, as politicians, principals, police officers and defence force Educate both men and woman on human rights and discuss how these may be influenced by religious beliefs Keep girls in school as long as possible - this has many positive effects on society. When educated girls grow up to be women they will know the facts about HIV and are empowered to live a healthier more prosperous lifestyle Encourage succession planning and will-making to stop property grabbing Counsel family, friends and collegues who have an addiction to alcohol or violence Assist abusive alcoholics to get help through counselling and other support Speak out or campaign against spousal abuse, child abuse and child labour Educate unemployed women on condom use and identify sources of condoms Educate the elderly about HIV and AIDS - they are often care givers of PLWHA Form peer groups for unemployed women for HIV education for sprevention Point to ponder The elderly must be included and educated about the risks of HIV. Discuss

114

Activity 8.19 More ways a community can protect itself from HIV infection
Identify community actions which would protect members from HIV. Many of the suggestions mentioned overlap with the actions you may have brought up in earler activities. Check off the ideas against what you already know. Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? A community full of positive role models is the best action to take Talk openly about HIV and AIDS and the need to support PLWA Diplomatically challenge and correct people who make incorrect comments about HIV/AIDS issues or discriminate against PLWHA Christian and Muslim beliefs strongly condemn stigmatising the sick or weak. Religious leaders, like Jesus and Muhammed showed that the marginalised of society were one of their main concerns. We should emulate them Discuss the fact that thousands of people living with HIV are not promiscuous Ensure the community can provide or support voluntary counselling and testing (VCT) programmes and ART education Treat the girl child with respect and work against stereotyping Help persons living with HIV and AIDS and their families or carers Form peer groups for youth-to-youth, elder-to-elder, widow-to-widow educators Provide information about HIV and STIs prevention to community the peer groups Support the different peer HIV education groups and use them to train future traditional marriage counsellors on HIV Campaign for reform of any pre-marriage counselling techniques which involve unsafe sexual activities Put up HIV awareness posters around the community Tell everyone in the community that HIV+ mothers can have HIV negative babies if the proper procedures are followed Encourage income generating activities for unemployed, unmarried or widowed Speak out against community practices that encourage the spread of HIV and STIs such as sugar daddies or sugar mommies or traditional practices like child labour, circumcision, initiation and under-age marriages Identify places where risky situations are common, eg beer halls and discos Talk to local bar owners about banning the young, sex-workers, drug dealers from their establishments Organise support for sex-workers in your community, encouraging those who cannot give up to use condom Point to ponder The spread of HIV and AIDS has given women a reason to speak out, and this has had unexpected benefits such as greater equality within sexual relationships. Discuss

115

Activity 8.20 Teacher networks to fight HIV: T’LIPO
T’LIPO is the Association Of Teachers Living Positively with HIV. In Chichewa it may be taken to mean we are alive. It has over 2,500 members nationwide. Read the information below and discuss what T’LIPO is proposing and how far they might assist in HIV prevention, treatment, care and support. Introduction Teachers interact with many people as they perform their many roles as counsellors, parents and role models both in the classrooms, and at home. In the community teachers are often held in high esteem and this enables them to effectively advocate for behaviour change. Why was T’LIPO formed? It was formed when it was noted that many HIV+ teachers were suffering from self-stigma, denial and shame about their sero-status. The Vision of T’LIPO T’LIPO envisages a nation with healthy teachers in which the rights of HIV+ teachers are protected, and in which teachers live positively in order to reduce the transmission and enhance positive living. The Mission of T’LIPO T’LIPO exists to provide adequate services and support to teachers infected and affected by HIV and AIDS in order to reduce HIV transmission and enhance positive living while at the same time upholding the dignity and professionalism of teachers. The Objectives of T’LIPO T’LIPO works to: Create an opportunity for sharing experiences among teachers in relation to their HIV status and enable them to demand for services on prevention, treatment, care and support from service providers Reduce stigma and discrimination against teachers living with HIV and AIDS and orphans in and out of school Promote access to high quality HIV/AIDS treatment, care and support services Target teachers who are not infected with behaviour change out reach initiatives Some recommendations of T’LIPO More dialogue should be encouraged between education managers and teachers and also among the teachers themselves on HIV and AIDS issues There is a need to disseminate the Ministry of Education HIV and AIDS strategy and plan of action and advocate for its implementation The work place measure policy should state clearly punitive measures for any teacher found stigmatizing another and action taken immediately The views of HIV+ teachers should be sought for any further amesndment to the education sub sector work place policy Become a member by going for VCT and registering
Source: T’LIPO Blantyre Urban, c/o Balntyre DEM. E-mail: tlipourban@yahoo.co.uk

116

Activity 8.21 Networks to fight HIV: MANET
People living with HIV (PLHIV or PLWH) founded the Malawi Network of People Living with HIV/AIDS (MANET+) in 1997. People living with HIV/AIDS identified the serious need to harmonise the efforts of NGOs working with PLHIV. MANET+ is a web of solidarity of associations or support groups of HIV+ persons and those affected. The image of the spider’s web is found in our traditional proverbs like, When spider webs unite, they can tie up a lion. The Mandates of MANET+ MANET+ has the mandate to: Facilitate free flow of information between PLHIV support groups and all collaborators Initiate and promote harmonious and effective networking amongst different groups and all other players Ensure representation and participation of PLHIV in all national policy-making bodies regarding HIV and AIDS Help solicit support for support groups and associations from various sources, locally and internationally with the view of strengthening the capacity of people living with HIV and AIDS Advocate for greater respect and protection of the rights and freedoms of people living with HIV and AIDS in all spheres of human treatment, be it social, religious, ethical, political, legal etc The Vision of MANET+ MANET+ envisages an enabling environment for people living with or affected by HIV and AIDS in Malawi - one that is free of stigma and discrimination. This vision statement is a long-term commitment. The Mission of MANET+ MANET+ exists to improve the quality of life of people living with or affected by HIV and AIDS in Malawi through the promotion and protection of their rights and freedoms, empowerment and meaningful involvement in issues that affect their lives at individual, family, community, workplace and national levels. The Core Values of MANET+ Together with the vision, MANET+ has core values that provide the fundamental building blocks for the Network as outlined below: Peaceful co-existence with all people whether living with/affected by HIV and AIDS or not Openness about HIV and AIDS Freedom of expression and association for PLWHIV Respect of human dignity regardless of HIV status by volunteering for an HIV test Non-discrimination Moral behaviour Postive living Being an exemplary role model
Source: MANET+, Kang’ombe House, City Centre, Private bag B377, Lilongwe 3 Tel: 01-772-727, E-mail: director@manetplus.com website: www.manetplus.com

117

Activity 8.22 Malawi’s sex industry and the spread of HIV/AIDS

Welcome to Malawi’s sex industry

It has a nickname ‘survival sex’

Patricia is a sex worker in Blantyre. Here is part of her story as told by Wonderful Hunga in the Daily Times in Oct.08 Points for your discussion, debate, drawing, song, story, play, poem, poster etc • I can’t go back home. Nobody can help me. My grandparents are too poor. • Patricia is wiggling her waist as she strolls... the tavern is the busiest place... music is blaring... people are dancing... sipping their beers... • I got myself here some months ago... my mum passed away... things became difficult at home... I packed up and left... I wanted to do my own thing • Welcome to Malawi’s sex industry. Patricia is not alone. Sex work is a trend in Malawi, and it is especially affecting young women... forced to engage in sex work or transactional sex in exchange for survival items such as food, protection and money... Although illegal... women congregate at nightclubs and bars and sell their bodies in order to survive. Some begin work at 14 or 15. It is survival sex. • Women like Patricia earn anywhere from K1,000 to K140 per day depending on the type of customer and place. So, everyday they are risking their lives, health and dignity for these incomes... Some male customers refuse to put on a condom... the majority of those infected with HIV in Malawi are women... • Gender equalities, which stem from cultural beliefs... put woman at greater risk... It continues despite Malawi is bound by the principles of the UN Charter, the Universal Declaration of Human Rights, the Convention on the Elimination of All Forms of Discrimination Against Women and the Convention on the Rights of the Child. All these treaties discourage discrimination on the basis of gender. • Patricia always uses a condom. She says it is to guard against pregancy not HIV/ AIDS... young girls have proven to be especially vulnerable to sexual violence, or to being trafficked or coerced into sex work... Patricia recalls such violence... • I was ambushed... he wanted to kill me... he grabbed me by the neck... I screamed and ran away. It was just around 11pm... Since then I refuse to be taken to anybody’s place... We tell each other... this guy did this and that and don’t ever accept him. • Like many sex workers in Malawi, Patricia admits to a history of violence in previous relationships. • No, I reject love relationships. No, I don’t want to get married. Somebody once abused me and that was enough... He was jealous. He beat me up when I was late from the market for no reason... He called me a whore... But, eh, he was abusive. If I came late from drawing water, he would beat me up. That was slavery, so I kicked him out of my house... life is better as a bar girl or sex worker than at the hands of an abusive boyfriend or husband... I will marry but not now. I’m enjoying my life. That lover really abused me. Point to ponder Poverty turned Patricia into a prostitute. What else could she have done? Discuss

118

• They said I was the most beautiful young woman in the village. They told my mother I would get a good job in SouthAfrica. I’d have a good life and be able to send money home. My mum agreed as they were such a nicely dressed man and woman... and the money was needed. • We travelled a long way, but when we got to the city there was no housemaid’s job... then the man came shouting that he needed me to pay back the money owed to him for transport, clothes, accommodation and food... He said I owed him hundreds of dollars! I told him I had nothing. • He said if I had no money he would make me work at a nearby hotel until I had paid off all that I owed him. • At the hotel he made me wear a very short shirt and low cut top and high heeled shoes. I now knew how I was to get his money back. I was so embarrassed and refused. • I never expected what happened next. He took me into a room, beat me all over my body and violently raped me... I was bleeding... I was a virgin and had never known a man... It hurt so much... I cried and cried... two more men came in and raped me... I still refused to sell myself... so they took all my clothes and locked me in the room. • Over the next week I was beaten and raped so many times I could never count. I worried about HIV as none of the men used a condom... They said I would starve and die in the room if I didn’t agree. No one would ever know what happened to me. If I agreed I could send money home to my mother and relatives and help them as planned. • So, I agreed to become a sex worker. Me! A regular church-goer and choir member. • The man is now my pimp. He takes me to places where men want company, finds me clients (Johns) and protects me. The clients pay well but my pimp takes most and his repayments. Hotels know us and my pimp arranges my rooms... he gets a cheap rate. • In primary school I had dreamed of being a teacher, doctor even our MP... How did this happen? Will I ever pay off my debt? Am I HIV+? Will ever see Malawi again? Points for discussion In your opinion, which of these people has committed the most serious offence? 1 Grace (prostitute) 2 The John (client) who pays and uses the prostitute 3 The pimp (or madam) who controls and makes money from the prostitute 4 The person who rents the client and prostitute a bedroom In some countries prostitution is legal for those over the age of consent (eg Holland). In other countries a third time offender may be sentenced to death for prostitution (eg Sudan). In other countries prostitution is not illegal, but living off the earnings of a prostitute is a crime. While in Germany prostitution is a legal business and sex workers have their own unions and pay tax to the government on what they earn. Point to ponder The issue of prostitution and HIV in Malawi will not be resolved by silence. Unless we start to discuss more openly the part played by all those in the sex industry: prostitute; client; pimp/madam and traffickers, we are in serious danger as a society. Discuss

Grace’s story

119

Activity 8.23 The education-vaccine against HIV?
Read the following extract from a UNESCO report. It was written by Father Michael Kelly from Zambia, one of our regions experts on both education and HIV.

• Select four positive statements from the passage that you would like to share with others • Select four negative statements that identify issues that need addressed • Malawi is addressing some of the issues through the Safe Schools initiative, how far are you aware of its achievements? • If you were the President or the Minister of Education, what would you do in order to make the best use of education as a vaccine against HIV?
Point to ponder We must encourage behaviour change in the home, in the work place and at school. Discuss.

120

Activity 8.24 Does staying silent on homosexuality help spread HIV?
Recently, stories have appeared in our newspapers which seem to conflict with what communities say are traditions or culture. Read the newspaper article below and discuss the implications in the fight against HIV.

Points to ponder from Malawian newspapers Policeman rapes a male prisoner held in police cell Man raped by fellow inmates while in prison Uncle sodomises nephew School boy caught sodomising a friend at boarding school Tourists pay for homo-sexual sex with locals Points to ponder Talking about homosexuality is a taboo that needs to be addressed now! Discuss.

Homosexuality is illegal in Malawi, but in August 2008, the Malawi Gay Rights Body was formed to protect the rights of gay citizens. Is this right? Will it help fight HIV? Discuss.

121

Activity 8.25 Looking closely at the global approach to HIV prevention
In activity 2.13 (page 34) we looked at the values that the United Nations recognises as key parts of the Millenium Development Goals. Point to ponder I am just a poorly paid Malawian living in a rural village, so what has the UN action plan got to do with me? The following passage comes from the UN document Committing to action: Achieving the Millenium Development Goals. It lists the specific actions to be taken by countries who want to meet the goals. Read through the passage and discuss how far you think community, national and international efforts are moving towards the goals. The UN believes the following things should happen? Implement a long-term multi-stakeholder, multi-sectoral and gender-sensitive approach, based on national AIDS plans. Create closer linkages between HIV/AIDS interventions and sexual and reproductive health care to reduce unsafe sexual risk-taking behaviours, and reduce sexually transmitted infections, including HIV. Increase access to both male and female condoms, which are the only currently available and effective ways to prevent HIV and other sexually transmitted infections among sexually active people. Make sure all young people, who are at the centre of the epidemic, have the knowledge and means to prevent infection. Ensure predictable and sustained funding to address the HIV/AIDS pandemic. Scale up programmes for HIV prevention and ensure universal access to treatment for HIV/AIDS for women and men. Develop sustainable national health systems, delivering quality services and retaining professional staff. Develop primary healthcare systems to ensure universal coverage for essential health services, including for poor and underserved populations in rural areas and urban slums. Promote mechanisms to substantially increase funding for research and development of essential drugs to treat tuberculosis, malaria, HIV/AIDS and other infectious diseases. Fill critical funding gaps for the World Health Organisation (WHO) strategy to combat tuberculosis (DOTS) programmes, and new research and development activities, including work on a vaccine. Ensure adequate financing for key interventions under the Roll Back Malaria Partnership to end malaria deaths in Africa by 2010. Take decisive action to control and treat neglected tropical diseases. Commit additional funding for the global partnership for affordable essential drugs. Point to ponder If people in over 200 member states of the United Nations, are working to slow down and halt the spread of HIV, that is such a combined force, it cannot fail. Can it? Discuss

122

Activity 8.26 How are people who spend time in prison put at risk?

The Malawi Human Rights Commission and other international human rights groups, have produced reports showing that many prisoners’ rights to health and life are being abused. Many of the problems and solutions are outlined below. Points for your discussion, debate, drawing, song, story, play, poem, poster etc Many prisoners have little knowledge about HIV transmission and AIDS care. Prisoners share razors or razor blades can cause HIV cross-infection. Rape of both female and male prisoners by other inmates - especially the young and new prisoners - in some cases gang rape. Rape is about power not just sex. Rape by police officers while in holding cells at police stations - police officers raping both females and males in detention Prisoners exchanging sexual favours for food, freedom or protection from violence Overcrowded and unhealthy living conditions spread diseases like STIs, scabies, TB and prevent prisoners living positively Poor nutrition leaves prsoners’vbodies unable to fight opportunistic infections Shortage of medicines, medical facilities and proper nutrition Shortage of transport for hospital referrals Lack of access to education on HIV and ART or a regular supply of ARV drugs Poor medical care for patients suffering from STIs and other infections Greater protection of inmates from intimidation and violence especially rape More funding for prisons and free distribution of condoms to inmates HIV/AIDS education for prisoners and officers, possibly through peer groups Reduce number of prisoners per cell Campaign for a new prison building programme and expansion Education on ARVs and regular distribution of ARVs to prisoners LWHA More funding for medicines, medical facilities and nutrition More funding for transport for emergency referrals to hospital Establish more prison farms with a wider variety of animals and plant breeds Complementary basic education programmes to improve education levels Education programmes on income generation and rehabilitation Banja La Mtsogolo ran The Health For Prisons Initiative from 2005-8, which focused on sexual and reproductive health programmes for prisoners Point to ponder Once a prisoner is released he has completed his sentence, his debt to society is paid off, but if he became HIV positive in prison doesn’t society now owe him compensation? Discuss.

123

Activity 8.27 How does trafficking for sexploitation spreads HIV and AIDS?
A report for the United States government stated: As unimaginable as it seems, slavery and bondage still persist in the early 21st century. Millions of people around the world still suffer in silence in slave-like situations of forced labor and commercial sexual exploitation from which they cannot free themselves. Trafficking in persons is one of the greatest human rights challenges of our time. Read the following article and carry out the activities that follow.

Points for your discussion, debate, drawing, song, story, play, poem, poster etc • Pick out five or six sentences from the passage that you think carry the most important points • Who should stop people trafficking? • What can you and your peer group do to help stop trafficking? • What can communities do to support victims of people trafficking? • What do you think are the best ways in which to eradicate people trafficking?

124

Activity 8.28

How does HIV /AIDS affect the elderly?

A report by the Population Reference Bureau in 2007 said: As the HIV epidemic progresses, the elderly must be counted and educated about the risks of HIV. Here are some more extracts from the report: Of the estimated 40 million people living with HIV, the vast majority are adults in their prime working years, but as this middle generation dies of AIDS, a generation of young children and a generation of elderly ages 50 and older are left behind. Despite extensive amounts of research on the AIDS epidemic, little attention has been given to the impact of HIV/AIDS on the elderly in developing countries. It highlights the following areas of concern • Caring for families and ARVs. Some elderly take on the care of their adult children or relatives who are sick. More elderly are also assuming the role of caretaker for their grandchildren and other orphaned children. Expanding access to antiretroviral therapy will likely decrease deaths of adult children and delay serious illness. As a result, parents may change how they help - instead of providing terminal stage care, they may help ensure adherence to demanding regimes of medications. • Economic impact. Old age, declining health status, and caretaking responsibilities at home compromise older people’s ability to earn an income. • Health consequences. In developing countries where family support systems exist, elderly people who care for their adult children or relatives often receive material support from other relatives. In Malawi, for example, intergenerational support networks exist between adult children and their parents and also with maternal and paternal aunts and uncles. • Attitudes. Community reactions toward those living with HIV as well as toward their caregivers have generally been positive or neutral, despite widely held assumptions to the contrary. Educational campaigns and knowledge about HIV have likely alleviated fears about casual transmission, thus contributing to lower levels of stigma Despite their considerable caretaking role, the elderly still remain largely hidden from the international HIV/AIDS agenda. Because it is assumed that they are not at risk of contracting HIV, the elderly have received minimal program and policy attention. Older people are not only at risk of infection, but their income and health may also be adversely affected when they take on the role of caregiver. Particularly important in the context of increasing access to antiretroviral therapy is determining the potential of older parents in encouraging treatment and monitoring adherence and how increased access to these drug regimes alters the consequences of having an HIV-infected son or daughter.

Points for your discussion, debate, drawing, song, story, play, poem, poster etc The Mzake ndi mzake peer education programme covers prevention, treatment, care and support. How far do you think that the elderly are involved in all of the four aspects of HIV/AIDS programmes in your community?

125

Activity 8.29 Talking to children about sexual and reproductive health
Young children are interested in almost everything they see and hear. A child’s world is full of suprises and they love asking questions. One of the most popular children’s question is, Where do babies come from? Have you ever been asked this question by a child? What did you say in reply to the question? Here are a some answers children have received from adults: • The stork (bird) brought him • God put baby into mummy’s tummy What do you think is the best explanation to give a child? Depending upon the age of the young person, these talks can take various forms. They could be part of talks which can be classified as man-to-boy, woman-to-girl, child-tochild, sister-to-brother for example. Point to ponder The most important thing to tell children about sex is the truth, but the truth phrased in such a way that it neither over-excites nor seriously frightens them. Discuss. If an adult does not give answers to a child’s questions, then the child will go and ask their peers. Adults must be prepared for comments or questions about breasts, genitalia, sex and relationships. How should they prepare properly for this responsibility? Points for your discussion or role play Read through the following examples of conversations between adults and children. Discuss whether they contain ideas that are acceptable in your community or if they need to be adapted. What would you say in this conversation? Child What are those two dogs doing? Adult Making a baby dog Child Mummy, can those two goats make a baby goat? Mummy, does it take two people to make a baby? Adult Yes, a mummy and a daddy Child Do all animals have mummies and daddies? Adult Most animals and many plants have mummies and daddies Child Has everything in the whole world got a mummy and a daddy? Can children be mummies and daddies? What would you say in this conversation? Girl child Can I make a baby with my brother when we grow up Mother No, mummies and daddies have to be grown up People are not allowed to marry their sisters and brothers. They will find other really special friends to marry

126

Girl child Mother Girl child

Is daddy your special friend Yes, because he helped to make you! Will I find a special friend to be happy with and make babies? Mother Yes, I hope you will find a good man to marry. But you have to grow up into a woman first Girl child Why can’t little girls have babies too? Mother Babies grow inside the mummy and a little girl’s baby hole is not big enough to let the baby out Girl child Does every girl and woman have a baby hole? Mother Yes, that’s one of the things that makes us special. There a lots of things about us that make us special Girl child Are boys special too? Mother They are special too, for lots of reasons Girl child What makes boys special? Use role play to continue this conversation

Activity 8.30 Role play: Discussing sex education for young children
Introduce the role play with the brief overview found below. Background to the role play Two mothers, Christine and Ada, are concerned about their children because they are growing up rapidly. They have just finished listening to a radio programmme that talked about the importance of preventing child sexual abuse, early sexual activities and HIV infection. They both want their children learn how to lead healthy lives. The role play begins Christine How am I going to tell my son the facts of life? Ada And how am I going to tell my daughter the important things she needs to know, to keep her safe from HIV/AIDS and pregnancy? Christine Should we leave it until the initiation, that is the traditional way isn’t it? Ada Children can be sexually active in primary school, I am not so sure we should leave it until initiation, that is too late! Christine What would you say to your daughter if she asked about sex and babies? Ada What would you say to your son if he asked you why he has a penis*? (* substitute a traditional term if appropriate) Christine Who should we ask? The elders, religious leader, teacher or nurse? After the role play • How old should children be when they start learning about sex? • Who should teach the children about sex? • Does life skills education at school provide enough information and skills? • Where could parents and community elders get information about reproductive health and child sexual abuse to share with their children?

127

Activity 8.31

Role play: Talking to a child about sex and HIV/AIDS

Continue the previous role-play • Choose whether your role play will involve a young boy or a young girl • Try to use the exact words that could be used when talking to the young person The role play begins Adult You may have heard some boys talking about sex Child Some boys say that everyone who has sex will die of AIDS After the role play • In what other ways could you have started this conversation? • Were the explanations clear and simple? • Did the conversation mention sexual feelings and values? • Will the child feel that they can come to the adult for more advice at a later date?

Activity 8.32

Keeping children safe from sexual abuse and HIV

You may combine this activity with earlier role plays if you wish. Look back at pages 65-67, 104 and 111 for source material. Background to the role play Edina should be baby sitting, but she runs out of the house. Her uncle looks out of the window as she races past her older brother George. The role play begins: George What’s wrong with you? Edina Nothing. It’s just uncle wanting to tickle me again George You shouldn’t let him touch you that way After the role play • What did George say to Edina and what did he do? • Describe or act out, four different endings to this play • Which ending seemed to bring the most satisfying conclusion to the situation?

Activity 6.20 Assignment
Select one of the social issues raised in this unit and carry out research within your local community, to discover how far it may be linked to the spread of HIV and AIDS. Evaluation Evaluate the peer group activities in this unit by using the questions on page 166.

128

Unit 9 Living positively with HIV and AIDS
Introduction
In the past, if a person was tested and found that they were HIV+, they felt as if a death sentence had been passed upon them. Some people living with HIV+, gave up on life and prepared to die. But, experience has shown that there are many things an HIV + person can do to both prolong and enrich their life.

Learning outcomes
By the end of the unit you should be able to: • describe how different people may react when learning that they are HIV+ • explain how reducing stress can help a person live postively with HIV • describe ways of living positively with HIV and AIDS • explain the importance of eating positively • identify foods which should be used by PLWHA • identify medicinal plants that can be used by PLWHA • describe how some foods can relieve the common symptoms of HIV/AIDS • describe natural remedies that can be used to alleviate diarrhoea • explain the importance of hygiene for a PLWHA • explain how spirituality may strengthen the immune system • carry out succession planning • explain why home-based care is important • identify the time when a family may begin home-based care for PLWA

Activity 9.1 Assignment review
Share your research with the group.

Activity 9.2 How do people react when learning they are living with HIV?
By the time you reach this unit you will have a lot of ideas on how to answer this question. The focus of the activity in this unit move away from the negative responses and looking at the the vaiety of positive responses. • Why is it important for a PLWHA to share feelings and concerns with others? • Who would you confide in if you were HIV+? Why did you select that person?

129

Activity 9.3 What causes stress for people living postively with HIV?
What sort of things could cause stress to people with HIV infection? What have peer group members suggested? Receiving an HIV positive result Others being told of someone’s HIV status without their consent Thinking how community members will react to the news that you are HIV+ Having inadequate finances to support family Being unable to afford medical treatment and drugs Being unable to afford school fees for children Fewer relatives to look after children if you die Fear for children’s future Loss of employment and opportunities Loss of friends and isolation Rejection by some community members Fear of dying Death of loves ones, a spouse or a child What problems does stress cause for PLWHA? What have peer group members suggested? Stress often blocks our minds with negative thoughts and this can stop us doing other important or essential tasks It makes us feel that we have had enough - we want to escape from the problem, to get away so we can be stress free again - sometimes suicide is contemplated Stress can blind us to the many alternative choices and sap us of the energy to do any thing at all People may look only at a problem and not the opportunities or circumstances around the problem People focus on their condition and forget that there is lot they can do to improve their lives People living with HIV/AIDS can develop stress related illnesses which weaken the immune system, which is then more vulnerable to opportunistic infectionss Living a positive lifestyle can greatly reduce the stress experienced by PLWHA You may wish to go through activity 9.11 and 9.12 next - they are concerned with methods of stress relief. Point to ponder The greatest amount of stress for a PLWHA is caused by having a pessimistic outlook on life. Discuss

130

Activity 9.4 Living positively with HIV and AIDS
Most of us have heard the phrase, Living positively with HIV and AIDS. But, what does it actually mean? There are many ways in which a person with HIV can protect their immune system and prolong a healthy life. The first and major positive move a person can make is to accept their sero-status. What can a person do in order to live a positive life, while living with HIV/AIDS? What have peer group members suggested? Accept your status, denial can hinder living positively Seek medical advice and decide, where and when to start ARV treatment Develop a positive attitude with a determination to live Learn all they can about HIV, how the body is affected by HIV and what can be done to strengthen the immune system Eat a good balanced diet and check on any drop in body weight Keep your digestive system clean, this helps the body to fight HIV - diarrhoea should be dealt with immediately Drink plenty of clean water -it is essential Learn how to make and use ORS (oral rehydration solution) - see page 163 Use some simple natural remedies to help the immune system stay strong and help with common health problems (see pages 134-6) Some people use natural remedies, not to cure HIV and AIDS, but to fight opportunistic infections and their symptoms - it is always wise to get professional advice from your health worker or doctor on this matter Beware of some local herbs as they may be toxic and may not be recommended to be taken together with some drugs like ARVs Exercise gently to keep the body as fit as possible Develop a healthy mind that can deal with stresses (worry) Live in a more organised way by tidying and keeping a clean environment, be it a room, house or garden Find out if there are any HIV/AIDS support groups in your community learn from others who have successfully resolved the many issues facing PLWHA Have medical check ups and treat problems like TB promptly Reduce your workload and consider possible retirement issues Enjoy a full sexual relationships but always practice safe sex to avoid re-infection or cross-infection Make a will or a living will - with ART it may not be needed for a long time, and HIV negative people should also make wills to protect their loved ones Write a memory book for those you may leave behind if you die of AIDS - what you write can be kept a secret until after your death Points to ponder I exercise every day. I walk around the village, usually wearing a smile on my face. If I do this people always smile back and their smiles really help me to stay positive. Discuss After I started exercising I noticed that mentally I felt sharper. Exercise does work! Discuss

131

Activity 9.5 HIV and nutrition: Eating positively
When your body gets enough of the right foods, you feel better and more positive about yourself and the future. Eating the right foods can help your immune system fight infection and stay stronger during treatment. Following a nutritious diet is key to positive living.

by Carmen Aspinell

The way foods are classified in Malawi has changed. The diagram above, shows the new food groupings. Can you identify the 6 food groups shown in the drawing? Recommended eating habits for people living with HIV and AIDS Eat a variety of foods from all of the food groups Choose small, frequent meals of foods that are easily tolerated by the body - so eat small meals (4-5) instead of 3 big meals Snacks are foods eaten between meals and help fill the energy gap and are a way of giving children or people living with HIV extra food Try to eat less meat and fat Increase amount of fruit and vegetables in the diet Avoid skipping meals or eating only when you are hungry Try to keep your weight constant Listen to your body, because some foods make symptoms worse Inform health care workers if some foods make you ill Use fresh food and try eating raw fruit and vegetables or cook them on low heat, steam or bake them - remember that boiling destroys many vitamins Consult your health care worker or doctor before taking vitamin tablets Avoid coffee and don’t eat too many processed foods

132

Activity 9.6 Which FOOD GROUPSs can be used by PLWHA?
Which local plants can be used medicinally by people living with HIV and AIDS?

133

Activity 9.7 Which medicinal plants can be used by PLWHA?

134

Activity 9.8 How can foods relieve common symptoms of HIV/AIDS?

Point to ponder By relieving many of the uncomfortable symptoms of AIDS, natural remedies play a significant part in helping people to live more positively. Discuss

135

Activity 9.9

Which recipes can be used to alleviate diarrhoea?

136

Activity 9.10 HIV and hygiene: Positively clean
Good hygiene is essential, especially when preparing and storing foodstuffs. Many of the hygienic routines for living positively with HIV, are exactly the same as for people who are HIV free. What do you think are some of the things that need to be done to ensure food and environmental safety ? Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? Always wash hands with soap and water before handling food Pounded, clean pawpaw leaves can be used as soap Cooking utensils should be dried carefully with a clean cloth or air dried If you are ill be careful when you prepare food particularly if you are vomiting or have diarrhoea Left over food should not be left at room temperature for longer than two hours Keep uncooked meat and fish away from other cooked foods Don’t overcook or over boil food Serve food fresh - as milk, fish, cooked meat and cooked rice can spoil quickly Other important health and safety tips What have peer group members suggested? Avoid spreading infections by washing hands frequently with soap and water Cover cuts and sores on hands and always wear clean clothing Go to the clinic immediately at the first sign of infection such as fever, chills, sores in the mouth, diarrhoea, or a rash over their body. Early treatment can catch infections when they are easiest to treat Keep your body warm as a cold body can’t fight infection as well as a warm one Exercise to keep the body warm and working Gentle exercises help you feel good without overstressing the body Don’t overstress the body if you have symptoms like diarrhoea, cough or fever Avoid smoking as this can affect the body’s ability to take in vitamin C Avoid alcohol which may affect liver function - some ARVs also affect the liver Only take medicines advised by professional and qualified people Avoid self-medicaton, don’t take unprescribed drugs as they can be harmful and cause serious side effects Protect food and kitchen surfaces from flies and cockroaches which spread diseases which can weaken the body of a PLWHA - cover food and make sure utensils and toothbrushes are not exposed to insects Point to ponder Don’t let a small insect spoil all of your great efforts to live positively and happily. Discuss

137

Activity 9.11 How can spirituality strengthen the immune system?

Points for your discussion, debate, drawing, song, story, play, poem, poster etc Peer group members with religious faith and others with no faith, have suggested these ways of strengthening the immune system: It is important to use your faith to help you live positively, by asking for advice from your religious leader or advisor People of faith, believe that humans have a mind, body and a spirit A religious person believes that as well as working to strengthen the mind and the body, they can strengthen the spirit and this improves personal well-being Attending regular services or holding a house meeting at home, where fellowship and worship take place and spiritual matters are discussed Faith is not just about thoughts and words, but more about feelings - so, share your feelings with your family, friends and fellow believers Find ways to show your love for God, your family and your fellow human being and develop a love for all creation Giving and receiving love makes your immune system stronger Be thankful for the beautiful things in the world around you and this will make you feel better Identify passages from your holy book that lift the spirit and then write some down on pieces of paper, so that you can carry them with you, to read or share Develop respect for people you meet and accept them as fellow travellers through life who are born, are living and will one day die Smile and share smiles with others, because smiling lifts both the spirits of the smiler and the people who are smiled at Think about your life from childhood to present day - make a list of your favourite experiences, share them with friends and relatives and then thank God for those special times

Point to ponder If I exercise my mind and body for health reasons, shouldn’t I exercise my spirit too? Discuss

138

Activity 9.12 Reducing stress by deep breathing and quiet time
In this activity we will look at two things that many people say can reduce stress. Select one person to quietly read the instructions while others do the practical.
Deep breathing

Deep breathing is something you can easily teach peers. Try this exercise to see how relaxing deep breathing can be: • Close your eyes • Now count 1, 2, 3 as you breathe in through your nose • Hold your breath and count 1, 2, 3 • Breathe out counting 1, 2, 3 • You need to do this activity at least three times - get to the point where you can feel yourself relax as you do it • It may not happen the first time you try it - it’s a skill you develop
Quiet time

You can also encourage peers to set aside a quiet time each day for meditation and prayer. Try this exercise for meditation: • Choose one simple word to focus on - this will help to block-out other stressful thoughts from your mind • The shorter the word the better - eg. peace, joy, calm, cool, love, happiness • By choosing a peaceful and calming word, the mind will become more peaceful • A religious person may mediate on the 99 names for God or the life of Jesus • It is your individual meditation word - so, experiment with different words • In a quiet place, think of your word over and over again - it should be a word that makes you feel good, relaxed and comfortable

Activity 9.13 Role play: Talking about living positively with HIV and AIDS
John and his wife, Rebecca, have loved each other since they married ten years ago. Rebecca has been reading about people living positively with HIV and knows a great deal about the topic, but she has never mentioned this to John. Background to the role play John is thinking • How can a person like me, go for VCT and be HIV positive, maybe the test is wrong! • I am a dead man and have probably sentenced my wife to die too! • What will they say at church and work when they find out? • This diarrhoea is going on too long, is it full blown AIDS already? • I think I’ll find a quiet place well away from here, commit suicide and save my family the embarrassment The play begins: Rebecca comes in and sees that her husband, John, is almost in tears Rebecca Is something wrong husband? A problem shared is a problem halved. John Just one problem my dear, but I think I can handle the issue by myself Continue the role play and afterwards, discuss any interesting points raised.

139

Activity 9.14 Succession planning
Succession planning is planning for what will happen to children and young people after their parents have died. Many children and young people in developing countries face problems inheriting their parents’ property when they die. This may be partially due to cultural traditions concerning property inheritance at death. These may prevent women and young children inheriting property. Instead, property may be inherited by a male relative of the father. It is expected that he would then take on responsibility for care of his brother’s family. However, sometimes relatives may take the property without taking on responsibility of care. Points for your discussion, debate, drawing, song, story, play, poem, poster etc There are many problems when a parent dies. These are worse if there has been no planning. There are many reasons why succession planning does not happen in developing countries. Responses which focus on encouraging succession planning use a variety of methods, including the use of memory books and boxes. Benefits of succession planning projects include increased appointment of guardians, improved disclosure of positive HIV test results to children and increased use of wills. What are the problems with poor succession planning? There are many problems when a parent dies and these are made worse if there has been no succession planning. These problems include: children and young people not understanding what has happened or what will happen to them adults being unclear as to who will care for the children and act as their guardian property being taken by relatives and others. What are the barriers to succession planning? There are many reasons why succession planning does not happen in developing countries. For example, wills can be a key tool in this planning. However, people rarely write wills in some developing countries. Reasons for this include: belief that writing wills and preparing for death can cause death. the tradition that property is only distributed after death by senior people within the extended family the tradition that women and young children can not inherit property the tradition that wills are verbal not written limited knowledge and enforcement of laws limited literacy limited experience with legal issues among NGOs in rural areas

140

What would encourage succession planning? Encourage succession planning in a number of different ways, including: counselling HIV positive parents or guardians, regarding telling their children about their test results. creating memory books or boxes. These consist of a book or box which describes and remembers a person’s life. They may focus on specific events or periods within a person’s life. Memory boxes may be used to hold important documents, such as birth certificates and wills. What would you put in a memory box? support to appoint a standby guardian. This person will take on the responsibilities of a parent for a child if the parent is no longer able to do this. training of guardians. education legal matters including practical support to write wills. assistance with school fees and supplies. training in ways of generating income and funds to get activities started. community sensitization on needs of AIDS-affected children. Why is succession planning important? Benefits of encouraging succession planning include an increase in the number of: guardians appointed before a parent dies parents who tell their children the results of their HIV test - this is particularly true where those children are over the age of 12 years wills written, which protect loved ones Experience has shown that a project has benefits beyond the area in which it operates. This is because people within the project area share the benefits with those outside the area.

Activity 9.15 What things should you put in your will?
Choose who you would like to leave your possessions to after your death Make a list of who you would leave your possessions to - writing down your wishes and having 2 responsible witnesses sign and date your will.

Activity 9.16 What things would you write in your memory book?
Who will read your memory book after your death? What special memories would you write in the book? What special messages would you include? You could include a list of your favourite music, foods, places, books, prayers, books etc

Activity 9.17 What things would you put in your memory box?
Put in some of your favourite photographs and letters Special souvenirs, diaries or journals, books, jewelry etc What other special things would you leave for others?s

141

Activity 9.18 Why is home-based care so important?
Point to ponder. Home can offer a far higher standard of patient care than some hospitals and clinics. What do you think? Further points for your discussion, debate, song, story, play, poem, poster etc Peer group members have suggested that home-based care can help in various ways. It provides the personal touch to caring It is less expensive than a hospital stay and this is very important for poor families Can provide a larger number of carers The patient is in familiar surroundings There is more time for succession planning The touch of family carers reinforces bonds of love and encourages positive living Improves the quality of life for a PLWHA Helps to prevent the spread of opportunistic infections such as TB When a person is referred for home-based care, the health care worker needs to find out if the family has been informed of the full details of a person’s illness If the family has not been told, the health care worker has to inform the future home care giver to help family members learn more Sometimes it is necessary for the home care giver and family members to be informed by a qualified counsellor, if health workers feel unable to handle the situation

Activity 9.19 When should a family start home based care of PLWA?
When a family knows that a relative is living with HIV, they must be made aware that a time may come when they will no longer be able to look after themselves. If peer group members have personal experiences of caring for a PLWA, give them an opportunity to tell their stories. Points for your discussion, debate, drawing, song, story, play, poem, poster etc Peer group members have suggested • As HIV weakens the immune system the patient starts to get opportunistic, but treatable illnesses requiring frequent visits to the clinic or hospital • Later on the person then becomes chronically ill, and is no longer able to work and do daily life activities • At the advanced stage of AIDS, hospitalisation may no longer be effective and useful or desired by the person who is ill • The person now requires support services through home-based care and the family now has to take over

Activity 9.20 Assignment
Interview people who have personal experiences of caring for a PLWA. Make a list of the issues raised by the interview in preparation for the unit on Educating caregivers.

Evaluation. Evaluate the unit by using the questions on page 166. 142

Unit 10
Introduction

Educating caregivers

This short unit, aims to bring together what you have already learned about HIV and AIDS, and focus it upon the important role of the care giver. It is essential to educate the people looking after those members of our communities living with HIV or AIDS. In Malawi carers are found in hospitals, clinics and in our homes. They are often the relatives of PLWHA - the spouses, grandparents, children or neighbours of the patient. By educating first line caregivers it is hoped that their health will be protected and their work will be made more effective.

Learning outcomes
By the end of the unit you will be able to: • describe some of the concerns of the caregivers of people living with HIV/AIDS • describe how healthworkers can help families with PLWHA • practice ways of helping care givers prevent HIV infection • explain the role of counselling in home-based care • describe the different forms of counselling available in Malawi • practice ways of reducing opportunistic infections affecting PLWHA

Activity 10.1 Assignment review
Review the assignment. When caregivers share their concerns and demonstrate how they look after a PLWHA, both the care and support systems improve. Carers often fear not knowing what course of action to take, worrying about the effects of treatment, concern about the amount of time available and the deterioration in the patient’s health. Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? By showing new carers what to do, they pass on first-hand experience and skills Holding a group session with a PLWA in their home or bedroom, brings issues to life - the PLWA is considered and treated as a resource person during this activity Using the actual resources of a caregiver, would make the topic real - by repeating an activity or adapting it can also improves learning Carers need information and skills because, a person living with AIDS requires: - palliative care to relieve symptoms associated with AIDS - help in preventing opportunistic infections - a support system which includes many different forms of help - ongoing counselling - safe and supportive environment - spiritual and moral support - a healthy diet and exercise Point to ponder. Everything I do as a caregiver, is done in order to boost my patient’s immune system and therefore strengthen resistance to infection. Discuss

143

Activity 10.2 Practical ways of preventing HIV cross-infection
What can be done to prevent HIV cross-infection? Personal experiences will add weight to this discussion. Points for your discussion, debate, drawing, song, story, play, poem, poster etc You only need to practice these precautions when you are in direct contact with body secretions which may carry HIV. Remember, if the caregiver’s hands have wounds, cuts or cracks extra special care must be taken. What have peer group members suggested? Always wash hands with soap and water if you touch infected body fluids - use pounded pawpaw leaves if soap is unavailable Wear gloves or small plastic bags over the hands if possible Make a plastic apron out of large plastic bag - use this when handling body secretions on linen, bed clothes, towels, dressings or cleaning up spills of blood and other body fluids Never leave blood spills or other body fluids lying on floors, furniture or in containers - clean them up or dispose of them safely Cover body fluid spills with bleech or hypochlorine (Jik) solution if possible For everyday cleaning of surfaces you can use mix 1 cup of Jik with 2 cups of water - pour onto the spill and mop up carefully Boil soiled laundry for at least 20 minutes or use bleach (Jik). If laundry is not boiled use water and household bleach - 1 part bleach to 9 or 10 parts water - to kill the HIV on any household items. If this is not possible to boil or treat items with bleech, let items dry thoroughly before using again Discuss how to dispose of possibly contaminated waste Keep other family members and friends who may have infectious illnesses - flu, TB - away so that they do not spread their infections to the PLWHA Be very careful with sharp instruments and avoid punctures with objects that may contain blood Place used needles and all other sharp instruments in a separate sturdy box or container with a cover and label it Sharps Use caution when administering first aid as blood can pass on HIV infection Cover any sores and cuts with bandages or waterproof plaster Put on gloves when changing wound dressings, giving an injection or cleaning a person - take them off as soon as you finish

144

Activity 10.3 What is the role of counselling in home based care?
Counselling is part of home-based care, it is a process of helping another person to better understand their own and other’s problem or situation and then constructively manage the problem or situation. It aims to prevent further spread of HIV and support people living with HIV or AIDS and the affected. Ask the group to discuss what things home-based counselling should include. Then to list them. Points for your discussion, debate, drawing, song, story, play, poem, poster etc Peer group members have suggested • Educate people living with HIV so that they understand the nature of the disease • Help people understand the treatment options and make informed decisions • Explore safer sex option and other preventive measures • Communicate test results • Deal with issues surrounding grief, loss, and bereavement etc • Clarify questions the person may have, such as the development and effects of opportunistic infections and the need to treat them when they first appear • Counselling individuals and their families so they understand and can deal with the implications of HIV and the possible impact of AIDS • Understand the risks associated with caring for someone with an HIV infection

Activity 10.4 What forms of counselling can a person access in Malawi?
In rural areas the counselling role is often assumed by traditional elders. In urban areas, many people may be unaware of the different types of counselling that are available. The provision of counsellors in Malawi is improving. Ask the group to look at the points below and discuss which issues would fit under the different types of counselling. Points for your discussion, debate, drawing, song, story, play, poem, poster etc • Preventive counselling - to stop something before it develops. • Problem solving counselling - help individuals understand, analyze and find solutions to problems they may be experiencing • Decision making counselling - to help on e to make difficult decisions such as getting pregnant when one is HIV positive • Bereavement counselling - offered in response to loss, especially by death, whether real, imagined or anticipated - it offers support to individuals and their families and friends throughout the grieving process • Spiritual counselling - often offered by religious groups to cater for spiritual needs of those with whom they come in contact Points to ponder I didn’t know there were so many different types of counselling available, but what are the differences between them? Discuss Some of our traditional activities, give more ‘guidance’s than ‘counselling.’ Discuss

145

Activity 10.5 How can we reduce opportunistic infections?
How can families and care providers reduce opportunistic infections in PLWA? Using personal experiences where appropriate, ask the group to list examples of best practice. Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? People with HIV get infections easily and have a hard time getting rid of them A person with an infection may have a fever, chills, sores in the mouth, diarrhoea, or a rash over their body Go to the clinic immediately on noticing any of these signs of infection, as this can catch the problem when it is easiest to treat Health care providers may give medicine to take regularly to stop an infection from coming back and these should always be taken as prescribed When a person has a cough that won’t go away, they should go to the clinic to be tested for TB Prior to starting ART (antiretroviral treatment), the patient must be checked and treated for TB, malaria, and parasites, as these conditions weaken immunity Become familiar with traditional herbal treatments which relieve symptoms, but remember no traditional medicine can cure HIV infection or AIDS

Activity 10.6 How can health professionals help families with PLWA?
What sort of help should people expect from a health professional? In an ideal world every PLWA in Malawi could expect the very best treatment. Unfortunately, our health professionals are under a lot of pressure, with time and medicines often in short supply. But, we must always remember that health workers are the experts in the HIV AIDS field and they must always be consulted before traditional healers or self-medication. Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? • Hospitals need to provide family members with sanitary facilities for toileting, bathing, cooking, doing laundry and waste disposal so that guardians do not spread infection • Health workers need to teach families how to use universal precautions so they can care for their relatives without spreading infections • Family members and caregivers also need some basic supplies to provide safe care, including hand washing facilities and gloves • When health workers use gloves, it helps family members understand that using gloves (or plastic bags) and taking other precautions does not mean a lack of love and respect • When health workers have a positive, non-blaming attitude, it helps reduce the feelings of shame or stigma associated with HIV and AIDS • The National Council of Nurses and Midwives of Malawi (NMCM) is mandated to develop, maintain, monitor, evaluate and control the profession of nursing and midwifery and encourages the public to report any form of malpractice and negligence - everyone should help NMCM achieve this goal

146

Activity 10.7 What can care-givers do in the fight against HIV and AIDS?
Health professionals and other caregivers are intimately involved in the fight against HIV/AIDS, and their personal experiences are an invaluable resource for community action. This activity can be combined with 10.5 and 10.6. Points for your discussion, debate, drawing, song, story, play, poem, poster etc What have peer group members suggested? Provide counselling or opportunities to chat informally Share basic information about HIV and AIDS Join or create support groups and networks of PLWHA Take part in home-based care education activities Community mobilisation for better health services Provide guidelines for individual patient management Help people get access to essential drugs Provide specialist bed services for AIDS management Arrange support for children orphaned or children living with HIV and AIDS Encourage people to behave responsibly even when living with HIV and AIDS

Activity 10.8 Living positively: ideas for role plays
These role plays will assess how much you have learned about care giving, by bringing up many of the ideas from previous units. During the role pays make sure you both act (use the appropriate actions) and talk about: • ways to live a positive lifestyle with HIV/AIDS • the safety precautions to protect people from infection or re-infection Choose from the following role plays: Cooking healthy meals together Eating a meal together Keeping the house tidy and healthy Bathing a PLWHA Washing clothes and bed linen Listening to hopes and fears Discussing keeping children safe Discussing succession planning Discussing and writing a will Discuss what to put in your memory box or memory book Giving spiritual support Talking to a child about the death of a relative Administering first aid on a fresh cut Discussing ART and checking whether the patient is keeping to instructions Returning to work and planning for the future, because the ART has been successful and the patient is healthier and ready to do more!

Activity 10.9 Assignment
Find out about the prevention of mother-to-child-transmission of HIV (MTCT).

Evaluation. Evaluate the unit by using the questions on page 166. 147

Unit 11 Preventing Mother-To-Child-Transmission
Introduction and learning outcomes
For you assignment you were asked to find out about preventing mother-to-childtransmission of HIV (MTCT). We will review your findings and by the end of the unit participants will be able to: • define mother to child transmission (MTCT) • identify why mothers are at risk of HIV infection • identify when HIV can be transmitted through MTCT • describe how HIV can be transmitted through MTCT • identify cultural practices which can put a child at risk of becoming infected with HIV through MTCT • describe methods of preventing MTCT of HIV • describe the importance of exclusive breastfeeding of babies for the first six months of their lives

Activity 11.1 What is mother-to-child-transmission?
Mother-to-child transmission is when an HIV positive woman passes the HIV virus to her child. This can happen before, during or after birth, and as the child grows up. • Mother-to-child transmission (MTCT) is the second most common mode of HIV transmission in Malawi • In recent years, 90% of child infections are from their mothers, with 10% of infections coming from exposure to infected body fluids and child sexual abuse • In the past most people believed that if a woman was HIV+ she would always give birth to an HIV+ child - but, that is not the case today, because drugs which will reduce the risk of a mother passing on HIV to her baby

Activity 11.2 Preventing mother-to-child-transmission during pregnancy
How can we prevent HIV being transmitted from a woman to her unborn child? These factors increase the chances of a baby being born HIV positive: Mother having a high viral load or in an advanced stage of AIDS Spousal abuse when expressed physically, mentally or through neglect Rough sexual intercourse during pregnancy Re-infection from an HIV+ sexual partner These factors increase the chances of a baby being born HIV negative: Pregnant women need to be cared for and loved even more than usual, because pregnancy can cause mood changes Help to reduce pregnant mothers stress level Treat any STIs especially open sores before giving birth Pregnant women need more food than normal to stay healthy - the healthier the expectant mother the healthier the baby Involving men in PMTCT helps to involve men in feeding programmes as well

148

Activity 11.3 Preventing mother-to-child-transmission during childbirth
During labour and delivery, membranes may rapture early, exposing the child to the mother’s body fluids. These factors increase the chances of a baby being born HIV positive: Mother is very young and her birth passage is too small, it can tear badly Mother has a high viral load or in an advanced stage of AIDS Mother has an STI and open sores in and around genitals Mother’s amnion is infected by HIV Mother has a severe lack of vitamin A Unclean surrounding during birth Birth attendent is HIV positive and does not wear gloves Birth attendants not washing hands properly before a birth Birth attendent uses old, unsterilised blade to cut the umbilical cord These factors increase the chances of a baby being born HIV negative: Deliver at health care centre or with qualified medical staff present Avoid trauma to the unborn baby (foetus) through instrument deliveries Caesarean section is the best mode of delivery Take anti-retroviral medicines at the beginning of labour pains. The drug passes through the placenta to the baby Don’t put unclean traditional medicines on the umbilical cord Use a new or boiled blade to cut the umbilical cord Campaign against the child abuse of child brides and under-age marriage Do not let local midwives put any herbal medicine into the new mother’s vagina Educate traditional birth attendents on the new medicines available and why they are important Educate school girls and boys, in appropriate sexual and reproductive health issues related to healthy childbirth - then allow them fully mature before they become well-educated parents Points to ponder If a woman is cared for during her pregnancy then her baby has a far better chance of being born healthy. Discuss The education of parents begins at home and in our primary schools. Discuss

149

Activity 11.4 Preventing HIV transmission during breastfeeding?
In Malawi all mothers , whether they are HIV positive or negative, should breastfeed exclusively for the first six months of their babies’ lives! Exclusively means only breast milk, the baby is given no other liquids, no foods nor local medicines for six months. These factors increase the chances of a baby being born HIV positive: One baby in every five, born in Malawi, dies before it is one month old One child in eight dies before its fifth birthday In Malawi, 27% of children are underweight Almost 50 % of our children are stunted Malnutrition is associated with 54% of child deaths Dwale, can kill a baby - drinking dirty water can’t straighten the baby’s intestines or stop abdominal pain - it can make a baby seriously ill and irritates the babies digestive system and makes it even smore vulnerable to HIV infection It is not true that the first breastmilk a mother produces after giving birth contains bad elements - first breast milk is good Hundreds of Malawian babies die, because their mothers think that bottle feeding is the best way, even if the milk mixture is made with unsafe, germ-filled water - this can kill baby! Bottle feeding lacks many health benefits of breast milk for babies, including protection from many infectious diseases, much less diarrhoea and better growth Unclean bottles, water and rubber nipples are often used and these can kill babies - bottles and rubber nipples must be boiled in order to kill germs Breast milk does contain HIV and their is a risk of it passing to the baby These factors increase the chances of a baby being born HIV negative: Research shows that babies in Malawi will be healthier with exclusive breast feeding for six months, even if the mothers are HIV positive Breastmilk is easily digested and the child gets the nutrients it needs - the body can easily absorb these nutrients and it does not cause constipation Breastmilk protects the child from allergies and promotes emotional bonding between child and mother The chance of getting HIV infection from breast feeding is not as great as the chance of dying due to lack of breast feeding or poor quality bottle milk Cultural gender imbalances, which leave women with lots of domestic work, also prevent women from suckling their babies properly Fight strongly and vocally in your community, to stop practices like dwale, where a new born is given dirty water to drink instead of breastmilk! Encourage mothers to let the baby drink the first breast milk, because it is the perfect food for the new born baby - speak out when local beliefs are wrong Through frequent skin-to-skin contact the baby learns to trust its mother Point to ponder Apart from being the best food for the health of the child, breast milk is also the cheapest and most convenient food for the baby. Breastfeeding for six months is the equivalent of buying 400 tins of milk, each costing K1,000 and that amounts to spending over K400,000. (2008) Discuss

150

Activity 11.5 Why is it dangerous for a mother to mix feed a baby?
These words were spoken in 2008 and reported in the Nation newspaper, I raised my first two children in a traditional way, breastfeeding them and other foods. I have breastfed my third child for six months; he is healthier than the other two. Points for your discussion, debate, drawing, song, story, play, poem, poster etc Never use mixed feeding in the first six months, as it damages the baby’s gut making it easier for HIV to enter the baby’s body. Ban these things from a new born baby’s diet: water, formula milk, gripe water, herbal medicines or cooking oil Babies who are on supplementary feeding schemes can be at risk and can develop sores, thrush and inflammation in the mouth and gut - this exposes such babies to HIV that may be in breast milk Why do you think that Conditions like STIs, cracked nipples and sores or thrush in the baby’s mouth need immediate powdered milk is shown medical treatment as a monster? Ask for medical advice before using replacement feeding includes commercial full infant formula from cow - cow milk or soya protein Ban foods like skimmed milk and yoghurt, eggs, meat, fish, fruit and vegetables from a baby’s diet for the first six months if it is being breastfeed If there is an irregular supply of formula milk or lack of clean water then don’t use formula feed If sanitation services are poor, the water supply may be contaminated - boil water before using it in a feed bottle Some nursing mother does not fully understand how to mix the formula milk - educate them If a mother develops a cracked nipple she should feed the baby with the other breast as the crack could expose the child to risk of contracting HIV - then seek medical attention Don’t allow another mother to breastfeed your baby, even if she is HIV negative, this can upset baby’s digestive system and leave it open to HIV infection Practising safer sex during the breastfeeding period, by using condoms correctly, and consistently or abstaining, to prevent acquiring more virus or re-infection with different HIV strains Richer nations advise mothers with HIV not to breastfeed whenever the use of replacements is acceptable, feasible, affordable, sustainable and safe. If you are HIV positive mother living a very good lifestyle where you have an adequate supply of clean and safe formula, you may want to discuss bottle feeding with a health professional Point to ponder Everyone in every community should know that an HIV positive mother can have an HIV negative baby, provided the proper procedures are followed. Discuss

151

Activity 11.6 Role play: Partners talking about having an HIV free baby
In the role play a couple are discussing the best way to have a baby that is HIV free. Background Mwayi and Taylor are planning to get married and start a family. When they first started going together they used condoms, but they stopped using condoms because they trusted each other. Through peer group meetings they have learned about the Prevention of Mother-to-Child Transmission of HIV (PMTCT). • Mwayi really wants to be a mother • She is worried about having unprotected sex • She does not want to take a chance on having a baby that is infected with HIV • She worries that if Taylor finds out that she is infected with HIV then he will leave her • Taylor is worried, because he had several partners before Mwayi - but he really wants to be a father • He feels that there is no point in getting tested now because they already had unprotected sex The play begins: Mwayi and Taylor are sitting together listening to music Taylor How many children do you want? Mwayi, one day I’d like to be a grandfather. Mwayi Two children, a boy and a girl. I’d like two healthy children, that’s why we should plan carefully for the future. After the role play What have peer group members suggested? Preventing babies being infected through MTCT, means that couples and their families could produce HIV free children - this gives fresh hope to familes hit by HIV who feel that their name or history will be lost Both parents should take joint responsibility in order to prevent MTCT Involving men in PMTCT helps to involve men in feeding programmes as well Partners should both go for VCT - the only way people can be sure After VCT it is easier to make decisions about sex, marriage and children Use condoms for three months and then have a blood test for HIV and AIDS If the blood test confirms that both you and your partner do not have HIV and AIDS, you can have unprotected sex with each other until pregnancy occurs You and your partner must not have sex with other partners, or always use condoms with other partners, to avoid the possibility of becoming infected Point to ponder If a man and a woman are both HIV positive, and wish to have an HIV free child, then they must both closely follow medical advice. Discuss Conclusion. The last learning activity of the Mzake ndi mzake course involves using our A to Z of HIV as a quick revision tool. Go through the A to Z and use song, dance and poetry to celebrate successfully completing the course.

152

The A to Z against HIV: it’s much more than just ABC
We created these simple messages based upon all of the letters of the alphabet. You may wish to use or adapt some of them for your activities. Remember, that some of these messages may not be appropriate for some audiences. Be careful when, where and how you use them.

A
Useful starter words: ask; always; assert; avoid; all; abstain; attitudes; adultery; ARVs; alcohol

C
Useful starter words: choose; caregivers; child; clubs; classroom; courage; circumcision; change

1

Abject poverty leaves millions of people more vulnerable to HIV infection and other health problems... help relieve poverty 2 Abstain 3 Adultery can kill 4 Aged grandparents caring for orphans may need your help and education about HIV 5 Agree-to-differ if an HIV prevention strategy is being hotly debated. 6 Alcohol can alter your feelings and thoughts, and they influence your actions 7 Anal sex is a very high risk and illegal 8 Aroused sexual passions can be dangerous... keep control of them 9 ART works for most people but not for all 10 Assert yourself and help other to do so

1 2

Caesarian births save many new babies Chaste - do not have sex except with the person to whom you are married 3 Correct and consistent use of condoms 4 Child protection officers are now at work in Malawi 5 Clinics are special places 6 Colleges and schools should be safe places free from abuse 7 Counselling plays an important part 8 Condoms should be used by every prostitute and every one of the clients 9 Condoms should only be used once 10 CHBC - Community Home-Based Care

D
Useful starter words: do; don’t; delay; daughters; discrimination;

Always abstain!
B
Useful starter words: boys; babies; become; bad; behave; beliefs; birth; babies; blood; body fluids

1 2 3 4

Delay your first sexual activity Don’t do dry sex - where medicines are put in the vagina can kill both partners Don’t let anyone touch your private parts - except a nurse or doctor Don’t self-medicate when on ARVs

1 2 3 4

Be faithful Break the silence over HIV and AIDS Be careful with Body fluids Boys and girls both need to know the true facts of life about love and sex 5 Bed nets to combat malaria 6 Bars can be dangerous places 7 Behaviour change may be hard 8 Bar owners have a part to play 9 Birth certificates protect children 10 Babies should be born in a clinic/hospital

Don’t self-medicate if you are on ARVs!
5 Development is good change - what are you going to change for the better today? 6 Don’t let Development be slowed by HIV 7 Diplomatically challenge and correct people who make incorrect or negative comments about PLWHA or HIV 8 Don’t give up if your discipline weakens, resolve to stay strong 9 Deal with STIs immediately! 10 Deal with Depression by talking to a trusted person

Beware of body fluids!
153

G
Useful starter words: girls; get; government; good

J
Useful starter words: join; joke; justice for;

G1 G2 G3 G4 G5 G6 G7 G8 G9 G10

Get tested for HIV Generosity can fight poverty and HIV Girls need encouragement to be assertive Girls should delay first sexual encounter Grooming small children for sex is wrong Grow vegetables and fruits to eat Greater involvement of PLWHA Genital sores should be treated now! Genital parts are special and private Grow in confidence and self-discipline

J1 J2

J3 J4 J5 J6 J7 J8

H
Useful starter words: help; halt; hope; home; happiness

Join together to spread the information Joke about your HIV, talk to it. Positive living and these ARVs will keep you (HIV) locked up in my body. You will never escape from me HIV!’ Just say NO to unprotected sex Join together to fight HIV and AIDS Join local networks to national networks, Join house visits and house religious services for PLWA Joke about things in life - humour and smiling makes life feel better Jesus would not leave PLWA to suffer and die alone - will you?

K
Useful starter words: kill; keep; know;

H1 H2 H3 H4

Homeless people are vulnerable to HIV Halt Human trafficking Handle and dispose of condoms carefully Help Homeless girls from becoming Hookers (sex workers) H5 Help PLWHA and their families and carers H6 Humans spread HIV not by witchcraft H7 Hold the hand of your HIV+ friend and let the fingers speak of your friendship H8 Home-based care is very important H9 Homosexuality can spread HIV H10 Hope Is Vital when PLWHA

K1 K2 K3 K4

Know your sero status - go for VCT Know how to stay safe from HIV Keep VCT test results confidential Keep good company in safe surrounding if you are at risk of being tempted K5 Keep faithful K6 Keep hoping for new medicines to make life easier K7 Keep taking your ARVs as prescribed K8 Keep HIV from reproducing - take ARVs K9 Keep your trousers zipped (men) K10 Keep your legs crossed (women)

L I
Useful starter words: if; improve; information; imagine; infant; identify; inmates; infections
Useful starter words:leaders; let; listen; life; live; love; look; liberate; laws

I1 Imagine an HIV and AIDS free Malawi I2 Information on HIV is essential for all I3 Identify human traffickers of children and adults for sex I4 Income generating activities help I5 Improve the well-being of the poor and give them more life choices I6 Innocent people may be blamed for bringing HIV into the relationship I7 Impoverished communities are at great risk I8 Ignorance spreads HIV and AIDS I9 Imagine the best things you could do to fight HIV in Malawi... then talk them over with others... and act I10 Injecting drugs can spread HIV

L1 L2 L3 L4 L5 L6 L7 L8 L9

Let all discussions on HIV be peaceful Learn all you can about HIV Liberate child labourers Love without prejudice Life is precious, protect it! Literacy helps defeat HIV Live positively with HIV+ Loose morals can make you lose your life Listen to the bereaved... encourage them to celebrate the life of the deceased. L10 Let only your marriage partner be your only sexual partner

Literacy against HIV!
154

M
Useful starter words: mothers; men; man; make; Malawi; Muhammed would; myths

O
Useful starter words: only; orphans; open; over; oppose; organise; orgasms

M1 Malawians have a duty to fight poverty which encourages the spread of HIV M2 Malawi is star in the fight against AIDS (headline in Daily Times 18 Aug 2008) M3 Man-to-man talks between boys and their fathers about sex and HIV, can really help in the fight M4 Most people living with HIV were not promiscuous M5 Memory boxes or books bring great happiness to those left behind after a bereavement M6 Mother-To-Child-Transmission of HIV can be prevented by following the correct procedures M7 Malnurished people cannot fight off infections and are more vulnerable to HIV M8 Malnurishment contributes to the spread of HIV we must address it - if we fight malnutrition of the poor, we fight HIV M9 Most cases of child sexual abuse and rape are carried out by people the victim knows M10 Mother’s breast Milk exclusively for six months for new born HIV free babies

O1 Open and frank talk about HIV and AIDS O2 Openly say if a relative died of AIDS O3 Organise to fight any discrimination against PLWHA O4 Over seventy percent of human traffickers in Malawi are no prosecuted O5 Oppose child brides O6 Only drink in bars where there are no sex workers O7 Orgasms are important for both partners O8 Orphans are vulnerable O9 Oral Rehydration Solution (ORS) saves lives (see page ) O10 Opportunistic Infections must be treated promptly O11 Only One faithful partner for life

P
Useful starter words: put; prevent; proper; parents; partners; poverty; poor; powerless; power: play; prosecute;

N
Useful starter words: no!; never; new mothers;

N1 No condom no sex! N2 No traditional Malawian medicines can cure AIDS - but there are local medicines which ease the symptoms of HIV N3 No sex until marriage or VCT! N4 Never put local medicines in the vagina to make it dry N5 Non-penetrative sex is safe sex N6 No sex is safer sex N7 Nations budgets should have the needs of the poor at its heart - Need can spread HIV N8 Never put your penis into the vagina of someone who is not your wife N9 Nevariprim during childbirth (check for any new drugs being used locally) N10 Nobody has ever died from abstinence. Try it!

P1 Poverty Prevention is an important factor in Preventing the spread of HIV P2 Peer education on HIV and AIDS does make a difference P3 People living with HIV and AIDS have the same rights as everyone else P4 Prevent mother-to-child transmission of HIV learn the facts and tell others P5 Prisons can spread HIV, Protect inmates and officers through peer education P6 Partners should learn how to open up and talk about sex and HIV P7 Property grabbing is a crime - stamp it out in your community by making wills P8 Power relationship need to change especially those connected with gender P9 Professional medical advice is important P10 Pray with or for all those infected or affected

Poverty is a factor in the spread of HIV! If we fight poverty we fight HIV!
155

Q
Useful starter words: question; quote; quiz;

S
Useful starter words:sons; stop; speak out; share; stigma; safe; sex; schools; street-children

1

Question traditional practices that put people at risk 2 Quiz - create a quiz from these messages 3 Quote from the holy books - the messages that bring courage, love, compassion and response to the fight against HIV 4 Question the community that allows full sexual intercourse to be part of girls’ initiation 5 Quit those bad habits! 6 Question if he really does love you, if he’s pressuring you for sex before marriage 7 Qualify as a HIV/AIDS peer educator 8 Quietly and forcefully say, “No!” 9 Question your own beliefs and behaviour 10 eQuality of opportunity for all citizens

1 2 3

Stop early marriages and child-brides Stop Stigmatizing PLWHA Sex is beautiful, with the right person, at the right time, and in the right place 4 Sex Should be Safe and pleasurable for men and women 5 Street children need our protection 6 Schools must treat boys and girls equally 7 Stigma feeds the Spread of HIV 8 Succession planning is vital 9 Spread Safe Sex 10 STIs (STDs) must be treated Swiftly

Stop early marriages!
T
Useful starter words: think; thoughts; talk; tell; teach; train; truth; translate;

Quietly say, “No!”
R
Useful starter words: remember; refuse; report; role model;

1 2

1

Religious groups of all faiths should work together in the fight against HIV and AIDS 2 Role model by living positively and helping others to do so 3 Refugees are very vulnerable 4 Religious leaders must know accurate facts - and share them with their community 5 Remember to carry a condom if you cannot abstain or be faithful 6 Rural communities need the information about HIV just as urban areas do 7 Refuse sex before marriage or before VCT 8 Review your behaviour regularly 9 Read for pleasure and for learning about HIV/AIDS issues and development 10 Report teachers sexually abusing their students

Train Traditional birth attendents Talk openly about about irradicating stigma from society 3 Traditional customs may put people at risk 4 Translate these messages into local languages when speaking in a local setting 5 Temptations can be overcome 6 Temperance helps us behave well 7 Think Twice before you act, especially if you have been drinking 8 Teacher support groups are important 9 TB is the most opportunistic infection 10 Tatooing and body marking can be very dangerous

Uneducated, unemployed and unloved take more risks!
Carefully choose the right words for your audience
156

Report sexually abusive teachers!

U
Starter words: umunthu would; unprotected

X
Useful starter words: seX;

1

Unprotected sex with an HIV+ person is responsible for 90% of all HIV infections 2 Umunthu - the role model to aspire to 3 U should try to be Umunthu 4 Unmarried people should wait before sex 5 Unemployment can breed desperation and encourage risky behaviour 6 Uneducated, Unemployed, Unskilled, and the Unloved, take more risks 7 UDHR: Universal Declaration of Human Rights (1948) 8 UNAIDS: United Nations Joint programme on HIV/AIDS 9 UNICEF: United Nations Childrens’ Fund 10 Unitedand Unable to stop fighting HIV

1 2 3 4 5 6 7 8

seX workers need educated seXploitation of human being infringes their human rights seX is to be enjoyed within a lifelong relationship with one faithful partner seX that is safe and within marriage eXplore the many different ways you and your partner can stay safe from HIV eXpose aduts who have seX with children eXchange marriage vows before you eXchange body fluids eXamine your values and behaviour

Y
Useful starter words: you; your; youths; young;

V
Useful starter words: voices; volunteer; VCT; value; virtue; vice; virgin; vagina

Voluntary Counselling and Testing before and during marriage 2 Vote for candidates who are part of the fight against HIV 3 Virgins are Vulnerable 4 Values are the key to behaviour change 5 Vices can make you Vulnerable 6 Volunteer to help the Vulnerable 7 Voices of the poor, Voices of women and Voices of PLWA should be listened to more 8 Violent partners put people at risk 9 Vulnerable children are at risk of HIV 10 Voice your fears and hopes

1

You can stop any risky behaviour if you really want to! 2 You may have a vice that puts you at risk. So, you are the one who must make the change! 3 Your partner and children may be at risk if you have casual sex partners 4 Your marriage is worth more than a one night stand 5 You can get pregnant when you have sex for the first time 6 You can’t be cured by having sex with a virgin 7 Behaviour change begins with You! 8 Youths need education for protection 9 Young children should not marry 10 Your Young ones need information

1

W
Useful starter words: women; widows; wash

Z
Useful starter words: zero

1 2 3 4 5 6 7 8 9 10

Want to make that important behaviour change so much that you change We cannot ban Workshops because of the risk of HIV infection - Want to abstain Women Will be empowered What do you think Jesus would do to fight HIV/AIDS? When people are really in love they can and Will Wait until after marriage or VCT Wills protect the Widowed and the childen Witchcraft cannot cure AIDS Wives club meetings can assist Work place HIV education is needed Welcome positive behaviour changes

1 2 3 4 5

Zero tolerance for sexual abuse anywhere! Zero tolerance for initiation practices that put children at risk of HIV infection... adapt or stop it Zero tolerance for body cutting and tatooing using an unsafe blade Zero tolerance for spousal abuse Zero tolerance in my marriage if my partner has sex with some who is not me!

Zero tolerance of spousal abuse!
157

Facilitation techniques
The aim of this programme is to help group members to learn , share what they know and apply what they have learnt. A peer leader or the group as a whole, can choose the best teaching and learning techniques to be used during a session. It should be remembered that when working with adults it may be necessary to use a variety of different techniques. Adults often resent being told what to do, they may learn more from discussions with their peers. They are often highly motivated if they can see the training as relevant and composed of a variety of different activites. They often learn more by developing their own ideas, than from just listening to the ideas of others. So, interactive methods are suitable for teaching and training adults. Before each session, ask the following questions: • Who are you working with? • Which activities are you going to go through? • Where will the group work? • When will the group meet? • How will you teach/facilitate the selected activities? Peers can decide how each activity will be completed and when people will work as: • individuals • pairs • small groups • whole group Mzake ndi mzake peer group members have suggested the following techniques: 1 Discussion - This is the consideration of a question in an open and often informal debate. Group discussions can be used to generate a lot of ideas and opinions, share information and facts under the guidance of a facilitator. 2 Lecturette - Lecturettes are short lectures. A lecture is an oral presentation intended to transmit knowledge and procedure that often have to be memorized. 3 Presentation is the practice of showing and explaining the content of a topic to an audience or learner. It can be illustrated with models, posters, slide shows etc. 4 Question and answer - Group work or as a checklist for individual work 5 Demonstration is used to reinforce theory, by showing exactly what should or could happen in a situation. It helps to pass on both skills and knowledge, and show procedures that may be difficult to describe in words alone. It can help both the demonstrator and the audience to recognise future problems that may arise and where opportunities for improvement exist. 6 Research is a systematic inquiry or investigation into a subject in order to discover or revise facts, ideas or procedures. Research results can then be presented

158

in a detailed and accurate manner to the group. 7 Diary or journal writing - Members may wish to keep a diary or help a PLWHA to do so. This diary may be a very useful source of ideas for the group sessions. 8 Story telling and story writing - The story can be true or ficticious, in prose or verse. It is designed to interest, amuse and instruct the audience. Case studies and extracts form life stories are particularly useful in open peer group work. 9 Proverb - A short memorable saying that expresses simply and effectively some commoplace truth or useful thought. Often of unknown or ancient origin, traditional proverbs focus on a ‘teaching point’ or moral. 10 Poetry reading and writing - Poetry is a way in which we can get in touch with our inner feelings and then share those feelings with others. Poetry can also be found in drama, hymns, song lyrics, rap and chants as well as in prose. Look at the A-Z of HIV on page 157 for ideas. You can also use ideas as slogans on posters and charts. 11 Singing and song writing - Traditional songs can be adapted as icebreakers to pass on simple messages. Songs can also be used to open and close a session. Look at pages 157 to 161 to find new words to fit with well known tunes. 12 Music - Adapt well known tunes from traditional and religious sources for use in HIV education. Find out who can play a musical instrument. Drumming is a significant part of using and developing music for dance. 13 Dancing and dance developing - Traditional dances can be adapted to carry important messages. New dances can be developed by group members. Dancing can be integrated into dramas and story-telling. 14 Drama and drama development - Drama allows participants to use words and actions to tell serious stories to an audience. Peer groups can focus on issues they may face in everyday life and gives the opportunity to generate possible solutions. Unlike our role-plays, drama is rehearsed. 15 Roleplay - In a role play, members are given a situation and a little background. the chose actors continue the play. Actors can develop their own ending and remain in their roles for the first part of discussions that follow. This can help people to gain an insight into behaviour and feelings and look at, and practice life skills necessary to prevent HIV infection. The actors often answer questions in their roles before they de-role. A general discussion follows after they de-role. 16 Writing replies to imaginary ‘Problem page’ letters about HIV and AIDS Most magazines have a problem page, where readers letters are printed and an expert writes a reply giving advice. Group members can both write and reply to real or specially created problems. 17 Drawing or cartooning - Make use of the groups drawing skills by working together to design posters and cartoons on HIV education. 18 Educational visits - Some people caring for someone living with HIV and AIDS may have created a successful caring environment in their home. With the patients permission the group may find an on-site visit both interesting and enlightening. 19 and 20 Writing speeches and newspaper briefings - Members can assist religious, traditional and civic leaders when they are asked to speak about HIV and AIDS. Short statements, like or A-Z on page 157 may be useful for ‘sound bites’.

159

The TALULAR Challenge
Teachers and trainers, often say that they do not have enough teaching and learning materials. But, we often ignore the rich variety of resources that are all around us in our communities. Talular stands for Teaching And Learning Using Locally Available Resources. This double page contains drawings of hundreds of objects and ideas. All of them can be used as resources. Take a few minutes to look over these pages and then complete the activities.

160

HIV prevention activities
1. What does the word TALULAR mean? 2. Why is TALULAR important for Mzake ndi mazke peer group training? 3. Make a list of 30 objects found in your community that could be used during peer group training activities. Briefly describe how you would use each one. 5. Which people in your community could be the most useful to a peer group? 6. What important resources (materials, skills, attitudes etc) do you think we’ve left off these pages? 7. What do you think are our most valuable resources in the fight against the spread of HIV?

161

Drama: The spread of HIV

One participant should represent the human body while others represent white blood cells (WBC), which protect the body from infection by germs, represented by a third group of participants. Choose one participant to represent HIV. • Ask participants to act out the spread of HIV • HIV knocks out the white blood cells so they can no longer protect the body • The body is now open to attack by germs of all kinds (eg. TB, diarrhoea) • Eventually the body is overcome by diseases which are normally not fatal • Adapt the drama to suit participants of different ages and educational background

Model: How amniotic sac and fluid protect an unborn baby
• Place a plastic doll inside an empty, clear plastic bag • Pass the doll around the peer group • Fill the bag with water, place the doll inside and know the opening soit is sealed • Pass the water-filled bag around the group and discuss how a baby is protected while inside its mother • Amniotic sac and fluid can also play a role in protecting an unborn baby from HIV - see pages 148-149 to consider the risks of HIV infection before and during childbirth

Model: Coughs and sneezes spread diseases
Construct the model as shown in the diagram. Ignite one of the matches at the edge of the model. Use the resulting effect to illustrate how coughs and sneezes can spread diseases. Catching coughs and sneezes in a handkerchief reduces the rate of transmission.

162

• Make a model baby from a bottle, can or gourd • The main opening of the container represents the mouth of the baby • Put two holes in the bottom of the container - a large hole to represent the anus and a small hole to represent where urine leaves the body • Put two stoppers in the lower holes • Fill the baby with water to represent a healthy hydrated body • Remove the smaller stopper (cork) and water will be lost slowly • Remove the large stopper to illustrate how diarrhoea can cause severe loss of water • Water lost through the holes can only be replaced through the mouth • If more water is lost than is taken in dehydration occurs and this can be fatal, especially in small babies

Model: The dangers of dehydration

Practical: The ORS miracle

• Dehydration caused by diarrhoea is probably the biggest killer of children in today • Our bodies need water to function normally, but we also need essential electrolytes like sodium and potassium - these are lost in diarrhoea and must be replaced • The ORS drink (oral rehydration solution) is used to save lives by replacing some of the lost electrolytes • For smaller amounts of the drink put a pinch of salt into a cup of clean water and add 8-10 pinches of sugar • Consult a health professional if diarrhoea persists

Game: What is AIDS?
Games are a good way to interest and motivate participants. The game illustrated below is based upon four cards. The cards can be used individually at first to introduce each word in isolation. Then the four can be put in the correct order and used to define the term AIDS.

163

Chalkboard
The chalkboard will the most readily available teaching and learning resource for many peer groups. Here are a few tips that may improve the effectiveness of boardwork. • Untidy presentation encourages untidy work from learners • Divide a large chalkboard into smaller sections • Write clearly - do not add too many flourishes to writing style • Underline headings and key statements • Do not write toomany words in upper case • When dusting a board pull the dust to the side • If you wash a board, let it dry and then pat the surface with a duster - chalk can react with water making it hard to rub off • Boards are useful for presenting group feedback and lists • Floors and table surfaces can be used as writing surfaces

Different types of lines
There are many different ways of creating lines on a chalkboard.

• Chalk can be sharpened with a knife like a pencil • Experiment using other surfaces like tables and floors (both inside and outside)

String display lines
Strings can be used in many ways to display items. Here are a few ideas.

Experiment with different types of string and thread, length of string and ways of attaching the ends of strings to supports.

Stick a flap or tail on the back of pictures and this will help to hold them in place.

164

Display: Zigzags and multi-boards
Zigzag multi-boards are made from pieces of board joined together in such a way that they can be folded easily and carried. A zigzag multi-board can be built up from one portable board. The faces of each board can be prepared to suit a teacher or trainers personal requirements. Eight different types of board are shown below.

The board can be displayed in a variety of different ways. It can be free-standing or hung on a wall or support. Experiment with different angles and techniques.

Carrying handles can be made from rope or cloth strips. Protect the outer surfaces by paint or by covering them with plastic. Design a zigzag board to fit your own particular needs.

Mother tongue songs, music and dance
• Translate the A to Z of HIV messages into your mother tongue - spread them among different groups within your community • Adapt traditional dances for use in spreading important messages about sexual and reproductive health • Create new costumes and steps by using the role plays and other ideas found in our activities • Use the A to Z of HIV as a source ideas for song lyrics They can be very useful as chorus lines between verses • Songs that are developed in your mother tongue and then translated often work better than songs first written in your second language. Discuss Experiment with other TALULAR ideas that could be adapted for Mzake ndi mzake.

165
We have marked the peer group members suggestions with the

symbol b

Evaluation questions
The aim of this programme is to help group members to learn, share what they know and apply what they have learnt. After each sesion go through the questions suggested by peer group members:

1 2

Did you start the session on time? Which unit or activities did you cover in this session? Have you put a mark next to them in the contents section of this manual? 3 Was the introduction clear? 4 Was the content clear? If your answer was ‘No’, give reasons for your answer so that it help future planning. 5 Did the group use a variety of teaching and learning techniques, such as question and answer, pair and group work, lecture, song, poetry, role play, visits etc? 6 Did you feel comfortable or uncomfortable during the session? If so, talk about these feelings and the need to talk about sexual activity within the peer group. 7 Have you made a note of interesting or useful ideas that could be added or adapted to the units or activities in this manual. 8 Have the group or individuals chosen activities or topics as assignments? 9 Have members set an agreed date and time for the next meeting? 10 Do group members know the activities that will form the core of the work for the next meeting? Remind members that activities can be added to the core if the group thinks that they are important. Peer groups are free to add other questions to this list. There may be some people in your group who find it difficult to discuss the sensitive issues in this programme. They may decide not to continue the training. If so thank them for attending and tell them they would be welcome to return or join another group later. Did the group manage the do if people find the discussion of HIV and AIDS or partner sexual relationship issues upsetting? Be sure to emphasize the positive messages about protection from HIV and AIDS. However, for those who continue the training, you probably should not change the later units. Always remember to be sensitive to people’s discomfort in discussing these important issues.

166

Planning future Mzake ndi Mzake peer groups
Now that you have finished the units about HIV and AIDS prevention, some of you may wish to start a new group to teach others. You might want to have a partner, as the two of you could help each other. You could start by inviting your friends, neighbours or the people you work with to join your group. Now we need to develop simple action plans, to outline the different ways in which we can continue to work for HIV and AIDS prevention. Peer group members have suggested that you can do the following: • What is one way each of you can help stop the spread of HIV and AIDS? • What specifically are you going to do in the next four weeks? • Would you like to continue meeting as a group? If we meet, what will we do and how often should we get together? • Do you know where to get good information about testing and other services and about new developments in the fight against HIV and AIDS? Here is a list of services available to you that you may find helpful. • Thank you all for being a part of the group. We’ve really enjoyed getting to know you and talking about these important issues with you. • Ask each member of the group the following questions to help them plan their future HIV and AIDS prevention activities. Encourage several people to work together. • Discuss whether the group wants to continue meeting and if so, how you will organise this. • Thank the group for participating.

167

Glossary of terms
AIDS: Acquired Immune Deficiency Syndrome; this is the stage where a person who lives with HIV becomes very weak and his or her immune system cannot fight illnesses very well anymore. This happens when a person’s T-cell count decreases to about 200. Usually this happens about 6 to 8 years after getting HIV. When HIV and other illnesses such as tuberculosis, cancer or pneumonia enter ther body when it is weak from HIV, we call it AIDS. AIDS related illness: an illness that a person living with AIDS gets because HIV has seriously weakened their immune system. TB can be an AIDS related illness antibody: a chemical made by your body. It is one of the main ways in which your body fights HIV and other illnesses...substance produced by the human immune system that reacts to antigens antigen: that identifying feature on organisms and foreign tissues that triggers the immune system to produce antibodies ART: anti-retroviral treatment ARVs: anti-retrovirals; medicines used to fight HIV. ARVs are used at the AIDS stage of infection. There are different types of ARVs. each type fights HIV differently. Usually, a person takes two or three types of ARVs to fight HIV. This is called combinationtherapy or HAART. asymptomatic stage: the period between becoming infected with HIV and becoming ill that ranges from a few week to as many as 8 to 10 years incubation period: period between the time of infection and becoming ill due to HIV CD4 cell count: a count of the number of T-cells in a small amount of you blood, which shows the measure of how strong your immune system is. chronic: a situation or an illness which goes on for a long time without being curable, eg HIV is a chronic condition as there is no cure; one has to live with it for a long time. combination-therapy: a combination of two or more drugs taken by a person to fight HIV infection. See ARVs and HAART coping: a process of adjusting to new life situation and getting back to near normal as possible. That means regaining hope, self esteem, self confidence, planning and going on with life, making appropriate behaviour changes and regaining hope. depression: deep sadness, helplessness, coupled with low self esteem and loss of hope that is linked with fear of rejection, loneliness, loss of control fear of stigma, blame suffering and death and leaving dependents without support. epidemic: Large outbreak of a disease, AIDS is an epidemic fundamental rights: your basic human rights under the Bill of Rights in the Constitution. generic drugs: drugs that replace well-known drugs HAART: stops HIV from multiplying and reduces viral load in the blood. helper T-cell: cells that are a very important part of the immune system, they fight germs that invade the body. Helper T-cells are the main kind of cells that HIV attacks. HIV test: a test to see if there are antibodies in a persons blood. HIV anitibodies will only be in your blood if you have HIV. It can take up to six months for the body to make antibodies so it is important for some one who tests HIV-negative, to be tested again after six months. HIV status: whether a person is HIV- positive or HIV-negative. You can only know this if you take an HIV/AIDS test.

168

PLWHA, People living with HIV and AIDS: when you have tested positive or have developed AIDS then you are said to be living with HIV and AIDS immune system: the system in your body which uses all knids of different cells to fight infection by germs. opportunistic infections: an infection that attacks people with weaker immune systems, TB, herpes are opportunistic infections pandemic: large outbreak that is at local level. AIDS is a pandemic in Malawi seroconvertion: occurs when there are enough HIV antibodies in your blood that can be detected by an HIV test which imply that you are changing from being HIV negative to HIV positive in that test stress: competing issues with limited ability to accomplish them which leads to mental, spiritual tiredness, frustration and a threatening feeling and eventual depression T-cell count: same as the CD4 or helper T-cell count. A test to see how many T-cells are in a small amount of blood. To see how strong the immune system is. A healthy person may have 800 to 1000 cell count. window period: the time it takes for a body to make HIV-antibodies; usually this is only a week or so, but can be up to six months from the time of infection.the time between infection and the possible detection of antibodies to HIV vaccine: a medication that is normally taken as an injection to prepare your body’s immune system to recognize and protect itself against a virus or disease viral load: the amount of HIV in your body. The number of HIV viruses present in your blood; a test is done to find out what your viral load is. A count higher than 100,000 is considered a high viral load.

Names used to for human sexual organs and sex acts
1 Malawian names and slang for female genitalia Vagina: nanyoni; nyo; njira ya abambo; puna, kumaso; cunt**; fanny*; twat**; pussy*. Clitoris: phiri, joy-pea, passion-pea, kongo, clit, mnakanaka. 2 Malawian names and slang for male genitalia Penis: willy*, prick, cock*, dick*, boner*, mbolo, chida, abambo, nododo, Mangochi. Testicles: nuts*, balls*, bollocks*, machende, mapwala, mabativi, ingiri. 3 Slang for sexual intercourse and non-penetrative sex Make love: have sex; sleep with; make babies; fuck***; screw**; shag*; bonk*.bone**. 4 The sexual climax: ejaculation (male); orgasm; come, cum. 5 Oral sex on male genitalia (tehnical name is falatio): blow-job; head; giving head. 6 Oral sex on female genitalia (cunnilingus): going down on; tonguing. 7 Anal sex most often refers to the act involving insertion of a penis into a rectum Masturbation: jerk off; pull off; wank off**; touch yourself. The English slang names with * next to them indicate how unacceptable they are at present in the mainstream media. Be very careful when and where you use some of these words. • Write the names on the board or flip chart. • Ask the group to decide what names they want to use in the group for each organ or sexual activity. Scientifc names or slang or a mixture. • This activity usually produces a lot of laughter and that can relieve tension! • Which of these names are you all comfortable using? Scientifc names or slang or a mixture? These are the names we will use during the group units.

169

References and further reading
American Dietetic Association (2004), Appetite for Life: an easy eating guide for people with HIV/AIDS, New York, UNIMED ANAMED (2006), Healing plants in the tropics (poster), Winnenden, ANAMED Braslavsky, Cecilia et al (2002), Prospects vol XXXII: Scaling up the response to HIV/AIDS within education systems, Paris IBE Byers, Andy et al (1994), The science teacher’s handbook, Oxford, Heinemann Byers, Lillian Muyunda et al (2002), Stress: its origins and management, Lusaka, GOZ Cargnel, Antonietta (2006), Assistance and care for the terminally ill, Nairobi, Paulines CCAP (2006), HIV/AIDS policy: love, care and compassion, Lilongwe, CCAP Coombe, Carol (2003), HIV and teacher education in east and Southern Africa, Bonn, INWENT Department of Nutrition, HIV and AIDS (2005), Malawi HIV and AIDS: Monitoring and evaluation report 2005, Lilongwe. Domasi College of Education (2003), HIV/AIDS awareness (version 1.1), Domasi, DCE European Union (2004), Living positively with HIV and AIDS, Blantyre, Pakachere Goergen, Regina (2001), Healthy relationships: The questions adolescents ask most frequently, Dar es Salaam, GTZ Gordon, P and Crehan (1999), Gender, sexual violence and the HIV epidemic, London, Macmillan. Granich, R (2001), HIV Health and your community: A guide for action, New York. GTZ (2001), German workplace initiative: Reference manual for HIV/AIDS focal persons, Kampala. Hirt, Hans-Martin et al (2004), AIDS and natural medicine: a resource book for carers of AIDS patients, Winnenden, ANAMED. Hirt, Hans-Martin et al (2001), Natural medicine in the tropics, Winnenden, ANAMED. International HIV/AIDS Alliance (2005), Getting started in HIV prevention: a toolkit on participatory community assessment and project design, Lusaka, International Organisation of Employees (2002), Employers’ handbook on HIV/AIDS: A guide for action, Geneva, IOE. Kabwila, Venencia et al (2005), Lekani Nkhanza: HIV/AIDS and Nkhanza, Trainer’s notes, GTZ-Combating gender-based violence, Zomba, Kachere Kabwila, Venencia et al (2005), Employees’ handbook on HIV/AIDS, Lilongwe, GTZ Kurian, Manoj(2002), Religion and education for HIV/AIDS prevention: a Christian view, Paris, UNESCO/IBE Kelly, Bob (2003), HIV/AIDS: A response of love, Nairobi, Paulines Malawi Council of Churches (2004), HIV/AIDS Learner’s manual for the clergy, Lilongwe. MCC. Malawi Institute of Education (1998), A student’s handbook for population education in Malawi, Domasi, MIE Malawi Institute of Education (2004), Life skills for HIV and AIDS education for teacher training in Malawi: a training manual, Domasi, MIE Malawi Institute of Education (2006), IPTE Life skills: tutor units, Domasi, MIE Moloney, Michael (2005), Counselling for HIV/AIDS: the use of counselling skills for HIV/AIDS, Nairobi, Paulines Muchiri, John (2002), HIV/AIDS: Breaking the silence: a guide book for pastoral caregivers, Nairobi, Paulines Musso, Sandrine et al (2002), Religion and education for HIV/AIDS prevention: an Arab-Islamic view, Paris, UNESCO/IBE National AIDS Commission (2007), Voluntary counselling and testing of HIV, Lilongwe, NAC National AIDS Commission (2004), Malawi National HIV/AIDS strategic framework 2000-04, Lilongwe National AIDS Commission (2005), Malawi HIV/AIDS National action framework (NAF), Lilongwe National AIDS Commission (2004), National HIV and AIDS Policy: A call for renewed action, Lilongwe National AIDS Commission (2003), Peer education at the workplace: Training manual, Lilongwe NGO/HIV/AIDS Code of practice project (2007), Renewing our voice: Code of good practice for NGOs responding to HIV/AIDS, Oxford, OXFAM

170

Office of the President and Cabinet (2005), HIV/AIDS Research strategy for Malawi 2005-07, Lilongwe Open Society Initiative for Southern Africa (2007), Amplifying Voices: a series of digital stories (CD), Johannesberg, OSISA Orr, Neil M (2005), Positive health: Living positively with HIV, Cape town, Double Storey. Pridmore, Pat et al (2006), The role of open, distance and flexible learning in HIV/AIDS prevention.., London, DFID Slattery, Hugh (2004), HIV/AIDS A call for action: responding as Christians, Nairobi, Paulines Steinberg, Abraham et al (2002), Religion and education for HIV/AIDS prevention: an Jewish view, Paris, UNESCO/IBE UNAIDS (1999) AIDS and HIV infection: Information for United Nations employees and their families, Geneva. UNAIDS (2006) Global facts and figures, Geneva. UNAIDS (2006) Fact sheet on sub-Saharan Africa, Geneva. UNAIDS (2006) Report on the global AIDS epidemic, Geneva. UNDP (2002) Impact of HIV/AIDS on human resources in Malawi public sector: UNDP UNESCO (2002) Education for HIV/AIDS prevention, Paris, IBE Vack, Dale le (2005), God’s golden acre: a biography of Heather Reynolds, Oxford, Monarch World Health Organisation (2001), Prevention of Mother to child transmission of HIV: Selection and use of Nevirapine, Technical notes, Geneva.

171

Certificate

172

173

Mzake ndi mzake
Training manual for peer educators for HIV prevention

The Mzake ndi Mzake peer educators’ manual has been developed specifically for those people who wish to enhance their life skills by participating in AIDS prevention programmes as peer educators. This manual is not intended as a substitute for medical advice. Peer group members and the communities members they reach should regularly consult their doctors or qualified medical health practitioners in matters relating to their health, particularly in respect to symptoms and treatment which require diagnosis or medical attention. It is essential that people who have been exposed to the risk of HIV, and their sexual partners seek proper medical diagnosis and treatment. The aims of the manual The manual was developed to equip peer educators with knowledge and life skills to enable them to disseminate information on STIs, HIV and AIDS and develop skills and attitudes in their peers that will consequently influence positive behavioural change. After going through the manual it is hoped that you will be able to: • explain basic facts about human sexuality, STIs and HIV and AIDS • protect yourself and others from HIV and AIDS by changing any behaviours that put people at risk • help yourself and others in your community avoid getting infected by STIs, HIV and developing AIDS • encourage yourself and others in your community to live positively with HIV and AIDS.

174

Sign up to vote on this title
UsefulNot useful