3. MODULE OUTCOMES
By the end of this module, you should have gained sufficient skills to:
1. Define common terms used in HIV/AIDS/STIs
2. Appreciate the fundamentals of HIV and AIDS
3. Understand the preventive measures of HIV and AIDS
4. Describe the management of HIV and AIDS
5. Explain Strategic Behavior Change Communication (SBCC)
6. Understand Home and Community-Based Care (HCBC)
7. Understand the concepts of STIs
4. DEFINITION OF TERMS
HIV stands for Human Immunodeficiency Virus.
It is a Retrovirus. HIV Infection is the state where the virus is in the
body. In most instances this is the asymptomatic state, which is a
prelude to AIDS
AIDS stands for Acquired Immune Deficiency Syndrome.
“Acquired” means it is transmissible, and “Immune-Deficiency”
means it damages the body defense system “Syndrome” refers to a
group of illnesses
5. HISTORICAL BACKGROUND OF HIV
1981 – Doctors in the United States recognized it in homosexual males
1984– The first case in Kenya was described
1986 – Human Immunodeficiency Virus (HIV) was accepted as the
international designation for the retrovirus in a WHO consultative meeting
1996 – ARVs became available in the world.
1997 – ARVs became available in the private sector in Kenya.
1999 – HIV was declared a national disaster in Kenya
2003 – ARVs became available in public sector in Kenya
6. HIV EPIDEMIC UPDATE 2018 - KENYA
Kenya Population-based HIV Impact Assessment (KENPHIA) 2018
survey indicated:
That Kenya’s HIV prevalence now stands at 4.9%.(15-49 yrs)
The prevalence of HIV in women is at 6.6%, twice that in men at 3.1%.
The gender disparity in the burden of HIV is even greater than 3 times in
between the ages of 20-34 years.
The top five HIV high-prevalence counties with a prevalence of more than
9% were Homa Bay, Kisumu, Siaya, Migori and Busia; while prevalence was
lowest in nine counties of Samburu, Tana River, Garissa, Wajir, Mandera,
Marsabit, Kiambu, West Pokot, and Baringo
7. Most at Risk populations for HIV infection
This are populations at highest risk for sexual acquisition/transmission of
HIV due to either the number of partners that they have or the higher risk sex
that they engage in.
30% of new infections occur among these populations and the vulnerable
1. Intravenous Drug Users
2. Commercial sex workers
3. Men who have sex with men (MSM)
4. Vulnerable: Prisoners; transgender persons, children, women and girls and
persons with disability
5. Young people and adolescents. WHY?
8. Vulnerable Populations
These are people who because of their circumstances, are at an increased risk of contracting HIV.
They include;
i. Widows and widowers
ii. Opharns and vulnerable children
iii. Families and children living in the streets
iv. Young women aged 15 – 24 years
v. Service men and women
vi. Refuges and displaced migrants persons
vii. Fisher folks
viii. Truckers
ix. Alcoholic
9. Key determinants of HIV Prevalence
Socio cultural Factors like high HIV stigma and discrimination,
negative attitude towards consistent use of condoms and
gender inequalities.
High risk sexual behavior characterized by high incidences of
concurrent sexual relations linked to mobility,
intergenerational sex, transactional sex, denial and
marginalization of LGBTQ groups.
Biological factors including male circumcision and high
prevalence of STIs are among the key risks
10. Origin of HIV
Scientists believe that HIV originally came from a virus
particular to chimpanzees in West Africa during the 1930s,
and originally transmitted to humans through the transfer of
blood through hunting. Over the decades, the virus spread
through Africa, and to other parts of the world
However, it wasn’t until the early 1980s, when rare types of
pneumonia, cancer, and other illnesses were being reported to
doctors that the world became aware of HIV and AIDS.
11. Properties of the HIV Virus
It is an obligate intracellular parasite, that cannot survive outside the host
cell for long
It depends on the host cell for multiplication/replication.
It is classified as a prokaryotic – does not have normal cellular organization
Contains RNA genetic material
As a retrovirus, it inserts a copy of its RNA genome into the DNA of a host
cell that it invades, thus changing the genome of the host cell
The structures on its surface (surface antigens) helps the virus attach to
host cells
It is quickly destroyed by heat, and common disinfectants such as JIK
(Sodium hypochlorite)
12.
13. Cont’d…
Glycoproteins gp41 and gp120 are responsible for attachment to the host
cell
p17 helps in replication of the virus
p24 is a distinctive HIV antigen. It is a structural protein that makes up
most the of the HIV viral core, or capsid.
Reverse transcriptase is an enzyme that the HIV virus uses to convert its
RNA into viral DNA, in a process known as reverse transcription
Integrase enzyme helps the virus integrate (incorporate) its viral DNA into
the host genome
Protease enzyme is used by the virus to manufacture proteins during viral
maturation i.e. processing of the gag and gag-pol polyproteins
The RNA is the genome of the virus. It plays a central role in viral
replication, serving as a template for Gag/Gag-Pol translation and as a
genome for the progeny virion
14. How HIV Infects the Body
Exponential viral replication
Widespread systemic dissemination to the
brain, spleen, distant lymph nodes, etc. (5-11
Days)
HIV makes contact with cells located within the genital mucosa
Virus is carried to regional lymph nodes (1-2 Days)
5
15. How HIV Affects the Immune System
HIV attaches to cells of the immune system with special surface
markers called CD4 receptors. Immune cells with CD4 receptors
include:
T-helper Lymphocytes
Macrophages
Monocytes
Dendritic cells
Microglial cells
15
16. cont’d…
The hallmark of HIV/AIDS is profound immunodeficiency as a
result depletion of CD4+ T lymphocytes.
The CD4+ T cell dysfunction is two fold ;
Reduction in numbers
Impairment in function
16
17. Immune suppression
• HIV attacks white blood cells, called CD4 cells,
that protect body from illness
• Over time, the body’s ability to fight common
infections is lost
• Opportunistic infections occur
17
18. HIV Disease
Progression of HIV disease is measured by:
1. CD4+ count
Degree of immune suppression
Lower CD4+ count means decreasing immunity
2. Viral load
Amount of virus in the blood
Higher viral load means more immune suppression
18
19. HIV Disease
Severity of illness is determined by amount of virus in the
body (increasing viral load) and the degree of immune
suppression (decreasing CD4+ counts)
Higher the viral load, the sooner immune suppression occurs
When the body’s immunity is suppressed, there will be
increased clinical symptoms (such as opportunistic infections)
19
20. Adult problems
Adults infected with HIV often experience the following clinical problems
Depending on the stage of HIV infection, PTB can occur at any time.
As HIV disease progresses, HIV patients develop;
Bacterial infection ( acute respiratory infection, pneumonia, and skin infection)
Fungal infection
More severe conditions occur as immune system deteriorates. Conditions including the following
may develop:
Chronic diarrhea
Wasting
PCP
Extra pulmonary TB
Cryptococcal meningitis
Kaposi sarcoma
20
21. HIV Disease: Summary
• HIV multiplies inside the CD4+ cells, destroying them
• As CD4+ cell count decreases and viral load increases, the
immune defences are weakened
• HIV-infected people become vulnerable to opportunistic
infections
• HIV is a chronic viral infection with no known cure
• Without ARV treatment, HIV progresses to symptomatic disease
and AIDS
21
22. Key Points
• HIV is a global pandemic and the number of people living
with HIV continues to increase worldwide.
• HIV epidemic is especially severe in poor populations
• HIV is a virus that destroys the immune system, leading to
opportunistic infections.
• The progression from initial infection with HIV to end-stage
AIDS varies from person to person and can take more than 10
years.
22
23. Key Points (continued)
• The most common main route of transmission worldwide
is heterosexual transmission.
• Women of childbearing age are at particular risk for
acquiring HIV through unprotected sex
• HIV-positive women who are pregnant are at risk of
passing HIV infection to their newborn.
• Risk of HIV transmission from mother-to-child can be
greatly reduced through effective PMTCT programs
23
24. HIV Life Cycle
1. Binding, fusion and entry
2. Reverse transcription
3. Integration
4. Transcription and translation
5. Assembly, budding and maturation
When the virus infects body, it attacks and multiplies within the host cells (CD4
group of lymphocytes). The host cell eventually gets destroyed when new virus
particles are released and proceed to infect other cells
The steps involved are;
25.
26. 1. Binding, fusion and entry
During this step, viral gp120 binds to the CD4 receptor and
CCR5 or CXCR4 co-receptor on the host surface
The binding facilitates the fusion of viral and host cell
membrane thereby facilitating the entry of viral nuclear
material into the host cell
27. 2. Reverse transcription
Viral RNA is reverse transcribed to viral DNA
This process is mediated by the enzyme reverse transcriptase
(RT)
This enzyme has no proof-reading function, and therefore the
process is error-prone and responsible for development of
drug-resistant mutations
28. 3. Integration
The viral DNA is inserted into host cell DNA using the viral
enzyme integrase
This is the process that establishes replication-competent
virus in the body and makes HIV incurable even with effective
ART
Further, drug-resistant virus that occurs in patients on ART
may also be achieved in the same way, establishing a
permanent pool of resistant viruses.
29. 4. Transcription and Translation
Host cell enzymes transcribe viral DNA into viral RNA
Viral RNA uses host cell energy and synthetic pathways to
make viral proteins
30. 5. Assembly, budding and maturation
Viral proteins and RNA aggregate on the cell surface for
assembly into a mature viral particle by budding through host
cell membrane
31. Types of HIV Virus
There are two types of HIV.
HIV – 1
Is found worldwide
Is the main cause of the worldwide pandemic
HIV – 2
Is mainly found in West Africa, Mozambique and Angola.
Causes a similar illness to HIV – 1
Less efficiently transmissible
Less aggressive with slower disease progression
33. Body Fluids that may Contain HIV Virus
HIV can be spread only in certain body fluids from a person infected
with HIV:
a)Blood
b)Semen
c)Pre-seminal fluids/pre-ejaculatory fluid/Cowper’s fluid
d)Rectal fluids
e)Breast milk f) Vaginal fluid.
34. Modes Transmission of HIV
HIV is can be transmitted through;
1. Unprotected sexual intercourse with infected person: oral, anal, or
vaginal sex
2. Direct contact of open wound with infected blood
3. Direct contact with semen or vaginal and
cervical secretions of infected person
4. Infected mother to her child during
pregnancy, delivery, or breastfeeding
5. Blood transfusion with contaminated/unscreened blood
6. Sharing of needles by injectable drug users
7. Needlestick injury with contaminated needle in hospitals
8. Sharing of personal effects, especially toothbrush
35. Semen and Vaginal
Fluids
Sharing Needles
& Syringes
Through Infected
Blood
During Pregnancy
or Birth
Breast Feeding
Images Courtesy HIV Basics Course for Nurses, I-TECH
Needle Stick
Injury
Modes of HIV Transmission
Natural History of HIV
3
36. HIV cannot be transmitted through;
Insect bites
Coughing or sneezing
Sharing food, drinks or utensils
hugging or kissing
Handshakes
Work or school contact
37. Exposure Route
Risk of
Transmission
Blood transfusion 90-95%
Perinatal (from pregnancy to 1yr
after birth)
20-40%
Sexual intercourse: 0.1 to 1%
Vaginal 0.05-0.1%
Anal 0.065-0.5%
Oral 0.005-0.01%
Injecting drugs use 0.67%
Needle stick exposure 0.3%
Mucous membrane splash to eye,
oro-nasal
0.09%
HIV Transmission Risk
38. Key determinants of HIV Prevalence
1. Socio-cultural Factors like high HIV stigma and
discrimination, denial and discrimination of LGBTQI
community, inconsistent use of condoms and gender
inequalities.
2. High risk sexual behavior such as anal sex, concurrent
sexual relations, transactional sex
3. Biological factors including non-circumcision of males and
presence of STIs
39. Risk factors for High HIV/AIDS Transmission
in women
i. Inability of women and young girls to negotiate for sex.
ii. Vulnerability to pressure from male counterparts
iii. Trauma and bleeding caused by sexual intercourse at an early age, a time of
physical immaturity, increases exposure to HIV
iv. Early marriages encouraged by some cultures, expose young women to
older men who may be HIV POSITIVE
v. Forced sex through rape, traditional rituals and practices such as wife
inheritance, or wife cleansing which increase the risk of HIV.
vi. Economic pressures which force women to exchange sex for the necessities
of survival- food, shelter and safety.
39
40. Risk factor for HIV/AIDS Transmission in
men
i. Failure to seek proper care for HIV and other STIs due to lack of
knowledge, lack of comfort in Health care setting or stigma
ii. Cultural accepted practices such as polygamy
iii. Men who have sex with men
iv. Ego-driven behaviors to display their manhood including drug and
alcohol abuse that may lead to irresponsible sexual risk practices.
v. Peer pressure from other young men to conform to unsafe sex without
regard to consequences.
40
41. Impact of HIV/AIDS on Communities
1. Economic drawback at personal and community level
2. Reduction of productive workforce
3. Loss of loved ones and bread winners
4. Family conflicts – rejection, divorce
5. Increased budgets for health services
6. Increased number of orphans and vulnerable children
7. Increased number of child-headed families
8. Added responsibilities to grandparents or other family
members who have to care for the sick and OVCs
9. Depopulation of communities
42. Global Impact of HIV
• Negative economic impact to countries
• Increased healthcare costs
• Decreasing life expectancy
• Reversal of child survival gains
• Increased numbers of orphans
42
43. The natural history of HIV infection refers to the stages in the progression of
HIV to AIDS if HIV is left untreated. There are 5 stages;
1. Infection stage – a person gets infected
2. Acute seroconversion: 2-3 weeks
3. Asymptomatic HIV infection (clinical latency): 8 yrs (Avg.)
4. Symptomatic HIV infection/AIDS: 1.3 yrs (Avg.)
5. AIDS
Natural History of HIV Infection
(Natural Progression of HIV Disease)
8
43
44. Cont’d: Progression of HIV Disease
1. Infection stage – no signs and symptoms
2. Acute seroconversion:
• The body begins to produce antibodies against
• Fever, rash and adenopathy
• Usually 3-6 weeks after exposure
3. Asymptomatic HIV (clinical latency):
• Patient often unaware of infection, antibodies detectable.
• Immune system able to control virus to limited extent and CD4 >350/cu.mm
• Able to transmit HIV to others
4. Symptomatic HIV:
• Minor to moderately severe symptoms
• Recurrent symptoms
5. AIDS:
• Severe immuno-suppression associated with opportunistic infections or cancers
44
45. Patterns of Progression of HIV to AIDS
13
Depending on the rate of progression of the HIV infection, there are 4 types
of progressors;
Typical progressors – where AIDS develops in 8-10 yrs
Rapid progressors - where AIDS develops within 3 years of infection
Slow progressors – may take up to 15 years to develop AIDS
Long-term non-progressors - where HIV-infected people maintain high CD4+
and CD8+ T-cell counts. Take longer than 15 years to develop AIDS
45
46. WHO Clinical Staging of HIV/AIDS
There are four (4) clinical stages of AIDS according to
WHO;
WHO Clinical Stage 1
• This is the asymptomatic stage
• However, the patient may have Persistent generalised
lymphadenopathy (PGL)
Painless enlarged lymph nodes >1 cm In two or more non-contiguous sites (excluding inguinal),
in absence of known cause
Persisting for 3 months
14
46
47. WHO Clinical Stage 2
Characterized by;
Unexplained moderate weight loss (<10%
of presumed or measured body weight)
Recurrent respiratory tract infections (sinusitis,
tonsillitis, otitis media, pharyngitis)
Herpes zoster
Angular cheilitis
Recurrent oral ulceration
Pruritic popular eruptions (PPE)
Seborrhoeic dermatitis (scaling of skin, mainly scalp)
Fungal nail infections
15
47
48. WHO Clinical Stage 3
Characterized by;
Unexplained severe weight loss (>10%
of presumed or measured body weight)
Unexplained chronic diarrhoea for longer than one month
Unexplained persistent fever (above 37.5oC intermittent or
constant for longer than one month)
Persistent oral candidiasis
Oral hairy leukoplakia (OHL)
Pulmonary tuberculosis
Candidiasis
16
48
49. Cont’d: WHO Stage 3
Severe bacterial infections (e.g. pneumonia, empyema,
pyomyositis, bone or joint infection, meningitis,
bacteraemia)
Acute necrotizing ulcerative stomatitis, gingivitis or
periodontitis
Unexplained
Anaemia (<8 g/dl)
Neutropenia (<0.5 x 109 /L) and or
Chronic thrombocytopenia (<50 X 109 /L)
17
49
50. WHO Clinical Stage 4
This is the last stage that is characterized by;
HIV wasting syndrome (severe weight loss)
Pneumocystis pneumonia (PCP)
Recurrent severe bacterial pneumonia
Chronic herpes simplex infection (orolabial, genital or anorectal of more
than one month’s duration or visceral at any site)
Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs)
Extra pulmonary tuberculosis – TB affecting other organs other than
lungs
Kaposi’s sarcoma
18
50
51. Cont’d: WHO Clinical Staging 4
Cytomegalovirus infection (retinitis or infection of other organs)
Central nervous system toxoplasmosis
HIV encephalopathy – affects CNS and immune system
Extra pulmonary cryptococcosis including meningitis
Disseminated non-tuberculous mycobacteria infection
Progressive multifocal leukoencephalopathy
Chronic cryptosporidiosis
Chronic isosporiasis
19
51
56. OPPORTUNISTIC INFECTIONS IN HIV/AIDS
What is an opportunistic infection?
An opportunistic infection (OI) is a disease caused by microorganism that
does not normally cause illness in a person with a healthy immune system,
but that may cause serious disease when the immune system is weakened.
For example, as the immune system of people living with HIV weakens,
they become susceptible to a number of opportunistic infections at
different stages of HIV disease progression
56
57. Common Opportunistic Infections (OIs) in Adults
1. Tuberculosis
2. Bacterial infections e.g. bacterial pneumonia
3. Pneumocystis pneumonia (PCP)
4. Cryptococcal meningitis
5. Toxoplasmosis
6. Candidiasis
7. Infective diarrhoea
8. Infective dermatoses
9. Herpes zoster
10.Karposi’s sarcoma
11. primary CNS lymphoma
12.Carcinoma of the cervix
13.Other lymphoma
57
For adults living with HIV, the common OIs include;
71. Introduction
Although most STIs can be cured except HIV/ AIDS , it is more cost effective
to prevent them
Community education on the risk factors and promotion of behavior change
in prevention and control of STIs and HIV are important.
HIV/AIDS/STIs prevention measures revolve around intervention on sexual
behavior of individuals.
Various intervention measures are needed to control the spread of
HIV/AIDS/STIs
72. HIV/AIDS Prevention Strategies
Despite many years of research, there is no cure for AIDS.
Hope for fighting the scourge continues to be in prevention
of transmission.
Preventive strategies are therefore aimed at curtailing
transmission via known routes of transmission
72
73. Primary Prevention Strategies (activities)
1. Sexual behavior change – promoting the adoption of safe sex practices
2. Condom promotion and availability
3. Early treatment of Sexually Transmitted Infections
4. Voluntary Counseling and Testing of HIV
5. Voluntary male circumcision
6. Prevention of mother to Child Transmission
7. Blood Safety, screening for HIV
8. Stigma reduction through attitude change
9. Harm reduction for Injecting drug users
10. HIV prophylaxis – PEP and PreP
73
Primary prevention strategies seek to prevent transmission of HIV to individuals who
are not infected yet. The measures include;
74. Secondary Prevention Strategies
Secondary prevention strategies target persons who are HIV positive to
become partners in the fight to prevent spread of HIV to the general
population. This is a holistic approach that involves physical, social,
psychological and spiritual interventions. The strategies include;
1. Attitude change – by linking the newly diagnosed to support groups
2. The provision of care for sexually transmitted diseases to PLWHA
3. The provision of Anti-Retro viral medications
4. Provision of care for opportunistic infections
5. Reducing fertility. This alludes to encouraging women who have the
infection not to have children
6. Prevention with positives – involving HIV patients in HIV advocacy
7. Health promotion strategies must be pursued aggressively
74
75. The ABCD of HIV Prevention
1. A – Abstinence
2. B – Be faithful to one partner with known HIV
Status
3. C – Correct and consistent condom use
4. D – Delayed Sexual Debut
75
76. Barrier Methods and Dual Protection
Both male and female condoms, used correctly and consistently can provide
protection against STIs , reduce the risk of HIV transmission and also prevent
unintended pregnancy.
Dual protection is the use of one or more methods of contraception that prevent
STIs , including HIV and unintended pregnancies. Examples include: birth control
pills would be a single method while use of birth control pills and Barrier
protection (condoms) would be dual protection.
The use of dual protection by HIV –infected couples can also protect then from
re- infection with variant strains of HIV and effectively help to space their children.
76
77. PMTCT
Stands for prevention of mother-to-child transmission of HIV
Mother to child transmission (MTCT) of HIV may occur at any
stage during pregnancy, labour and delivery, or breastfeeding
PMTCT can be achieved by:
i. Use of antiretroviral therapy (ART) – PreP and PEP
ii. Appropriate infant feeding practices
iii. Safe obstetrical practices
77
78. Cont’d…
Mother to child transmission (MTCT) of HIV infection during pregnancy,
labour and delivery or through breastfeeding is also refer to as vertical or
perinatal transmission.
The overall MTCT rate is approximately 40% without intervention.
78
79. Maternal factors that may increase the risk
of HIV
Pregnancy labour and delivery Breastfeeding
i. High maternal viral load
ii. Viral or bacterial infection
iii. STIs
iv. Maternal malnutrition
v. Anemia
i. High maternal viral load
ii. Ruptured of membranes
iii. Invasive delivery procedures
iv. External cephalon version
v. Premature delivery
vi. Low birth weight
vii. Broken skin
i. High maternal viral load
ii. Duration of breastfeeding
iii. Mixed feeding (food or fluids)
iv. Breast abscesses
v. Poor maternal nutrition status
vi. Oral disease in the baby
79
80. Elements of comprehensive PMCTC
approach
i. Element 1: primary prevention of HIV infection
ii. Element 2: Prevention of unintended pregnancies among women infected with
HIV
iii. Element 3: Prevention of HIV transmission from women infected with HIV to their
infants
iv. Element 4: Provision of treatment,care, and support to women infected with HIV,
their infants and their families
80
81. Feeding Options in PMTCT
Feeding options: exclusive breastfeeding for 6 Months
Benefits of breastmilk;
a) Easily digestable and has all the nutrients and water they need.
b) Available
c) Protects infants against diarrhea and pneumonia
d) Improves brain growth
e) Gives close contact
f) Lowers risk of passing HIV
g) Reduces the mother from getting breast cancer
82. Other methods of feeding
Exclusive breast feeding and early cessation. There is replacement feeding.
Wet nursing (to breastfeed another’s child)
Expressing and heat treatment of milk
82
83. Voluntary Medical Male Circumcision
(VMMC)
This is complete removal of the foreskin of the skin penis by surgical means.
Though VMMC may be conducted for a number reasons, evidence from research has
shown that medical male circumcision can significantly reduce (but not eliminate)
men's risk of acquiring HIV through sex.
HIV prevalence in uncircumcised men (16.9%) was five times higher than that of
circumcised men (3.1%). Among men who had sex across all age groups, HIV
prevalence was approximately seven times higher among uncircumcised men (22.5%)
compared with those who were circumcised (3.4%).
83
85. Post Exposure Prophylaxis (PEP)
Pre-exposure prophylaxis (PrEP) is the administration of
antiretroviral therapy to HIV- uninfected persons to reduce
their chance of acquiring HIV.
85
87. HIV Testing and Counselling (HTC)
HIV testing provides:
Information about HIV status
Opportunity to identify persons with HIV and
empower them to live normal life
Opportunity to identify persons who are HIV
negative and empower them to remain negative
88. Definitions
HIV testing: process of determining if client is infected with
HIV
HIV counselling: confidential dialogue between an individual
or a couple and a healthcare worker (HCW) to help clients
examine their risk of acquiring or transmitting HIV
HIV counselling is tailored to the risk behaviour,
circumstances and special needs of the client
89. Guiding Principles in Counselling
and Testing
1. Confidentiality
2. Informed consent
3. Post-test support and services
90. Guiding Principles (Continued)
1. Confidentiality
Keeping private information shared between HCW
and client
It is an essential element in establishing and
maintaining client trust
91. Guiding Principles (Continued)
2. Informed Consent
Process during which clients receive clear and
accurate information about HIV testing to make
an informed decision about whether to accept or
decline testing
Consent may be written or oral
The client must give informed consent before
being tested
92. Guiding Principles (Continued)
3. Post-test counselling support and services
Provide both HIV-negative and HIV-positive clients with
test results and counselling
Inform client that follow-up treatment, care, support are
available, including support for disclosure when needed
93. Provider-initiated and Client-Initiated
Approaches to HIV Testing
There are two basic approaches to HIV testing:
1. Provider-initiated
2. Client-initiated
Both approaches include
Basic information about providing HIV testing
Risks and benefits of testing
94. Provider-Initiated Approach
Also referred to as “opt-out”
All clients provided with pre-test information
Testing is still voluntary under the provider-
initiated approach
95. Client-Initiated Approach
Client specifically requests HIV test
Also referred to as “opt-in”
Only clients who specifically request to be tested
are provided with HIV testing
Client gives verbal or written consent
97. Role of the HCW in Counselling
Role of Counsellor: to support and assist client’s decision-making process by:
Listening to client
Understanding the choices client needs to make
Helping client explore her/his circumstances and options
Helping client develop self-confidence to carry out her/his
decision about testing
98. Role of the HCW in Counselling
(Continued)
Counsellor is not responsible for:
Solving all of the client’s problems
The client’s decisions
99. Counselling Skills: Active Listening
It involves:
Listening to and understanding the client
Taking note of client’s non-verbal behaviour
Listening for client’s social and cultural context
Listening to client’s negative comments or
feelings—make note of things that may have to be
challenged
Active listening helps establish a trusting
relationship with the client
100. Listening and Learning Skills
Skill 1: Use helpful non-verbal communication
Includes all aspects of message not conveyed by literal
meaning of the words
It includes the Impact of gestures, gaze, posture and
expressions that convey information
Reflects attitude
Helpful non-verbal communication encourages client to feel
HCW is interested in her
101. Non-Verbal Communication
R A relaxed and natural attitude with clients
O Open posture should be adopted—it shows that you
are open to the client and to what client is saying
L Leaning forward toward the client is a sign of
involvement
E Maintain culturally appropriate eye contact
S Sit squarely facing client to show involvement
102. Listening and Learning Skills (Continued)
Skill 2: Ask open-ended questions
Open-ended questions begin with “how?” “what?”
“when?” “where?” or “why?”
Encourages responses that lead to further discussion
Try to avoid questions with a “yes” or “no” answer
103. Listening and Learning Skills (Continued)
Skill 2: Ask open-ended questions, examples of closed-ended questions:
You know what HIV is, don’t you?
Do you have any other questions about MTCT?
Are you going to tell your partner that you tested for HIV today?
Is your husband your only partner?
Do you plan to replacement feed?
How would you revise these questions so that they are open-ended?
104. Listening and Learning Skills (Continued)
Closed-ended Open-ended
You know what HIV is, don’t you? What is HIV?
Do you have any other questions
about MTCT?
What other questions do you have
about MTCT?
Are you going to tell your partner
about your HIV test result?
Who are you going to tell about
your HIV test result?
Is your husband your only
partner?
How many partners have you have
in the last 3 months?
Do you plan to replacement
feed?
How do you plan to feed your
baby?
105. Listening and Learning Skills (Continued)
Skill 3: Use gestures and
responses that show interest
Gestures: nodding and smiling
Responses: “Mmm,” “Aha”
Attending skills: clarifying and
summarizing—invite client to relax,
talk about herself and her problems
106. Listening and Learning Skills (Continued)
Skill 4: Reflect back what the client says
Encourages client to say more
Shows HCW is actively listening, encourages dialogue, gives
HCW opportunity to better understand client’s feelings
Say what client said in a slightly different way
107. Listening and Learning Skills (Continued)
Skill 5: Empathize—show you understand how she feels
Used in response to an emotional statement
Encourages mother to discuss the issue further
If client says, “I just can’t tell my partner that I have HIV,”
HCW could respond with “You sound like you are afraid to
tell your partner your HIV test result”
HCW is not empathizing if she responds with a question that
has a factual answer
108. Listening and Learning Skills (Continued)
Skill 6: Avoid words that sound judging
Words like: right, wrong, well, badly, good, enough, properly
Using these words may make client feels she is wrong, or that
there is something wrong with her baby
BUT, sometimes HCW needs to use “good” judging words to
build a mother's confidence
109. Common Mistakes in Counselling
Controlling the discussion
Judging the client
Preaching to a client
Labelling a client instead of finding out their
individual motivations, fears or anxieties
Reassuring a client without knowing
110. Common Mistakes (Continued)
Not accepting the client’s feelings
Advising before client has arrived at a personal solution
Interrogating
Encouraging dependence
Persuading or coaxing
112. Pre-test Information
The purpose of the pre-test session is
to provide the client or couple with
adequate information to make an
informed decision about HIV testing
113. Pre-test Information (Continued)
Objectives and components of the pre-test session:
Help client understand HIV
Explain importance and benefits of HIV testing
Explain HIV testing procedures
Explain importance of partner testing, discordance, disclosure
Explain risk reduction and available services (sexual, MTCT) and provide
referrals
Encourage continuous healthcare attendance (ANC and post-delivery)
114. Delivery of Pre-test Information
Pre-test session models:
Group information
Individual counselling
Couple counselling
115. Couple Pre-test Session (Continued)
Advantages of couple counselling:
o Partners hear messages together shared
understanding
o Environment is safe to discuss concerns
o HCW can ease tension and diffuse blame
o Post-test counselling messages reflect the test
results of both partners
o Neither is burdened with disclosure or partner
referral
o Facilitates risk reduction such as condom use
o Prevention (including PMTCT), care and treatment
decisions can be made together
117. PMTCT Generic
Training Package
Module 5, Slide
117
Overview of HIV Testing
HIV tests detect antibodies or antigens associated with HIV in whole
blood, saliva, or urine
Blood sampling is the
most common method
of testing
HIV tests are very accurate
118. Significance of HIV Testing
HIV testing is important for the following reasons;
1. Helps individuals know their HIV status
2. Helps prevent the spread of HIV – persons who know their status are better
informed on preventive measures
3. Helps assess the prevalence of HIV in general population
4. Facilitates initiation of HIV management in infected persons
5. Helps monitor the effectiveness of ARVs (by testing for CD4 and viral load)
119. Types of HIV Tests
Broadly, rapid and non-rapid tests are used to test for HIV
Assignment:
Differentiate between Rapid and Non-rapid HIV tests
120. HIV Rapid Tests (Antibody Tests)
Examples;
i. Western blot
ii. Determine
iii. Unigold
iv. Genie II
v. Hema-strip
vi. Ora-Quick
o After infection with HIV, the body makes antibodies to fight the virus
o It may take 4 to 6 weeks, but occasionally up to 3 months for antibodies to
become detectable in the blood
o During this time, a person can still transmit the virus to others
o Rapid HIV tests are the most common tests in VCT and PMTCT settings
121. Accurate results within 20-40 minutes
Can be done in the clinic setting
Accurate when performed correctly
Usually performed on serum or whole
blood (by fingerprick or venous sample);
some rapid HIV tests use saliva
No batching required
HCWs can be trained to perform the tests
Usually do not require special equipment, electricity or refrigeration
Cont’d: Rapid tests
122. Body Fluids Used for HIV Rapid Testing
Serum
Plasma
Whole blood
Oral fluids
123. There are only three possible outcomes for single HIV
antibody tests:
1. Reactive or “Positive”
Test band
Control band
2. Non-reactive or “Negative”
Control band only
3. Invalid
No control band present
Test has failed. Repeat with new device.
Interpreting Rapid Test Results
125. cont’d…
A positive HIV test means that antibodies to HIV are present. It does not
mean that the client has AIDS
A negative HIV test can mean:
The person is not infected with HIV, or
The person is infected with the virus but is in the window period
A negative test does not mean that person cannot
become infected. There is no such thing as
immunity to HIV infection
126. Rapid HIV Testing Algorithms
1. Serial testing
Blood sample taken and tested once
If first test result is non-reactive, result is given to client as HIV-negative
If first test result is reactive, blood sample is tested again using different
brand of rapid test
If second test is reactive, result is reported as HIV-positive
If second test is negative, a third test known as a “tiebreaker” is performed
127. Rapid HIV Testing
(Serial testing)
First Test
Positive Negative
Counsel for Negative Result
Second Test
Negative
Positive
Counsel for Positive
Result
Tie-breaker Test
Positive
Counsel for Positive
Result
Negative
Counsel for Negative
Result
128. Rapid HIV Testing Algorithms (Continued)
2. Parallel testing
Two HIV tests are performed on same sample at the same time, e.g., in
parallel
If both are non-reactive, client reported HIV-negative
If both are reactive, client reported HIV-positive
If one is reactive and the other non-reactive, a “tiebreaker test” is
performed
129. Rapid HIV Testing
(Parallel Testing)
Both Tests Positive
Counsel for Positive Result
Both Tests Negative
Counsel for Negative Result
Tie-breaker Test
Positive
Counsel for Positive
Result
Negative
Counsel for Negative
Result
First AND Second Test
Discordant
130. HIV Rapid Tests: Advantages
i. Rapid tests increase access to HIV prevention (VCT)
and interventions (PMTCT)
ii. Supports increased number of testing sites
iii. Same-day diagnosis and counseling
iv. Robust and easy to use
v. Test time under 30 minutes
vi. Most require no refrigeration
vii. None or one reagent
viii. Minimal or no equipment required
ix. Minimum technical skill
131. Cont’d….
x. On-site testing and same day results
xi. Lower risk of administrative error
xii. Widely accepted by clients
xiii. Fewer resources required:
oHuman resources
oResources at the facility
oFinancial resources
132. HIV Rapid Tests: Disadvantages
i. Only a few tests can be done concurrently
ii. Need for quality assurance/quality control at multiple sites
iii. Test performance varies by product
iv. Refrigeration required by some products, e.g., Capillus
v. There may be reader variability in interpretation of results
vi. Limited end-point stability of test results (results may appear
different after some time)
133. Non-rapid Tests (HIV Viral Tests)
Viral tests detect the presence of HIV in blood
Viral tests are performed by trained personnel in the laboratory
134. HIV Viral Tests (Continued)
There are two types of viral tests:
p24 antigen test: measures one of the HIV proteins used for screening blood and for
infant diagnosis
PCR (polymerase chain reaction) tests:
DNA PCR detects presence of HIV in
blood and is used for infant diagnosis
RNA PCR detects and measures
amount of virus in blood (viral load)
135. Assignment
1. What are the advantages of HIV antigen tests over antibody/rapid tests?
2. What are the demerits of HIV antigen tests
136. CD4 T-Lymphocyte Counts
CD4 T-lymphocyte counts used
for:
Determining clinical prognosis
Assessing criteria for antiretroviral
therapy
Monitoring therapy
137. Viral Load Test
The viral load test measures amount of HIV in blood
Used to:
o Predict disease progression
o Assist with deciding when to initiate anti-retroviral therapy
o Monitors response to anti-retrovirals
138. Discordant couple
Refers to situation where one of the sex partners is HIV positive whereas the other
one is HIV negative.
The HIV negative partner is at risk for HIV acquisition and so requires a coupe
specific HIV prevention package
In line with the WHO guidelines , the HIV negative client should be retested 4
weeks after initial testing then after 6 months and thereafter annually
140. Post-test Counselling
All HIV test results, whether positive or negative, must be given in
person, privately (as a single client or couple)
Put the client or couple at ease
Where possible, provide a quiet
and private room for the discussion
Ideally, the same HCW who
conducted the pre-test session
will also conduct the post-test
session
143. When Client Tests
HIV-negative (Continued)
Objectives of the post-test session:
1. Provide HIV test result and assess understanding of result
2. Identify and address client questions
3. Discuss:
Partner HIV testing and disclosure
Safer sex and risk reduction
Exclusive breastfeeding
Antenatal care, post-delivery care
Importance of delivering in a healthcare facility
Infant care
4. Provide referrals, take-home information
144. When Client Tests
HIV-positive
Client reactions to results can range from acceptance to disbelief
Remain non-judgemental, supportive and confident throughout the
counselling process
Encourage client to return for visits and follow-up HIV post-test
counselling
145. When Client Tests
HIV-positive (Continued)
Objectives of the post-test session:
Same as for post-test session when client tests HIV-negative, but counselor should
additionally discuss:
ARV therapy or prophylaxis
Infant feeding options
Treatment and support services for client and family
146. Disclosure of HIV Status
Disclosure is informing others of a test result
Clients who disclose are in a better position to:
Encourage partner(s) to be tested
Prevent transmission of HIV to partner(s)
Access PMTCT interventions
Receive support from partner(s) and family
It is important to respect client's choice
regarding timing and process of disclosure
148. DRUGS FOR HIV/AIDS
Drugs which suppress HIV have been named antiretroviral drugs (ARVs) due to
their ability to slow down HIV activity. Therapy that uses ARVS is called ART
(antiretroviral therapy)
ART is once of the components of comprehensive HIV care, it works best when
other components are in place.
ARVS improve the quality of life by stopping the virus from multiplying and allow
the body to recover.
Although patients on ARVS may appear healthy, and gain weight, they can still
infect other people.
Side effects and other problems may occur due to ART
149. Goals of ART
The goal of antiretroviral therapy is to;
i. Reduce the amount of HIV virus in the body
ii. Support and restore the immune system
iii. Reduce HIV illnesses and death
iv. Improve the quality of life
v. Reduce general risk of transmission in the public
150. Types of ARVs and How They Work
ARVS act on the HIV virus by interfering with its viral cycle.
There are 5 classes of ARVs currently in use namely;
o Nucleoside and nucleotide reverse transcriptase inhibitors
o Non nucleoside reverse transcriptase inhibitors
o Integrase inhibitors
o Protease inhibitors
o Fusion inhibitors
151. 1. Nucleoside/ Nucleotide Reverse
Transcriptase Inhibitors (NRTIs)
NRTIs inhibit the viral enzyme reverse transcriptase from converting viral RNA
into viral DNA, thereby halting HIV replication.
Examples;
o Abacavir (ABC)
o Zidovudine (AZT)
o Lamivudine(3TC)
o Tenofovir
152. 2. Non- Nucleoside Reverse Transcriptase
Inhibitors (NNRTIS)
NNRTIs inhibit the viral enzyme reverse transcriptase by binding
directly to it, blocking the reverse transcription process
Example are:
o nevirapine (NVP)
o efavirenz (EFV)
o Etravirine
153. 3. Integrase Inhibitors
They target viral enzyme integrase
Integrase is responsible for inserting viral DNA into the host chromosome
Integrase inhibitors stop the virus from inserting itself into the DNA of
human cells
Examples
o Dolutegravir
o Raltegravir
o Cabotegravir
154. 4. Protease Inhibitors (PIs)
Protease inhibitors work by blocking the activity of the viral enzyme protease
HIV uses protease to break up large polyproteins into smaller pieces required for
assembly of new viral particle
Examples:
o Lopinavir
o Atazanavir
o indinavir
155. 5. Fusion Inhibitors
They act by stopping the virus from attaching to the host cell by blocking the CD4
receptors on T cell
The virus must attach to CD4 receptors to gain entry into the cells
Example (only one available): Fostemsavir
157. Stigma and discrimination
HIV is not only the greatest public health challenge of our time, but it is also the greatest human
rights challenges.
People love going with HIV are burdened not only with the disease but also with stigma and
discrimination
Stigma and discrimination remain major barriers to,preventing HIV transmission and providing
treatment, care and support to,people who are HIV – infected and their families.
The most effective responses to HIV epidemic are those that work to prevent stigma and
discrimination associated with HIV and protect the human rights of people living with HIV and
those at risk
158. What is stigma and discrimination?
Stigma refers to unfavorable attitudes and beliefs directed towards someone or
something .
HIV related stigma refers to unfavorable attitudes and beliefs directed towards people
living with HIV, their family and friends,,social groups, and communities.
HIV related stigma is part of a " process of devaluation " off people either love living with
or associated with HIV and AIDS
HIV related stigma is usually pronounced when behavior causing disease is perceived to
be under individual's control ( sex work or injecting drug use)
159. Cont’d…
Certain groups ( men who have sex with men, sex workers, people who inject drugs
) bear heaviest burden of HIV – related stigma- people who are HIV – infected are
often assumed to be members of these groups whether they are not or not.
Members of these groups are already heavily stigmatized and are more likely to
fade desrimination than others when diagnosed with HIV infection, especially when
the behavior linked to the origin of the infections is perceived to be under the
individuals control such as sex work, gay sex or injection of drugs.
160.
161. The main forms of stigma include
i. Physical and social isolation from family,,friends and community
ii. Shaming and blaming people by condemning them for their behavior
iii. Depriving people of their right and decision making
iv. Self – stigma :- when people blame and isolate themselves
v. Secondary stigma :- th bus,ily and friends of people living with HIV are also
stigmatized.
vi. Stigma by looks appearance, or by types of occupation or lifestyle
162. EXAMPLE OF SELF STIGMA
Examples of self stigma and stigmatizing attitude are numerous;
i. Believing HIV is Devine punishment for moral misconduct
ii. Thinking women are responsible for transmitting HIV and other sexually
transmitted infections in the community
iii. Feeling "dirtied" by contact with PLHIV
iv. Stigma in language : referring to AIDS as " that disease" or to PLHIV as "walking
corpses" or "those expected to die"
163. CAUSES OF HIV – RELATED STIGMA
Research conducted all round the world has revealed 3 key causes of HIV –related stigma in
the community setting
i. Lack of awareness of what stigma looks like and why it was damaging
ii. Fear of causal contact stemming from incomplete knowledge about HIV transmission (
with high levels of fear of contagion among health workers) ( fear of death)
iii. Values linking people with HIV to improver or immoral behavior
iv. Fear and ignorance – people do not have clear idea of how HIV can and cannot be
transmitted
v. Gender and poverty: women get stigmatized more than men and rich people.
164. Cont’d…
Appearance: person living with HIVs appearance e.g thinness, and ski rashes is used
as a basis of stigmatizing
Media images : images of horrible death make people afraid of people living with
HIV
165. Fear of stigma stops people from;
Getting tested
Disclosing to partners
Accessing treatment for opportunistic infections
Fear of stigma keeps HIV underground
166. Effect of stigma
Personal effect : shame, isolation, withdraw, feeling excluded, loss of self esteem ,
rights ,reputation and hope
Feeling unproductive:- self blame,self hatred, take more risks , stress, anger,
violence, alcoholism, depression, suicide
Family : family quarrels, blame, and conflicts,,Devore and separation
Community : fired from work, forced to leave community drop out of school
167. Strategies for fighting stigma
Deal with the stigmatizer privately not publicly
Do not get upset
Do not crisis the stigmatizer
Help the stigmatizer to know how it feels to be treated like this
Empower the person living with HIV to speak for his elf
Get other family members to hep challenge the stigma
168. DISCRIMINATION
Discrimination: the treatment of an individual or group with prejudice –
preconceived opinion that is not based on reason or actual experience.
Discrimination includes the denial of basic human rights such as health care,
employment, legal services and social welfare benefits
People living with HIV are kicked out of the family , home work or organization's
169. Example of discrimination
i. Health care worker denies services to person who is HIV –infected
ii. Family or village rejects wife and children of man who died of AIDS
iii. Man loses job because people Learn that he is HIV –related
iv. Community rejects woman who decides not to breastfeed because they assume she is
HIV – infected.
v. HIV –infected clients receive poor care are clinic because of health care worker's fears
about caring for people infected with HIV.
170.
171. Cont’d…
Stigma is an attitude directed towards a person but discrimination is an act
Discrimination follows stigma and is the unfair and unjust treatment of an
individual based on his her real or perceived HIV status.
172. Human rights in relation to HIV
i. All people have a right to make decides about sexual and reproductive health
ii. People have the right to HIV testing and counseling and to know their HIV status
iii. People have a right to chose not to be tested or to choose not to be told their
test results.
173. Manifestations of stigma in health facilities
Many studies around the world have documented stigma and discrimination taking
place in the health care settings here some examples:
i. Neglect
ii. Different treatment
iii. Denial of care
iv. Testing and disclosing HIV status without consent
v. Verbal /abuse/ gossip/ harassment
vi. Avoiding and isolating HIV – positive patient
vii. Referring patients for HIV testing without counseling
174. Other forms of stigma and discrimination
Informing family members of a patient's HIV status without his her consent
Doing the following only with HIV – positive patient
Burning their bedding upon discharge
Charging them for the cost infection control supplies
Using gl bed during all interactions,regardless
175. Cont’d…
Even loving and surprise caregivers may stigmatize and discriminate against people
with HIV ( blaming scolding saying those poodle ) and so may not recognize
behavior of as stigmatizing.
Stigmatizing happens even among health care workers opposed to HIV related
stigma who are not aware of their attitude
176. Reducing stigma in health facilities
Stigma and discrimination are now recognized as one of the greatest challenges to
slower no the spread of the diseases key barriers to the delivery of quality services
by health providers and their utilization.
HIV –related stigma is particularly harmful to any efficient response.
The pervasive effects of HIV –related stigma and discrimination are devastating in
many ways and have been documented in many studies
177. Cont’d…
So as to reduce stigma and discrimination, especially in health care setting,
interventions must focus on three aspects.
i. Individual level
ii. Environmental level
iii. Policy level
178. Individual level
At the individual level, it is important to among health care workers on stigma and
its consequences ( reduced quality of care, unwillingness to disclose its HIV status
and adhere to treatment regimens)
Benefits of reducing stigma for the country
It is also important to address health care about HIV transmission by giving the
complete information about how HIV is and is not transmitted and enforcing the
use of the universal precautions
179. Cont’d…
Issues of association of HIV and AIDS with assumed immoral and improper behaviors
can be addressed by:
Helping health care workers to dissociate PLHIV from the behaviors considered
improper or immoral often associated with HIV infection.
Providing health care workers with a safe space to reflect on the underlying values
that lead to the shame and blame
180. Cont’d…
Health care workers should serve as role model by
Treat PLHIV same clients assumed to be HIV – negative
Be aware of own feelings,thoughts attitudes about HIV
Ensure feelings, thoughts, attitudes do no have negative effect on care provided
181. 2. ENVIRONMENTAL LEVEL
At the environmental level, it's important to ensure availability to health workers of
the information, supplies and equipment necessary to practice universal
precautions and prevent occupational transmission of HIV
Gloves for invasive procedures
Sharp containers
Adequate water and soap or disinfectant for hand washing
Post –exposure
182. Cont’d…
At the policy level, policies need to be enacted that protect the safety of patients, as well
as health workers, to prevent discrimination against PLHIV
Developed in a participatory manner
Clearly communicated to staff
Routinely monitored after implementation
All staff members need to be involved, not just health professional. This included
doctors, nurses, guards cleaners, and supportive staff
Training needs to be provided on both stigma and universal precautions
183. Summary
Sometimes, we treat people badly because of how they look or we suspect they do.
We isolate them , e.g refusing to sit beside a person suspected to have HIV in the
clinic, or we gossip about them and call them names because of the way they
look.when we isolate or make fun of other propels, this is called stigma.
Stigma is the process in which we ( society) create a " spoiled identity" for an
individual or a group of persons. We identify a difference in a person or group, such
as physical differences ( physical disfiguration) or a behavior difference ( people
having lots of sex) and then mark the difference as a sign of disgrace. This allows us
to stigmatize the person or groups. Stigmatized people loose status because of
these assigned signs of shame that other people consider indications or evidence of
sinful or immoral behavior
184. Summary
Stigma is the belief or attitude that leads to discrimination. The action
resulting from stigma is discrimination unfair treatment such as people
living with HIV getting fire, kicked out of house or they get refused to be
treated at the clinic.
When we stigmatize people living with HIV, we judge them saying that
they have broken social norms hence they should be ashamed, sad, and
rejected. They feel unwanted and lose confidence. As a result, they might
take less in protecting their health ( e.g stop using clinics and condoms)
185. SOCIAL BEHAVIOUR CHANGE COMMUNICATION
(SBCC)FOR HIV PREVENTION
Social Behaviour Change Communication is the use of communication to change
behaviours including service utilization, by positively influencing peoples’
knowledge, attitudes and social norms.
Reducing the spread of HIV and improving care and treatment for people living
with HIV and AIDS requires addressing social factors and behaviors that put people
at risk.
Social and behavior change communication (SBCC) goes beneath the surface to
uncover the causes of the behaviors as well as the social structures that drive the
epidemic and the factors that increase risk and vulnerability
185
186. Cont’d…
The key principle of social behaviour change approach is promoting positive
behaviour change. Community engagement, ownership and empowerment at the
community level are needed for the behaviour change approach, which focuses on
activities that create and sustain an enabling environment for behaviour change.
Behavior change communication (BCC) is an approach used to support individuals’
ability to adopt and maintain a new positive behavior.
This approach aims at increasing knowledge, stimulating dialogue and ensuring
that people are given accurate and timely information about HIV and AIDS in their
preferred language or medium.
186
187. Cont’d…
The shift in terminology from BCC to SBCC is a recent milestone in health
communication
SBCC puts emphasis on improving health outcomes through more healthful
individual and group behaviours, as well as strengthening the social context,
systems and processes.
187
188. Evolution of Behaviour Change
Health Education BCC SBCC
Older approaches tried to persuade individuals to change their behaviours
Newer approaches try to create an enabling environment to encourage healthy
behaviours
New approaches look for tipping points of change that need to address social
change as much as individual behaviour change
188
189. Cont’d
BCC approaches that ensure young people have the knowledge, skills, self esteem
and support (through youth-friendly comprehensive reproductive health services)
to make appropriate and responsible sexuality decisions that empower them to
avoid HIV infection.
Involving young people themselves, parents, teachers, the religious community and
policymakers is essential in reversing the current trend and changing the
epidemic’s course.
189
190. Key Elements of SBCC
1. Communication using channels and themes that fit the target audience’s needs
and preferences.
2. Behaviour change through efforts to make specific health actions easier, feasible,
and closer to an ideal, that will protect or improve health outcomes.
3. Social change to achieve shifts in the definition of an issue, people’s participation
and engagement, policies, and gender norms and relations.
190
191. THE PROCESS OF BEHAVIOR CHANGE
Stages of behavior change
continuum
Enabling factors channels
Unaware Providing effective communication Mass media
Aware
Concerned Creating an enabling environment –
policies , community values , human
rights
Community networks and traditional
media
Knowledgeable
Motivated to change
Practicing trial behavior Providing user-friendly , accessible
services and commodities
Interpersonal / group
communication.
Practicing sustained behavior
change
191
192. Behaviour Change and Sexual Health
Behaviour plays an important role in a person’s health.
Behaviour is the way in which a person acts in response to a particular situation or
stimulus
Human behaviour determines the health of the individual and the community
Some of the human behaviours can have a major impact on community mortality
and morbidity (eg: unprotected sexual behaviours can cause Sexually Transmitted
Diseases (STD) including HIV infections and unwanted pregnancies).
Many health interventions use Behaviour Change Communication (BCC) to change
the behaviour in a positive way to improve the health of the community
192
193. Cont’d…
Human sexual behaviour is any activity occurring in solitude, between two persons,
or in a group, that induces sexual arousal
Sexual behaviours are very sensitive and private in each one’s life
however, it is important to promote desirable sexual behaviours to promote health.
193
194. Cont’d…
Social behaviour change communication aimed to achieve
UNAIDS targets of 90-90-90 by 2020 i.e.
1. 90% of all people living with HIV to know their HIV status
2. 90% of people diagnosed with HIV to receive sustained antiretroviral
therapy, and
3. 90% of people receiving Anti Retroviral Theraphy (ART) to have viral
suppression
194
195. Continuum of HIV Services
Continuum of HIV services refers to a comprehensive package of HIV prevention,
diagnostic, treatment, care and support services provided for people at risk of, or
living with HIV, and their families.
Examples of these services include combination of HIV prevention including
preexposure prophylaxis, HIV testing and linkage to care, management of
opportunistic infections and other co-morbid conditions, initiating, maintaining
and monitoring ART, switching to second-line and third-line ART, and palliative
care.
Continuum of HIV care refers to a comprehensive package of HIV services for
people living with HIV (PLHIV).
195
196. Goals of SBCC
Generally, the goals of SBCC are to;
1. Increase condom use.
2. Increase appropriate STI care seeking behavior.
3. Delay sexual debut.
4. Reduce number of partners.
5. Increase perception of risk or change attitudes towards use of condoms.
6. Increase demand for services.
7. Create demand for information on HIV and AIDS.
8. Create demand for appropriate STI services
9. Interest policymakers in investing in youth –friendly VCT services.
10. Promote acceptance among communities of youth sexuality and the value of
reproductive health services for youth.
196
197. Desirable Behaviors in SBCC
Acceptance and use of VCT services
Using condoms and using a separate one for each sexual activity
Using lubricants for anal sex by MSM
100% adherence to ART
Regular CCC follow-ups
Involving partners/clients in HIV/STI interventions
Empathy of general population towards people living with HIV/AIDS (PLWHAs)
197
198. Guiding Principles for SBCC
i. SBCC should be integrated with all HIV program goals from the start
ii. Formative BCC assessments must be conducted to improve understanding of the
needs of target populations, as well as of the barriers to and supports for behavior
change that their members face
iii. The target population should participate in all phases of SBCC development and
in much of implementation.
iv. Stakeholders need to be involved from the design stage.
v. Having a variety of linked communication channels is more effective than relying
on one specific one.
vi. Pre-testing is essential for developing effective BCC materials.
vii. Planning for monitoring and evaluation should be part of the design of any BCC
program.
viii. SBCC strategies should be positive and action-oriented.
ix. PLHA should be involved in BCC planning and implementation.
198
199. Steps for developing an HIV/AIDS BCC program
Step 1: Advocacy and stakeholder involvement
Step 2: Identification and segmentation of target populations
Step 3: Formative assessment for SBCC
Step 4: Development of a SBCC strategy
Step 5: Development of communication support materials
Step 6: Implementation of the SBCC program
Step 7: Monitoring and evaluation
Step 8: Feedback and revision
199
200. Components of SBCC
The key components of SBCC are;
i. Advocacy
ii. Behavior communication intervention
iii. Social mobilization
200
201. 1. Advocacy
Aims to secure much needed financial resources and improve existing policies,
guidelines and procedures by influencing concerned public leaders and other stake
holders.
Example of targeted advocacy activities include:
i. engaging policy makers in review of policies and legislation
ii. educating community leaders or sensitization of the media.
201
202. 2. Behavior communication intervention
Seeks to increase awareness, influence social norms, induced behavior change
among targeted sub-populations and improve interpersonal communication and
Counseling between service providers and the target community.
Specific BCI activities may include disseminating accurate information and
addressing misconceptions about HIV-related risky behaviors, educating and
encouraging key population groups to individuals to access the available health
services and promoting peer- based approaches that enhance service uptake
202
203. 3. Social Mobilization
Aims to change societal norms, to improve services and build community support
by bringing groups together to fight stigma and address underlying social
problems at the community level.
Specific activities may include promoting dialogue and health seeking behavior
through awareness – raising at community level.
203
204. Strategies used in BCC
1. Media campaigns
2. Use of interactive media and multiple channels to facilitate behaviour change
3. Use of mass media to reach a broad audience and introduce new desirable behaviours
4. Combining education with entertainment to engage young people and also connecting youth with
parents or other role models, schools, communities and religious groups.
5. Empowering young people in planning and implementing youth-related HIV and AIDS
interventions
6. Use of peer counseling
7. Use of community outreaches
8. Changing gender norms by building partnerships between men and women that transform
attitudes and beliefs about gender that fuel the epidemic
9. Challenging stigma and discrimination
10. Strengthening local capacity through training, volunteer work etc. to help fight HIV/AIDS
204
205. Intervention Strategies Under SBCC in HIV
Prevention and Control
The following intervention strategies are used for HIV prevention and control under
SBCC;
Biomedical Intervention strategies to Reduce Exposure, Transmission or Infection
Behavioural Intervention Strategies to Promote Individual Risk Reduction
Social and Cultural Intervention Strategies
Political, Legal and Economical Strategies
205
206. 1. Biomedical Intervention strategies to Reduce Exposure,
Transmission or Infection
These interventions include;
Male and female condoms
ART for pre and post prophylaxis and prevention of mother to child transmission
ART for people living with HIV
Blood safety- Standard precautions in health care settings
Male circumcision( available in other countries)
206
207. 2. Behavioural Interventions to Promote
Individual Risk Reduction
Behavioural interventions at individual level include;
HIV testing and risk reduction counseling
Behaviour change communication to promote partner reduction, stick to one
faithful partner, condom use
Cash incentives for individual risk avoidance
Interpersonal communication, including peer education and persuasion
207
208. 3. Social and Cultural Intervention
Strategies
Social and Cultural Intervention Strategies include;
Community dialogue and mobilization to demand services
Stigma reduction programmes
Advocacy for social justice
Education and curriculum reforms
Quality control
Support youth leadership
208
209. 4. Political, Legal and Economical
Strategies
Political, Legal and Economical Strategies for HIV prevention and control include;
Human rights programs
Revision of workplace policies to minimize discrimination
Strategic advocacy for legal reforms & regulations
Policies e.g. for access to condoms, sexual education
Training and capacity building of Police and Judicial sector
Prevention diplomacy with leaders at all levels
Community microfinance
209
210. Factors to be Considered in SBCC
Promoting client-provider Interaction
Provision of correct information including the benefits and availability of different
forms of treatment or interventions
Provision of services to all regardless of sex, colour, marital status and sexual
orientation
Allowing the client to choose which option of the intervention
Assuring the client of the safety of the intervention
Assuring the client that any personal information will remain confidential
Maintaining the clients dignity throughout the interactions
210
211. Benefits of SBCC
It increases the level of knowledge of HIV and AIDS
It stimulates social and community dialogue
It promotes attitude and behaviour change
It promotes change in social norms in communities
It helps reduce stigma and discrimination against people living with HIV
and AIDS
It creates demand for information and services
It promotes an effective response to the HIV epidemic
It promotes services for prevention, care and support of vulnerable populations
It promotes advocacy/policy change
211
212. HOME AND COMMUNITY BASED CARE
(HCBC)
Home-based care (HBC) refers to any form of care given to ill people in their
homes, including physical, psychosocial, palliative and spiritual activities
HBC entails the provision of care to HIV/AIDS patients and their affected families at
home.
Home and community-based care (HCBC) is used in many countries to increase
quality of life and limit hospital stay, particularly where public health services are
overburdened
212
213. Cont’d…
HBC includes care extended from health facilities through family participation and
community involvement .
It involves include strengthening of the patient s individuals responsibility for their
health – positive living.
HBC integrates care with HIV education which prompted healthy lifestyles.
HBC can be carried out by a variety of people including qualified healthcare
practitioners, nurses, trained lay community health workers, peer health workers
and HBC volunteers
213
214. Components of HBC
1. Counseling
2. Nutrition
3. Social support systems
4. Nursing care
5. Treatment
214
215. Key players in CHBC
1. Community health workers
2. Family
3. Health worker
4. Spiritual leader
5. CHVs
6. The patient
215
216. Benefits of HBC
1. Patients are nursed in familiar environment
2. Patients can get personalized care
3. Affordable
4. Close support from family and relatives
5. Flexible visitations
6. Easy to access patients
7. Helps in reducing stigmatization
8. Helps reduce burden of health facilities
9. Improves adherence to ART
10. Can provide coordinated care for a number of conditions, for instance combining
HIV and tuberculosis management
216
217. Objectives of HCBC
1. to provide medical care
2. To deliver ARVs
3. To provide psychosocial support
217
218. Comprehensive Care in HIV/AIDS
Comprehensive care in HIV/AIDS is care that takes into consideration the client’s
spiritual , social , emotional and physical needs.
The comprehensive care concept refers to the holistic approach towards the
management of a person infected with HIV.
It addresses the persons wholesomeness in terms of body, mind and spirit.
218
220. Elements of Comprehensive Care
Comprehensive care consists of;
1. Psychological support (on-going counseling)
2. Anti-retroviral therapy
3. Treatment of opportunistic infections
4. Nutritional counseling
5. PMTCT
6. Home-based care
7. Palliative care
8. Supportive groups (social support)
220
223. Definition
The abbreviation STIs stand for sexually-transmitted infections
They are viral, bacterial or parasitic infections that are spread
from person to person during sexual contact.
Other modes of transmission may be through blood
transfusion, and from mother-to-child during pregnancy or
delivery
There are so many STIs in the world which are curable but HIV
is the most serious STI.
223
224. Epidemiology of STIs
More that 1 million people acquire STIs everyday around the world
The most common STIs in Kenya are;
i. Chlamydia
ii. Gonorrhoea
iii. Syphilis
iv. Herpes
v. Genital warts
vi. Trichomonas vaginalis
Chlamydia is the most prevalent, affecting mostly those aged 25- 29 years.
Candidiasis is not considered a sexually transmitted infection, but it can be transmitted
during vaginal intercourse
224
225. Risk factors for STIs
A. Behavioral risk factors
1. Having multiple sex partners
2. Sex with commercial sex workers
3. Having unprotected sexual intercourse
225
226. B. Biological Risk factors for STIs
Biological risk factors include;
1. Age
2. Sex of the individual
3. Low immune status of the host
4. Virulence of the organism causing STI
226
227. C. Socio-cultural Risk Factors for STIs
1. Occupations involving a lot of travelling e.g. long distance drivers
2. In some societies, where men’s risky behavior of multiple sexual partners is tolerated
3. Early girl-child marriages to adults exposes the girl to infection
4. High numbers of single poorly paid and unemployed young people
5. Rural-urban migration
6. Sexual intercourse for pleasure and gain
227
228. Complications Associated with STIs
Failure to diagnose and treat STIs may result in serious complications
i. Increased risk of acquiring HIV
ii. They may cause infertility in both men and women
iii. Increased risk to cervical cancers
iv. They cause pregnancy complications e.g. ectopic pregnancy
v. Still birth
vi. Neonatal conjunctivitis (ophthalmia neonatorum caused by maternal
gonorrheoa)
vii. Urethral stricture which can lead to renal failure in men
viii. Painful intercourse
ix. Congenital blindness & congenital malformations
x. Death- HIV infection within 10yrs or more or within 1-2yrs after onset of serious
illness
228
229. Reasons why STIs are prevalent
1. Avoiding treatment
Lack of symptoms- failure to recognise s/s
Lack of access of health care
Preference to traditional healers
Fear of stigma, lack of confidence on health workers
2. Reluctance to refer partners
People with STI are reluctant to refer their partners
229
230. 3. Reluctance to use condoms
Lack of familiarity with condoms
Stigma associated with condom use
Cultural and religious prohibition
Fear that sex is less enjoyable
Fear of side effects (allergy)
230
231. Modes of transmission of STIs
Sexual Exposures
1. Unprotected sexual intercourse (over 80%)
2. Blood transfusion or contact with contaminated blood or blood
products (3 to 5% )
3. Transplant of contaminated organs
4. Use unsterile needles skin piercing implants including surgical
instrument
5. From mother to child during pregnancy, delivery, or
breastfeeding e.g. HIV, chlamydia, gonorrhoea, herpes
231
232. Non sexual exposures
6. Tattooing
7. Traditional circumcision
8. Traditional delivery with unsterile equipment
9. Intravenous (IV) Drug Use (5 – 10% )
10. Occupational Exposure to HIV infected
Material/specimens e.g. accidental needlestick injury
232
Cont’d…
233. Association Between HIV/AIDS and STI/RTI
STI primarily disrupt the integrity of the skin/mucosal barrier, enabling HIV
easy access to the body.
The presence of genital ulcers is known to increase the risk of HIV
transmission by upto 10 to 100 times.
STIs that primarily cause inflammation, such as gonorrhoea, trichomoniasis,
and Chlamydia, and thus weaken the skin barrier to HIV.
233
234. Cont’d…
Increased viral shedding has been reported in genital fluids of patients
with STI/RTI.
STI/RTI treatment has been demonstrated to significantly reduce HIV
viral shedding.
234
235. HIV infection effect on STIs:
HIV alters the response of STIs pathogens to antibiotics. This has been
reported for chancroid and syphilis.
HIV alters the clinical appearance and natural history of STI/RTI as in
genital herpes and syphilis.
HIV-infected individuals have increased susceptibility to STI/RTI.
235
236. Cont’d…
Number of sexual partners and high risk partner selection, and are associated with
increased heterosexual HIV transmission.
Due to this epidemiological synergy, STI/RTI control is considered a key strategy in the
primary prevention of HIV transmission.
236
237. Classification /Categories of STIs
There are 4 classes of STIs based on aetiology (cause);
1. Bacterial: Chlamydia, Syphilis, Gonorrhoea
2. Fungal: Candidiasis
3. Viral: Hepatitis, Genital Herpes Simplex, HIV, Genital
Warts
4. Protozoa: Trichomoniasis
237
239. 1. Urethral Discharge Syndrome
Urethral discharge is one of the most common STI/RTI syndromes among
men, and is associated with serious complications.
This syndrome is commonly caused by Neisseria gonorrhoeae and Chlamydia
trachomatis in over 98% of cases.
Other infectious agents include Trichomonas vaginalis, Ureaplasma
urealyticum, and Mycoplasma spp.
Mixed infections, especially of Neisseria gonorrhoeae and Chlamydia
trachomatis, occur.
239
240. Cont’d…
It is characterized by purulent urethral discharge
with or without dysuria.
The amount of discharge varies depending on the
causative pathogens as well as prior antibiotic
treatment.
240
241. Cont’d…
If the discharge is not readily apparent, it may be necessary to milk the penis
and massage it forwards before the discharge becomes apparent.
In uncircumcised patients, examination with the foreskin retracted will ascertain
whether the discharge is from the urethra or from beneath the prepuce.
241
243. Management
Norfloxacin 800mg stat (or Ciprofloxacin 500mg stat) and
Doxycycline 100mg BD x 7 days
ALTERNATIVE TREATMENT
IM Spectinomycin 2g stat (or IM Ceftriaxone 125-250mg single
dose) and Doxycycline 100mg BD x 7 days
Emphasize 4Cs – counselling, compliance, contact tracing, and
condom use
Offer or refer for HIV testing services.
243
244. Assignment
Write short notes on the following STIs;
1. Gonorrhoea
2. Chlamydia
3. Candidiasis
For each, include;
o Aetiological agent
o Signs and symptoms
o Laboratory test/s for the STI
o Treatment
o Prevention and control
245. 2. Genital Ulcer Disease
Genital ulcer disease is one of the most common syndromes that affect men
and women.
Genital ulcers have an epidemiologically synergistic relationship with HIV.
HIV alters the natural history of syphilis and chancroid, where more aggressive
lesions may manifest.
HIV transmission, on the other hand, is enhanced in presence of ulcerative
STI/RTI.
245
248. Ct’
In men, GUD occurring under the prepuce may present as a discharge.
Similarly, GUD in women may also present as a discharge, underlying
the importance of clinical examination.
Genital herpes manifest with more persistent lesions.
Single or multiple ulcers can present.
248
249. a. Chancroid
Chancroid is caused by a bacterium known as Haemophilus Ducreyi.
Both males and females with chancroid develop painful genital ulcers.
In males, ulcers are commonly found on the edge of the glans-penis, but
can appear anywhere on the external genitalia.
249
250. Ct’
In females, ulcers may be found anywhere on the external genitalia
including around the vulva, clitoris, and anus, or inside the vagina and
on the cervix.
A chancroid ulcer is painful while a syphilitic ulcer is not.
250
251. Clinical features
Ulcer
Enlarged, red, hot lymph nodes in the groin, called buboes. They
should be aspirated with a wide-bore needle every two days if
necessary.
When a bubo is ready for aspiration, the skin overlying it is shiny
and the area underneath it is soft.
251
252. b. Syphilis
The disease is caused by a bacterium known as Treponema Pallidum.
It can affect all organs of the body. It occurs in two forms: early (primary)
and late syphilis.
In early syphilis a client is infectious to his/her sexual partners. During
late syphilis, the client is not infectious to sexual partners.
252
253. 1. Primary Syphilis
Three weeks after contact with an infected partner, the ulcer develops
at the site of infection. This is the primary chancre.
It may be found anywhere on the penis in males. In females it is found
on the external genitalia, the vaginal opening, inside the vagina, or on
the cervix.
In both men and women, it is a painless, single, firm ulcer with a
punched-out appearance.
253
254. Ct, 1⁰ syphilis
It may heal without treatment but the client can still infect others and may
develop serious cardiac and CNS symptoms later. The client needs to be
treated.
254
255. 2. Secondary Syphilis
Between two and four months following initial infection, clients may
develop secondary syphilis.
The first sign is a non-itchy rash all over the body which may become
papular(round, solid raised lesion), pustular(infected pimples), or may
develop into flat warts (condylomata lata).
255
256. Manifestations of 2⁰ syphilis
There may be whitish lines on the tongue and mucous membrane of the
mouth called snail track ulcers. They may be generalised lymph node
enlargement.
Neurologic infection- cranial nerve dysfunction, meningitis, stroke, acute
or chronic altered mental status, loss of vibration sense, and
auditory/ophthalmic abnormalities, which might occur through the
natural history of untreated infection
256
257. 3. Latent Syphilis
During this stage, there are no signs or symptoms but a blood test is
positive and the client should be treated.
Late syphilis
Untreated syphilis may progress. After two to 15 years, the heart and
brain may be affected.
The patient may develop mental problems
At this time the disease cannot be passed to other people.
257
258. C. Genital Herpes
Infection is caused by the herpes simplex virus.
In males, the client develops itchiness at the site of infection. This may
be on the foreskin, the shaft of the penis, or the glans-penis. A small
area of redness appears which develops into small blisters. This may
break down to reveal painful, shallow ulcers.
258
259. Ct’
In the first attack, lesions are more extensive and cause
severe pain. The attacks heal after about two to three weeks.
In females, the lesions are on the cervix, the labia, the vagina,
or around the anus. During the first attack, there may be
quite extensive inflammation of the cervix, the vulva, and the
vagina.
259
260. Ct’
Recurrence of lesions occurs in about 50% of clients; lesions are usually
less extensive and heal within five to seven days.
Recurrences in both males and females may follow sexual contact and
stress. In females they may also follow the menstrual period.
260
261. Ct’
There is no effective cure. Clients should be reassured, but warned that a
recurrence of ulceration is possible and that they should not have sexual
intercourse while lesions are present.
Herpes simplex virus can be passed on when there are ulcers.
Tell the client to keep the lesions clean and dry and wash with soap and
water.
261
262. Management of Genital Ulcer Disease
Erythromycin 500mg TID x 7 days
&
Benzathine Penicillin 2.4 MU IM stat
If Penicillin allergy:
Use Erythromycin 500mg QID x 14 days
Alternative GUD Rx:
Ciprofloxacin 500mg single dose
262
263. 3. Vaginal Discharge
Physiological discharge: normal
Clear or white
Viscous in consistency
Located in the posterior fornix of the vagina
Microscopy of normal vaginal secretions reveals:
Superficial epithelial cells
Lactobacilli with long rods
Few white blood cells
Physiologic vaginal discharge requires no Rx
263
264. Abnormal Vaginal Discharge
Abnormal vaginal discharge is one of the most common STI/RTI syndromes
among women, but also one of the most complicated to manage.
All women have a physiological vaginal discharge which may increase during
certain situations.
Normally, women will only complain if they perceive the discharge to be
abnormal.
264
266. Aetiology
The symptom of abnormal vaginal discharge is highly indicative of
vaginitis and poorly predictive of cervicitis
Bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis are
the most common causes of vaginitis
Gonococcal and chlamydial infections cause cervicitis.
Distinction between the two on clinical grounds is usually difficult.
266
268. Management
Offer or refer for HIV testing services
VAGINITIS Rx
Clotrimazole 1 pessary intravaginally daily for 6 days Or
Clotrimazole 200mgs pessaries intravaginally daily for 3 days) AND
Metronidazole 400mg
If pregnant
Clotrimazole 1 pessary intravaginally daily x 6 days Or
Clotrimazole 200mgs pessaries intravaginally daily for 3 days)
268
269. Cervicitis Rx
Norfloxacin 800mg stat (or Ciprofloxacin 500mg stat)
&
Doxycycline 100mg BD x 7 days
IF PREGNANT
IM Spectinomycin 2gm stat (or IM Ceftriaxone 250mg single dose)
&
Erythromycin 500mg QID x 7 days
269
270. 4. Lower Abdominal Pain Syndrome (PID)
This is one of the most common and most serious STI syndromes among
women, with very serious reproductive health and socioeconomic
consequences.
PID comprises a spectrum of inflammatory disorders of the upper
female genital tract, including any combination of endometritis,
salpingitis, tubo-ovarian abscess, and pelvic peritonitis
270
271. Causes
Sexually transmitted organisms, especially N. gonorrhoeae and C.
trachomatis, are implicated in many cases; however, microorganisms that
comprise the vaginal flora (e.g., anaerobes, G. vaginalis, Haemophilus
influenzae, enteric Gram-negative rods, and Streptococcus agalactiae)
have been associated with PID
271
272. Clinical manifestations
Abdominal pain,
abnormal cervical or vaginal mucopurulent vaginal bleeding
Dyspareunia
fever, and sometimes vomiting.
N/B
Patients should be carefully evaluated for abdominal tenderness, cervical motion and
adnexial tenderness, enlargement of uterine tubes, and tender pelvic masses.
272
273. Diagnosis
A thorough history and examination to exclude other surgical and/or
gynaecological emergencies must be done.
Bimanual vaginal examination
273
274. Management
Norfloxacin 800mg stat (or Ciprofloxacin 500mg single dose) AND
Doxycycline 100mg BD x 7 days
Metronidazole 400mg BD x 10 days
If pregnant:
Refer for obstetric evaluation if PID is suspected
274
276. 5. Ophthalmia Neonatorum
This refers to conjunctival infection of neonates.
Neonates acquire this infection during passage through an infected birth
canal during delivery.
Occurs between 4–7 days of life, but can occur anytime in the first 28
days.
Caused by Neisseria gonorrhoea(GC) or Chlamydia
trachomatis(Chlamydia).
276
277. Clinical manifestations
This disease is often characterized by bilateral purulent eye discharge. In
early stages, the discharge may be “sticky,” causing the eyelids to be
stuck together in the morning, rather than the thick, greenish pus seen
later.
The conjunctiva is inflamed and eyelids swollen.
Corneal scarring may occur if treatment is delayed.
Blindness in children is associated with high infant morbidity and
mortality.
277
279. Treatment
1% TETRACYCLINE eye ointment TDS x 10 days
Treat mother for cervicitis and partner for urethritis
Alternative
Ceftriaxone 62.5mg IM stat and 1%
Tetracycline eye ointment TDS x 10 days and 4Cs
279
281. Genital warts
Genital warts are caused by a virus –human papilloma virus.
They usually have the appearance of flesh-coloured cauliflower-like growths on
the genitals.
The penis and foreskin (men) and the labia or vagina (women) are the most
common sites of the warts.
The warts can be variable in number and size, either few or multiple, small to
very large.
281
282. Clinical manifestations
Are usually asymptomatic, but depending on the size and anatomic location, they
can be painful or pruritic.
Genital warts are usually flat, papular, or pedunculated growths on the genital
mucosa
Genital warts occur commonly at the introitus in women, under the foreskin of the
uncircumcised penis, and on the shaft of the circumcised penis.
282