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- July 2009
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INTRODUCTIONIntended Participants
This course is designed for nurses and counselors in health care settings and community settings who wish to increase their comfort in providing support for prevention and health promotion to persons living with HIV/AIDS (PLWHIV). This course is designed to be applicable for participants from non-governmental organizations (NGOs), health care, and community settings.
Objectives
By the completion of this training, participants will be able to:
1. Discuss importance of self care for persons with HIV/AIDS;
2. Provide brief, targeted health education on nutrition, food safety, stress management and other self-care topics;
3. Describe brief HIV prevention intervention approach for PLWHA;
4. Effectively provide referral to community programs, medical care, and intensive prevention support.
Background and Rationale
As countries in the Caribbean continue to scale up HIV counseling and testing and work toward the goal of universal access to treatment, care and prevention, increasing numbers of persons with HIV/AIDS are being identified in the
Region. Most of these individuals alter their behavior to either abstain from sexual activity or use barrier protection and other strategies to both avoid transmitting HIV and also to enhance their chances of avoiding STIs or other strains of HIV.
That said, studies—and anecdotal reports—suggest that some individuals living with HIV are, for a multitude of reasons unable to consistently practice risk-reducing strategies. This course is designed to help health care workers in diverse settings identify the HIV prevention needs of persons living with HIV/AIDS and develop some strategies to enhance their prevention practice.
The emphasis of this course is two-fold: the course explores a model for brief clinician-delivered intervention and identifying other psychosocial issues which may require an additional [....]
Adapting this Curriculum
These training materials have been developed for health care providers in high-prevalence medical settings who want to increase their comfort in offering HIV testing and counseling to patients. The attempt in developing this training package has been to create an easily adaptable course which might have broad utility in a number of settings. These materials will not address certain specific regional and cultural differences or specific needs of unique settings. It is anticipated that program managers working with local trainers may modify these materials to meet the unique programmatic needs in their settings.
At the same time, this material has been created with distinct learning objectives. These make up the ‘core messages’ for a training on provider-initiated HIV testing and counseling, and altering these may dilute the intention of this course and change information about good practice in HIV testing and counseling interactions. Thus, the learning objectives should be met, whatever modifications are made to the course. A good rule of thumb is trainers may consider altering how the course material is taught, but should avoid altering the essence of what is being conveyed.
Preparing to Train
Trainers who utilize these materials should be familiar with three tools: facilitator guide, participant handouts, and slides.
The facilitator guide is designed to help trainers guide participants through lectures and exercises which are the foundation of this course. Existing knowledge of and experience in HIV prevention is a prerequisite for trainers. In addition, some experience in training health care providers should be seen as a minimum requirement to teach this course. Good pacing and ability at managing group discussion are two important skills trainers of these materials need. Whenever possible, pairing with an additional trainer provides benefit to learners as well as making the tasks of training more manageable.
The facilitator guide is divided into six modules. At the beginning of each module, expecting time needed for the module to be delivered is introduced. In addition, a narrative description of the objectives for the module and suggestions for preparation are outlined. In the course of the module, sub-modules with specific activities and content are outlined. When the content calls for didactic presentation, a numbered outline is to be followed.
When prompted by a bullet with checked box, ["<>"] the trainer should plan to either engage participants in discussion or facilitate an activity.
The handouts for this course accompany certain interactive activities. These should be reproduced and made accessible so that, at appropriate points in the training, the materials will be readily available for the facilitator to distribute. The handouts are numbered in order to assist during the training.
The slides are designed for use as slide or overheads, but, for the most part, can easily be adapted and placed on flip charts. Again, these have been created in Power Point and have been numbered for easy reference. The participant manual is typically formed by printing handouts of PowerPoint slides which accompany this training package. For facilitators who prefer to not focus on the use of slides [or where use of slides is logistically challenging], handouts may also be prepared in using the text for the slides transferred to a word processing format. References in facilitator guide to slides correspond to slide numbers in the slide set.
MODULE 1: INTRODUCTION TO TRAINING AND OVERVIEW
Total Time: 20 minutes
10 minutes Welcome and Introductions
5 minutes Course Objectives
5 minutes Introducing the Topic: Positive Prevention
Module Objectives: Participants will be introduced to one another, and the trainer will introduce themselves and the training content. Overview, agenda and objectives for the course will be presented, and the rationale for
prevention with positives will be explained.
Preparation: Participant manuals should be prepared. If slides are to be shown, projector with back-up bulb should be ready. A flipchart and newsprint should be available for notes and lecture points. If a slide projector is not used, writing most notes from slides onto newsprint should work nicely.
WELCOME AND INTRODUCTIONS
Time: 10 minutes
Materials: Newsprint
Steps:
1. Welcome participants to the training. Thank them for their willingness to participate in this important course on HIV prevention and their openness to learning. Emphasize that HIV is an important problem, and everyone in their community is lucky to have caring health care workers willing to respond.
Introduce yourself and, if applicable, your co-trainer. Emphasize your experience in training and HIV testing and care as well as other relevant health care experience. Ask participants to introduce themselves briefly to the group, noting that there will be other opportunities through the day to continue finding out more about one another. Ask participants to share their name, work setting, and something that makes living with HIV challenging. Ask them to give their;
• Name
• Work setting
• Challenges for persons living with HIV/AIDS [PLWHA]
2. As participants introduce themselves, model effective listening and convey interest and empathy. If anyone takes too long, remind them that this exercise is designed to be brief.
<> As people are stating the challenges for PLWHA, record these on newsprint labeled ‘Challenges’.
3. Once introductions are complete, acknowledge the important experience and compassion of participants, and advise them that they can enhance this learning experience by offering solutions they have found in
addressing some of the challenges which are part of the lives of PLWHA. If any participants disclose that they are living with HIV/AIDS, stress that they are an extraordinary resource in this training and to patients of the clinic. Be sure to thank them for their disclosure.
4. Briefly review the challenges listed in the introductory exercise. You should make sure to note that living with HIV presents multiple challenges; reinforce issues related to community stigma of HIV infection, and desire for intimacy. Ask which of the challenges listed affect the work of health care workers trying to promote health for PLWHA. Listen and confirm responses, and reinforce that these challenges are directly related to the rationale for a course on positive prevention.
5. Briefly discuss logistics for the training. State that a full training day is planned, and attendance all day is necessary for participants to learn what they will need to know. Explain there will be tea breaks in the morning and afternoon, and discuss options for lunch. Make sure everyone is informed where the lavatories are, and ask that all mobile phones be turned off to minimize distractions during the day.
COURSE OBJECTIVES/AGENDA
Time: 5 minutes
Materials: Agenda (see Slide 1), Course Goal (see Slide 2), Course Objectives (see Slide 3)
Steps:
<> Reveal Slide 1, and ask refer participants to turn to the agenda in participant manuals. Remind them that all slides presenting be will available in their materials.
1. Review structure for the day, inviting any questions about content as you proceed. Invite any questions about the structure for the day.
<> Reveal Slide 2, and discuss goal for the course: “The goal of this course is to improve capacity in HIV care settings to provide support of HIV prevention among PLWHA.”
<> Reveal Slide 3, and discuss objectives for the course (note these are also in participant manual). By the completion of this training, participants will be able to:
<> Discuss the importance of self care for persons with HIV/AIDS;
<> Provide brief, targeted health education on nutrition, food safety, stress management and other self-care topics;
<> Describe brief HIV prevention intervention approach for PLWHA;
<> Effectively provide referral to community programs, medical care, and intensive prevention support.
INTRODUCING THE TOPIC: POSITIVE PREVENTION
Time: 10 minutes
Materials: Newsprint; Slide 4 (Positive Prevention)
Steps:
1. Remind participants of the title of the course. Ask their thoughts on why a course was developed that focused on HIV prevention needs of PLWHA. If they need another prompt, ask what percent of their patients with HIV know all their options for promoting good health. Next ask what percent of patients use condoms every single time they have sex. Listen and confirm responses.
<> Refer to the newsprint with recorded participant challenges for PLWHA. Inform them that this course has been designed in hopes of addressing some of the challenges they have identified.
<> Show Slide 4 using the following to guide your talking points and offer an overview of the components of positive prevention.
Positive Living: Begin by pointing out that positive prevention begins with safer self care. Most health care providers believe that there are important health-promoting and disease-preventing steps PLWHA can incorporate into their lives.
Safer Sex and Drug Use: A second important component of positive prevention this course will address will be safer sex and safer drug use. Explain that a major rationale for a course on positive prevention is the need of PLWHA
on
Community Involvement: A final important component of positive prevention is to encourage PLWHA to attend support groups or volunteer in community organizations and NGOs. Ask participants what benefit community
involvement might have for PLWHA. Listen and confirm responses, listening closely for concepts related to overcoming stigma and feeling empowered. Make the connection that this relates to overcoming the concerns raised in the earlier exercise.
2. State that, while no course can address all the possible options for positive living, this course attempts to build on what seems to have shown success in the lives of multiple PLWHA. Stress that the three components of positive prevention are not necessarily about prescribing a ‘recipe’. Rather, good prevention providers offer information, guide decision-making, and invite PLWHA to make better informed, healthier choices.
3. Explain that the focus of the course is two-fold: encouraging the clinic-wide commitment necessary to change the norms of including positive prevention in care settings and on a brief intervention focused on the health care provider offering risk reduction information.
4. Invite any questions about the objectives, the agenda, or the overview of positive prevention, and then proceed to the next section.
END OF MODULE 1
MODULE 2: LIVING WITH HIV/AIDSTotal Time: 50 minutes [ 30 mins HIV in the Family ] [20 mins Living with HIV/AIDS]
Module Objectives: Participants will discuss predictable phases for PLWHA and their significant others, psychosocial impact of HIV illness, and implications for prevention. Focus will be on understanding the importance of staging a person’s acceptance and awareness of HIV will affect their need for support and health education strategies.
Preparation: Flipcharts and markers should be available for note-taking during group exercises. If slides will be used, projector with Slides 4-6 should be ready. You should prepare for the first activity by copying roles from Handout 1, placing them in an envelope for participants to choose their role.
HIV/AIDS IN THE FAMILY
Time: 30 minutes
Materials: Newsprint, Handout 1 with roles cut and placed in envelopes
Steps:
<> Quickly divide participants into three groups-ideally with 6-8 people per group. One simple way to achieve this aim is to ask participants to count off by three’s.
<> Once groups are formed, explain that they will be a family for the next 15 minutes. Distribute three envelopes with scenarios from Handout 1 cut up and placed in the envelope. Advise them that this scenario is a brief sketch of someone in this family, and that they will need to add additional embellishment. Make the point that each member has some relationship to the family and that all have had some risk for HIV.
<> After all members have taken a role, ask for a volunteer to play the family member living with HIV/AIDS. If you have difficulty finding a volunteer, explain that this is the most important role in the exercise and requires exceptional commitment. If asked, state we do not know for sure how the PLWHA contracted the virus; advise participants that they may or may not choose to disclose to their families their risk history.
<> With groups formed and the PLWHA selected, you should now instruct the groups that they are families in three different stages of living with HIV/AIDS.
o~ Advise the first group that, when the exercise begins, they are going to role play being a family whose loved one has just taken an HIV test and been informed that the test results are positive. Explain the primary task is for the PLWHA to inform their family they have taken and HIV antibody test and that it was positive.
o~ For the second group, ask that they be a family that has lived with the knowledge of their loved ones’ illness for several years. The PLWHA has felt fine for this time, and has had only a few, minor problems. Just recently, they had a serious turn of events resulting in a hospital stay and an opportunistic illness. Their loved one takes HIV medicine, and sees the doctor regularly. Instruct them that this is the first family meeting after the PLWHA has returned from the hospital-having had an opportunistic illness and receiving a diagnosis of AIDS.
o~ Instruct the final group that they will be a family that has lived many years with a loved one ill from HIV/AIDS. They have seen their family member struggle mightily, and appear to be very fragile. Their loved one has been told by the doctor that they do not have long to live. This is the first family gathering after this news has been shared.
Advise groups they are gathered at the dinner table or in a family room for a family meeting. Acknowledge this may be a bit artificial [i.e. many PLWHA would deal with difficult topics one-on-one for instance], but it will yield insights into the experiences of families addressing HIV/AIDS. Ask if there are any questions, and instruct groups to begin.
<> After about 7 minutes, instruct participants to end the role play. Begin to debrief the exercise by asking participants initially to discuss with each other what their character was feeling, thinking, or needing as their family faced the issues confronting them.
<> After 4-5 minutes, ask participants to return to their original seats, and begin to process the exercise with the entire group.
1. Begin with the first group, and generate a list of issues raised in their group. Record the issues, feelings, reactions of ‘family members’ first, then invite the participant who portrayed the PLWHA to discuss their issues and feelings.
2. After the first group has listed the issues they faced, thank them. Repeat the process with the remaining groups. You should have newsprint recording the issues for each of the groups posted in such a way that everyone can view the issues and you can use as a reference point in the remaining discussion.
<> Make a transition to the next exercise by stating that the groups have generated a realistic look at issues facing PLWHA and their families across the timeline of living with HIV/AIDS. State that the next challenge will be for providers to assess the unique education needs and support needs at various stages.
LIVING WITH HIV/AIDS
Time: 10 minutes
Materials: Posted Newsprints, Slides 5-7 (Stages of HIV/AIDS)
Steps:
1. Acknowledge that the course of living with HIV/AIDS is unique for every person and every family. That said, state that the patterns that emerged in the previous activity are indicative of some predictable challenges for PLWHA.
2. State that part of what emerges when examining HIV across a spectrum is unique tasks for health care workers emerge associated with the phase of patient illness and awareness. The following lecture points are designed to provide an overview of stages of HIV illness and relevant tasks for education and support.
<> Reveal Slide 5 (Crisis of Diagnosis) begin discussion of implications for service providers. Make the connection to the first group who was confronted with issues of HIV diagnosis. Use the following as your discussion points.
• Emotional Support- Stress that one of the most important things PLWHA need early in their diagnosis is usually emotional support.
Ask participants what emotions individuals experience after learning they are living with HIV. If participants need another prompt, ask what anyone receiving a diagnosis that they had a potentially life-threatening condition might
face. Listen and confirm responses, and stress that these underscore the need for emotional support.
• Stigma of HIV/AIDS- Emphasize that a unique factor in a diagnosis of HIV/AIDS is the stigma associated with the disease in many communities. Define stigma as a negative reaction and prejudice associated with a health condition.
Ask how persons with HIV/AIDS are treated when communities find out they have HIV. Listen and confirm response, then point out that the negative aspects describe are examples of how stigma affects the lives of PLWHA—and
their loved ones. Point out that, in the family exercise, some of the issues of stigma related not to HIV itself, but to the behaviors that put the person at risk in the first place.
• Access to Care- Note that an early task in responding to the crisis of diagnosis is to make sure someone knows their options in terms of treatment and care. It is good practice for testing centers to know where care resources exist and how PLWHA can access these.
• HIV Prevention Messages- Note that frequently when individuals first are identified as HIV positive, it is common for individuals to experience a decrease in sexual interest-with casual or main partners. Reiterate what was
previously said about a majority of individuals with HIV who do take measure immediately to protect themselves and protect others. Reiterate that it is still critically important that health care workers be well versed in routine prevention messages.
Ask the group to turn to a partner seated beside them, and construct important prevention HIV prevention messages everyone with HIV/AIDS needs to receive from health care workers. After 3 or 4 minutes, ask participants what they discussed.
Listen and confirm all responses. Be sure that the following are covered:
• “You could infect anyone you have sex with or share blood with.”
• “This will never go away-you must be careful forever.”
• “You should avoid other people’s germs and protect yourself or you may get ill more quickly.”
• “Use a condom every time for every sex act.”
• “If you had a baby, your baby may get HIV/AIDS from your blood.”
• “You must make sure your health care providers know you have HIV.”
• Positive Living- While no one can give any guarantees, PLWHA should know about strategies to promote their health and prevent disease. Specific strategies will be covered in the next module.
• Assistance with Disclosure- This is an important time to remind PLWHA that it is critical for their partners to be informed and referred to voluntary counseling and testing (VCT). Acknowledge that for some clients, disclosure and fear of partner’s reactions may seem overwhelming. It is important that providers assess reactions to our recommendation that patient’s disclose their status to partners and be provide to offer support, including offering to talk with partners with patients if indicated.
<> Reveal Slide 6 (Living with HIV/AIDS) and begin discussion of implications for service providers as PLWHA resolve the crisis of diagnosis and reintegrate into their families, communities, and lives. Make the link to the second family dealing with a family member who experienced a major health problem. Use the following as your discussion points:
• Re-entry after Diagnosis- State that often PLWHA will resolve the emotional crisis and resume working and normal activities. Sometimes, this can be accompanied by a period of denial of the seriousness of illness. At times, patients can be so sure their self-care plan will protect them that they become over confident. And, still other times, PLWHA will be discouraged and frightened.
This multiplicity of moods and changing support needs reinforces the need for care providers to remain patient-centered in their orientation. It is imperative that care providers allow PLWHA to set goals and determine priorities, support ways they can feel in control of their lives, and experience the full range of emotions which coincide with living with a serious health challenge.
• Prevention and Reproductive Health- For some PLWHIV, a return to health or ‘normal’ living can raise the question of having children. It is important to not that health workers should not judge a PLWHA if they express a desire to have children. Ask what reaction individuals have when they feel judged by a health care worker. Listen and confirm responses, emphasizing that judgment impacts the ability to form partnerships. Explain that, if someone has a desire for children after they have been counseled, it is imperative that we establish the kind of relationship that would allow them to work with us in partnership so we could do all we could to prevent perinatal transmission.
• Practical Concerns- State that often after someone has developed symptomatic HIV illness, the disease state becomes more ‘real’. Along with that, there are tangible questions that individuals and families face. Issues of
continuing to work, economics, paying for medicines and health care, care of children, planning for late-stage illness may all be issues facing PLWHIV at this time.
Stress the importance of letting the PLWHIV determine the agenda and have their concerns met first. Emphasize the important role community groups and NGOs play in responding to these non-medical needs. If appropriate, use this opportunity to discuss with participants local resources for support to PLWHA and their families.
• Adherence Support- Stress that support for adhering to medications for persons on ART is essential for the individual affected and, potentially, as a prevention strategy. Factors which appear to promote adherence to ART include comprehension of information, hope about the future, belief in benefit of medication, and trusting relationship with health workers.
In addition to enhancing the health of PLWHA, there may be a prevention benefit associated with improved adherence. Ask participants if they can offer an explanation. Listen and confirm responses. If a follow-up question is indicated, ask why having someone on ART could make HIV transmission more difficult. Confirm or offer response that a PLWHA successfully taking medication should, most often, have lower viral activity than if they were not
taking HIV medications. Note that this information should be shared cautiously—if at all—with PLWHA. This information could easily be misconstrued as ART preventing HIV transmission which is not the case. Still, there is real public health benefit to persons with HIV consistently taking medications and lowered viral loads
• Social Support- Ask the individuals who played PLWHA in the family role-play if they had family members who were supportive of them after their diagnosis. Next, ask how they felt about that support. Listen and confirm responses. If there is another prompt necessary, ask all participants how they think positive supportive loved ones would impact their ability to live with HIV/AIDS. Expect responses like:
o More optimistic/hopeful
o Better emotional health
o Capable of self-care
o More comfortable disclosing status
o Less stress
State that this discussion emphasizes the need for support programs to be willing to offer counseling and support services to family members and significant others as an extension of services. Moreover, it also emphasizes the need for community organizations, support groups, and other options of the non-medical support PLWHA need.
<> Reveal Slide 7 (Late-stage HIV/AIDS) and begin discussion of needs for PLWHA late in their lives, and implications for care providers. Use the following to guide discussion:
• Final Planning- Offer the observation that, as families face late-stage illness, concerns turn to traditional ‘end-of-life’ issues. These include practical matters such as disposition of possessions and desired funeral and burial arrangements. More importantly, these include concerns for the future of one’s children. State that, while some people prefer to avoid facing these issues, it is important that we offer PLWHA the opportunity to express their desires about their wishes for their children after they die.
• Spiritual Support- Spirituality and ritual are a source of comfort to many people throughout their lives. It must be noted that, at this point, the ability to participate in ritual or find pastoral counseling from a spiritual leader may be extremely important. That said, no one should assume the desires of a PLWHA, as some individuals may not have spiritual need or may fear contact with spiritual leaders. It is always good practice to make spiritual
resources known.
• Comfort Care- State that this time is often a time when medical care focuses less on ‘curing’ and moves toward ‘comfort’ measures. The priority is to keep PLWHA comfortable, pain-free, and manage symptoms which affect quality of life.
• Family Needs- As someone reaches a terminal stage in their illness, it is important to think about the needs of family and significant others. While providing support to individuals in late-stage illness, families at this time can also be expected to have tremendous needs. Reinforce the issues raised in the role-play activity as proof that families of PLWHA are extremely stressed as their loved ones face the terminal stages of HIV disease.
<> Ask if there are other issues which participants feel are important that have not been discussed. Confirm responses.
<> Invite any final questions. State that the activities will shift to the next module, focusing on positive living and the advice for positive self-care for PLWHA.
<> Adjourn for a BREAK of fifteen minutes
END OF MODULE 2
MODULE 3: POSITIVE LIVING
Total Time: 30 minutes - [15 mins Positive Living] [15 mins Strategies for Effective Health Education]
Module Objectives: Participants will be given basic information about good health education practices for PLWHA, and strategies for successful health communication.
Preparation: If using slide projector, Slide 8 should be prepared. Flipcharts can be substituted and should be available for note-taking as desired.
POSITIVE LIVING
Time: 15 Minutes
Materials: Newsprint, Slide 8 (Positive Living)
Steps:
1. Remind participants about the previous discussion of self-care for PWHIV from the previous module. State that, in many ways, the discussion about health promotion begins with common sense health advice that most individuals should adhere to. State that the first activity of this module will involve an opportunity to assess what is already known about good health habits for PLWHA.
<> Quickly divide participants into 4 groups and ask them to assemble together. Once groups have formed, explain that they will each be asked to reflect on what they know about health promotion for PLWHA. State that, many of the precautions taken by individuals with HIV are food and home safety suggestions that make everyone’s health better. Ask groups to spend five minutes listing as many suggestions for promoting health and avoiding
disease.
<> When five minutes has elapsed, call time. Briefly, ask groups to take turns listing one or two suggestions until all groups have finished reporting their suggestions. Listen and confirm accurate information, being sure to reinforce proven, local health advice. Once all groups have finished you should begin lecture, reinforcing any points made in the group work, and calling particular attention to suggestions not addressed in group reports.
2. Reveal Slide 8, and begin lecture on positive health habits, using the following as talking points:
• Proper Nutrition- Begin by offering the observation that eating well is an important health strategy for everyone-including PLWHA. Including fruits and vegetables, eating small regular meals, and focusing on healthy, fresh choices makes good sense for anyone concerned about their well-being.
Foods with high protein, fat, and carbohydrate content are good for persons attempting to maintain health. For individuals having difficulty with eating or digestion, the following suggestions may help:
o Squeeze lemon juice over fatty food like meat, chicken, or nuts.
o Eat papaya with meat.
o Drink in between, not during, meals.
o Avoid alcohol, smoking, and non-prescribed drugs.
• Food Safety- Cooking food until it is thoroughly heated (begins bubbling) is a way to make sure most germs are killed. Fruits and vegetables should be washed in clean water; using explicit caution if water safety is a concern.
• Exercise- Regular exercise has many benefits for PLWHA. Ask participants the potential benefits of exercise. Listen and confirm responses. You should expect answers like:
o Improved muscle tone
o Manages stress
o Improved appetite
o Assists digestive process
Note that everyone must find their own comfort level in exercising, and over-exertion will not be beneficial.
• Hand-washing- Stress the importance for persons with HIV to use good home infection practices. The most important is for PLWHA—and caregivers—to use good hand-washing practice. Special attention should be paid after using the toilet, before preparing food, after coughing, after handling garbage or touching animals
• Non-Sexual Household Safety-Advise participants that non-sexual spread of HIV is very unlikely, but that certain precautions will help PLWHA and their families be comfortable. Note that many of these practices will protect PLWHA from illness borne by their loved ones.
Being cautious with razors, needles, and other sharp objects is important. Any open cuts or sores should be covered to protect anyone from potential infection. Spills of body fluids should be carefully cleaned up. Washing clothes or bedding with body fluid spills separate from other laundry is a good practice.
Most household cleaners effectively sanitize against spread of HIV. Use of a mixture of 1 part bleach and 10 parts water will safely sanitize infectious fluids and is a good household infection control agent.
STRATEGIES FOR EFFECTIVE HEALTH EDUCATION
Time: 15 minutes
Materials: Newsprint; Slide 9 (Strategies for Effective Health Education)
Steps:
1. State that you will attempt to cover what are generally regarded as standards for effective patient education.
<> Reveal Slide 9. Use the following suggestions as your talking points.
• Address your patient’s chief concern first.
Ask if anyone has ever been to the market when someone was trying to sell you something that you weren’t interested in buying. Acknowledge responses and ask what they were thinking as this person continued to describe items they did not want to buy.
Make the connection that when we don’t offer education in a client-centered way, we run the risk that our patients feel the same way the participants felt in the market. Explain that, while we have information and expertise clients might need, our abilities to convey information are maximized if we begin by finding out our patient’s agenda. State the simplest ways to learn patient’s chief concern is to ask. Questions like:
“What are you most concerned about?” or “What would you like to get out of today’s visit?” are excellent examples.
• Start education by asking what your patient already knows.
One simple strategy for assessing a patient’s information gaps as well as verbal abilities can be to ask an open question like “What have you heard about how someone with HIV stays healthy?” A patient’s response gives you valuable information about their existing knowledge, and allows providers to work more efficiently by not teaching patients what they already know.
• Use simple, non-technical language; use terms your patient uses.
Note that one ongoing challenge for health care workers is translating medical knowledge into concepts easily understood by patients. Stress that most providers do this all the time, but ask if anyone has ever realized that their patient hadn’t understood what they said. Ask how they knew their patient had not comprehended. Listen and confirm responses.
Ask what providers can do to increase the chances that the information we are trying to convey has been received. Listen and confirm strategies. Remind participants that one of the most certain ways to be sure you will be understood is to use language that is identical to the language patients use.
• You can sometimes provide health education on sensitive topics by discussing them in third-person language.
One strategy with shy patients or uncomfortable topics may be to say something like, “many of our patients find it really hard to disclose their status to their husbands/partners.” Ask participants what benefit might come from making statements in the third person terms. Listen and confirm responses like minimizing confrontation, decreasing anxiety, allowing patient to maintain confidentiality.
State that the goal of health education is for patients to use information, and presenting information in a minimally threatening way is ideal. Note also that these kinds of interventions can also be important prompts for clients to discuss barriers to behavior change or feelings and issues which are getting in their way.
• Patients can retain an average of only three take-home messages in any health education intervention.
Ask if anyone has ever needed to be taught a new skill by someone who was trying to offer them too much information and too many choices. Confirm responses. Explain that health information is as foreign to our patients as that information may have been for many of us.
The skill for providers is to triage which health education issues are most important at this visit and to prioritize those while allowing the opportunity to return to other topics in subsequent visits.
An important concept in behavior change is self-efficacy, a patient’s ability to feel ‘I can do that new behavior.’ If patients are overwhelmed or given a message that there are many things they need to work on, the provider may actually decrease self-efficacy and increase feelings of pessimism about behavior change.
END OF MODULE 3
MODULE 4: POSITIVE RELATIONSHIPS
Total Time: 85 minutes
15 minutes Partner Reactions to HIV Diagnosis
10 minutes Assisting with Disclosure
20 minutes HIV Risks
30 minutes HIV Prevention Messages
Module Objectives: Participants will be familiar with possible reactions of partners to HIV testing, as well as strategies for assisting PLWHA with support for disclosure of HIV status. Discussion will include strategies for HIV prevention education and counseling as well as indicators that an individual needs intensive prevention support.
Preparation: If using slide projector, Slides 10-13 should be prepared. Flipcharts can be substituted and should be available for note-taking as desired. Sets of cards for HIV transmission activity should be prepared and available for group exercise as described below.
PARTNER REACTIONS TO HIV DIAGNOSIS
Time: 15 minutes
Materials: Flipchart
Steps:
<> Ask participants what reactions they would expect from individuals whose partners disclose to them that they have tested positive for HIV. Listen and confirm responses. Expect responses like:
o Frightened
o Sad
o Angry
o Confused
o Betrayed
o Overwhelmed
<> Once the group has finished, ask which participants have had a patient with a spouse or partner who tested positive. Ask which of the reactions listed was similar to feelings spouses and partners had in their patient’s lives. Listen and confirm all responses.
1. Reinforce this discussion by offering the observation that finding out a loved one has HIV is a very powerful emotional experience. Note that, most often, this involves concern for their loved one and fear for their loved one’s well being.
That said, a diagnosis of HIV also brings with it the potential concern of infection for the partner. In addition, issues of jealousy, infidelity or guilt may be a component of an individual’s reaction.
2. Given the potential of a negative reaction from partners, it is extremely important that health workers, HIV test counselors, and concerned service providers examine all the possible ways they can minimize the negative reaction of partners.
<> As participants to quickly partner with someone seated near them for five minutes. Ask them to discuss ways that health workers can assist PLWHA to minimize or avoid a partner’s negative response. Allow about five minutes for discussion, and then call time.
<> Invite participants to quickly debrief, sharing suggestions for how to support PLWHA with HIV in disclosure. Listen and confirm all responses. Allow all individuals to finish and thank them for their suggestions.
3. Invite any final questions or comments and transition to the next section.
ASSISTING WITH DISCLOSURE
Time: 10 minutes
Materials: Newsprint; Slide 10 (Assisting with Disclosure) should be ready.
Steps:
1. State that issues of assisting with partner issues is a critical component of support for PLWHA. Suggest the course offers some possible ways in which programs doing HIV testing or HIV care can address needs of individual’s partners.
<> Reveal Slide 10 and state that this course offers some suggestions based on practice experience about options for assisting PLWHA. Use the following points to guide your discussion:
• Couples Counseling- One strategy used in testing sites is the opportunity for couples to receive VCT at the same time. The advantages of this intervention appear to address some of the concerns raised earlier, particularly minimizing blame and guilt for partners. It is also an important opportunity to do teaching about HIV prevention together and assess barriers to prevention. Some research suggests this strategy may be more effective when partners are casual or commercial.
• Partner Notification- A very important service clinics should offer is the confidential notification of partners that they may have been exposed to HIV, and encouragement to receive VCT. Partner notification must include the following:
o always based on informed consent;
o maintains confidentiality of patient whenever possible;
o sensitive to the impact of news on partners;
o delivery is adapted to particular situation (i.e. provider- delivered vs patient-delivered)
• VCT for Partners- Getting partners tested for HIV is an important component of an effective HIV prevention campaign. WHO/UNAIDS policy states that HIV testing and counseling should always involved informed consent,
maintain confidentiality, and that individuals who test positive should have access to care.
• Couples Counseling for Disclosure- Offer the suggestion that one way to assist PLWHA—particularly those who fear a partner’s response or have low self-confidence—might be to offer your willingness to be with patients
when they disclose to their partner. Ask participants how this might benefit clients. Listen and confirm responses. Reinforce or add the following points;
o Allows provider to assess threat;
o May foster increased confidence;
o Reinforces need for risk-reduction and family planning;
o Allows questions about HIV and prevention to be answered factually and immediately.
• Risk-Reduction Counseling- State that among the important health education opportunities when working with PLWHA and their partners is the opportunity to provide counseling on safer sexual relations. Make the
suggestion that an important charge to educators and counselors is to try to offer information in a manner which affirms an individual’s right for healthy relationships—including a happy, healthy sexual life.
Offer the observation that any support for healthier sexual relationships must include basics of HIV transmission and prevention. It is also important that this education involve a realistic appraisal of individual’s ability to change their
behavior. Note that this will be the topic covered in the next section.
2. Invite any additional suggestions or final questions. Transition to the next activity.
HIV RISKS
Time: 20 minutes
Materials: Newsprint; Activity cards with Fluids and Sites as described in the exercise; masking tape to post one set of cards; newsprint labeled “Options”, bulleted down the left-hand side with ‘Abstinence’ behind the first bullet.
Steps:
1. Explain that this module will focus on how to offer HIV prevention information to PLWHA, and discuss options and strategies for lowering risk and preventing disease.
<> Write on newsprint the following in quotations: “I already have HIV, why use the condom now?” Ask if anyone in the group has ever had this resistance to prevention interventions for PLWHA. State that another variation might be “We both have HIV, why worry?”
<> State that one obvious reason for PLWHA to practice safer sex with partners who are negative or whose status is unknown is to prevent new infections. Ask what other reasons PLWHA should practice safer sex. If participants need another prompt, ask what PLWHA can avoid if they practice safer sex.
2. Advise participants that avoid new infections is one benefit of prevention interventions with persons with HIV/AIDS. State that there are several key benefits for PLWHA. If the group has not already mentioned them, be sure to add:
[] Avoid STIs
[] Avoid HIV reinfection
[] Avoid infection with drug resistant strains of HIV
[] Avoid legal complications [where this applies]
[] Avoid negative partner reactions/community reactions
Ask if there are questions or any additional discussion.
NOTE: It is imperative that trainers firmly contain discussion which is negatively reacting to PLWHA who are having difficulty changing their behavior. You should model tolerance, reinforce the difficulty of behavior change, and actively intervene if any participant spends too much energy blaming or judging patients.
3. Begin by explaining the first component of effective HIV prevention intervention is to clearly know facts about transmission and the ability to convey information about relative risk. State that the next two exercises will offer participants an opportunity to improve their knowledge of HIV risk and HIV prevention by focusing on understanding the basics of HIV transmission.
<> Quickly divide participants into 4 groups and ask them to assemble together. Once groups have formed, explain that they will each be asked to reflect on what they know about fluids containing HIV. Distribute cards individually labeled with the following fluids: blood, semen, vaginal secretions, breast milk from Handout 2.
4. Instruct the group that their task is to agree on the order of HIV infectiousness—from most to least risky—for each of the fluids. Give groups about five minutes to complete their discussions, and instruct them to stop.
<> As groups to share their results, you should have a set of cards posted with tape on the front of the room; you should attempt to capture their discussion by moving cards as they direct you. You should facilitate a discussion to resolve any disagreement. In processing, you should ask how groups made their decisions. Listen for and confirm presence of blood cells as the most important criteria for determining infectiousness. Invite any questions, and begin the next activity.
5. Next, state that an important corollary question for understanding HIV risk involves understanding how efficient a route of transmission body openings present. Remind participant that two factors must be present for HIV infection to occur: presence of an infectious fluid and a portal of entry into someone else’s bloodstream. Share the observation that if one of these two conditions is not present, HIV transmission will not occur.
<> Distribute a second set of cards individually labeled with the following sites in the body: mouth, vein, anus, vagina, and meatus (the opening of the male urethra]. Instruct groups that they are to perform a process similar to the last one. Inform them the cards they now possess are labeled with sites of the human body which may come in contact with fluids during sexual or drug-using interactions. State that their group task is to arrange in order-- from most to least vulnerable—how likely HIV transmission is at the given sites. Allow approximately five minutes for the group to complete the task, and then call time.
<> As groups to share their results, you should again use a set of cards posted with tape on the front of the room and attempt to capture their discussion by moving cards as they direct you. As in the previous exercise, facilitate a discussion about receptivity to HIV-infected fluids. Ask groups to explain their rationale. Explain the correct order for sites is: vein, anus, vagina, mouth, meatus.
<> Invite any questions and ask participants to return to their original chairs. [Note: if anyone raises the issue of exposure via non-intact skin, make the point that this is theoretically possible but an inefficient route of transmission.]
6. After participants return to their chairs, invite a discussion of the implications of this activity. Confirm that the task for risk reduction is to assist consumers in understanding the relative risk of their behavior-to themselves and their partners.
7. Reveal the newsprint labeled ‘Options’ and ask participants to assist with creating a list of options from which consumers might choose in their risk reduction plan. Point to the option of abstinence already on the posted newsprint and confirm this as the safest option. Ask why abstinence may not be an acceptable option for some consumers. Listen and confirm responses. Suggest that, if patients are not able to accept abstinence as their current
choice, providers should be comfortable generating a list of safer options-choices which would lower the potential risk of re-infection or STIs for our patients.
8. Ask what sexual behaviors would be very risky. Listen and confirm responses, focused on more infectious fluids and more efficient sites. Record participant responses on newsprint. Expect unprotected anal and vaginal intercourse without condom to be among the highest risk alternatives.
9. Ask about options which would carry a relatively lower risk to the first behaviors identified. Listen and confirm responses, focused on less infectious fluids and less efficient sites. Expect options like use of condoms, limiting partners, and having lower risk sexual activities—like more oral sex.]
10. Offer a caution that offering exact guidance about risk in sexual interactions would involve very complicated scientific processes. Still, there is some evidence-based discussion of relative HIV risk for PLWHA and their partners that can be used to provide consumer education. Stress the point of this activity is that educators will be able to impart facts that individuals need to understand the relative risk of their sexual behavior to themselves and
their partners and then make the safest choice they are able to at that time.
11. Conclude the discussion by advising participants that the value of this exercise to guide their practice is they should have the ability to generate options with an individual who is not able to be abstinent about options they could employ to lower the potential risk to themselves and other people. Remind them that excellence in health care is achieved by moving through discomfort and delivering interventions which have the potential to be life-saving.
DELIVERING RISK-REDUCTION MESSAGES
Time: 30 minutes
Materials: Newsprint labeled “Options”, Slide 11 (Provider-Delivered HIV Prevention Message), Slide 12 (Intervention Themes), Slide 13 (Global Prevention Goals); Handout 2 [Fluids/Portals of Entry] and Handout 3 [Provider-Delivered scenarios]
Steps:
1. Introduce module by stressing the importance of the relationship and influence of HIV care provider. Note that many patients have changed their health behavior in response to a message of concern from their health care provider—especially when they knew the provider had genuine concern for their well-being.
2. Ask participants to name the barriers to positive prevention that consumers in care settings bring that inhibit effective prevention. Listen and confirm issues like shame, denial, ambivalence, confusion. Validate all responses.
3. Next, ask participants to think about provider barriers to prevention in HIV care settings. Again, listen for responses like embarrassment, lack of time, lack of training, and patient discomfort. Acknowledge that the work of
doing HIV prevention in care settings is challenging—and important—work for health care workers.
4. Reveal Slide 11, and state that the goal of this module is to increase the comfort of health care workers in delivering HIV prevention messages. State that the model intervention has been adapted from an HIV prevention intervention called Partnership for Health which was developed in the U.S. and adapted to positive prevention activities in multiple international settings. Suggest the central element of the program is a 3-5 minute prevention
intervention delivered by the health care provider. Use the following to guide your discussion:
<> Introduce the topic- Given the barriers for both patients and health care workers; this starting point may be the most important. State that some studies suggest as few as 17% of HIV care providers assess HIV prevention needs at every visit.
<> Assess patient’s existing risk-reduction plan- This course advocates a brief assessment of current risk-reduction practices. Make the case that, if a plan and step have been documented, the notes from the previous patient visit will be available to begin the discussion.
<> Compliment any protective behavior- Offering praise for any moement toward change is important. Behavior change—for all of us—is a difficult and sometimes slow process.
<> Ask a question [barriers/facilitators]- Finding brief ways to continue the dialogue should focus on one or two effective open questions. Perhaps the best goal for these inquiries could be ascertaining what is getting in the way [barriers] or helping [facilitators] change their HIV risk patterns.
<> Renegotiate risk reduction plan- Ultimately, the health care worker hopes the patient is willing to take another step toward being safer between visits. This is best accomplished by asking about a step the patient is willing to take to continue increasing safer behavior.
5. Invite any questions about the intervention and reiterate that the intervention is designed to take 3-5 minutes at the end of a patient’s clinic visit.
6. Reveal Slide 12 and review the intervention themes. Make the point that appealing to a patient’s self-interest first is suggested.
7. Follow-up by stating it is important to emphasize partner protection, but point out that this may need to be done very thoughtfully. Ask participants what might happen if a health care worker was not thoughtful in raising the
issue of partner protection. Listen and confirm responses, focusing on the possibility that we may reinforce stigma or guilt in providing prevention support.
8. Discuss the issues of disclosure, and point out the connection between disclosure and safer sex. State that many experts agree there is a significant increase in use of condoms when a PLWHA discloses their HIV status.
Invite any questions, and transition to the last activity in the module--practicing the intervention approach.
9. Quickly divide participants into pairs and explain you will arbitrarily be assigning roles of patient and provider. Each participant will be given notes on their role which they should not share with their partner unless asked.
For the purpose of this practice, the assumption is the provider has delivered all HIV medical care and in the last component of the medical visit will provide the brief prevention intervention. Invite any questions.
10. Distribute participant handouts and instruct participants to take a moment to review the notes. After two minutes, advise participants that they will have five minutes to accomplish the goals of the intervention and instruct them to begin.
11. After five minutes, call time. Invite participants to debrief by focusing on feedback from the patient. Ask that the feedback begin with the participant who was in the patient role sharing all the positive feedback they can with their colleague about what they would say felt good. Once this has been accomplished, the provider can ask for any concerns, and then the two of them can analyze the practice.
12. After five minutes, instruct participants to change roles. State that you will conduct a second practice, using different roles and case examples. Distribute new handout materials and, as before, give participants an opportunity to familiarize themselves with the scenarios. After two minutes, invite them to begin the session.
13. After four minutes, call time. Invite participants to debrief with one another, focusing first on what the client would identify as successful interventions. Next, both participants should identify what worked well and problem-solve any challenges.
[NOTE: If time allows, you may wish to repeat this practice once or twice more.]
14. After five minutes, you should call time, and invite participants to return to their original seats. Process the exercise using the following questions to guide the discussion:
<> What did you find was effective when you were in the ‘patient’ role?
<> As the health care worker, what did you find effective?
<> Where did you struggle? [As challenges arise, you may use these as a chance to problem-solve with participants.]
<> How could adopting a model like this benefit your clinic(s)?
<> What alterations to the model or your clinic processes would help?
<> What else can your clinic do to enhance prevention among your patients?
15. Finally, invite participants to add to the de-brief of the demonstration, adding positive feedback first then any concerns or questions. Next, transition to the next activity of the module by reminding participants of the importance of being able to articulate options for a risk-reducing goal.
<> Reveal posted newsprint labeled “Options”, and advise participants they will be working in two teams. Note that each newsprint begins with a bullet labeled ‘Abstinence’.
<> State that abstinence from any sexual activity is the only 100% way to avoid HIV transmission. Ask participants if that solution would be workable 100% of the time. Listen and confirm responses. Make the suggestion that abstinence should always be presented as the safest choice, but that good public health practice must include an array of options for safer sexual behavior.
<> Instruct the group that they are to continue to generate options for safer sexual behavior. Offer the premise that they have presented the option of abstinence, but that their patient has indicated that is not a viable option.
State that they are to generate as many options for lowering risk for sexually-active patients as they can think of in eight minutes. Offer the example that their patient is someone who has oral, anal, and vaginal sex with multiple partners. Invite any questions, and instruct them to begin. After seven or eight minutes, end group work and invite participants to return to their seats.
<> Process the activity by reviewing options generated by both groups. You should expect options like:
• Using condoms
• Reduce partners
• Non-penetrative sex
• Mutual masturbation
• Ejaculating outside of partner’s body
<> Gently correct any misinformation, again focusing on issues of decreasing effectiveness of transmission.
16. Ask participants how they would feel offering options such as the ones discussed. Confirm responses, and reinforce the idea of personal discomfort if it arises. State that it can feel uncomfortable negotiating recommendations that are imperfect but, for clients who are not ready to do the completely safe thing, these options could help prevent new infections or prevention a PLWHA from experiencing serious health consequences.
17. Reveal Slide 13, and use the opportunity to summarize the lessons of this Module and reiterate the ‘take-home’ message of this section of the course.
18. Invite any final comments or questions, and thank participants for their engagement in the process. Advise them this is the end of Module 4.
END OF MODULE 4
MODULE 5: CLINIC-WIDE RESPONSE TO HIV PREVENTION
Total Time: 90 minutes
20 minutes Clinic-Wide Response
30 minutes Risk Reduction Counseling
20 minutes Health Behavior Change
Module Objectives: Participants will be presented with skills for achieving HIV prevention goals with their patients. Emphasis will be placed on thorough rationale for community involvement for PLWHA. Several illustrations of ways in which individuals can become more involved in their community will be offered, and suggestions for how to make effective referrals will be made.
Preparation: Newsprint; Slides 14-20
CLINIC-WIDE RESPONSE
Time: 20 minutes
Materials: Slide 14 (Clinic-Wide Response), Slide 15, (Cultural Competency)
Steps:
1. Begin the module by suggesting that, in order for HIV prevention efforts to be successful with a maximum number of individuals with HIV, the commitment and efforts of everyone on the care team to positive prevention must be demonstrated.
2. Reveal Slide 14, and offer a brief overview of suggestions for a clinic-wide response. Review the interventions on the slide, inviting a discussion or what is currently in place in the clinic. Suggest that these interventions will be the subject of this module.
3. Make the recommendation that, in order to meet the prevention needs of PLWHA, it will be important to have empathy. One of the challenges for health workers can be to understand why their patients with HIV are not able to consistently change their health behavior. State that the next exercise is designed to assist with this process.
<> Reveal pre-hung newsprint labeled: “Please Understand…” Suggest that you would like participant’s to step into the shoes of their patients with HIV who are not able to consistently do the right thing in terms of HIV prevention. Ask them to finish the phrase in their patient’s own voice. Emphasize the exercise is not designed to focus on PLWHA who do not care about themselves or others; rather, this exercise—and this course—are designed to think about the feelings of individuals who may desire the right thing but can’t always do it.
<> You should begin by modeling a response like “Please understand, my partner insists we not use protection.” Invite a participant to follow up, thanking them for their contribution. Continue until 8-10 responses have been shared. Thank all participants for their thoughtful responses
4. Make the observation that one aspect of successfully meeting the prevention needs of PLWHA will be appreciating differences that present in values, beliefs, and practices between providers and patients. Reiterate the theme of partnership and collaboration and suggest that, in order for prevention efforts to be successful, patients cannot feel judgment.
5. Advise participants that this skill-to be able to overcome differences begins with acknowledging differences that exist. Using newsprint labeled ‘Differences’, invite a discussion of the differences between patients and providers that are visible. NOTE: You may choose to draw an ‘iceberg’, making the point that differences are below or above the line of visibility.
6. As participants generate a list of visible differences; record these as participants offer suggestions. Next, ask participants to discuss differences that exist which may not be visible. Again, record these on newsprint.
7. Once all suggestions have been recorded, ask participants what will happen if providers do not pay attention to these differences. If a follow-up questions is needed, ask how patients may feel knowing our values, beliefs, or practices may be different than theirs. Listen and confirm ways in which patients may feel stigma, judgment, or be disinclined to collaborate with their health worker.
8. Reveal Slide 15, and make the point that the skills to work successfully to overcome differences are often called cultural competence. Use the following to guide a discussion of cultural competence in Positive Prevention:
<> Listen with Empathy- The first goal of effectively overcoming difference in HIV care should be attempting to listen well. If providers are attempting to listen with the goal of truly understanding, the likelihood of culturally competent practice is virtually guaranteed.
<> Elicit Patient Perspective- If providers are listening to understand a patient’s motivation and goals, this will increase understanding and allow us to direct our practice in a client-centered way.
<> Acknowledge Differences- When differences are revealed, it can be important to acknowledge these. This not only admits the obvious, but also paves the way for enhanced understanding.
<> Recommend Treatment- It is important to remember it is our role as health care providers to offer recommendations regarding behavior change or treatment advise.
<> Negotiate Agreement- It will also be critically important to the success of our partnerships with patients that we be willing to ‘meet patients where they are’ in terms of behavior change and allow that any movement toward behavior change is success.
9. Invite any additional suggestions about helping overcome difference, and then suggest that the rationale for including this in the workshop is the importance of the relationships we form between PLWHA and their health care providers. Suggest that this ability to form caring relationships may be one of the most important variables to patient behavior change; certainly, it is the one over which health care workers have control.
10. Transition to the next activity by suggesting the discussion of health behavior change begins by looking at strategies for HIV behavior change.
INTENSIVE PREVENTION SUPPORT
Time: 30 minutes
Materials: Newsprints, Slide 16 (Assessing Barriers to Change), Slide 17 (Communication Skills), Slide 18 (Model for Prevention Case Management)
Steps:
1. Remind participants of the exercise on fluids and portals of entry. Ask if patients understand routes of transmission. Acknowledge that, for many patients, understanding the ‘facts’ about transmission may not be the barrier to behavior change. Suggest that, in fact, most patients have a pretty good idea of the risks associated with unsafe sex or substance use.
2. Suggest that, if patients have information, health workers may need to provide more intensive prevention support for individuals who are experiencing difficulty altering their behavior. Reveal Slide 16 (Assessing Barriers) and begin a discussion of how to conduct an assessment of additional needs for prevention support. Suggest the barriers to health behavior change may vary, and the point of effective assessment is matching the intervention to the particular need. Offer the following illustrations as you review the points on the slide:
<> Intrapersonal Factors- patients may be experiencing depression or problems with misuse of alcohol/drugs that impact their ability to sustain behavior change
<> Interpersonal Factors- for some patients partner pressure or resistance may impact their ability to use barrier protections
<> Environmental Factors- for patients whose environment doesn’t support healthy self care, this may create an influence which counters our message of self care
<> Community norms- if the community norm is one that doesn’t support safer sex [e.g. we’re all going to die anyway’]
<> Social/peer norms- if the peer norms are that unsafe sex is acceptable, this message may contradict the message from the health care worker
<> Issues of access- the best example is access to affordable condoms
3. Suggest that the best option for understanding patient’s inability to change behavioral will involve an interactive discussion with them. This discussion should focus on attempting to identify the challenges that patient is facing in an empathic manner while attempting to build patient’s self-efficacy.
4. Reveal Slide 17 (Communication Skills) and use the following to guide your discussion:
<> Open Questions- Explain that open questions are questions that don’t expect a ‘yes’ or ‘no’ answer. Ask participants to take a moment and write one or two open questions which are suggestions for risk assessment. After a moment, invite discussion. Focus on questions that invite a discussion of who, what, where, when, and how as well as other iterations of open questions.
<> Affirmations- Make the point that the use of affirmations is the skill of finding patient’s strengths or successes.
<> Reflective Listening- In using reflective listening, the health care worker focuses on playing back in simpler language what your patient is saying. Ask participants to think about why reflective listening may be helpful to patients. Listen and confirm responses.
<> Assess Patient’s Perception- Suggest that the patient’s perception of their risk—and the risks to their partners—is critical information for health care workers and patients. This information should help guide recommendations for prevention efforts and determine support that patients need for behavior change.
5. Invite any questions about the communication skills discussion or any additional comment. Transition to the next activity by suggesting that participants will now have a chance to practice these skills.
<> Ask participants to find a partner. Once dyads have formed, instruct one participant to take the role of patient, and ask that they be mindful of the issues generated in the discussion about why patients cannot do the safest thing every time. Ask that they select in advance one primary barrier to behavior change that their health worker should seek to explore. Ask that they identify this barrier, but not share with the counselor until an appropriate question is asked.
<> Speak to the person who will conduct the assessment and instruct them that the primary point of this practice is to determine how the skills presented enhance an understanding of this patient’s unique barriers to HIV prevention.
Take a minute to invite participants to think about introducing the assessment. Suggest that the person playing the health care worker introduce the process, ask for permission to begin, and give the patient permission to disclose at a level they feel comfortable. Invite participants to think about questions, explain they will have five minutes to practice, and instruct them to begin.
<> After five minutes call time, and ask partners to take a minute to de-brief focusing on what went well. After a few minutes, explain that they will now switch roles. Ask the person who was the health care worker to step into the shoes of a PLWHA who is not able to consistently use HIV risk reduction measures. Explain the goal is for the health care worker to understand the recent risk behavior and the patient’s motivation. Invite any questions and instruct them to begin.
Invite the participant portraying patient to think of one primary barrier to behavior change which they will share if their health care provider asks an appropriate question. Instruct participants to begin.
<> After five minutes, call time. As before ask participants to de-brief, focusing on what happened that was effective. After participants have finished debriefing with one another, invite them to return to their original seats.
<> Once the large group has reassembled, ask participants what skills and interventions were successful what they were in the patient role. Continue the discussion by talking about what they felt was successful when they were in the provider role. Invite any final comments and transition to the next activity by emphasizing that the value of behavioral assessment will be identifying specific barriers so that specific interventions can address the consumer’s unique circumstance.
6. Suggest that, for consumers for whom a brief intervention may not be appropriate, clinics may seek to implement programs which address the additional needs of individuals with HIV who are unable to change their HIV risk behavior consistently.
7. Reveal Slide 18, and present the elements of successful intensive prevention interventions. State that these characteristics have been demonstrated through a meta-analysis of effective behavioral interventions published in the journal AIDS from October 2006. Review the core elements of the intervention from the slide, offering illustrations as you do. Invite any questions.
8. Suggest that this article drew conclusions from twelve successful HIV prevention interventions which targeted PLWHA. Make the point that there are multiple ways in which intensive prevention support may be delivered.
Suggest that good practice would be for clinics desiring to provide intensive support familiarize themselves with the elements of successful PLWHA-focused interventions. Invite any questions about the characteristics of effective interventions.
9. Transition to the last activity in the module by suggesting that the emphasis of the module has been on understanding that complexity of health behavior change and the last activity invites an exploration of intervention approaches to impact health behavior. .
HEALTH BEHAVIOR CHANGE
Time: 20 minutes
Materials: Newsprint, Slide 19 (Factors Associated with Health Behavior Change)
Steps:
1. Reveal Slide 19 (Factors Associated with Health Behavior Change. Review the points on the slide, using the following to guide your discussion:
<> Knowledge/Awareness- a consumer must be aware of the risks and the methods to protect themselves
<> Perceived Susceptibility- for behavior change to occur, an individual must have a sense of personal vulnerability to the consequences of the unhealthy behavior
<> Perceived Benefit of Change- for an individual to embark on a behavior change, the sense of the positive impact must outweigh the ‘costs’ of changing behavior
<> Social Support- a very important factor in initiating—and sustaining—a health behavior is the perception that family/friends/ peers support adopting the healthier behavior
<> Skill Acquisition- often, consumers need to find additional skills which will be necessary to support health change [e.g. negotiation skills]
<> Reinforcement for Behavior Change- in order to sustain behavior change, a consumer must experience positive reward
2. Invite any questions or any additional comments. Quickly divide the group into six groups and assign each group one of the factors to consider. Ask them to focus on generating a list of strategies that health care workers can use to enhance that factor. Advise them they have about ten minutes to complete the task.
3. After fifteen minutes, ask invite participants to begin offering group reports. Ask one group to make their recommendations, and then invite other participants to ask for clarification or make any additional suggestions.
Repeat this process until group reports have been completed.
4. Distribute Handout 3, and review the suggestions for behavioral intervention. Point out the similarities between the group suggestions and the information on the handout.
5. Ask participants to return to their original seats, and de-brief the exercise by using the following to guide your discussion:
<> What insights does this exercise give you?
<> How can you enhance your practice?
<> Where do your patients typically struggle in changing their health behavior?
<> What can you do differently to encourage safer behavior?
6. Thank participants and transition to the next module.
END OF MODULE FIVE
MODULE 6: COMMUNITY SUPPORT AND EFFECTIVE REFERRALS
Total Time: 35 minutes
10 minutes Value of Community Involvement
15minutes Support Networks, and PLWHA-Delivered Services
10 minutes Making Effective Referrals
Module Objectives: Participants will be offered a rationale for community involvement for PLWHA. Several illustrations of ways in which individuals can become more involved in their community will be offered, and suggestions for
how to make effective referrals will be made.
Preparation: Newsprint; Slide 20(Options for Community Involvement and Slide 21 (Successful Referrals)
VALUE OF COMMUNITY INVOLVEMENT
Time: 10 minutes
Materials: Newsprint, Slide 20
Steps:
1. Introduce the topic by explaining the last aspect of Positive Prevention relates to promoting community engagement. Explain that this presumes benefit to PLWHA and communities associated with encouraging community involvement.
2 Quickly divide the group into halves, and instruct one half of the group to brainstorm as many benefits to the community as they can think of in five minutes. Instruct the other group to think about the benefits to PLWHA.
Advise them they have five minutes.
3 After five minutes, call time. Ask members of the first group to discuss aspects of community involvement that impacts communities. As participants report their recommendations, listen and confirm responses.
Next, invite participants to discuss aspects of community involvement and its benefit to PLWHA. As before, confirm all responses. Once the group has finished their report, invite any final questions or comments.
2. Thank participants for their contribution, and emphasize the value to both communities and PLWHA of this involvement.
3. Reveal Slide 20, and discuss the options for community involvement. Use the following to guide your discussion:
<> Assistance within Social Networks- point out the value individuals with HIV can have in reaching their peers
<> Providing Education in the Community- many individuals have found that sharing their stories of being a person living with HIV has been helpful in terms of altering community norms; at times, young people have been impacted by individuals with whom they identify encouraging HIV prevention
<> Engaging in Support Group-the value of participation in support groups—for individuals and the group itself—is well known
<> Providing Support to Clinics/CBOs- some agencies have found volunteer and other assistance from individuals with HIV to provide enhancement to their existing services
<> Peer-delivered Interventions- some health education and counseling efforts delivered by peers have been proven to be effective
<> Decreasing Stigma- ultimately, HIV positive individuals who engage in communities have the potential to minimize stigma of HIV; the rationale is that individuals who are living with HIV and are open about this may change community attitudes and norms about HIV.
4. Invite any questions, and transition to the next activity by continuing to discuss interventions delivered by PLWHA.
SUPPORT NETWORKS AND PLWHA-DELIVERED INTERVENTION
Time: 15 minutes
Materials: Newsprint
Steps:
1. Suggest that the value of individuals with HIV assisting the health sector by partnering with us on prevention or care interventions is documented. Ask participants to think about the value of engaging PLWHA as partners in our prevention and outreach efforts. Listen and confirm responses.
2. Offer the caution that these interventions—while providing great benefits—must be undertaking very thoughtfully. Reveal a newsprint labeled ‘Cautions’, and invite participants to generate a list of safeguards which must be in place or cautions agencies or clinics should use to assure success of peer-based programs.
3. Begin the discussion by using the example ‘dual roles’. Point out how complicated
4. Invite any final additions, and transition to the final activity by reminding participants that some patients will need additional prevention support beyond what can be accomplished in clinics. This should be a reminder that many issues arise in the provision of secondary prevention which cannot be addressed fully in certain settings and require a successful referral.
STEPS IN EFFECTIVE REFERRAL
Time: 15 minutes
Materials: Slide 21 (Steps in Effective Referral)
Steps:
1. Finally, explain that acting as a client advocate may be another task for clinic staff. Acknowledge that, at times, agencies may accept clients or may have rules that are impeding our clients getting needed services.
Sometimes by advocating on behalf of clients, systems become more flexible or room for clients who may have ‘fallen through the cracks’ become available. While it may not be the role of the primary care provider, this need should be addressed by someone on the comprehensive care team.
Use Slide 21 to quickly offer some suggestions for effective referral, emphasizing that the goal is to maximize that a patient follows through with our referral. Stress that this is especially critical for the HIV positive patient who needs evaluation for treatment and care.
• Refer to known and trusted resources: the most effective referrals are to specific providers with whom you have had experience.
• Offer referral as one option: in a client-centered approach, the client is offered the referral as a possible resource for them to take advantage of.
• Assess client’s reaction to referral: note that clients may have history with agencies and providers we need to understand, and some referrals may have negative stigma in client’s minds.
• Instruct clients and prepare clients for agency services you are referring to: specific teaching about what to bring, how to get to agencies, and what to expect at the organization.
• Assess level of support for active referral: at times, client empowerment means giving client little direction and encouraging them to follow through, other clients need to have appointments made or a plan of assistance developed.
• Follow-up with client and referral source as appropriate: determine mechanism to find out from client and/or provider if client did follow through and how successful the interaction was.
2. Finally, explain that acting as a client advocate may be another task for clinic staff. Acknowledge that, at times, agencies may accept clients or may have rules that are impeding our clients getting needed services.
Sometimes by advocating on behalf of clients, systems become more flexible or room for clients who may have ‘fallen through the cracks’ become available. While it may not be the role of the primary care provider, this need should be addressed by someone on the comprehensive care team.
3. Invite any questions and transition to the module closure.
END OF MODULE 6
WORKSHOP CLOSURE
Time: 10 minutes
Materials: Evaluations
Steps:
<> Announce to participants that the training is concluding. Thank them for their hard work and willingness to participate.
<> Ask if anyone wants to complete the experience by sharing something they learned that was meaningful or something they will do differently. Invite participants who are willing to mention one thing they found valuable if they choose or something they will do differently in their practice.
1. When participants have finished, instruct them to complete evaluation, discuss any follow-up training opportunities, and adjourn the workshop
END OF WORKSHOP
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Positive Prevention
