IMAI Facilitator Guide for Basic HIV Care Training

Facilitator Guide
for the
Basic IMAI
Training Course
FOR NURSES
(Chronic HIV Care with ARV Therapy and
Prevention)
Based on the
IMAI Chronic HIV Care with ARV Therapy guideline module
(Integrated Management of Adolescent and Adult Illness)
DRAFT (2) for India Training, Jul 2007

Supported by WHO India
Generic version March 2007 Draft
DRAFT FOR INDIA TRAINING

The IMAI generic documents and training package were developed by the IMAI-WHO
team with partners.
The Indian version was adapted to the national context by WHO India Country Office
based on the inputs from national experts and partners (CDC, ITECH, KHPT, Engender
Health, St John’s Medical College, SAATHII, TANSACS, and KSAPS)
Contact: HIV/AIDS team, WHO India Country Office, Delhi

www.whoindia.org
2 DRAFT FOR INDIA TRAINING

Facilitator guide for the Basic IMAI Training Course
Table of Contents
Page
Preparation for the Clinical Courses 5
Overview of Basic IMAI and Acute Care Training Courses….. 6
Course Materials, Supplies, Venue, Timetable…………… 7
Facilitator techniques common to all courses………………….. 15
Chapter Facilitator Guide for the Basic IMAI training course 18
Chapter 1 Introduction to Chronic HIV Care with ARV Therapy………….. 19
Chapter 2 Communication skills……………………………………………… 29
Chapter 3 Stigma and discrimination………………………………………… 35
Chapter 4 Introduction to HIV/AIDS and opportunistic infections…………. 39
Chapter 5 HIV and antiretroviral drugs………………………………………. 43
Chapter 6 Adherence and resistance………………………………………… 47
Chapter 7 Assess and provide clinical care…………………………………. 49
Chapter 8 Use the Patient Treatment record………………………………... 55
Chapter 9 Prophylaxis………………………………………………………….. 57
Chapter 10 Adherence preparation……………………………………………. 61
Chapter 11 Four first-line ARV regimens……………………………………… 65
Chapter 12 Managing side effects and other causes of new symptoms and
signs in patients on the four first-line ARV regimens…………... 69
Chapter 13 Support ART initiation, then monitor and support adherence 71
Chapter 14 Integrating prevention with treatment……………………………. 73
Chapter 15 Universal precautions, occupational exposure and PEP………. 77
Chapter 16 Special considerations for ART in pregnant and post-partum
women………………………………………………………………. 81
Chapter 17 Special consideration in children…………………………………. 85
Chapter 18 Is ART working?......................................................................... 91
Annexe Day by day summary of skill stations and card sorts 93
DRAFT FOR INDIA TRAINING 3

Preparation for the Basic IMAI Training Courses
Target audiences:
 District medical officers without other ART training: to introduce them to chronic HIV
care and basic ART.
 Nurses and medical assistants who work in a district outpatient clinic or in peripheral
health centres and clinics
Objectives of training:
 To prepare doctors and nurses, to provide chronic HIV care and basic ART including
initiation, support and monitoring.
 To review common symptom/sign management using the acute care guidelines with an
emphasis on opportunistic infections.
Purpose of this guide:

This guide is meant to be used to aid in facilitation in conjunction with the Participant Manual
for the Basic IMAI training course. Along with the course materials, it is helpful to use the
Facilitator's Guide to the Preparation of Expert Patient-Trainers for instructions on set up and
use of the skill stations.
Expert patient-trainers (EPTs):

Involvement of PLHA as patients who are experts in their own illness can be a valuable
educational strategy to support the training of health workers. This is a very effective training
intervention, and also addresses the need for increased number of trainers necessary for
capacity-building during rapid ART scale up.
In the Basic IMAI training courses for doctors and for nurses, PLHA are trained to present
specific HIV cases with the course participants during the skill stations sessions two hours
per day in addition to joining small groups during the interactive classroom training. PLHA
trained as Expert Patient-Trainers (EPTs) add much needed experience and reality to
instruction of HIV care and ART.

Overview of Basic IMAI and Acute Care Training Courses
Agenda
Monday Tuesday Wednesday Thursday Friday
Basic IMAI Training Course for Nurses
Nurses, counsellors, medical assistants
Basic IMAI Training Course for Doctors Acute care and Opportunistic
Infections short course
Medical Officers Medical Officers
Preparation Skill stations

EPTs Role plays between EPTs and health care providers
Sample Training Schedule
Basic IMAI course for DOCTORS Basic IMAI course for NURSES
And Acute care short course
Day 1 Basic IMAI course Basic IMAI course

Monday Plenary session Plenary session
- introduction to IMAI approach - introduction to IMAI approach
Pre-test Pre-test
Chapters 1-3 Chapters 1-3
Day 2 Chapters 4-9 Chapters 4-8
Tuesday Skill Station: 1 hour Skill Station: 1 hour
Day 3 Chapters 10-14 Chapters 9-12

Wednesday Skill Station: 1 hour Skill Station: 1 hour
Day 4 Chapters 15-18

Thursday Skill Station: 1 hour Chapters 13-16
Post-test Skill Station: 1 hour
Acute care course
- Introduction to the use of the
Acute care guideline module
Day 5 Practical session at the hospital Chapters 17-18
Friday Review of the course
Evaluation and feedback Post test
Closing (plenary session) Skill station: 1 hour
Evaluation and feedback
Closing (plenary session)

Course materials (Guideline modules, training manuals, wall charts,
etc..), Supplies, Venue, Timetable for course preparation
A. Instructional Materials Needed by Each Small Group
Each small group will need the following course materials in the classroom setting. Some
can be used again and again; reusable materials include wall charts, photo booklet, cards for
card sorts, and (when available) training videos. Other material is given to each participant
and facilitator and used in exercises. You will need a supply of these for each course.
When planning continuous training for scale-up, photocopy enough for the first course, make
any small corrections identified during the course, then print a large number for subsequent
training.
Use the checklists below to plan your course. Figure the totals needed and when each item
has been reproduced and delivered to you in the quantity necessary, and has been checked
for accuracy and readability, check this off as ready in the far right column. All materials
should ideally be prepared at least 2 weeks before the course is scheduled to begin to allow
time to correct any errors in reproduction.
Steps in preparing course materials:
1. Calculate numbers needed, always adding a few extra.

2. Arrange for printing, photocopying and delivery of materials to be finished 2 weeks
before training begins.
3. Photocopy manuals on both sides of the page as they are too large to handle single-
sided.
4. Check each item for accuracy when finished (are page references correct, are titles
correct, has the final version been printed, are any pages missing, are all pages
readable, are there a correct number of copies). Check a portion of each item, not
every single copy of each item).
5. Put a check in the ready column only when each item is completely finished.
6. Store copies in clearly labelled boxes for transport to the training site.

B. Checklist of course materials needed for Courses:
Items needed Number needed per Total Day READY

participant, facilitator number needed
BASIC IMAI TRAINING COURSE FOR DOCTORS

and ACUTE CARE SHORT COURSE
Guideline Modules (country adapted)

Chronic HIV Care with ARV 1 for each participant and Day 1
Therapy and prevention facilitator
Acute Care 1 for each participant and Day 1
facilitator
Palliative Care: symptom 1 for each participant and Day 1
management and end-of-life care facilitator
National guidelines (ART, PMTCT, 1 for each participant and Day 1
etc.) facilitator
Participant Training Manuals
Participant Manual for the Basic 1 for each participant and Day 1
IMAI training course facilitator
Participant manual for the Acute 1 for each participant and Day 3
care and OIs short course facilitator
Facilitator Guides
Course Director/Facilitator Guide 1 for each facilitator Day 1
for the Basic IMAI training course
Facilitator guide for the Acute care 1 for each facilitator Day 3
and OIs short course
Tools for Patient Education
1 for each participant and Day 1
Flipchart for Patient Education facilitator (to be used in
(translated version) class and the skill
stations)
Patient Education Cards (Annex D 1 set of 4 cards for each Day 1
of the Participant Manual for the participant, plus some
Basic IMAI Training Course) extra sets
Miscellaneous
2 per participant plus 1 Day 1
Pretest = Post-test with answers for each
facilitator
Patient Treatment Record 2per participant, plus Day 1
(NACO simplified form-2 pages) some extras
Clinical Review Forms (Annex A of 1 per participant, plus Day 1
Participant Manual for the Basic some extras (for skill
IMAI Training Course) station use)
1 photo booklet for each Day 1
Photobooklet small group, i.e total 4 is
needed (collect after
course)
WALL CHARTS = complete set 1 set Day 1
SEE DETAILS in NEXT PAGES
Laminated cards for exercises 1 set Day 1

= SEE DETAILS in NEXT
PAGES

Items needed Number needed per Total Day READY
participant, facilitator number needed
BASIC IMAI TRAINING COURSE FOR THE NURSES
Guideline Modules (country adapted)

Chronic HIV Care with ARV 1 for each participant and Day 1
Therapy and prevention facilitator
Acute Care 1 for each participant and Day 1
facilitator
Palliative Care: symptom 1 for each participant and Day 1
management and end-of-life care facilitator
National guidelines (ART, PMTCT, 1 for each participant and Day 1
etc.) facilitator
Participant Training Manuals
Participant Manual for the Basic 1 for each participant and Day 1
IMAI training course for nurses facilitator
Translated
Facilitator Guide
Course Director/Facilitator Guide 1 for each facilitator Day 1
for the Basic IMAI training course
for nurses
Tools for Patient Education
1 for each participant and Day 1
Flipchart for Patient Education facilitator (to be used in
(translated version) class and the skill
stations)
Patient Education Cards (Annex D 1 set of 4 cards for each Day 1
of the Participant Manual for the participant, plus some
Basic IMAI Training Course) extra sets
Miscellaneous
2 per participant plus 1 Day 1
Pretest = Post-test with answers for each
facilitator
Patient Treatment Record 2per participant, plus Day 1
(NACO simplified form-2 pages) some extras
Clinical Review Forms (Annex A of 1 per participant, plus Day 1
Participant Manual for the Basic some extras (for skill
IMAI Training Course) station use)
1 photo booklet for each Day 1
Photobooklet small group, i.e total 4 is
needed (collect after
course)
WALL CHARTS = complete set 1 set Day 1
SEE DETAILS in NEXT PAGES
Laminated cards for exercises 1 set Day 1

= SEE DETAILS in NEXT
PAGES

PREPARATION OF THE EXPERT PATIENT TRAINERS
Facilitator guide
Facilitator manual for the 1 for each facilitator Day 1
preparation of the Expert Patient
Trainers
Participant handouts
Handouts for the preparation of the 1 for each Expert Patient Day 1
Expert Patient Trainers and each facilitators
Case-specific checklists (for EPT 6 checklists for each case
skill stations for the Basic IMAI (lose sheet) + one
training course complete set for each Day 1
participant and facilitator
Others
Clinical Review Forms (Annex A of Some forms as a support Day 1
Participant Manual for the Basic tool for the for skill station
IMAI Training Course)
Patient Education Flipchart one for each EPT and Day 1
facilitator
Side Effects Cards (for use in 1 set
class and skill stations) Day 1 skill
HIV Clinical Staging Cards (for 1 set station
skill station use) recto-verso
cards = to prepare
HIV/TB Cards (for skill station 1 set
use)
Wall charts: Day 1
The WHO staging 1 of each for the
The General principles of good classroom and will used in
care the skill station room
The sequence of care
The 5 As
Coordinated approach to chronic
care

Laminated Wallcharts for Basic IMAI training courses
FOR EACH GROUP (except the Expert Patient Trainers group which need only few of
them)
Sequence of Care After Positive HIV Test 1 for each room

The 5 A's 1 for each room
General Principles of Good Chronic Care 1 for each room
Clinical Review of Symptoms and Signs, 1 for each room
Medication Use, Side Effects, Complications
Coordinated Approach to Chronic Care 1 for each room
7 Requirements to Initiate ARV Therapy at First- 1 for each room
level Facility
Opportunistic Infections 1 for each room
WHO Adult HIV Clinical Staging 1 for each room plus 1
for the skill station
WHO Paediatric HIV Clinical Staging 1 for each room
Laminated Wallcharts for Acute Care/OI Training Course

IMAI Acute Care Recording Form frontside 1 for each room
IMAI Acute Care Recording Form backside 1 for each room
Assess Acute Illness/Classify/Identify Treatments 1 for each room
(Cough or difficult breathing)
Laminated Cards
Yes/No Cards (for in-class use) 1 set for each group

(each participant needs a
Yes and a No card)
OI Cards (for in class use) 1 set for each group
Side Effects Cards (for use in class and skill 1 set for each group + 1
stations) set for skill station
HIV/TB Cards (for skill station use) 1 set for skill station
Drug Name/Abbreviation Cards (for skill station 1 set for skill station
use)
HIV Clinical Staging Cards (for skill station use) 1 set for skill station
recto-verso cards

C. List of Other Supplies and Equipment Needed in the Classroom
Supplies needed for each facilitator and participant during the course:
 name tag
 notebook/stationary
 folder to organize manuals and loose forms or cloth bag (avoid binders with punching-
each guideline module and participant manual needs to be used actively during the
course)
 ball point pen
 1 pencil
Supplies needed for each small group/classroom:
 white putty or high quality very sticky tape to fasten large, laminated wallcharts and flip
charts to wall (test this out ahead of time—tape is often too weak to hold the laminated
posters)
 pencil sharpeners (few per group)
 scissors (1 per group)
 stapler and staple remover (1 per group)
 extra pens
 extra pencils
 erasers (few per group)
 paper clips
 blank flip chart pad
 set of markers
 Highlighter markers (one for each facilitator)
Supplies for demonstrations, role plays, and group activities for each small group:
 pillbox (if available)

 cotrimoxazole tablets
 example of pill charts/diaries (if available)
 nevirapine, efavirenz, zidovudine, stavudine, lamivudine tablets (single or combination
tablets, whatever is available locally)
 box of condoms, 2-3 models of the male penis or bananas
Other important supplies:

- plug adaptator and electric extension
- Computer, and printer
- video projector for Powerpoint presentation in plenary session (introduction)
- paper and ink for copies
- 30 blank CDs (for new facilitators with all the documents used during the trainings)
and a photocopy machine should be available on the site or as close as possible

D. Venue
To train 2 cadres simultaneously requires 2 classrooms, 1 big room for skill stations and
plenary sessions, and a small room for the secretariat (total 4 rooms). Classes should ideally
be from 15 to 20 participants. If more than this are planned for any one cadre, make a
second group and plan for extra rooms accordingly.
E. Timetable for course preparation

Prepare a realistic timetable, including all the preceding steps. Planning times will vary
according to local circumstances.
Task Estimated Done Comments

Time Needed
1. Arrange for budget and schedule 8 weeks
before
2. Arrange for facilitator/s 4 weeks
before
3. Arrange for EPTs 4 weeks
before
4. Arrange permissions for practicum at teaching 4 weeks Official letters
hospital, OPD before needed?
5. adaptation and translation of training material, as 4 weeks
needed before
6. Gather or produce training materials (manuals, 3 weeks
guidelines, training material as exercises and before
wallcharts, post and pre test, evaluation forms
7. Find and reserve venue 3 - 4 weeks If venue is
before unknown, visit to
ensure suitability
8. Reserve classrooms 3 - 4 weeks
before
9. Reserve meals, lodging 3 - 4 weeks
before
10. Arrange for transport as needed (lodging to class 3 - 4 weeks
to clinics) before
11. Budget with funds on hand 4 weeks
before
12. Compile list of participants 3 – 2 weeks
before
13. Elaborate agendas and send as needed 2 weeks
before
14. Send invitation letters to participants and 2 weeks
institutions before
15. Send travel authorizations to participants and 2 weeks
facilitators if needed before
16. Design and print course completion certificates 2 weeks
before
17. Arrange for course opening (agenda, guests…) 2 weeks
before
18. Arrange for closing ceremony (agendas, guests…) 2 weeks
before
19. Once at site, course director and local physician to During
visit hospital to arrange ward and OPD days and training
times. One day before OIs course, facilitators visit
to meet with ward nurse and choose patients.
20. Check if everything and everybody is ready !!! Day before
start training
21. Print the certificates During training

Experience has shown that important problems with training are,
 skipping or leaving too little time for the steps required before training (for
example, community and stakeholder meetings; prior preparation of participants)
 arranging for the key elements at the last minute.
General Instructions:
1. Administrative support
Arrange for secretary or administrative assistant to work from 2 to 3 days before the course
begins through the end of the course or one day later.
Arrange for photocopy machine accessible to classrooms in good working order, with extra
toner, and if possible, capable of collating pages.
2. Size of classes
Optimal size of each group is 15 to 20 with 3 facilitators per group.
3. "Housekeeping"
After the first day, set aside about 10 minutes daily to discuss with each group the rules and
responsibilities concerning breaks, cell phones, group discussion, set up and breakdown of
the classroom, etc.
4. Facilitator meetings
It is important to schedule a daily meeting of all facilitators and the Course Director at the
close of each day to review progress, solve problems, and to plan for the following day. This
may last from 10 minutes to an hour, depending on the situation and how things are
proceeding.
5. Course Inauguration and Closing
Arrange for special speaker to Inaugurate and close if desired. Invite the key stake holders in
the community for the inaugural or closing functions, like District Collector, JD/DD Health
services, etc. Be sure to thank patients for the work they have done. Thank all staff and
collaborators who have supported the training. Let participants know what future plans are
for post training activities and hand out course completion certificates.

Facilitator techniques common to all courses
A. How to give pre and post test (there are different tests for each cadre)
Explain to participants that the purpose of the pre test is to give facilitators a sense of
baseline knowledge of the group, and is not an evaluation. Allow 20-30 minutes for the test of
approximately 30 questions. Decide beforehand if test should be anonymous (in which case
participants will not know their scores) and what, if any, feedback will be given on test
results. Do not discuss answers to the questions when test is finished, as the same test will
be given as the post test, but explain that all material will be covered in the course. At least
two persons should score the test on the same day it is given so that facilitators can gear
each course to the level of knowledge of participants.
B. How to conduct a drill
1. Gather the participants together and tell them you will conduct a drill. During the drill,
they will review how to decide, for example, if a patient has come for an acute problem,
follow-up of an acute problem, or follow-up of a chronic problem.
Ask the participants why this is an important decision. They should answer that it is
necessary in order to determine which guideline module and section of the guidelines to
use to care for the patient.
2. Explain the procedures for doing the drill. Tell participants:
 This is not a test. The drill is an opportunity for participants to practise making this
decision.
 You will call on individual participants one at a time to answer the questions. You will
usually call on them in order, going around the table. If a participant cannot answer,
go to the next person and ask the question again.
 Participants should wait to be called on and should be prepared to answer as quickly

as they can. This will help keep the drill lively.
3. Ask if participants have any questions about how to do the drill.
4. Allow participants to review the text for a minute or two before the drill begins. Tell the
participants they may refer to the text during the drill, but they should try to answer the
question without looking.
5. Start the drill by asking the first question. Call on a particular participant to provide the
answer. He should answer as quickly as he can. Then ask the next question and call on
another participant to answer. If a participant gives an incorrect answer, ask the next
participant if he can answer.
6. Keep the drill moving at a rapid pace. Repeat the list of questions or make up additional
questions if you think participants need extra practise.
The drill ends when all the participants have had an opportunity to answer and when you feel
the participants are answering with confidence.

C. How to provide individual feedback to written exercises
When participants are working:

 Look available, interested and ready to help.
 Watch participants as they work and offer individual help if someone looks troubled or
is not writing answers or turning pages (clues someone may need help).
 Encourage questions and requests for help.
 If important issues or questions arise individually, make a note to discuss later with the
entire group.
 If a question arises which you feel unable to answer adequately, obtain assistance as
soon as possible from another facilitator or the Course Director.
Written exercises can also be read aloud and discussed in the group.
D. Reading
When the facilitator manual says participants should read part of the manual or guideline
module, you can have participants read silently on their own, or ask for a volunteer to read a
section in a loud, clear voice. Which method you choose depends on factors such as level of
education of the group as a whole, differing levels within the group, their understanding of
English, and what the group prefers. Make sure everyone is on the same page before
beginning. If you are reading aloud, make sure that all participants who are willing, get
chances to read during the course (do not force anyone). Sometimes it is helpful to ask
someone to read who seems particularly sleepy or inattentive to wake them up. You may
also choose a mixture of silent reading and reading aloud.
E. Explanations and lecturing
At times the facilitator is directed to explain certain important concepts. Explanations should
be short and to the point, using a flipchart and/or referring to the manual. Avoid lecturing as
this is not an effective way to learn. Occasionally, when pressed for time, it may be feasible
to present certain material as a short, interactive lecture, rather than having participants read
through a number of pages themselves, but this should not be the norm.
F. How to use the skill stations
Skill stations are a crucial part of competency based training for HIV care. During the
approximately 2 hour-long sessions, participants work with individual EPTs and participate in
card sort exercises which reinforce learning of material. Participants are introduced to skill
stations on the second day of training. Before this time, the Expert Patient Trainers need to
have been trained (see Expert Patient Training materials). Complete instructions for the
facilitator on skill stations are provided in this Guide on pp. 71 to 76, and for the participants
in their Participant Manual. Facilitators need to be present during skill stations to answer
questions and give guidance as needed.
Objectives:
 To provide health workers with the chance to practise skills they are learning in class
with the EPTs who will give each health worker feedback.

 To reinforce learning of new material such HIV staging, ARV names, regimens and
side effects, eligibility, and patient management.
Scheduling of skill stations needs to be done on a daily basis so that each group has the
time to work separately. Often 3 groups will be going to skill stations (2 clinician groups and
one ART Aid group).
Medical Doctors use of skill stations: It is advisable to have physicians spend at least one
full session with the EPTs as this presents a rare chance for PLHAs to give feedback on
physician interviewing skills and address issues of stigma around HIVAIDS experienced from
the patient perspective.
G. Singing competition
This is often an effective way to raise group spirits and to reinforce key points. Each group
should be told about this and encouraged to enter the competition which takes place during
the closing ceremony.
In the Masaka, Uganda course, the winning groups sang about the "7 requirements"; another
group presented the 5 A's. The facilitators entered a jingle on the first-line ARV regimens
(insert) which is helpful to sing during the class to reinforce learning of these regimens.
It is useful to have a prize or prizes that can be shared among the winning group.
H. Energizers
Ask individual participants to be responsible for a few exercises or songs during the course
of each day to make things livelier when attention is lagging or when people are tired but the
day is not over. This should be decided as part of "housekeeping" activities at the start of
each day. The facilitators should also have some energizers of their own to offer.

Facilitator Guide for the WHO Basic IMAI training course
General learning Objectives
 To prepare nurses and medical assistants for comprehensive chronic HIV care
including ARV therapy and prevention.
 To support chronic HIV care at the district and health centres in functioning as
an overall effective clinical team
Role of District and Sub district hospital nurses:
In general the nurses working in district and sub district level hospitals do OP, IP care, follow
up ANC, conduct deliveries, follow up immunization schedule for children, and assist in
conducting family planning clinics and special clinics.
IMAI training course is designed to train the hospital based nurses (ex. staff nurse, SHN) to
do following activities:
1. Suspect HIV and refer the patient for counseling and testing.
2. Do HIV clinical staging
3. Do Adherence preparation and support.
4. Do adherence follow up in the lost to follow up patients who are on ART.
5. Facilitate linkages with community support groups.
6. Do education and support for PLHAs, including positive living and nutritional counseling.
7. Assist the doctor in physical examination and in dispensing the drug refills.
8. Identify OIs earlier and refer for proper medical management.
9. To follow up referral and back referral.
10. To fill up and maintain the forms, registers and documents as suggested by the district
administration.

Chapter 1: Introduction to chronic HIV care including ARV therapy
Duration: Purpose:
2 hours and  Pre-test as baseline assessment of knowledge
 Overview of materials for the course
15 minutes  Introduction to chronic care including ARV therapy
Materials: Learning objectives:

 Understand how the guideline modules and training materials are
Blank
linked
flipchart/markers;
 Understand the difference between acute and chronic care
pre-test;
 Learn the general principles of good chronic care
Directory of the
 Define the 5 A's
local network
 Describe the HIV/AIDS local network and know where to refer
patients
Wallcharts:
Sequence of
care; Principles Content Methods Duration
of Good Chronic
Introductions to each Interview someone you 20 minutes
Care; 5 A's
other don’t know and introduce to
group
Introduction to the Explanation 10 minutes
Preparation: course and the material
Prepare a
wallchart with the Pre-test Written 20 minutes
national/local
health system Introduction of the Discussion, Q&A 20 minutes
sequence of care
Meet with expert
patient-trainer Introduction to the Lecture 20 minutes
(EPT) or one of general principles of
your co- good chronic care
facilitator, to The 5 A's Explanation, demonstration 30 minutes
prepare with EPT, discussion
demonstration
What is locally Exercise 1.2 15 minutes
available?
The expert patient-trainer (EPT) is a PLHA who has been trained to role-
play specific HIV clinical cases in class and in the skill stations (see
Facilitator's Guide to the Basic ART Expert-Patient Trainer Course).

Welcome and introduction to each other 20 minutes
Welcome the participants and organize a game to introduce each other (participants and
facilitators)
Ask to the group of participants to define the ground rules for the group
Introduction to the course 10 minutes
Present the general learning objectives of the course
Present the agenda and organisation of the week
Introduce the different documents and manuals that will be used during the course
Pre-test 20 minutes
Before giving the pre-test, let participants know that they are not expected to know all of the
answers, as the test covers much of what they will be learning in the course itself. The
purpose of the test is to give facilitators, and participants, a clear idea of what participants
already know, and what they need to learn.
Introduction to the sequence of care 20 minutes
1. Read the learning objectives aloud to the participants.
2. Introduce the sequence of care for the HIV positive patient.

We will be talking about an integrated process of chronic care for HIV patients, including
ART (point to the wallchart with the sequence of care after a positive HIV test, reading
only the titles in bold, but do not go through in detail. Explain which steps we will be
learning here and what is for another course for nursing assistants/ART aids). In this
course, we will learn all that are on the right side: steps 3,4,5,6,7,8,10, and 11. We will
also learn to use the Flipchart for Patient Education and Patient Education Cards to
educate the patient. Show each of these materials to participants. Tell them we need to
learn how to provide good chronic care for HIV patients, not just acute care.
3. Ask what is chronic care? What is acute care? Have participants give examples of what
the difference is between acute and chronic care.
4. Explain that currently most HIV care is episodic acute care, and this is a different
approach from good chronic care. Comprehensive HIV care includes both acute and
chronic care.
Have the participants read the Acute and chronic HIV care and prevention page of
chapter 1 which talks about acute and chronic care. Explain that you are training them both
as individuals and as a clinical team

The general principles of good chronic care 20 minutes
5. Ask a volunteer to read the Introduction to the General Principles of Good Chronic
Care in the participant manual.
6. Introduce the General principles of good chronic care, providing a short comment on
each of the principle, using the Annexe D: General Principles of Good Chronic Care of
the Chronic HIV care guideline module, and the wallchart.
The 5 A's 30minutes
7. Now introduce the 5 A’s. Use the wallchart.
8. Ask for volunteers to read about the 5 A's in the participant manual AND/OR comment
each of the 5 A’s, providing examples and asking additional examples to the participants.
9. Ask: What step of the 5 A’s do we tend to skip? Discuss in the group how they already
use the 5 A’s, and to consider how they could help you both in your individual encounters
with patients and as a clinical team.
10. Ask: Why are the 5 A’s helpful for ARV therapy? Which step is the most important?
Why?
11. Now introduce the role-play to the participants (the role play can be done with an expert
patient-trainer or with one of your co-facilitators).
 Give a brief history of the patient, including the purpose of the visit: “An HIV+ woman
get married sometimes ago; she wants to start a family and to have children”
 Introduce who will play the doctor and who will play the patient
 Ask participants to listen carefully and to identify the 5 A’s
 Lead a discussion at the end of each role play

FACILITATOR INSTRUCTIONS FOR
ROLE-PLAY IN TRAINING SESSIONS
Learning Objective: To demonstrate how to conduct an effective patient assessment

interview.
Before the session:

1. Meet with the designated expert patient (EPT or co-facilitator), or your co-facilitator,
and review the case study. Clarify how the EPT (or facilitator) will present his/her case
and what information they will provide from their health, personal/social, and treatment
history. Answer questions. Practise role-play. Repeat practise until you are both
comfortable with it. It should be about ten to twelve minutes.
2. Ask the EPT/or co-facilitator how he/she would like to be introduced to the students.
Note details.
3. Confirm details of demo—time, place, etc. Determine any possible time conflicts for the
EPT/or co-facilitator in case your session is behind schedule.
During training session:

1. Introduce the EPT/or co-facilitator to the students as per his/her instructions.
2. Set up the role-play in the front of the room and ensure that everyone will be able to
hear the entire role-play.
3. Ask your co-facilitator to time the exercise and to give you a two-minute warning at 10
minutes so you will have time to complete the most important learning objectives of the
exercise.
4. At the end of the exercise, ask the EPT / or co-facilitator to complete the Feedback
form out loud with the class as he/she fills it in (have EPT bring the generic feedback
checklist with him/her).
5. Process the exercise and the feedback with the class.

Role-play # 1: Good use of the 5 A's
Assess
Health Worker (HW): Hello, how are you doing today? What is the reason for your visit
today?
Patient (P): Hello, I would like to talk to you if you have some time.
HW: Yes, I do. What do you want to talk about today?
P: As you know I am HIV-positive. I got married some time ago, and my husband and I
would like to start a family and have children.
HW: This is good, let us start by checking how you are and then we can talk further about
this. How have you been since we last met?
Can I do a check on your health to be sure we do not to miss anything? (Use Clinical
review on H10)
Have you had any health problems lately? (EPT: No)
Have you had any of the following: Cough? Night sweats? Fever? STI signs?
Diarrhoea? Mouth sores? New skin rash? Headache? Fatigue? Nausea or vomiting?
Poor appetite? Tingling, numb or painful feet/legs? Sexual problems? (EPT: shakes
head “no” after each symptom)
P: No, I am fine. I do not have any symptoms.
HW: Let me just check your eyes, mouth, glands, skin (should go through the motions).
P: I do not have any pain or other symptoms anywhere.
HW: Ok, so that is good. Now, you wanted to talk about having children, is that right? Can
you tell me, do you have children at the moment?
P: No, but we want to start now.
HW: I hope you do not mind, but it is important to know if your husband has ever been
tested for HIV and if he is positive or not.
P: Well, he doesn’t know. He hasn’t been tested.
HW: Can you tell me what you know about the risks of having children when you are HIV-
positive?
P: Well, I don’t know what the risks are. Would I pass HIV on to my child?

Advise
HW: Well, perhaps it would be helpful if I gave you some information about this, would you
like to hear it?
P: Yes, please.
HW: It is possible for you to pass the virus to your baby but not all HIV-positive women
pass the virus to their babies—only about 1 in 3 will have babies born with HIV
infection. The infection can happen during pregnancy, birth, or breastfeeding.
There are things you can do to reduce the risk. There are drugs that you can take and
give to the baby at birth, and taking care with breastfeeding can make a significant
difference.
There is a clinic here called PPTCT which specializes in preventing mother-to-child

transmission. I would suggest that you make an appointment to talk to them about it.
Of course, there is also a risk to your partner, if he is HIV-negative, from having

unsafe sex in order to conceive. Do you think he understands this?
P: I am not sure what he understands.
Agree
HW: How would he feel about coming in for a test?
P: I could talk to him, I think he would be frightened though.
HW: Perhaps you might come with him and we could talk together about being tested and
having a baby? What do you think?
P: Yes, I think that would be all right.
HW: And, would you like to have an appointment with PPTCT, or shall we leave that until
you have come here with your husband?
P: Can I leave that until we have talked more?
HW: Of course. I can make an appointment with them whenever you want me to.
Assist
HW: So, we have agreed that you will talk to your partner about coming in to talk about
having a test and the risks of having a baby. Will you have any difficulties with that?
P: Yes, I do not really think he will want to come in.
HW: What do you think you could do to encourage him?
P: I think if I tell him that if we try for a baby I might be putting him at risk of HIV infection
himself, he might want to talk about it a bit more.
HW: Well, I would be very happy to talk to him about it.

Arrange
HW: So, let's make a date for next Wednesday, if that suits you.
P: Yes, that would be fine.
HW: I have an appointment available on Wednesday at 2 or 3pm. Which would be the

best for you?
P: 3 o’clock would be the best.
HW: OK, here is a note to remind you of the date. My phone number is at the top, please
ring me if you have any difficulties and need to cancel it. You can also ring me
anytime during work hours if you want to ask any other questions.
Do you have any other questions right now?
P: No, thank you.
HW: Thank you for coming today and I look forward to seeing you next Wednesday.
Role Play #2: Poor use of the 5 A's
Assess
HW: What is the reason for your visit today?
P: Hello, I have come for my regular check-up appointment and I would like to talk to you
if you have some time.
HW: Yes, I do. What do you want to talk about today?
P: As you know I am HIV-positive. I got married some time ago, and my husband and I
would like to start a family and have children.
HW: This is good, let us start by checking how you are and then we can talk. How are
you? How have you been since we last met?
P: Fine.
HW: Have you had any problems lately?
P: No, I am fine and I do not have any symptoms
HW: How are your eyes, mouth, glands, skin?
P: They are all fine.
HW: Ok, so that is good. Now, you wanted to talk about having children, is that right? Can
you tell me, do you have children at the moment?
P: No, but we want to start now.

HW: Is your husband HIV-positive as well?
P: He doesn’t know. He hasn’t been tested.
Advise
HW: Well, you know you can pass the virus to your baby. The infection can happen during
pregnancy, during birth or through breastfeeding.
You would need to go to the PPTCT clinic for advice.
Of course, there is also a risk to your partner, if he is HIV-negative, from having

unsafe sex in order to conceive. He should really have a test himself. Do you think he
understands this?
P: I am not sure what he understands.
Agree
HW: So, you will talk to your partner about going to have a test. Is that right?
P: Yes, I will try.
HW: And you will go to see the PPTCT clinic for more information.
P: Yes, all right.
Arrange
HW: So, I'll make an appointment for you to come back to tell me how things are going. I
can make Tuesday at 4 pm. Do you have any other questions right now?
P: No, thank you.
HW: OK see you on Tuesday at 4. Next patient please.

What is locally available? 15 minutes
This exercise can be used to illustrate the 5 A’s “ASSIST” (= assist the patient by referring
him to NGOs, other services, group support….). It is important for the participants to know
the local network.
12. Exercise 1.1:
Explain: One of the task of the health care provider will be to link patients to all services
for HIV available within their health district and in the local community. In order to do so,
he/she must be very familiar with the local reality.
In order to perform this exercise well, you should have gathered information on the
following:
 Structure of the district health system

 NGOs dealing with HIV/AIDS at the health centre level
 Faith-based organizations
 Village support groups
 Womens' support organizations
If somebody in the group is very familiar with the local organizations and existing structures,
it would be important to get his/her contribution in the discussion.
Based on the information you gathered beforehand, you may need to briefly explain the
structure of health care within your country/ State.
Write the following on the flipchart (to adapt locally).
MOH

Tertiary Level Medical College Hospital

District Hospital

Taluk Hospital

Community Health Centre/ Block Primary Health Care Centre

Primary Health Care Centre NGOs and CBOs dealing
with HIV/AIDS

Additional Primary health Care Centre 
Faith based organizations

Work based organizations
Subcentres
Village support groups

Women’s organizations
Family and friends 

Individual patient

Divide the participants so that they are working together according to region/district/health
centres (this part can also be need with all the group, not in small groups)
Ask them to list all the support services available for people living with HIV in their area, and
in particular, any services that will support ART
Go through the lists created by each group and confirm what services are provided by each.
Add any extra information you or the other facilitator might have.
If possible, cross-check information provided by participants and distribute a list of locally

available services for HIV to all participants at the next lesson.
Explain that these lists form the basis of an information resource they can continue to use.
13. Review the objectives at the beginning of this chapter and confirm that they have been
met. If you suspect that an objective has not been well understood by all, answer questions
and provide further explanation as needed.

Chapter 2: Communication skills
Total Purpose: To improve communication skills

duration:
70 minutes Objectives: By the end of this section the participants should be
able to:
Materials:  Use good communication skills including appropriate use of
questions and body language when interacting with patients.
Blank flipcharts
 Demonstrate good listening skills and empathetic approach to
patients’ concerns
 Ask appropriate questions to put patients at ease and obtain
needed information
Preparation:  Describe counselling and how it is used in the context of
Prepare a HIV/AIDS
flipchart for the
exercise Content Methods Duration
“listening”
How and when to ask Brainstorm in 20 minutes
different types of question group
Discussion and
comment
Listening Exercise-role play 20 minutes
and group
discussion
Empathy and sympathy Drill 10 minutes
Being non-judgemental Lecture 5 minutes
Counselling Group exercise 15 minutes
2.1

Note:
It is particularly important that this section be facilitated by someone with
considerable counselling experience and skills who is comfortable with the content.
1. Read aloud the objectives
2. Introduce the topic

Why are good communication skills important? Effective communication is a major
component of providing health care and counselling.
To be able to listen, hear and respond to the patient’s concerns.
To make sure the patient feels respected and comfortable discussing health and
social problems related to HIV.
To empower the patient with information and skills to manage their own health
effectively.
Different types of questions 20 minutes
3. Explain that it is often important to ask patient questions to find out more about what they
are saying or feeling.
EXERCISE 1.3: Ask the participants for examples of questions they might ask a
patient who has come to them (for any reason)
Write up the questions on the flipchart include the following if necessary:
How have you been since we last met? (O.Q)

What is your name? (C.Q)
Can you tell me what we have agreed today? (CH.Q)
You have taken the drugs correctly, haven’t you? (L.Q)
Why don’t you use condoms? (W.Q)
OPEN questions: Identify any open questions from the list provided by the
participants.
Explain that open questions open up the discussion and should be used as much as
possible. If relevant examples have not been provided by participants use the following
ones:
How have you been since we last met?
What might happen if you tell your partner?
What difficulties have you had with taking your drugs?
Ask for more examples of other open questions.
CLOSED questions: Identify any closed questions from the list
Explain that closed questions lead to one word answers. They can be helpful in
obtaining information but do not open up a discussion. Usually they will make the
health care provider ask another question. If relevant examples have not been
provided by participants use the following ones.
Do you have children?
Do you practise safer sex?
Where do you live?
How old are you?

Ask for more examples of other closed questions.
A closed version of the question “What difficulties have you had taking your drugs?”
would be “Have you had any difficulties taking your drugs?” Note the difference – open
question gives the person a chance to bring up a variety of things; the closed question
can be answered yes or no and the conversation is over.
CHECKING questions: Identify any checking questions from the list.
Explain that checking questions can be used for checking you have understood the
patient and for checking that the patient has understood you.
If relevant examples have not been provided by participants, use the following ones:
Tell me what you need to remember about taking your drugs? What actions have we
agreed upon today?
Remind me how you said you were going to remember to take your drugs?
You said that you could take the drugs at 7 in the morning and 7 in the evening, is that
right?
You said that you felt sick each time you took your pills, Have I heard you correctly?
Ask for more examples of other checking questions.
LEADING questions: Identify any leading questions from the list above.
Explain that when you ask a leading question you expect a particular answer.. It gives
the person less opportunity to give their own answer so provides you with less
information
You take the drugs as I told you to, don’t you?
You wouldn’t have unsafe sex, would you?
You know everything about ART, don’t you?
You are single, aren’t you?
You don’t want more children, do you?
Ask for more examples of leading questions.
WHY questions: Identify any why questions from the list.
Explain that why questions can be used for exploring issues with the patient when
there is something you do not understand. If relevant examples have not been provided
by participants use the following ones:
Why did you forget to take your drugs?
Why haven’t you told your wife about being HIV+?
Why did you miss your last appointment?
Why do you still have unsafe sex?
Why did you sleep with that person?
Ask for other examples of why questions.
Ask how patients feel about being asked “why…?” Explain that patients can feel
judged and threatened by questions beginning with ‘why’. Instead of asking ‘why”’ you
can turn a why question into a more open-ended question. For example instead of
“Why do you still have unsafe sex?” you can ask “Can you tell me more about the
difficulties you are having negotiationg safer sex with your partners?”

Listening 20 minutes
4. Explain that:
 Listening means to pay close attention to someone; to hear with intention. Good
listening involves listening ACTIVELY.
 Listening is one of the key roles of a counsellor, a nurse and any health care
provider.
 A good listener doesn’t interrupt, allows silences, does not speak until they have
listened, lets the other person see you are listening by nodding, maintaining eye
contact and asking questions.
 Good listening skills include good body language too.
5. EXERCISE 2.2: The following exercise will help the participants understand the effect of
good and bad listening skills.
Divide the group into pairs.
Explain that one person should be the “listener” and one the “talker”.
The “talkers” should talk about something that is good in their lives. Something that is going
well, is important, or they that they are enjoying.
Take the group of “listener” outside of the classroom to give them the instructions: tell them
to listen carefully their colleague (and to show that they are listening carefully) at the
beginning, and after one minute, tell them to not listening: e.g. answering to the phone,
looking somewhere else, starting to read something…
Start the exercise with the pairs. Go around observing.
Stop the exercise after few minutes and ask the following questions to the person who were
talking:
 What did it feel like to be listened to?

 What did it feel like to not be listened to?
 What did you do to show you were listening?
 What did you do to show you were not listening?
 Were you able to talk when you were not listened to?
Put up the pre-prepared flipchart and go over briefly
What shows you are listening What shows you are not listening
Facing the patient Looking away or around the room
Looking at the patient while s/he speaks Being distracted
Nodding Not acknowledging what is being said
Smiling or frowning appropriately Fidgeting
Being calm Writing notes, finding papers
Being patient Interrupting

Empathy and sympathy 10 minutes
6. Ask the participants the definition of empathy. Ask the difference with sympathy.
Correct and complete as needed I think people are unlikely to know this – so have
facilitator explain the difference. (where is def?)
7. Drill: Explain that you are going to read statements that are examples of what a
patient might say if they are experiencing a difficulty. There is a response which
communicates empathy and one of sympathy.
Ask the participant to spot which is which.

The chart is good but maybe better to use differently:
 have someone be the patient and read what the patient says;
 Facilitator should give response 1 and then response 2 and ask the patient to
describe how each response felt
 Re-emphasize difference between the two
The patient says Response 1 Response 2
Patient A: I have been told I It sounds as if you are Oh, you poor thing. Yes, it is
am HIV+ and I don’t know having a hard time. It is terrible to be HIV+. I don’t
what to do. good you have come know what you should do but
here because maybe at least I am here for you
talking it through will help.
(empathetic) (sympathetic)
Patient B: My husband is Oooh, that’s frightening! That sounds hard. A lot of
going to be so angry with You must feel awful. I’m people find telling their
me. I don’t think I can tell him so sorry. It is probably partner difficult. Is there
my results. better not to tell him. anything you think might
help?
(sympathetic) (empathetic)
Patient C: I’ve been feeling How awful for you. Being That doesn’t sound good. It
sick all week and have sick is so terrible. might be connected to your
vomited several times. I drugs or it might not be but it
think it might be connected (sympathetic) is worth checking it out with
to my drugs. the nurse.
(empathetic)
Being non judgemental 5 minutes
8. Explain what is being non judgemental, using the information in the participant
manual, OR ask a participant to read the section.
9. Say few words on values and attitudes OR ask a participant to read the section
in the manual.

Introduction to the meaning of counselling 15 minutes
10. EXERCISE 2.3:

Distribute the participants in 2 groups: one group should discuss “what
counselling does include?” and the other group should think about “what
counselling does not include?” (Provide examples if needed).
Ask them to record their answer on a blank flipchart, and after 10 minutes ask to
one representative of each group to present the result of their group work.
Comment and complete the information as needed; and ask to the participants to
take notes on the two tables in their manual.
Counselling includes Counselling does not include
 Establishing helping relationships with  Telling patients what to do

patients  Making decisions on behalf of patients
 Having conversations with a purpose  Judging patients
 Listening attentively to patients  Interrogating patients
 Helping patients tell their story  Blaming patients
 Giving patients correct and appropriate  Preaching to or lecturing patients
information  Making promises that you cannot keep
 Helping patients make informed  Imposing your own beliefs on patients
decisions  Arguing with patients.
 Helping patients recognize and build on
their strengths
 Helping patients develop a positive
attitude to life.
11. Explain the purpose of counselling in HIV/AIDS

The purpose of counselling in the context of HIV/AIDS and ART is to:
13. Help patients cope with the emotions and challenges they face when
diagnosed with HIV and thereafter
14. Prepare and support patients who want to begin or are taking ART and to
motivate them to be adherent
15. Help patients to avoid passing on, or getting re-infected with HIV
16. Help patients make choices and decisions that will prolong their life and
improve their quality of life.

Chapter 3 : Stigma and discrimination
Duration: Purpose: The participant will understand the concept of stigma and
95 minutes discrimination and appreciate the need for addressing these issues in
HIV care and treatment
Learning objectives:
Materials:  Introspect on one’s attitudes towards PLHAs
Cartoon cards  Define meaning of stigma and discrimination
Blank  List the different types of stigma
flipchart/markers;  Identify with personal experiences of being stigmatised or
discriminated
Content Methods Duration

Preparation: My attitudes towards Discussion, 10 minutes
Make the cards PLHAs Exercise 3.1
required
Make one flip Defining Stigma Brainstorming 20 minutes
chart with (if available Exercise 3.2 ) (+ 10 minutes if
definition of exercise done)
‘Stigma’ Causes of stigma Discussion 10 minutes
Exercise 3.3
Meet the EPT to
prepare the Personal experiences of Individual reflection 15 minutes
discussion being stigmatised Share pairs
Group discussion
Exercise 3.4
Effects of stigma Group discussion 10 minutes
How to address stigma Brainstorming 15 minutes

Group discussion and
mini lecture
Review
EPT experience of Discussion, exchange 15 minutes
stigma and
discrimination
1. Read the learning objectives aloud and the introduction of the chapter

My Attitudes towards PLHAs 10 minutes
2. Exercise 3.1:
Divide participants in to small groups of 3-4 each. Make sets of cards labelled ‘Agree’
‘Unsure’ ‘Disagree’. Read out a statement and then ask participants to discuss in their
groups for 1 minute what they feel about the statement. After a minute clap you hands to
signal to the groups to lift up the respective card that suits their response to the statement.
Ask groups to share their views of the statement.
Statements: CHOOSE 4 to 6 of the following statements that you think the most
relevant to discuss with your group of participants
 People with AIDS are to blame for bringing this disease on themselves
 Health Care Providers (HCP) should be able to refuse to care for a patient
with AIDS
 The HIV epidemic could be stopped if laws against prostitution/homosexual
behavior are stronger
 People with HIV have the same rights as all other patients
 Free condoms when distributed will encourage immoral behavior always
 The govt. is wasting money on PLHAs by giving free treatment
 HIV is a just punishment for immoral behavior
 All HCPs should be tested for HIV
 All HCPs who are positive must not be allowed to work in any hospital
 All patients should be tested for HIV whether they consent or not
 People with HIV who continue to have sex must be put in prison
 HCPs should have no fear of looking after people with HIV/AIDS
Defining stigma and discrimination 20 minutes
2. Brainstorm with participants ‘What do you understand by stigma?’ ‘What is

discrimination?’
Write responses on the flip chart/board
Then give them the definition of stigma and discrimination by either just stating it or
writing it in on the flip chart (pre prepared)
Stigma is defined as having unfavourable attitudes or beliefs directed towards something or

someone. Stigma reflects an attitude, but that attitude can be expressed through behaviour
that causes others to feel the experience of stigma.
Other definition that you can use to complete, to comment with participants:
Stigma: the shame or disgrace attached to something regarded as socially unacceptable (2)
Stigma is found in the thoughts of people and communities, when people believe that a
particular illness, or something a person has done or feels, is shameful and brings disgrace
on themselves, their family or their community. They believe that the person is bad and
should be despised and avoided by the community
Discrimination is the treatment of an individual or group with partiality or prejudice. It is

when people are treated differently just because of particular attribute or characteristic.

Ask to the participants to provide some examples of stigma and discrimination
(examples are provided in the participant manual)
3. If material is available: Exercise 3.2
Divide participants to sit in groups of 3-4 members. Distribute cartoon drawings of the
following scenarios. Ask the participants to discuss the following in their group ‘What do you
see in the picture?’ and ‘how does this picture show stigma’
 Make cartoon drawings of the following
o Parents pushing pregnant daughter out of the house: May be an unwanted
pregnancy. Do not know her HIV status. What could happen to her
o Man sitting all alone on the bed: No one seems to be caring for him.
Utensils under bed – shows that people are not sharing utensils with him.
He seems to have lost all hope
o Child going out to buy chicken and vegetables while rest of the children (2
others) including the father and mother are eating chicken in the house.
May be the child is HIV positive. So the child is treated differently from
other children in the family.
o Woman sitting all alone and crying: May be she has just discovered she is
HIV +. She is depressed, frightened of rejection, anxious and hopeless
o Man being told to leave the job and the community: Man just discovered to
be HIV positive. He reveals it to a friend and the next day he is being
thrown out of his job. The leaders of the community also tell him to leave
the village (picture shows luggage and furniture out of the house)
Causes of stigma and discrimination 10 minutes
4. Exercise 3.3: Causes of Stigma
Ask to the participants”what do you think is the cause for stigma?’”
Write the responses on the flip chart / board and comment them with the participants
Emphasize on the lack of education and information as a major causes (which are the cause
of fears, misbelieves, myths…)
Results of stigma and discrimination 15 + 10 minutes
5. Exercise 3.4: Personal experiences of being stigmatised

 Ask participants to think of a time in their life when they have stigmatised
(isolated, rejected, called names etc) another person because the person was
different.
 Ask them to think ‘What happened?’, ‘How did you feel?’
 Ask them to think of a time in their life when they have been stigmatized
 Then ask them to write out any feelings, attitudes, thoughts, or words they
would associate with ‘stigma’.
 Ask participants to share what they have written in their notes. Write them on
the flip chart/ board
 Then summarise by discussing feelings associated with stigma

o Everybody has felt ostracized or treated like a minority at different times in
their lives. And it is okay to feel like that because you are not alone—we have all
experienced this sense of social exclusion.
o Feelings could be: Depressed. Rejected. Feeling judged. Feeling discredited.
Outcast. Isolated. Alone/loneliness. Second class citizen. Pushed down.
Dehumanized—“people no longer take me seriously.” Unaccepted. Useless.
Failure. Hated. Degraded. Misunderstood. Teased. Insulted
6. Ask to the participants what are the results-effects of stigma and discrimination, and list
them on a blank flipchart. Comment
o Explain how stigma blocks both prevention and treatment of HIV and AIDS:
o Stigma keeps people from learning their HIV status through testing and
discourages them from telling their partners and as a result they infect them.
o Stigma keeps people who suspect they are positive from accessing treatment
and counselling services. For example, a TB patient hides his diagnosis
o Stigma discourages people from using other services (pregnant woman from
taking ARVs)
o Stigma prevents people from caring for people living with HIV and AIDS.
How can we address stigma and discrimination? 15 minutes
7. Brainstorm with participants ‘what are the ways to address stigma in the community and
health care setting
Then explain the points that are given in the participant manual
Personal experience of one of a PLHA-EPT 10 minutes
9. Expert Patient Trainer personal experience of stigma and discrimination

 In this exercise an EPT will share his/her personal experience of stigma and
discrimination, and will talk about the following:
i. Did she/he experience stigma and discrimination?
ii. In which circumstances?
iii. How did she/he felt?
iv. How did he/she overcome the situation?
v. What could be the done to reduce stigma and discrimination?
10. Summarise the session

Chapter 4: Introduction to HIV/AIDS and opportunistic infections
Duration: Purpose: To understand the natural history of HIV/AIDS and

70 minutes opportunistic infections.
 Understand and describe the natural history of HIV/AIDS and the
Materials: difference between HIV and AIDS
Blank  Describe the impact of HIV on the immune system
flipchart/markers;  recognise the common opportunistic infections required for clinical
HIV Chronic Care staging and for initiation of ART
photos  Understand the clinical stages of HIV/AIDS and be able to classify
patients into the appropriate clinical stage
 understand the correlation between HIV and tuberculosis
 understand and recognise atypical presentations of TB in HIV
infected persons
Wallcharts:
HIV clinical
staging Content Methods Duration
How HIV attacks our Discussion, Reading 10 minutes
health
Preparation: Clinical staging EXERCISES 4.1 and 40 minutes

None 4.2
HIV and TB Q&A, Discussion 20 minutes

How HIV attacks our health 10 minutes
1. Read the learning objectives aloud.
2. Ask a volunteer to read the HIV/CD4 story. Explain that this simple story with simple
pictures can be used to explain the process to the patients.
3. Using the blank flipchart, have them define these terms: CD4, opportunistic infection,
immune system.
4. Ask the group: How long does it take for a person who becomes infected with HIV to
become severly symptomatic (AIDS) without ART? 7-10 years
5. Comment with the group the diagram of the HIV/AIDS progress and explain that this
illustration can be used to explain it to the patients.
HIV clinical staging 40 minutes
Facilitator needs the HIV Chronic Care photos for this exercise and the HIV clinical stage
wallchart.
6. Ask the particpants to name and describe signs and symptoms that they have seen on
HIV+ patients. Record on a blank flipchart.
7. Ask a volunteer to read the section on the most common Ois. Comment with the group
8. Refre the participants to the section 3.6 from the Chronic HIV Care guideline on the
WHO Clinical Stages,
9. Explain how to determine the stage using the wallchart.
Important !! Emphasise that: the past history of the patient is determinant to identify the
clinical staging. E.g.: a patient is coming today with no signs, but he had a pulmonary TB last
year…..He will not be classified at stage 1 but he is already on stage 3
10. EXERCISE 4.1: Hand out individual clinical staging photos A through N to different
participants. One at a time, describe the cases below, and have the participant with the
photo that matches the description stick the photo on poster by the correct stage. If
necessary, ask others to help with the diagnosis, or supply the diagnosis
11.
The answers are actually in the participant manual in the staging table which you can
mention after the exercise—also, this wallchart with the photos should remain on the wall
until the end of the course so participants can refer to them).
Photo Case Clinical Stage

letter
K 47 year-old HIV+ thin man with this mass in his 4 (lymphoma)
mouth.
B 41 year-old HIV+ woman who comes to the health 2 (angular cheilitis)

centre complaining of having cuts on the side of
her mouth.

M 34 year-old HIV + male who complains of weight 4 (extrapulmonary TB-TB
loss and these large swellings on his neck. adenitis)
D 37 year-old HIV+ woman who complains of this 2 (prurigo)
rash on her back. She says that it is itchy.
J 38 year-old HIV+ woman with painful ulcers as 4 (chronic herpes simplex
seen in this picture. She says she has had this for ulcerations)
a long time.
F 27 year-old HIV+ woman with multiple of these 2 (recurrent mouth ulcers)
sores in her mouth. She says that they are painful
and that she gets them a lot.
C 42 year-old HIV + male has this itchy rash on his 2 (seborrhoea)

face.
H 41 year-old HIV+ man who says that he has this 3 (oral hairy leukoplakia)
whitish patch on the side of his tongue.
A 30 year-old HIV+ man who says he has some 1 (PGL)
slight swellings under his arms and on his neck as
seen. No other symptoms.
E 50 year-old HIV+ man who comes to the health 2 (herpes zoster)
centre because he has this painful rash.
G 35 year-old HIV+ woman who says that she has 3 (oral thrush)
lost weight and she has this painful white sore in
her mouth.
I 33 year-old HIV + woman who says that she has 3 (vaginal candidiasis)
a whitish discharge. She is frustrated, because
she has had it for over a month.
Tell the participants that the letters in the clinical staging table in the manual correspond to
the pictures (at the end of the exercise).
8. EXERCISE 4.2: Now tell the participants to do the additional written exercise in the
manual. Then go over individually to make sure that each understands.
Answers to EXERCISE 4.2:
1. An extremely thin HIV + patient has chronic fever for 3 Stage 4

months.
2. An HIV+ patient with pulmonary TB Stage 3
3. An HIV+ patient with oral thrush and intermittent Stage 3
diarrhoea for 1 month.
4. An HIV+ patient with TB of the cervical lymph nodes. Stage 4
5. An HIV + patient with big abscesses of the skin which Stage 3
extend to the muscle, with some yellow pus coming out of
them.
9. Point out what stage 4 problems can be diagnosed without laboratory.
10. Tell the participants that tomorrow (day 2) will be the start of the skill stations where they
get to practise the skills they learned today with the expert patient-trainer. The clinical
staging will be one of the exercises that they do as a card sort, so it would be a good idea
to review this at home tonight.

HIV and Tuberculosis 20 minutes
11. Ask to the particpants:

 What is TB?
 How is TB spread?
 How does HIV affect the risk for getting TB? Is it lower? Is it higher?
 What is the difference between pulmonary and extrapulmonary TB?
 What is the difference between TB disease and TB infection?
Then, have them read this section, Correlation Between HIV and Tuberculosis in the
manual.
12. Have the participants look at the cases at the end of the chapter. Explain that they will
meet 3 patients who will be seen throughout the manual. Introduce Sushma, Manish, and
businessman Kumar. Have 3 volunteers (1 female, 2 male) to read aloud the cases
(suggestion: as we will follow the stories of these 3 patients in different chapters, try to
have the same participants reading the cases for each chapter). Go through the clinical
stage together for each case.
Answers for cases:

Sushma Stage 2
Manish Stage 4
Kumar Stage 2
met. If you suspect that an objective has not been well understood by all, answer
questions and provide further explanation as needed.

Chapter 5: HIV and antiretroviral drugs
Duration: Purpose: To understand HIV/AIDS and antiretroviral drugs (ART).

60 minutes
 Describe how HIV replicates itself
Materials:  Name the different classes of antiretroviral drugs
Blank  Indicate the classes to which different antiretroviral drugs belong
flipchart/markers  Explain basics about how the different ARV drugs work
Drugs samples  Explain why we need to use a combination of 3 antiretroviral drugs
If available: a  Explain the difference between a first-line regimen and second- line
video on the HIV regimen and why it is important to stay on first-line regimen as long
life cycle as possible
 Learn the generic names, abbreviations, and locally available
common brand names of the 5 first-line drugs
Preparation:  Describe the benefits and goals of ART
None
How HIV infects the cell Reading, Discussion, 15 minutes
Introduction to ART Discussion; Reading; 30 minutes

EXERCISE 5.1; 5.2 and
5.3
The benefits of ART Q&A, Discussion, 15 minutes
EXERCISE 5.4

How HIV infects the cell 15 minutes
1. Read learning objectives aloud.
2. Ask for volunteers to read aloud up to Antiretroviral Drugs OR show a video on the
process of introduction of the virus in the cell and its replication (if available).
Introduction to ART 30 minutes
3. Have the participants do the EXERCISE 5.1 at the end of the chapter, individually then
discuss in group.
4. Then read the chapter through First- and Second-line Regimens.

NOTE: Please do not spend time on the classes of drugs. They do not need to
know this. They DO need to know the 4 first-line regimens and should learn to say
the names and know their abbreviations.
5. Have the participants do EXERCISE 5.2 and EXERCISE 5.3.
6. Go over the Answers EXERCISE 5.2:

Abbreviation Generic name
d4T stavudine
AZT Zidovudine (also ZDV)
3TC lamivudine
NVP nevirapine
EFV efavirenz
Circle the one that is included 3TC
in all 4 1st line regimens.
The 2 abbreviations for AZT, ZDV
zidovudine are:
Examples of answers for EXERCISE 5.3 could be as follows

d4T-3TC-NVP Triomune
AZT-3TC Duovir
NVP Nevimune
AZT-3TC-NVP Duovir-N
Benefits of ART 15 minutes
7. Ask: What are the benefits of ART? Write them on the flipchart.
8. Now have the participants read have a look to the Figure: showing impact of ART on
CD4 and viral load in the participant manual. (that illustration can be used to explain to
the patients.
9. Ask: Who can explain this figure?
10. Then, have the participants do EXERCISE 5.4. You can address the questions to the
whole group, as a drill.

Answers EXERCISE 5.4:
1. How many different drugs do we 3

need to take in order to have an
effective regimen?
2. Is d4T-3TC-NVP used as a first-line First-line
or as a second-line regimen?
3. What are the 2 main goals of ART? To reduce the number of virus in
the blood and increase the number
of CD4 as much as possible.
4. What is a second-line regimen? Another combination of 3 ARV
drugs (usually 2 NRTI and 1 PI) that
are used if there is a failure of
therapy on the first-line regimen.
5. What happens if we do not take the Resistance can occur.
combination of several antiretroviral
drugs?

CHAPTER 6: Adherence and Resistance
Duration: Purpose: To understand adherence and resistance

30 minutes
Materials:  Describe what adherence means
YES/NO cards  Describe what resistance means
 Explain the link between adherence and resistance
 Explain the consequences of resistance
 Explain what failure of therapy means
 Be able to use an effective local description to explain the danger of
Preparation: resistance in the community
None

Defining adherence and Reading, Discussion, 30 minutes
resistance Drills

Adherence and resistance 30 minutes
2. Ask for volunteers to read aloud the chapter and comment each section with the group.
3. Do EXERCISE 6.1 and discuss as a group how to best explain resistance and the
negative impact on both the individual and the community in your community.
4. Now, do the following adherence and resistance drill:
Materials: need YES/NO cards for this drill
Read each statement and tell participants: If you agree with the statement, put your
green YES card in the air. If you do not agree, put your red NO card in the air (Right
Answers in parenthesis).
Adherence and Resistance Drill Answers

1. Being adherent means that you take the correct numbers of pills each NO
day, even if you do not take them always at the same interval.
2. HIV can make variations of itself, by accident, even in patients who are YES
not taking ART.
3. Resistance is a change in the virus that makes the antiretroviral drugs YES
ineffective.
4. When a patient is not adherent, the patient will develop failure of therapy YES
and become sick again.

CHAPTER 7: ASSESS and provide clinical care
Duration: Purpose: To learn to assess the patient and provide clinical care
70 minutes
 Explain why doing the complete assessment is crucial in HIV/AIDS
Materials: patients
Clinical review  Do the complete assessment (including clinical review section 3.1
form (Annex A); and 3.2, pregnancy and contraception status, TB status section 5 of
Patient Chronic HIV Care guideline module)
Treatment  Understand meaning of clinical signs and symptoms in HIV patients
Record (Annex not yet on ART
B)  Determine what clinical care patient needs

Wallcharts:
Clinical review How to do a clinical Reading, Demonstration 30 minutes
review with EPT
Preparation: Review of functional Drill 10 minutes
Meet with EPT to status
prepare
demonstration Assess family status Reading, Discussion, 10 minutes
Drill
Review TB status Drills 10 minutes
Provide clinical care Reading, Drill, 10 minutes

Explanation and Q&A

How to do clinical review 30 minutes
1. Read through learning objectives aloud.
2. Ask for volunteers to read 3.1 through 3.5 of the Chronic HIV Care guideline module
while reading the explanations in the manual. Have them read up to 2: Assess family
status. Explain that we will go over how to ask about adherence later.
Tell the participants that they have an example of the Clinical Review form in the back of
their manual (Annex A). Give a photocopy/sample of the form to each participant.
3. Role-play (conducted by a facilitator with an expert patient-trainer or a co-facilitator).
Facilitator should meet with the EPT/co-facilitator outside of the class while the
participants are reading to discuss the role-play. Tell the EPT/co-facilitator to say that
s/he has diarrhoea and history of pulmonary TB. The EPT/co-facilitator may expand
accordingly in the case as well as for the rest of the review.
Have the participants use the form as you do the demonstration of the clinical review with
the expert patient-trainer/or co-facilitator of a clinical review of signs and symptoms (NOT
including adherence to medications). Tell them to circle the positives i.e. when the patient
says "yes" to diarrhoea or another symptom. Have them decide what clinical stage the
patient is in at the end of the role-play and fill it in the form.
4. Go over the stage together (Clinical stage 3).
Review functional status 10 minutes
Explain the 3 different functional status: W, A, B.
Ask: What status did the patient had in the role-play? Tell them to circle it in the form.
5. Drill: Facilitator should give the following examples and ask participants to determine the
patient’s functional status:
Drill: Functional Status Answers

1. 22 year-old HIV+ man who is attending school. W
2. 55 year-old HIV+ man who owns a business and is still running it. W
3. 59 year-old HIV+ woman who is a retired teacher but still does the W
housework.
4. 43 year-old HIV+ thin man who is unable to get out of bed most days B
because he feels “too weak.”
5. 29 year-old HIV + woman who is no longer able to work most days. She A
used to own a business and take care of things at home, but lately she has
had to rely on her brother to do this.
6. 37 year-old HIV+ woman who takes care of the children at home and does W
housework.

Assess family status 10 minutes
6. Assess family status: pregnancy, family planning, and the child’s HIV status.
Ask a volunteer to read section 4 in the guideline module on how to assess pregnancy
status, last menstrual period, use of contraception.
Explain that they should also ask questions to explore whether the woman is considering
having a child.
Explain that they should ask the woman if she does have children, and if so, ask about
whether or not her child has been tested yet.
Emphasize it is also important to ask these questions to men.
7. Drill: What is the status and what is the plan? This drill is about how to respond to
woman who is:
 pregnant,
 not pregnant and on contraception,
 not pregnant and not on contraception,
 breastfeeding
Drill: Review pregnancy status— Answers

Section 4
1. What should you ask to any HIV+ Sexually active?
woman of reproductive age coming to Date of last menstruation?
the health centre? Using contraception?
Breastfeeding?
2. What would you advise to a HIV+ If you are sexually active, it is still
pregnant woman whose partner is important to use condoms for protection in
HIV+? order to prevent re-infection.
3. What would you advise to a HIV+ It is important to use condoms for
pregnant woman whose partner is HIV- protection in order to prevent passing on
? HIV to your partner.
4. What would you advise to a non It is still important to use condoms for
pregnant HIV+ woman on contraception protection in order to prevent re-infection
whose partner is HIV+? as well as other STIs.
5. What would you advise to a non It is important to use condoms for
pregnant HIV+ woman on contraception protection in order to prevent passing on
whose partner is HIV-? HIV to your partner and to protect both of
you from other STIs.
6. What would you advise to a non Assess if woman is trying to be pregnant.
pregnant HIV+ woman not on Offer family planning i.e. oral contraceptive
contraception whose partner is HIV+? pills and stress the importance of condoms
to prevent re-infection—dual protection.
7. What would you advise to a non Assess if woman is trying to be pregnant.
pregnant HIV+ woman not on Offer family planning i.e. oral contraceptive
contraception whose partner is HIV-? pills and stress the importance of condoms
to prevent passing on HIV to the partner—
dual protection.

8. What would you advise to a woman Provide or refer for safer infant feeding and
who is breastfeeding? PPTCT interventions. Counsel on choice of
how to feed her infant and then support her
in that choice. Provide good support for
exclusive breastfeeding. Continue ARV
therapy when breastfeeding. Support
replacement feeding if this is her choice.
Review TB status 10 minutes
8. Explain the TB dial in section 5 in the Chronic HIV care guideline.
9. TB Drill: Where does the patient belong on the TB dial? Point to the segment of the dial.
TB Drill: Part 1
Case Answers—where on dial and what to

write on card
Patient has had a cough for 4 weeks. On
the last visit sputums were sent. Two Active TB: TB Rx (start treatment)
sputums are positive. Do CD4 for ART eligibility
Patient has had fever and is losing weight.

You can find no cause for the weight loss Suspect TB. Refer to RNTCP centre
other than HIV infection. (sputums)
Patient has no signs or symptoms of TB

No suspicion of TB: No signs.
Do regular TB screening
Patient has completed three months of TB

treatment. Active TB: TB Rx.
Do CD4 for ART eligibility
Patient returns for follow-up. Two weeks

ago he complained of 2 weeks of cough No suspicion of TB: No signs
with yellow sputum. You gave him Do regular TB screening
amoxicillin, and he is no longer coughing.
Both sputums are negative.
Patient was treated after being referred to

the hospital for a large neck node and is Active TB: TB Rx
now on TB treatment. Do CD4 for ART eligibility
Patient had TB last year and finished

treatment 5 months ago. She has no No suspicion of TB: No signs
cough, night sweats, or nodes. Do regular TB screening

12. TB Drill: Part 2
What should you do in these cases and what is the TB status?
Case Answers
HIV + man with cough for 4 weeks Suspect TB: Sputums: refer to
and no other symptoms. RNTCP/DOTS centre fro TB screening
HIV+ man with fever and weight loss Suspect TB: Refer to RNTCP/DOTS
for weeks, denies cough. No nodes, centre for TB screening
not producing sputums.
HIV+ woman with cough who has Record results and insure adherence
returned for the results of the sputum to ATT
test: sputum test is positive; started
on ATT
HIV+ woman with cough who has In Acute Care guideline p. 67—Since
returned for the results of the sputum still coughing, refer to clinician if
test: sputum test is negative and available, or treat with non-specific
patient is still coughing. antibiotic such as cotrimoxazole or
ampicillin. If cough persists, repeat
sputums.
13. Help participants review the assessment including the clinical review, functional status,
family status, and TB status. Explain that they will be using these skills in the following
day skill station.
Provide clinical care 10 minutes
14. Read section 6.1 in Chronic HIV Care guideline module and provide explanation.
15. Explain why we do specific treatment and symptomatic management. Explain why these
items are here (e.g. depression, drug and alcohol use interfere with adherence).

13. Have participants read cases at the beginning and at the end of the chapter and
answer to the questions.
Sushma answers:
1/ Stage 2,
2/ Stage 2
3/ The doctor looks section 6.1 of the Chronic HIV Care guideline module. There it is
indicated to go to the Acute Care guideline module in case of new symptoms. She finds
the treatment for herpes zoster on p. 43 of the Acute Care guideline module.
The doctor gives Sushma painkillers and some amitriptyline at night. She also gives a
local disinfectant to put on the blisters.
The doctor asks about Sushma 's new partner. He is also HIV-positive.
Manish answers:
She should refer Manish to the higher level centre for further assessment for TB and
other causes of persistent fever.
Kumar answers:
The nurse advises Kumar on nutrition, to keep his weight up. She finds the information
she needs in the Chronic HIV Care guideline module section 11.4 and the Palliative Care
guideline module p. 23. She was referred to those pages when reading section 6.1 in the
Chronic HIV Care guideline module. The nurse also explains the treatment for the itching
rash (chlorpheniramine tablets, and calamine lotion).
Let participants know that this is a lot of information but that they are doing a good job.
Remind them that for the skill station, they should review the clinical staging and the clinical
assessment.

Chapter 8: How to use the Patient Treatment Record
Duration: Purpose: Introduction to using the Patient Treatment Record

30 minutes

Blank  Understand the importance of keeping the correct data in HIV
flipchart/markers; patients
Patient  Understand how the Patient Treatment Record is used
Treatment  Fill out the Patient Treatment Record
Record and
Green book

Preparation: How to use the Reading, Explanation, 30 minutes
None Patient Treatment EXERCISE 8.1
Record

How to use the Patient Treatment record 30 minutes
1. Read learning objectives aloud and emphasize the need of a good patient monitoring
system
2. Show the participants Annex B which is the Patient Treatment Record
3. Go through the sections 1 to 3 of the summary Page together, and explain that these
sections are those that can be filled and completed by the nurse and/or the counsellor.
Note that in the section 5, the weight, height and functional status can also be filled by
the nurse.
4. Do EXERCISE 8.1 using a blank record. This exercise can be done individually (with
debriefing in group) or as a group. Ask to the participants to fill the Patient Treatment
Record according to the information provided.
5. Instruct participants to use the Patient Treatment Record at the skill stations.

Chapter 9: Prophylaxis
Duration: Purpose: To learn about prophylaxis

50 minutes
Materials:  Explain the advantages of cotrimoxazole prophylaxis
Acute Care  Decide when to start cotrimoxazole primary prophylaxis
photobooklet;  Explain the dose of co-trimoxazole prophylaxis
cotrimoxazole  Recognise and manage adverse reactions of cotrimoxazole
tablets (if prophylaxis
available)  Know how to monitor patients on cotrimoxazole prophylaxis.
 Follow treatment plan from ART centre for other prophylaxis
 Explain about fluconazole prophylaxis
Preparation
None Content Methods Duration
Advantages of CTX Reading, Photobooklet 30 minutes
prophylaxis discussion.
Management of patients EXERCISE 9.1, 20 minutes

on cotrimoxazole Reading, Case
discussion
Fluconazole prophylaxis Lecture 5 minutes

Prevention of opportunistic infections: advantages of CTX
prophylaxis 30 minutes
2. Ask for a volunteer to read about prevention of opportunistic infections in the chapter
up to “Cotrimoxazole side effects”.
3. Ask for a volunteer to read page Section 7.1 in the Chronic HIV Care guideline module
and then the chapter together using the photobooklet.
4. Look at photos of reaction to cotrimoxazole (rash, fixed drug reaction, Stevens-Johnson

reaction). Go over these in photobooklet and give explanations.
Management of patients on CTX prophylaxis 20 minutes
5. Ask for a volunteer to read “Monitoring” in the chapter. Explain when cotrimoxazole can
be stopped.
6. Have the participants do EXERCISE 9.1, then go over each answer individually.
Answers for EXERCISE 9.1:

1. A 25 year-old woman comes to the 1/ Yes;
consultation. She has been referred from 2/ 32, for one month;
the testing centre with a positive test for 3/ Cotrimoxazole is important because
HIV. She has white patches in her mouth will help to prevent a brain infection
and weight loss. 1/ Does she need (toxo brain abscess) which can cause
cotrimoxazole prophylaxis? 2/ How many paralysis on one side of the body,
pills will you give to the patient? 3/ What pneumonias, and some types of
will you explain? 4/ Will you refer her for diarrhoea
CD4 count? 4/ yes
2. A 34 year-old comes asking for ART.
He has known he is HIV+ for 2 years. He Explain to him the benefits of
is bothered by seborrhoea and recurrent cotrimoxazole prophylaxis and refer him
mouth ulcers. He had herpes zoster 2 for CD4 testing. Tell him that ART is not
years ago. He has no signs of stage 3 or an emergency.
4. How would you respond? What can be
offered?
Fluconazole prophylaxis 5 minutes
7. Ask participants if they see patients on fluconazole prophylaxis. Look briefly at guidelines
in Section 7.2.

8. Ask for the volunteers to read each of the stories at the end of the chapter, and to
answer to the questions
Answers for Kumar:
The doctor tells all she knows about prophylaxis. He agrees to take it, and she gives him
a 32-day supply.
The doctor arranges a follow-up date in one month, to see if Kumar tolerates the drug
and is adherent.

CHAPTER 10: Adherence Preparation
Duration: Purpose: Introduction to preparing a patient for ART

60 minutes
Materials:  Use the 5 A's to prepare patients for ART adherence
Blank  Assess the patient's goal for today's visit
flipchart/markers;  Assess the patient's understanding of ART
Flipchart for  Assess the patient's interest in receiving ART
Patient Education  Give complete advice to the patient about HIV/AIDS and ART
 Check that the patient is willing and motivated and agrees for ART
 Help the patient to develop the resources/support/arrangements
needed for adherence
 Make arrangements for follow-up after the ART preparation session
Preparation  Discuss case with clinical team to propose patient to start ART
Meet with EPT or
co-facilitator to
prepare Content: Methods Duration
demonstration
Use of the 5 A's to Demonstration with 30 minutes
assess readiness for EPT, EXERCISE 10.1
ART
Preparation for ART Case discussions 30 minutes

Use the 5 A’s to assess readiness for ART 30 minutes
2. Ask for a volunteer to read Section 8.9 in the Chronic HIV Care guideline module.
Explain that the chapter provides additional explanation and examples but what they will
rely on is in the guideline module. The guideline module text is highlighted in bold in the
participant manual chapter.
3. Read chapter and comment (note: the facilitator will have to evaluate how she/he would
like to proceed: ask volunteers to read aloud and comment, or comment and ask
questions to the participants…)
4. EXERCISE 10.1: Divide the participants in small groups and distribute equally the
questions (different questions to each group), and ask each group to report the answers
to the whole group.
Preparation to ART 30 minutes
5. Refer the participants to the Flipchart for Patient Education and explain how to use it.
Refer them to the Basic ART part—they should not just be reading from the back. They
need to learn to use it as a communication aid.
6. Ask: “What are conditions that can be a problem for adhering to ART?”
Write suggestions of the class on a blank flipchart. Explain what is relevant and what is not.
7. Do the following demonstration: Explain that 2 facilitators, or one facilitator and one
EPT, will do a role play (taking into consideration the examples selected).
Role-play:
32 year-old patient, who tested HIV+ three years ago. The patient has been followed at
the clinic in the past year. The patient completed TB treatment for pulmonary TB one
month ago, and he has had chronic diarrhoea for more than one month which has been
helped somewhat by antibiotics. Latest CD4 count is 180 cells. You decide he is
medically eligible for ART and you need to assess if he is ready for it. The patient has
been on cotrimoxazole in the past but had some problems with adhering to it and
sometimes had problems with the TB medications as well.
Use this case to demonstrate 5 A's using the examples of problems of adherence that
are generated in class.
Ask the class to write down at least one example of each of the 5 A's discussed during
the role play.
Discuss how the 5 A's were used in the role play.
What was skipped? How would they have used the 5 A's differently?

8. Now have the participants read the cases at the beginning of the chapter. Go over
as a group possible ways to discuss preparation for ART for these cases.

CHAPTER 11: Four First-Line ARV regimens
Duration: Purpose: Learn to use the four first-line ARV regimens

70 minutes
Materials:  Explain the four first-line regimens
Nevirapine,  Determine the correct dose for the 4 first line ARV regimens
efavirenz,  Advise patients on how to take each of four first-line regimens
zidovudine,  describe three ways ARV drugs interact with other drugs;
stavudine,  avoid or minimize drug interactions
lamivudine tablets
(single or
combination
tablets, whatever
available locally); Content Methods Duration
Copies of the
Patient Education First-line ARV regimens Lecture, discussion, 45 minutes
Cards (Annex D demonstrations
participant EXERCISES 11.1, 11.2
manual) First line ARV drugs Lecture and Exercises 30 minutes
interactions 11.3 and 11.4
Preparation
Prepared flipchart
with Sun/Moon
chart for all
regimens

First-line ARV regimen instructions 45 minutes
2. Ask for a volunteer to read, or explain yourself, the Section 8.5, in the Chronic HIV
Care guideline module, to understand the 4 first line regimens.
3. Briefly introduce the Patient Education Card (Annex D of the participant manual) for
each first-line regimen.
4. Explain dose escalation of NVP.
Ask: In the first 14 days of treatment, how many FDC tabs and separate tablets are given
for the regimen d4T-3TC-NVP?
5. Show the examples of sun/moon pill chart for all the regimens that you have drawn on
blank flipchart.
6. Dosing Drill: Give a regimen for a patient. Ask a participant to explain the dose for the
patient for one day. Have the participant write the prescription on a sun/moon pill chart for
the patient, using a blank sheet from the flipchart.
7. Refer the participants to the Patient Treatment Record and explain them how and
where the regimen would be filled = in the section 6 on summary/front page of the
Patient Treatment Record and in column 10 of the follow-upvisit record, section 9
8. Participants should do EXERCISES 11.1 and 11.2 at the end of the chapter. Discuss
answers in the group as needed.
Answers EXERCISE 11.1:

Write out the full names of the 3 drugs. Stavudine-lamivudine-nevirapine
What is the common name for the i.e. Triomune
combined tablet used in your area?
Savitha is starting on d4T-3TC-NVP. She needs to take an AM fixed dose
Instructions for the first 2 weeks on how combination of d4T-3TC-NVP and PM
to take the drugs. separate tablets of d4T (30mg) and 3TC
(150mg),
What instructions should be given to After 14 days she can take AM and PM
Savitha after 2 weeks if she has no combined tablets
problems?
EXERCISE 11.2:
Show bottles of the drugs. Have the participant arrange and explain the first 2 weeks
dose of d4T-3TC-NVP using the pills and including the number of tablets dispensed. If
you have other drug regimens available in pill bottles, have participants practise
arranging those regimens as well.

First line ARVs drugs interactions 30 minutes
9. Have the participants read Section 10.2 in the Chronic HIV Care Guideline module Avoid
first-line ARV drug interactions.
10. Have participants read the corresponding section Identify first-line drug interactions in
the Participant Manual to the end of the chapter.
11. Ask to the participants to do the EXERCISE 11.3, individually and comment the answers
with the group
nevirapine & oral contraceptive pill d4T-3TC-NVP & rifampicin
AZT-3TC-NVP & aciclovir, efavirenz & diazepam

ganciclovir
zidovudine & stavudine d4T-3TC-EFV & diazepam
AZT-3TC-EFV & phenytoin d4T-3TC-NVP & AZT, rifampicin; AZT

& cotrimoxazole
Answers for EXERCISES 11.4:
2. If the patient is a woman who is taking Avoid a regimen containing NVP or use
an oral contraceptive, what advice would additional protection or switch to
you give? another form of contraception as the
efficacy of the estrogen-based OCP is
decreased with NVP.
3. If a patient is being treated for Nevirapine
tuberculosis with rifampicin, which ARV
drug should he avoid? Both drugs work on the liver. Rifampicin
will cause the blood levels of nevirapine
For what reason? to be lower which can cause HIV
resistance. Also, both drugs together
can be toxic to the liver.
What ARV drugs can he take? Efavirenz

4. If a patient is taking d4T-3TC-EFV, what Do not give with diazepam, or other
other advice would you give the patient? benzodiazepines except lorazepam,
phenobarbitol, phenytoin, protease
inhibitors (ARV). Avoid eating highly
fatty meal with EFV
12. Ask to the participants to read the continuation of the 3 stories at the end of the
chapter
13. Review the objectives

Chapter 12: Managing side effects and other causes of new
symptoms and signs in patients on the four first-line ARV regimens
Duration: Purpose: To learn to management of side effects and new symptoms

70 minutes in patients on first-line ARV regimens.
Materials:  Explain the 3 different categories of side effects
Blank  Describe the most common side effects for each ARV drug used in
flipchart/markers; the first-line ARV regimens
 Give an adequate explanation of the most important side effects to
Side effect colour patients
cards  Explain to patients what to do if side effects occur
 Understand the possible explanations when new signs and
symptoms develop in a patient taking ART
 Identify and manage simple side effects
Preparation:  List which side effects need advice or referral
None

Common side Reading, Case 30 minutes
effects of each drug discussions;
3 different categories EXERCISE 12.1
of side effects
Clinical review Reading, 10 minutes
Explanation
Management of side Reading, 30 minutes

effects EXERCISE 12.2,
12.3

2. Ask those who have been around patients on ART—what are the most common side
effects you have seen? List them on the flip chart.
3. Read the clinical cases at the beginning of the chapter and discuss the cases.
The common ARV side effects 30 minutes
4. Explain the 3 types of side effects, using the information in the participant manual
5. Do EXERCISE 12.1 Side Effects Write the name of each first line drug on a separate
piece of paper and stick to the wall. Distribute a side effect card to each participant and
have the participants match them to the drugs.
6. Read section 8.7 in the Chronic HIV Care guideline module. The Patient Education Cards
are in Annex D. Point out the sections which talk about what to do with side effects
pertaining to the regimen. Also point out the prevention side of the card which is also
important for the patient to see.
7. Discuss what you should warn patient about; how to cope and when to seek care. Give
simple instructions.
Clinical review in patients on ART 10 minutes
8. Ask participants:
 What is the general difference between what the patient with HIV and
immunosuppression can have versus a patient without HIV?
 What about the HIV+ patient on ART versus before ART?
Refer the participants to the table “possible causes for signs and symptoms”, in this section
of their participant manual. For better understanding, you can write that table, step by step,
and commenting each of the three situations, on a blank flipchart
Management of side effects 30 minutes
9. Ask for volunteers to read from Immune reconstitution syndrome to the end of the
chapter and comment.
10. Then look at the table in section 8.12 in the Chronic HIV Care guideline module and
discuss some of the signs or symptoms
11. Have participants do the role-plays in EXERCISE 12.2 and tell them to use the
Patient Education Card to explain the regimens and side effects to the patient during the
role-play. Note: if you have some time constrains, do it as a drill by addressing questions
to the group

CHAPTER 13: Support ART initiation then monitor and support
adherence
Duration: Purpose: Learn to support initiation of ART, then monitoring and

75 minutes support of adherence

Blank  Assess and support adherence
flipchart/markers  Understand the importance of constructing a team with other people,
to increase your patient's adherence: friends, treatment supporter,
Pillbox home care teams, support groups
 Explain why safe sex is important, even when taking ART
 Recognise barriers to adherence
Preparation  Provide solutions for barriers to adherence
Meet with EPT
 Use a simple pill chart (including pill charts for patients who cannot
read)
 Give several practical tips to the patient on how to remember to take
the drugs
 Know the limitations of each method of assessment of adherence

Support ART initiation Reading, Case 20 minutes
discussions
Monitor and support Lecture, reading,

adherence Exchange and 40 minutes
discussion
● Barriers to adherence Exercise 13.1
● tips for adherence discussion
● Pill counting exercise
Experience of an EPT 15 minutes

1. Read learning objectives aloud and the note.
Support ART initiation 20 minutes
2. Refer the participants to the Section 8.9, in the Chronic HIV Care guideline module:
Support ART initiation”
=> comment the information with the participants (use also the information of the
participant manual) . Make the discussion interactive by asking to the participants,
some examples, stories, experiences of their professional practice or personal life
Monitor and support adherence 40 minutes
3. Refer the participants to the Section 8.9, in the Chronic HIV Care guideline module:
“Monitor and support adherence”
Assess
Barriers of adherence
4. Ask participants what factors might interfere with adherence for their patients and list
these on a blank flipchart. Make sure that all factors listed in their manuals are on the list.
5. Have the participants doing the EXERCISE 13.1. Then discuss what they have written
Tips for adherence
6. Ask participants to list ways to remember taking ART at the right time. Write this on the
blank flipchart.
Count pills
7. Explain how to assess adherence. calculating the adherence percentage Read section,
Count pills in the participant manual, together with the participants.
8. Use a blank flipchart to write examples on how to calculate the examples and creat
examples to practise with the participants (e.g. patient misses 5 pills, no pills, 10 pills, etc).
Show where adherence is recorded on the Patient Treatment Record.
9. Go through the other 5 A’s of ‘Monitor and support adherence” = Advise, Agree, Assist
and Arrange
10. Ask an Expert Patient Trainer to share his/her experience on adherence to the ART
(15 minutes)
 How was the preparation to ART?
 Did she/she face difficulties?
 What are the solutions that she/he found?
 Does she/he have any support from other people?
11. Have the participants read the clinical cases at the beginning of the chapter and then
discuss them.
12. Review the objectives

CHAPTER 14: Integrating Prevention with Treatment
Duration: Purpose: Learn how to integrate prevention with treatment

70 minutes
Materials:  List the different ways of getting infected with HIV
Blank  Explain and demonstrate the most common ways of preventing
flipchart/markers; HIV transmission through sexual contact
Flipchart for  Learn to efficiently counsel the patient on prevention during every
Patient treatment encounter, using the patient education flipchart or the
Education; backside of the Patient Education Cards
Male condoms
and model Content Methods Duration
penises or
bananas Linking ART with Case discussions, 15 minutes
increased prevention EXERCISE 14.1
Modes of transmission of Discussion, Drill, 30 minutes

Preparation HIV EXERCISE 14.2
None
Counselling patients on Q&A, EXERCISE 14.3 15 minutes
prevention at every
encounter
Safer sex for high risk Lecture and discussion 10 minutes
individual settings

2. Ask for volunteers to read through the clinical cases at the beginning of the chapter
and discuss the questions.
Linking ART with increased prevention 15 minutes
3. Ask to the participant “why it is important to continue to talk about prevention when
the patients are on ART?”.
 to comment, use the information in the section “Linking ART with increased
prevention” in the participant manual
Break into small groups and do EXERCISE 14.1.
Modes of transmission of HIV 30 minutes
4. Have them read the story of Priya and Ramseh and answer the questions at the end of
the story. Then go through the answers together.
Ramesh and Priya story answers:

1. How and by whom was Ramesh infected with By the sweet lady
HIV?
2. How and by whom was Priya infected with HIV? Ramesh
3. How and by whom was Mahesh infected with Priya
HIV?
4. Do you think Mahesh died of AIDS? Yes
5. Why didn't Rajesh get HIV? 1 in 3 children of HIV+ mothers
will get infected (without
prophylaxis)
6. How much time was there between the infection 5 years
of Ramesh and the year he started to have serious
symptoms?
7. How much time had passed between the time 7 years
Ramesh got infected and the time he died?
8. Why was Priya sick shortly after marriage? Acute viral syndrome
5. Have participants list all the ways of getting infected with HIV and record using the
blank flipchart.
6. Do EXERCISE 14.2.
Counselling patients on prevention 15 minutes
7. Have them look at the Flipchart for Patient Education and review the prevention part.
Tell them to practise giving advice about prevention with each other using the Flipchart
and not reading it.
8. Remind them about the back side of the Patient Education Card (Annex D) and the
prevention messages on it.
9. Read with them the section on “Ways to prevent infection with HIV”

10. Do EXERCISE 14.3: Practise demonstrating condoms
 One facilitator can do a good and complete demonstration
 Divide the participants by pairs (or small groups);
 Provide penis model and condoms and have each participant practicing the
demonstration for his/her colleagues
Safer sex for high risk individual or settings 10 minutes
11. Read the box on the “Safer sex for high risk individuals/settings” and comment it with
the participants
Note: To illustrate and discuss these issues, you can ask one of the EPTs and a facilitator to
demonstrate one of the cases on CWS or MSM (available for skill stations)

Chapter 15: Universal precautions, Occupational exposure and Post
Exposure Prophylaxis
Duration: Purpose: To understand the general safety practices to be taken while

90 minutes caring for clients, and precautions to be taken against accidental exposure
to infective and potentially infective body fluids in the health care setting

Blank  Recall the principles of universal precautions.
flipchart/markers;  Know the body fluids which are at risk of transmission of HIV
blackboard,  Use universal precautions within the available facilities while caring for
duster and chalk, patients or while handling potentially infections materials
plane paper and  Be aware of steps to be taken during an accidental exposure.
pen/pencil  Be sensitized to the meaning of Post Exposure Prophylaxis
 Identify the situations where PEP should be used
Preparation:
Prepare Content Methods Duration
wallchart: Introduction to Universal Discussion and explanation 10 minutes
Body fluid to precautions
which universal
10 minutes
precaution apply,
Body fluids and universal Exercise 15.1
Components of
precautions
Universal
precaution and Components of universal Discussion 45 minutes
PEP precautions Exercise 15.2
Occupational exposure Discussion 15 minutes
protocol
Reflective exercise, 10 minutes
Indications of PEP Explanation, discussion

1. Read the learning objectives aloud
Introduction to the universal precautions 10 minutes
2. Ask to the participants the definition of the universal precautions
3. Explain the cardinal rules
Body fluids and universal precautions 10 minutes
4. Exercise 15.1: Distribute small chits of paper with the name of body fluid in it. Ask
participant to identify the body fluids which are at risk of HIV transmission and to classify
them on the table that you had prepared on a flipchart. Tell to the participants to take note on
the same table in their manual.
Body fluids considered at risk of HIV Body fluids NOT considered at risk
transmission of HIV transmission
Infectious body fluids or secretions Non infectious body fluid or

 Blood secretion
 Semen  Feces
 Vaginal secretions  Nasal secretions
 Any visible bloody body fluid  Saliva
 Sputum
Any potentially infectious body fluid  Sweat
or secretion  Tears
 Amniotic fluid  Urine
 Breast milk  Vomitus
 CSF
 Pericardial fluid (Unless they contain visible
 Peritoneal fluid blood)
 Pleural fluid
 Pus
 Synovial fluid
Components of universal precautions 45 minutes
5. Ask to the participants what are the components of Universal precautions,

Ask them what universal precautions are applied in their health facility
Explain, comment them, one by one (use information in the participant manual).
Hand washing and hygiene

Using protective equipment
Preventing accidents
Proper use of disinfecting techniques and sterilization
Disposal of wastes

Method of disposal of specific wastes
6. Ask to the participants what the methods of disposal are needed for each type of waste
and what it is done at their health facility
Wastes Examples Method of disposal

Liquid  Blood  Flush into the sanitary sewer or pit
 Urine latrine
 Stool
Solid  Soaked dressing  Burn or carefully bury

 Sanitary pads /  Incinerate if possible
napkins  Avoid placing these materials in open
 Placenta dumps to which animals and children
 Tissue biopsy have access
specimens  Avoid burying where there is a
possibility of it being dug up or where it
might contaminate water sources
Sharp 
 Needles Dispose into puncture proof containers.
instruments
 Scalpel Bottles with a narrow neck is well
 Blades suited for the purpose.
 Disinfected with chemicals or autoclave
or incinerate before disposal
Precautions in the event of handling potentially infective material
7. ere is a blood / body fluid spill

7. Exercise in groups
The purpose of this exercise is to help participants become aware of the steps to be taken in
the following situation. Divide the group into three and give each group one topic to
discuss. After 10 minutes, ask to the groups to report: the groups can present a role play, or
a flipchart….
Group 1: As you are, collecting blood for lab tests, blood spilled on the floor. How will
you clear the blood spill from the floor?
Group 2: While starting an IV line for a patient blood stain is found on the bed linen.
How is the linen with blood stain cleaned?
Group 3: A 39year old lady, HIV+, died at your health centre. How will you handle the
body after death?

Occupational exposure protocol 15 minutes
8. Case study: Ms Sheela gets a needle stick injury while collecting blood from a restless
patient..
- what should Ms Sheela do immediately
- to whom and when should Ms Sheela report after the incident?
- How high is the risk of infection to Ms Sheela?
- What tests to be carried out for Ms Sheela and what counseling has to be
given?
- For how long should she take PEP medication?
9. Ask to the participants which is the protocol to follow after an occupational exposure
•Crisis management
•Immediate care
•Recording and reporting
•Risk assessment
•Testing and counseling
•PEP medication
•Follow- up
10. Explain, comment them, one by one (use information in the participant manual).
Indications of Post Exposure Prophylaxis (PEP) 10 minutes
10. Ask to the participant the definition of the Post exposure Prophylaxis and the
indications for PEP
Small volume  Few drops of blood / body fluids / other potentially Basic Regimen
infectious materials (OPIM) AZT + 3TC twice daily
 Short duration
Less severe  Solid needle (no bore in it) for 4 weeks (28 days)
 Superficial scratch
Large volume  Several drops of blood / body fluids / OPIM Advanced Regimen
 Long duration (several minutes or more) AZT + 3TC twice daily
More severe  Large bore hollow needle + Indinavir every 8 hours
 Deep puncture
 Visible blood or needle used in persons artery /vein for 4 weeks (28 days)

CHAPTER 16: Special considerations for ART in pregnant and post-
partum women
Duration: Purpose: To learn about special considerations for ART in pregnant

60 minutes and post-partum women

Blank  Know when pregnant women are medically eligible for ART
flipchart/markers  Know which ARV drugs pregnant women cannot take
 Explain the difference between ART and ARV prophylaxis to
prevent mother to child transmission of HIV
 Describe special considerations for ART adherence during
pregnancy and post-partum
 support HIV-infected women and their partner get PPTCT
interventions and refer them appropriately
Preparation:
None
Content: Methods Duration
Eligibility for ART in Reading, Case 10 minutes

pregnant women discussions
PPTCT interventions Group exercise, 20 minutes

brainstorming
ART and ARV Explanation, 30 minutes

prophylaxis Discussion,
EXERCISES 16.1,
16.2

2. Refer the participants to the section on special considerations in pregnant women in

section 8.6 of the Chronic HIV Care guideline module.
Eligibility of ART for a pregnant woman 10 minutes
3. Explain the eligibility criteria for ART in pregnant women: refer the participants to the
table in their manual. .
Emphasize: Highest priority for CD4 testing should be given to pregnant women
PPTCT interventions 20 minutes
4. Lead a group brainstorm on PPTCT:
 Step 1: Ask participants to briefly describe what they do in their clinics to prevent
mother to child transmission of HIV. Record on flipchart. Note if they have PPTCT
program.
 Step 2: Ask PPTCT program staff to list the key points of their PPTCT program.
Record on flipchart.
 Step 3: Summarize the exercise by highlighting the PPTCT interventions they are
currently providing.
 Step 4: Conclude exercise by stressing PPTCT gaps in existing services.
(Please note that we are not trying to quickly teach PPTCT interventions for safer labour and
delivery or counselling on infant feeding choice. We do want to relate what we are teaching in this
course to what they may be practising in providing PPTCT interventions, to make them realize ART
is a PPTCT intervention, and to be sure pregnant women receive the other PPTCT interventions
which are available).
ART and ARV prophylaxis in the context of pregnancy 30 minutes
5. Lead the following discussion on ART and ARV prophylaxis for pregnant women
Step 1: Explain the difference between ART and ARV prophylaxis.
 ART is the provision of a combination of 3 ARV drugs that are prescribed for the life
of the patient. It is only appropriate for pregnant women with advanced disease.
 ARV prophylaxis is the short-term use of one drug, Nevirapine (200mg) at onset of
labour. The infant should also receive ARV prophylaxis (nevirapine) as soon as
possible after birth, within the first 72 hours.
 ARV prophylaxis is appropriate for all pregnant women who are not on ART in
order to PPTCT of HIV
Step 2: Stress the need to provide the other PPTCT interventions even if a woman is on
ART.
 Prepare a flipchart with the headings below.
 Conduct a group brainstorm and ask the group to fill in the correct responses that
are listed in bold.

 At the end of the brainstorm record any responses that were not mentioned.
 Remind the group that Labour and Delivery and Safer Infant Feeding Counselling
require special PPTCT training.
PPTCT in HIV+ Woman on ART PPTCT in HIV+ woman not yet

medically eligible for ART
 ARV prophylaxis to baby  ARV Prophylaxis to mother and

baby
 Safer Labour and Delivery
Interventions  Safer Labour and Delivery
Interventions*
*
 Counsel on Safer Infant Feeding
 Counsel on Safer Infant Feeding
6. Now have the participants do EXERCISES 16.1 & 16.2 at the end of the chapter.
All the regimens without EFV are safe to start in pregnancy in a woman without anaemia.
EFV should not be given during the first trimester of pregnancy.
Choose a couple of questions or do the entire exercise if the time permits it

1. A 22-year-old woman comes to the consultation. She has been sent for testing by the
antenatal care nurse. She is HIV+, but is very surprised, since she feels very healthy and
does not suffer from any disease. The physical exam is normal. She is 4 months
pregnant. You assess her and conclude that she is in clinical stage 1. What type of
intervention(s) does this woman need?
Refer for CD4 testing. Explain, advise PPTCT interventions: If she is not eligible for
ARTshe will receive ARV prophylaxis: nevirapine 200mg single dose at the onset of
labour, her baby also need ARV prophylaxis.
Arrange for counselling on infant feeding options (if you have not been trained to do
these)
2. A 25-year-old woman is pregnant. You think she must be no further than 2 months.
She is thin and she had just started TB treatment for smear-negative pulmonary TB. She
also had oral thrush 2 weeks ago. Her CD4 count is 260.What will you do?
This woman needs ART for her own health. The doctor may advise to start AZT-
3TC-EFV two weeks after the intensive phase finished. She should still be informed
on PPTCT interventions, and counselling on institutional delivery and infant feeding
options. Give CTX prophylaxis starting from 2nd trimester. She does not need ARV
prophylaxis as she is on ART. Her baby needs ARV prophylaxis.

3. A 26-year old HIV+ woman is 3 months pregnant. She feels fine and has no problems.
On one side of the trunk, you see scars from herpes zoster. What will you do?
You decide she is HIV clinical stage 2. Refer for CD4 testing. Do CD4. If her CD4
count is > 200 she is not eligible for ART. Counsel on institutional delivery, arrange
for counselling on infant feeding options. Give CTX prophylaxis starting from 2nd
trimester. She will be receiving ARV prophylaxis nevirapine 200mg single dose at the
onset of labour, her baby also need ARV prophylaxis.
4. A 24-year-old woman has been taking ART for 2 years. She tolerates the therapy,
and is adherent. Her weight has increased and she did not have any serious OIs
within the last 2 years. She was in stage 4 when she started ART. Her regimen is
d4T-3TC-NVP. She is now pregnant in her first trimester. What will you do?
Inform on the risk of PPTCT. Discuss the advantages of ART in reducing the risk of
HIV transmission; explain the risks and benefits of ART during the first trimester. She
should still be referred to someone trained in the PPTCT interventions (if health
worker is not trained), for counselling on institutional delivery and infant feeding
options. She does not need ARV prophylaxis as she is on ART. Her baby needs ARV
prophylaxis.
5. A woman is taking AZT-3TC-EFV for 6 months. Before, she took d4T-3TC-NVP,

but she had to interrupt it because she had a severe rash on NVP. Now she
comes to the health centre and tells you she is pregnant in her first trimester.
When she started ART, she was in stage 4, but now she feels fine. What will you
do?
This case should be referred. She needs ART for her own health. She needs to
interrupt the EFV containing regimen, but cannot use NVP anymore. The doctor can
put her on NFV or may need to stop all the drugs and then restart. She still needs
PPTCT interventions. Her baby needs ARV prophylaxis.
As a recap, have participants read the about Sushma and discuss how to manage
Sushma:
 The nurse informs Sushma that she should continue the drug. This regimen is not
harmful for the baby. Sushma needs the drug to stay healthy, but the drug will also
reduce strongly the risk that the baby acquires HIV infection. Sushma is happy about
this because it is very important to her that the baby is born negative.
 The doctor and/or nurse advises Sushma to go to the PPTCT program, to get advice
on safe delivery and infant feeding options.
 The doctor advises Sushma to continue the cotrimoxazole

Chapter 17: Special considerations in children
Duration: Purpose: To understand the differences in HIV care and ART

100 minutes management needs in children

Blank  Explain the key differences on HIV between adults and children
flipchart/markers;  explain how to diagnose HIV infection and do clinical staging in
examples of liquid children;
formulation of  recognize important opportunistic infections in children;
common  describe initiation of prophylaxis for HIV+ children
paediatric ARV's  explain the preparation and adherence support for ART for HIV+
(if available) children
 Describe the first line regimen and monitoring of ART for HIV+
children
 describe the nutritional and psychosocial needs to support children
Wallcharts: with HIV/AIDS;
Adult WHO
 Recognize how communicate with children and how to discuss
Staging table;
disclosure according to the age of the child
Paediatric WHO
Staging table
Preparation: Key differences adults Reading, Brainstorm/ 20 minutes

and children discussion
None
Diagnosis of HIV in
children
Clinical staging in Discussion, 10 minutes
children EXERCISE 17.1
Prophylaxis Lecture 10 minutes
Preparation and Discussion, Case 15 minutes

adherence support in discussion
children
First line ARV regiment Lecture 15 minutes
and monitoring of ART
Nutritional and Reading, Discussion, 20 minutes

psychosocial support
Good communication Discussion 10 minutes

and disclosure EXERCISE 17.2

Key differences in chronic HIV care between adults and children
10 minutes
1. Group discussion: Ask participants to discuss the possible differences between adults
and children as regards HIV infection and its treatment. List the differences mentioned by
them on a flipchart.
2. Refer them to page H 81 in the Chronic HIV care guideline module
Diagnosis and Identify HIV infection in children 10 minutes
3. Explain to the participant how to identify HIV infected children (information is on page
H82, H83, H86 in the Chronic HIV care guideline module and the participant manual)
WHO revised paediatric clinical staging 10 minutes
4. Discuss the differences in the clinical staging between adults and children. Hold the two
wallcharts and point out the similarities:
 Both have 4 stages.

 In both cases, stage 4 means initiate ARV's. And stage III alerts to consider ART.
 Look at the conditions in each stage and identify similarities and differences.
5. Ask participants to do EXERCISE 17.1 at the end of the chapter in Participant Manual.
Make sure everyone understands the correct answers.
Answers to EXERCISE 17.1:
1. Stage I
2. Stage III
3. Stage III
4. Stage III
5. Stage I
Prophylaxis in children 10 minutes
6. Explain and Discuss cotrimoxazole prophylaxis with the participants.

Preparation for adherence in children 15 minutes
Background information for the facilitator:
Adherence is the cornerstone of successful ART in children. It is important that the

child is involved depending on his/her age and maturity. Follow the same
principles as for adults as presented in section 8.9. Assess the caregiver's and the
child's:
 Interest in receiving ART

 Understanding of the importance of adherence to ARV
 Understanding of ARV therapy and the side effects
Help the caregiver develop the resources/support/arrangements needed for

adherence. At least three counselling sessions may be required to achieve the
above. The caregiver (or treatment supporter) should attend as many of these
sessions as possible. Discuss the formulations of the drugs to be taken. Discuss
how tablets could be divided into halves. Crushed tablets should be dissolved in a
small quantity of liquid to ensure that all of it is swallowed. Discuss what is
available at home that can be used to dissolve the tablet or to sweeten it e.g. milk,
honey, tea, or just water. If the child cannot swallow the tablet or syrup in one go,
he should be allowed to do that over a period of few minutes in divided doses.
Child's ability to follow the above depends on family and environmental factors
including the way s/he is brought up, educational and the psychosocial support
from parents, siblings and other guardians. The health worker should be guided by
parents as well as his or her maturity (i.e. the child's ability to interact and grasp
and understand issues) as to when to involve the child for adherence.
The health worker needs to work with the caregiver and the child to develop a
treatment plan.
Children, who need ART, particularly when they are very young, face multiple
challenges. The health worker should follow the same principles, and use the 5
A's. Involvement of other people and carers (e.g. school nurses, or staff of
orphanage) in the dispensing of drugs when away from home for long periods or
when attending school is important. There is also the challenge of sustaining
confidentiality as caregivers change. There is also fear and related stress from
repeated painful procedures on the child. Timing of disclosure of HIV sero status
and counselling for the chronic medication needs careful and frequent close and
intimate adherence sessions.
Adherence may be affected by knowledge, skills for administering the medicines,

attitudes, personality, life style and life situation of the child and the parents.
Adherence will be affected by beliefs of family and peers. So, as much as possible,
involve parents, relatives, guardians and other supporters in the preparation for
adherence. Refer to 8.9 for further details which apply for both children and adults.
7. Ask participants why and how children are different in terms of adherence and record
answers on the flipchart.

8. Ask them to read the section on preparation for adherence in children in the Participant
Manual.
9. Ask them to read sections 8.9 and 12.8 in the Chronic HIV Care with ARV Therapy and
Prevention guideline module.
10. Have them discuss the following questions on Case study on Ramya , in Participant
Manual.
QUESTIONS and ANSWERS on Ramya case study.
Q: What questions does the health worker need to ask about the situation?
A: Should include questions such as:
 Where is grandmother?
 Has there been a problem getting Ramya. to take her medicines?
 What is the nature of the problem?
 How often were doses missed?
 Has the family been able to obtain the medicines?
 Have there been side effects from the medicines?
 What is the situation at home?
 How many children are at home and who is caring for them?
 Is there enough food at home?
 What does Ramya understand about her need to take medicines every day?
 Is stigma an issue?
 Are there other problems at home?
Q: What does the health worker need to do to address the problems?

A: Depending on the situation, she needs to:
 Find out who the caregiver/s are
 Find ways to support the caregiver/s
 Possibly get food supplements for the household
 Help the caregiver/s to involve Ramya. in taking medicines and understanding
why
 Help ensure medicines are there
 Change to easier to use formulation if possible
The first line ARV regimens for children 15 minutes
Stabilizing the patient before initiation of ART
11. Ask participants to read section on stabilizing the child before initiation of ART.
12. Discuss medical eligibility for ART for children younger and older than 18 months using
national guidelines and the clinical staging table in Participant Manual.
13. Explain to the participants t the nationally recommended paediatric first line regimens.

Monitoring response to ARV therapy
14. Briefly explain to the participants the information on
- clinical monitoring,
- managing side effects and chronic problems,
Nutrition and psychosocial support 20 minutes
15. Discuss with the participants the management of nutrition for HIV+ children and
the specific (information are in the participant manual and in the Chronic HIV care
guideline moduleH94).
Background information for the Facilitator:
As children living with HIV benefit from ART, they will live longer and in better
health. Many of them will reach adolescence and adulthood and their full
integration into society will become a necessity, not only for themselves but
for society in general.
Interventions need to be carried out on many different levels, in order to

promote a supportive environment in the community and in the family and
ensure these children’s participation in children’s activities such as school,
play, sports, entertainment.
The benefits of a stimulating environment include increased social

responsibility and improved education performance (for example, better
performance on IQ tests has been demonstrated).
In those children with malnutrition, combining psychosocial stimulation and

food supplementation has been shown to result in better growth.
Good communication with children and disclosure 10 minutes
Ask to the participants to read the section on good communication with children, in their
participant manual, discuss and comment with the participants
16. Discuss with the group:

 Communication skills needed by health workers.
 Ask how participants should normally communicate to children?
 And how to disclose the child's status.
17. Ask to the participants how it is possible to disclose his/her status to the child.
18. Refer the participants to the section on disclosure in the Chronic HIV care guideline
module (page H95) .

19. As a recap of the chapter, ask participants to do EXERCISE 17.2 at the end of the
chapter.
Answers to EXERCISE17. 2:
1. Assess John further using "the HIV component of IMCI" box. As John has two
conditions: Low weight for age and pneumonia, he has possibly symptomatic HIV
infection.
 Do pre-test session for John's mum and himself
 Monitor his growth
 Begin cotrimoxazole prophylaxis if HIV result is positive
2. Kavita has persistent diarrhoea and severe malnutrition

 Refer to hospital to manage the severe malnutrition
 Do the pre test session with Kavitas’ parents
 If HIV positive, assess for the clinical staging and decide for ARVs
 Prepare for adherence support
 Start cotrimoxazole prophylaxis
 Counsel for feeding
 Monitoring her growth and development
 Continue immunization and vitamin A and other vitamins
3. Shilpa has persistent diarrhoea and severe malnutrition

 Refer to hospital to manage the severe malnutrition and if refractory to treatment,
ART should be initiated.
 Prepare for adherence support
 Start cotrimoxazole prophylaxis, if not already started
 Counsel for feeding
 Monitoring her growth and development
 Continue immunization and vitamin A and other vitamins
4. High grade fever, headache and neck stiffness are ominous signs of meningitis.
Consider cryptococcal meningitis.
 Use follow up schedule. To be seen at least 3-monthly by clinician.
 Continue ART and fluconzole as secondary prophylaxis
 Follow for side effects of d4T, 3TC and NVP
5. Naveen has probably herpes zoster.
6. Aruna developed the abscesses on 3rd week. Difficult to assess response to ART so
soon. However, it could be due to immune reconstitution syndrome. Drain abscess
and treat with potent antibiotics and continue the ART.
Review the objectives at the beginning of this chapter and confirm that they have been met.
If you suspect that an objective has not been well understood by all, answer questions and
provide further explanation as needed.

Chapter 18 Is ART working?
Duration: Purpose: Learn how to tell if ART is working

30 minutes
Materials:  Recognise therapy success and failure
None  Explain frequency of clinical monitoring and its interpretation
 Explain frequency of CD4 monitoring and its interpretation
 Explain the principles of immune reconstitution syndrome and give
some common examples
Preparation:
None Content: Methods Duration
How to recognise Reading, Case 15 minutes
success and failure of discussion
ART
Clinical monitoring Reading, EXERCISE 15 minutes
18.1
CD4 monitoring Reading, EXERCISE 10 minutes

18.2

2. Ask for volunteers to read through the cases at the beginning of the chapter and then
discuss them.
=> the end of the stories of Sushma, Manish and Kumar will permit to the facilitator
and the participants to recap some issues discussed in the previous chapters
3. Ask to the participants
a. “What is the goal of ART?” and

b. “How do we know if the goal as been reached?”.
Comment , using the information in the participant manual
4. Have participants do EXERCISE 18.2 and then discuss answers.

1. A patient takes ART for 1 year and 6 1. Encourage him to continue
months. CD4 was measured at adhering to the regimen and tell him
baseline (50), month 6 (143), month 12 that his CD4 is improving
(247) and month 18 (233). What will
you do and why?
2. A patient has been taking ART for 3 2. This is likely a new OI due to
years now. At first, the weight was failure of therapy, the HW should
increasing, and he did not have a call for advice
serious OI since he started treatment.
Now, the patient develops itching of the
skin, he also had herpes zoster last
month. He starts to lose a lot of weight.
What will you do and why?
3. A patient has been taking ART for 6 3. Encourage him to continue
months. The CD4 has increased from 2 adhering to the regimen and tell him
cells/mm3 at baseline to 60 cells/mm3 that his CD4 is improving. The time
now. What would you do and why? it takes to increase the CD4 varies
from person to person.
4. A patient has been taking ART for 2 4. This is likely immune
weeks. He never took ART before. Now reconstitution syndrome, the HW
he develops fever and cough. Do you should call for advice.
think this is a failure of therapy? What
would you do?

ANNEXE
Day by day summary of skill stations and card sorts
The facilitator for the first skill station of the day should make sure that the card sort
exercises are ready for the skill station. Facilitator should also make sure to have enough
copies of clinical review forms, Patient Treatment Records, and case-specific checklists at
each skill station.
Introduction and instructions for the EPT skill stations
Starting on Day 2 of the course to the Day 5, the skill stations are 2 hours each day and 1
hour on the last day. Cases that will be practised today are numbers 1-10.
The skill station is a way for the health worker to practise the skills that they have learned in
class with expert patient-trainers who are PLHA and have been trained to role-play HIV
cases with them. At the end of the role-play they will give the health worker feedback.
As facilitators, you are responsible for setting up the skill station, so whoever is the first group
to go should be the ones to set it up that day. In order to facilitate setting up and facilitating
the skill station it would be helpful to look at ''Section H: Skill Station Procedures'' from the
Facilitator Guide for the WHO Basic ART Expert Patient-Trainer Course. This guide also has
the facilitator's guide to each case and set up needs of each case. Each case also has a
case-specific checklist (found in the Handouts for the Expert Patient-Trainer) and enough
copies should be made of each case's checklist for the skill stations.
As part of the skill station, there are also card-sorts exercises which are exercises similar to
the exercises which are done in the class. As seen in the table below, each day there are
different card sorts where cases on the cards or drug abbreviations need to be matched to
the appropriate answers. All the cards for the card-sorts are available in the reusable kit. The
explanation for each card-sorts exercise is at the back of this facilitator guide in Annex B of
the Basic ART section and contains the set up needs for each exercise.
Prior to the start of the skill station, the facilitator should introduce the skill station and the
skills/materials to be used which will be important to be practised. The facilitator can use the
''Introduction to the health worker,'' Annex 7 of the Facilitator Guide for the WHO Basic ART
Expert Patient-Trainer Course to help with the first day introduction. Tell the health worker to
bring their manual which has the health worker case book in Annex C of the Participant
Manual as well as their guideline module. Explain to the participants that they should be
trying to use the materials which are at the skill station even if they have not completed that
chapter in class yet (i.e. the first day of the skill station introduces the Patient Treatment
Record and the first group will likely not have done that chapter yet. They can, however, fill
out the clinical stage, family status, functional status, and TB status in the card as they
learned from the previous day). The participants should practise using the 5 A's during the
skill station and use the clinical review forms (available at the skill station).
Explain to the participants that they should use the skill stations as an opportunity to put what
has been learned into practise. Remind them that this is not a test. It is an exercise of which
they should take advantage. The feedback given by the EPT is meant to be non-judgemental
and should be taken in a positive manner. The skill stations should be used as a tool to
improve their learning.

Before going to the skill stations on each day, explain to the participants the skills to be
practised. They should be practising the 5 A's as in all patient interactions, using the clinical
review, giving cotrimoxazole and other prophylaxis as indicated, and filling out the Patient
Treatment Records. The materials which should be used at the skill stations are their
guideline modules (Chronic HIV Care with ARV Therapy and Acute Care), the HW casebook,
Patient Education Cards (will be available at the skill station) and the Flipchart for Patient
Education. The Flipchart should be used during the skill station to practise giving advice and
explanations to the patient.
Skill Station Schedule
Day # Case # Card Sorts Topics Covered
1 No skill stations
 Clinical review
2
 HIV Clinical Stages (link  HIV clinical staging
(1 hour
1-10 the symptoms/signs to  Functional status
for each
the stage)  TB status
group)
 Prevention
 Prophylaxis
3  TB Testing, Treatment,  Opportunistic Infections and

(1 hour and Follow-Up Treatment
11-20
for each  Drug Names and  Medical eligibility for ART
group) Abbreviations  Adherence
 Preparation for ART
 Major and Minor Side
Effects (link side effect to
4
correct 1st line regimen)  Preparation for ART
(1 hour
21-30  Treatment of Side  ART Initiation
for each
Effects (link correct  Side Effects
group)
clinical response to side  Assess Adherence on ART
effect)
5
(1 hour
31-40 No card sorts
for each  Assess Adherence, Side Effects
group)

Card Sorts
Actual card sorts material is part of the training course materials and should be found in the
Reusable Kit with the other cards.
When facilitating the card sorts, remind the participants that it is more important to practise
their skills with the EPTs. If an EPT becomes available, they should be working with them
over the card sorts exercise.
HIV Clinical Staging (Day 2)

This skill station will include card sorts of patient cases and photos which should be paired to
the clinical stage chart.
Materials needed: HIV clinical staging wallchart, HIV clinical staging cards.
Set up: Place clinical staging wallchart on table and have all the cards in a pile next to
wallchart. The cards have an A side and a B side. The A side lists the initial presentation; the
B side lists the presentation on the next visit. You will have to tape the two sides together (or
laminate them together) to make the cards.
Participants should sort cards and group into correct clinical stage on the wallchart.
Facilitator should provide feedback.
Turn all cards over to look at the B side—decide if stays in same clinical stage or goes up
(re-sort).
Identify what medical care (participants can refer to stages in chart) should be provided
appropriate to the stage of infection.
Another option is to use a blank clinical staging table and then try matching the photos/cases
to the appropriate stage through practise.
First-Line Drugs (Day 3)

In this exercise, the participants will need to match the drug abbreviation to the drug name
(i.e. EFV to efavirenz). You can also add locally common brand names to the card sort.
Materials needed: Blank flipchart paper, Drug name/abbreviation cards, TB/HIV cards, tape.
Set up: Tape blank flipchart paper to wall (or table) and write the following directions on it:
"Link the drug abbreviation to the corresponding drug name". Tape the drug
abbreviation cards to this blank paper in a row. Then put tape on the back of the drug name
cards, so participants can place the card next to the proper abbreviation.
To make the exercise more interactive and interesting, you can ask the participants to put the
abbreviations and the names in the correct first-line regimens once they finish the first part of
the exercise.

TB Testing, Treatment, and Follow-Up (Day 3)
This card sort includes clinical cases about TB and HIV and how the HW at the 1st level
facility should manage the patient cases such as whether to treat TB, start ART, or refer.
Materials needed: blank flipchart paper, TB/HIV cards, tape.
Set up: Tape blank flipchart paper to the wall (or table) and write the following directions on
it: "TB/HIV Cases: Match the clinical cases to the correct management plan". Tape the
cases to the blank flipchart and put tape on the back of the management plan cards so
participants can tape them up on the flipchart next to the correct case.
Have the participants refer to section 8.4, p. H25 of their Chronic HIV Care guideline module
to do this exercise.
Go through each case together and have them decide what is the correct management.
Major and minor side effects on ART and treatment of side effects (Day 4)
This skill station includes card sorts of the side effects of the first-line drugs. Here the
participants should practise matching the major/minor side effects with the appropriate
regimen.
Materials needed: Side effects and drug regimen cards, blank flipchart paper and tape.
Set up: Tape blank flipchart paper to wall with the following directions on it: "Major/Minor
Side Effects of the 1st-line Drug Regimen: Match the side effect to the correct
regimen."
Tape each regimen to the flipchart and put tape on the back of the side effects cards, so
participants can tape the cards next to the appropriate drug.
Have the participants practise matching the side effects to the individual drugs and the
regimen.
Treatment of side effects (Day 4)

This skill station includes clinical cases about patients who are on a 1st-line regimen who
come to the health centre with side effects and the participants need to match the cases to
the appropriate management.
Materials needed: Treatment of side effects cards, blank flipchart paper and tape.
Set up: Tape a blank flipchart paper to wall with the following directions on it: "Management
of Side Effects — Match the appropriate treatment plan to the clinical case."
Tape the cases to the blank paper and put tape on the back of the management cards, so
the participants can tape it on the wall next to the correct case.


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Facilitator Guide

DRAFT (2) for India Training, Jul 2007

Generic version March 2007 Draft

DRAFT FOR INDIA TRAINING

Contact: HIV/AIDS team, WHO India Country Office, Delhi

2 DRAFT FOR INDIA TRAINING

Annexe Day by day summary of skill stations and card sorts 93

DRAFT FOR INDIA TRAINING 3

Purpose of this guide:

Expert patient-trainers (EPTs):

DRAFT FOR INDIA TRAINING 5

Monday Tuesday Wednesday Thursday Friday

Basic IMAI Training Course for Nurses

Nurses, counsellors, medical assistants

Preparation Skill stations

Sample Training Schedule

Day 1 Basic IMAI course Basic IMAI course

Day 3 Chapters 10-14 Chapters 9-12

Day 4 Chapters 15-18

6 DRAFT FOR INDIA TRAINING

A. Instructional Materials Needed by Each Small Group

Steps in preparing course materials:

1. Calculate numbers needed, always adding a few extra.

DRAFT FOR INDIA TRAINING 7

Items needed Number needed per Total Day READY

BASIC IMAI TRAINING COURSE FOR DOCTORS

Guideline Modules (country adapted)

Laminated cards for exercises 1 set Day 1

8 DRAFT FOR INDIA TRAINING

BASIC IMAI TRAINING COURSE FOR THE NURSES

Guideline Modules (country adapted)

Laminated cards for exercises 1 set Day 1

DRAFT FOR INDIA TRAINING 9

10 DRAFT FOR INDIA TRAINING

Sequence of Care After Positive HIV Test 1 for each room

Laminated Wallcharts for Acute Care/OI Training Course

Yes/No Cards (for in-class use) 1 set for each group

DRAFT FOR INDIA TRAINING 11

Supplies needed for each small group/classroom:

 pillbox (if available)

Other important supplies:

and a photocopy machine should be available on the site or as close as possible

12 DRAFT FOR INDIA TRAINING

E. Timetable for course preparation

Task Estimated Done Comments

DRAFT FOR INDIA TRAINING 13

Optimal size of each group is 15 to 20 with 3 facilitators per group.

5. Course Inauguration and Closing

14 DRAFT FOR INDIA TRAINING

B. How to conduct a drill

2. Explain the procedures for doing the drill. Tell participants:

 Participants should wait to be called on and should be prepared to answer as quickly

3. Ask if participants have any questions about how to do the drill.

DRAFT FOR INDIA TRAINING 15

When participants are working:

E. Explanations and lecturing

F. How to use the skill stations

16 DRAFT FOR INDIA TRAINING

DRAFT FOR INDIA TRAINING 17

General learning Objectives

Role of District and Sub district hospital nurses:

18 DRAFT FOR INDIA TRAINING

Materials: Learning objectives: