Hiv/Aids Basics for Ngos and Family Planning Program Managers

THE CEDPA TRAINING MANUAL SERIES family planning plus: hiv/aids basics for ngos and family planning program managers

Integrating Reproductive Health and HIV/AIDS for NGOs, FBOs & CBOs Vol. I

THE enable PROJECT

ENABLING CHANGE FOR WOMEN'S THE CENTRE FOR DEVELOPMENT REPRODUCTIVE HEALTH AND POPULATION ACTIVITIES Family Planning Plus: HIV/AIDS Basics for Non-Governmental Organizations and Family Planning Program Managers

Integrating Reproductive Health and HIV/AIDS for Non-Governmental Organizations, Faith-Based Organizations and Community-Based Organizations

Volume I Family Planning Plus: HIV/AIDS Basics for NGOs and Family Planning Program Managers

Authors Kathleen Callahan, MA Laurette Cucuzza, MPH

This publication was supported by the United States Agency for International Development under Cooperative Agreement # HRN-A-00-98-00009-00. The contents of this document do not necessarily reflect the views or policies of the U.S. Agency for International Development or The Centre for Development and Population Activities (CEDPA). ii Family Planning Plus Abbreviations

AIDS Acquired Immune Deficiency Syndrome

ARV Antiretroviral

CEDPA The Centre for Development and Population Activities

HIV Human Immunodeficiency Virus

MTCT Mother-to-Child Transmission

NGO Non-Governmental Organization

PLWHA People Living with HIV/AIDS

RH Reproductive Health

STI Sexually Transmitted Infection

WHO World Health Organization

UNAIDS Joint United Nations Program on AIDS

UNDP United Nations Development Programme

USAID United States Agency for International Development

VCT Voluntary Counseling and Testing

Overview iii Acknowledgements

Headquartered in Washington, DC, The Centre for Development and Population Activities (CEDPA) is an international nonprofit organization that seeks to empower women at all levels of society to be full partners in development. Founded in 1975, CEDPA supports programs and training in leadership, capacity building, advocacy, governance and civil society, youth participation, and reproductive health.

The Enabling Change for Women’s Reproductive Health (ENABLE) project works to strengthen women’s capabilities for informed and autonomous decision-making to prevent unintended pregnancy and improve reproductive health. Begun in 1998, ENABLE seeks to increase the capacity of NGO networks to expand reproductive health services and to promote a supportive environment for women’s decision-making.

ENABLE is implemented by CEDPA under Cooperative Agreement HRN-A-00-98-00009-00 with the United States Agency for International Development (USAID), and we thank USAID for making this series of manuals possible.

Acknowledgment and thanks must be given to the various organizations and individuals whose resources and knowledge helped make this manual possible. Sources for technical information include the World Health Organization, UNAIDS, and R. Arnold’s Educating for a Change. In addition, many activities were adapted from and inspired by the Peace Corps Life Skills Manual.

Our thanks also go to Robert Kelly, Nancy McCharen, Margaret Marshall, Lakshmi Goparaju, Faria Zaman, Vicky Wells, and Lucy Owusu-Darko for their support and contributions.

Kathleen Callahan Laurette Cucuzza Consultant Advisor, RH/HIV/AIDS Integration CEDPA/Washington, DC

iv Family Planning Plus Table of Contents Family Planning Plus: HIV/AIDS Basics for NGOs and Family Planning Program Managers

Volume I

Abbreviations ...... iii Acknowledgements...... iv Overview Methodology ...... II Evaluation ...... II Learning Objectives ...... III How the Manual Is Organized ...... IV Sample Training Schedule ...... VI Chapter 1 Impact of HIV/AIDS Introduction...... 1-3 Activities and Handouts for Impact of HIV/AIDS ...... 1-11 Chapter 2 Transmission of HIV/AIDS Introduction...... 2-23 Activities and Handouts for Transmission of HIV ...... 2-32 Chapter 3 HIV Prevention Introduction...... 3-55 Activities and Handouts for HIV Prevention...... 3-63 Alternate Activities and Handouts ...... 3-90 Chapter 4 HIV/AIDS and the Immune System Introduction...... 4-99 Activities and Handouts for HIV/AIDS and the Immune System ...... 4-106 Chapter 5 Disease Progression Introduction...... 5-119 Activities and Handouts for Disease Progression ...... 5-126

Overview v Chapter 6 Living with HIV/AIDS Introduction...... 6-151 Activities and Handouts for Living with HIV/AIDS ...... 6-158 Chapter 7 HIV/AIDS in Our Lives and Our Community Introduction...... 7-167 Activities and Handouts for the HIV/AIDS in Our Lives and Our Community...... 7-173 Alternate Activities and Handouts ...... 7-185 Appendices Appendix I: References and Resources...... I-191 Appendix II: Evaluation...... II-193

vi Family Planning Plus Overview

The International Conference on Population and Development in Cairo in 1994 was a watershed point in the history of reproductive health. At Cairo, the thinking about population and development underwent a major change. From the previous focus on “population control,” focus shifted to the interrelation of population, sustainable development, and economic growth, and advances in the education, economic status, and empowerment of women. Women’s groups, nongovernmental organizations, and other members of civil society pressed for a new, holistic interpretation of reproductive health that focused on the individual’s needs and desires throughout the life cycle.

The Centre for Development and Population Activities (CEDPA) has subscribed to this holistic view for many years. CEDPA’s mission is to empower women at all levels of society to be full partners in development with men, creating a sustainable future for themselves, their families, communities and nations. CEDPA’s strategies for empowerment include building the capacities of individuals and NGOs; mobilizing political and economic participation at the community, national, regional, and international levels; establishing gender-sensitive and inclusive reproductive health programs; and involving youth in development. All CEDPA activities are designed to advance gender equality and equity, and to facilitate the economic and political participation of under-served groups.

Given the call to action from Cairo, the ENABLE Project was designed “to strengthen women’s capabilities for informed and autonomous decision-making to prevent unintended pregnancy and improve reproductive health.” Through partner NGO networks, women have greater access to high-quality, integrated family planning, reproductive and child health services and an enabling environment.

ENABLE has many partners through which integrated reproductive health services are provided. In the countries where ENABLE works, especially in sub-Saharan Africa, it is imperative to address the growing HIV/AIDS pandemic that affects the reproductive health of women, men, and youth, by including HIV/AIDS prevention and care in reproductive health and family planning projects.

As part of ENABLE’s strategic response to the HIV/AIDS pandemic, the project has developed a series of manuals for use in building the capacity of nongovernmental organizations, faith-based groups, and communities. This curriculum was developed to provide staff of nongovernmental organizations and the community at large a deeper understanding of the dynamics and effects of the disease, and to sensitize them to the current issues and challenges that people living with HIV/AIDS face. The curriculum covers— • Modes of transmission • Prevention, including proper condom use and universal precautions • Cultural and social factors that contribute to the spread of the epidemic • The immune system and disease progression • Strategies for healthy living and coping with HIV/AIDS

Overview I The curriculum was designed to assist trainers in delivering a four-day workshop. (See the sample schedule at the end of this section on page VI.) The curriculum is divided into seven chapters. The introduction of each chapter provides background information for the trainers about the topics covered.

In addition, the activities in this manual can be used to address awareness creation and information, education, and communication about HIV/AIDS with the larger community. Activities can be used with various groups such as women, youth, workplace/union groups, etc. It is not necessary to be confined to the four-day format—you may want to use activities in regular weekly or monthly meetings on an on-going basis.

Methodology

Activities have been designed to involve participants at the fullest level. Different methodologies used include— • Demonstration • Discussion • Brainstorming • Group Work • Role-play • Presentation/Lecture • Guest Speakers • Games

Evaluation

It is important to gain an idea of the participants’ level of knowledge about HIV/AIDS before the training starts, in order to tailor the training to their needs, and to evaluate their learning of it. During the registration process on the first morning of the workshop, the trainer should give each participant the questionnaire, “What We Know About HIV/AIDS.” (See Appendix II for instructions and forms.) The same questionnaire will be distributed during the evaluation session at the end of the workshop. You can then compare the two to determine what was learned, and areas that need to be strengthened or followed up.

The Sample Lesson Plan in each chapter includes a method of evaluation for each exercise. These can be helpful in determining the level of understanding and learning during the course of the workshop. A checklist is provided for evaluation of condom use skills. The Review Game (see page 3-64 and 3-81 to 3-82) can be the first or the last exercise of each day. You will need to adapt it to reflect the content you actually covered.

II Family Planning Plus The training facilitation team should meet at the end of each day to evaluate the day’s work, and to plan and modify the training program as necessary. A final workshop evaluation (see chapter 7 page 7-165) will be given at the end of the workshop.

Learning Objectives

By the end of the training, participants will be able to— • Describe the effects of HIV/AIDS on the local community, the nation, the region, and the world • Identify at least five ways in which HIV is transmitted • Identify at least five reasons that men and women can be vulnerable to HIV/AIDS due to their expected social roles • Describe the “ABCs” of HIV/AIDS prevention • List the steps for proper male and female condom use • Define “dual protection” • Define “universal precautions” and identify when to use them • Identify at least three reasons that women and girls are more biologically vulnerable to HIV/AIDS than are men and boys • Describe the importance of treating Sexually Transmitted Infections (STIs) in preventing transmission of HIV • Describe the role, parts, and functions of the immune system and the effects of HIV on it • Describe the stages of HIV progression in the body using appropriate terms • Describe ways to prevent mother-to-child transmission (MTCT) and discuss issues surrounding it • Describe five aspects of wellbeing and the importance of positive living behaviors for people living with HIV/AIDS (PLWHA) • Name the benefits of voluntary counseling and testing (VCT) and the consequences of knowing and not knowing one’s HIV status • List testing resources and support services for people living with HIV/AIDS in their community • Identify participant’s own levels of risk for HIV infection

Overview III How the Manual Is Organized

The manual is divided into seven chapters and has been organized into a four-day training (sample schedule at the end of this section on page VI). Each chapter addresses a specific content area, or trainers can take material from several chapters and arrange it to meet their own training needs.

Each chapter may contain— • Key Questions • Introduction • Objectives • Sample Lesson Plan • Important Terms • Activities and Handouts • Notes to Trainers • Tools for Trainers • Resources • Additional or Alternate Activities or Handouts

Key Questions. This section allows the trainer to see at a glance what major questions will be addressed in the chapter.

Introduction. This section introduces the major theme of the chapter content, and orients the trainer to the overall lesson plan. It contains important background information for the trainer. It gives general and specific information that the trainer can use in the lecture activities and to facilitate discussions.

Objectives. The objectives set the learning goals for the sessions in specific, clear, and measurable terms. They can be used to focus the pretest/posttest material and to orient the participants to what will be the focus of the sessions.

Sample Lesson Plan. The sample lesson plan contains the average time required, the content, methodology used, materials needed, and a way to evaluate the participants’ learning. It helps the trainer to determine whether the content is appropriate for the audience, and to make sure that everything is prepared for the session.

Important Terms. This section contains definitions of key words that are necessary for comprehension of the session content. The trainer may want to use them as handouts for participants to help them learn new terms, and then keep as a reference.

IV Family Planning Plus Activities and Handouts. This section contains all of the activities included in the sample lesson plan. Each activity has the learning objectives and step-by-step directions on how to conduct the session. Any handouts needed are included after the activities.

Notes to Trainers. This section gives trainers tips or helpful hints based on experience on how to facilitate the session, or extra resources that can be used for the session.

Tools for Trainers. Pages marked as “Tools for Trainers” contain helpful examples or materials that trainers can use in sessions, and can be adapted by the trainer to fit various audiences.

Resources. These are publications listed for trainers to use for additional information on a given topic.

Alternate Activities and Handouts. This section includes exercises trainers may choose to better match their particular audience. It may give trainers ideas for activities that they can create on their own.

Overview V Family Planning Plus Sample Training Schedule Schedule Day One Day Two Day Three Day Four Registration Review Game Review Game Review Game 30 minutes 30 minutes 30 minutes 30 minutes Class Chapter 1 Chapter 3 Chapter 5 Chapter 7 Introductions Epidemic Game Story of Esi & Yao, HIV/AIDS in Our Ground Rules Prevention Facts Part II Community Goals & Expectations 1 hour Disease Progression 1 hour Diagram 1 hour 1 hour 30 minutes Break 15 minutes 15 minutes 15 minutes 15 minutes Class Chapter 1 Chapter 3 cont. Chapter 5 cont. Chapter 7 cont. Impact of HIV/AIDS Universal Precautions Mother-to-Child HIV/AIDS in Our 1 hour 30 minutes Biological Transmission Community (cont) Vulnerability of Girls Living Healthy Testing the Waters & Women 1 hour 40 minutes 1 hour 45 minutes 1 hour 30 minutes Lunch 1 hour 1 hour 1 hour 1 hour Class Chapter 2 Chapter 3 cont. Chapter 5 cont. Chapter 7 cont. Myths & Facts Condom Carousel Co-Factor Tug-of-war Evaluation Story of Esi & Yao, Condom Chapter 6 Closing: Head, Heart, Part I Demonstrations The Loss Exercise Feet Transmission Facts 1 hour 30 minutes 45 minutes 1 hour 40 minutes 2 hours Break 15 minutes 15 minutes 15 minutes Class Chapter 2 cont. Chapter 4 Chapter 6 cont. What’s the Fluid? Elephants & Lions Panel or Discussion Where’s the Door? Game with People Living Gender Toss/ Social Immune System Facts with HIV/AIDS & Processing Discussion Vulnerability to Immune System Role- HIV/AIDS play 2 hours 30 minutes 2 hours 10 minutes 1 hour 50 minutes Evaluation 15 minutes 15 minutes 15 minutes Total 8 hours, 55 minutes 8 hours, 5 minutes 8 hours, 40 minutes 6 hours, 10 minutes

VI Family Planning Plus Chapter 1

Impact of HIV/AIDS

“… Let us not equivocate: a tragedy of unprecedented proportions is unfolding in Africa. AIDS today in Africa is claiming more lives than the sum total of all wars, famines, and floods, and the ravages of such deadly diseases as malaria. It is devastating families and communities, overwhelming and depleting health care services, and robbing schools of both students and teachers. Business has suffered, or will suffer, losses of personnel, productivity and profits, economic growth is being undermined and scarce development resources have to be diverted to deal with the consequences of the pandemic.”

NELSON MANDELA Table of Contents Family Planning Plus Chapter 1: Impact of HIV/AIDS

Chapter 1 Impact of HIV/AIDS Introduction...... 1-3 Objectives...... 1-6 Overview ...... 1-7 Sample Session Design ...... 1-9 Activities and Handouts for Impact of HIV/AIDS Sample Session ...... 1-11 Opening of Meeting and Introductions ...... 1-12 Goals and Expectations ...... 1-13 Group Norms...... 1-15 Exchanging Stories: The Impact of HIV/AIDS ...... 1-16

1-2 Family Planning Plus Chapter 1: Impact of HIV/AIDS

Key Questions

• What is the impact of HIV/AIDS in the lives of those infected and affected? On the community? The nation? On a global scale?

• Why is HIV/AIDS considered a development issue?

• What are some of the effects of HIV/AIDS on the education system? The health system? The agricultural base? On the economy?

• What is our motivation for participating in this workshop?

Introduction

In its approximately 20-year history, HIV/AIDS has proven to be the “most devastating disease humankind has ever faced” (UNAIDS, 2001, pg. 2). The statistics are frightening—60 million people infected over the course of 20 years, 40 million currently living with HIV/AIDS, 28.1 million of whom are in sub-Saharan Africa. New infections continue at a dizzying rate in developing countries, along with a resurgence of new infections in high-income countries.

Although HIV/AIDS has wreaked havoc among some of the poorest health care systems worldwide, it is not simply a health issue, but a development crisis of enormous size. In nations already burdened by poverty and a history of being left on the fringes of development, HIV/AIDS has steadily reversed socioeconomic gains, threatening “human welfare, developmental progress, and social stability on an unprecedented scale” (UNAIDS, 2001, p. 7). Because HIV/AIDS hits hardest those in their reproductive years, it has claimed skilled professionals, wage earners, and parents.

Impact of HIV/AIDS 1-3 The loss of teachers, health workers, farmers, extension workers, and businesspeople has resulted in a reversal of development gains, as nations have become gripped in a devastating cycle of poverty. With fewer teachers in the classrooms, the already shaky educational systems of many countries have all but collapsed. With doctors, nurses, and other health professionals sick or dying with the disease, already understaffed health clinics are finding it impossible to provide services.

As farmers and extension workers become sick and die, agricultural output declines and countries experience the loss of agricultural knowledge. But perhaps most distressing is that these infected teachers, health workers, and farmers are also parents, and their deaths leave behind millions of orphans. These children are often poor, uneducated, unloved, and driven to the streets in search of food and shelter. The growing orphan problem has led to an increase in the number of street children and violence in cities throughout the developing world.

It is clear that HIV/AIDS has had a crippling impact on the entire global community. But the true devastation of HIV/AIDS can be seen on the ground, in the lives of individuals and families living with HIV/AIDS. In high prevalence countries, HIV/AIDS is more than a development problem, more than just another health concern. For these individuals and families, HIV/AIDS is an intimate, personal issue. It represents the worsening illness and eventual loss of loved ones, crushing poverty as families take on more and more orphans, and the eventual collapse of the extended family and communities.

For women and girls, HIV/AIDS represents a double burden. Women and girls are more vulnerable to HIV/AIDS for a number of biological and socio-cultural reasons, so they represent the majority of those infected and living with HIV/AIDS. In addition, as the primary caregivers in their families and communities, women and girls suffer the most in providing care to those infected and affected by the disease. Girls increasingly leave school to provide care to the sick, to work in the fields and at the market, and sometimes to provide sex in exchange for food, money, or services.

Although it may seem that nothing good has come out of the HIV pandemic, there have been some positive changes brought about by the need to address it. First, it has started to bring about honest and open discussion of sexuality, sexual behaviors, condoms, and promotion of dual protection (both for disease control and family planning). It has also brought about advances in medical technology: new HIV treatments, rapid testing methods, and better treatment for opportunistic infections. Emphasis has been placed on more and better psychosocial support for those affected or infected, and on home-care and other services for PLWHA and their families. The positive living approach, which encourages people living with the disease to take responsibility for their mental, physical, and emotional health and to protect themselves, their partners, families, and communities, promotes personal and community responsibility and is applicable to all sectors of development.

1-4 Family Planning Plus Finally, the challenge of fighting HIV/AIDS has been taken up by faith-based groups, governments, non-governmental organizations, and employers. With all of these sectors engaged, there is hope for an eventual end to the AIDS social epidemic. The power imbalances between men and women that put women at such risk; the economic factors such as poverty and migration that drive the epidemic and that splits up families and encourages transactional sex for survival; and the historical factors such as colonialism that disempower men, women, and communities. In addressing these issues, there is hope for overcoming the pandemic.

Especially in high prevalence countries, many of the points raised in the Family Planning Plus sessions will not be new to participants. Many participants in this workshop will have experienced HIV/AIDS first hand with the death of loved ones, caring for orphans, and possibly, being infected themselves. It is therefore crucial for the trainers in these sessions to be constantly aware of the knowledge of HIV/AIDS that participants already have, and of the very personal experiences that many have had with the disease. The activities and exercises throughout these sessions seek first to gather knowledge and experiences from the group before providing new information and passing on new skills. The approach is one of sharing knowledge and experiences, and respecting the personal contributions of each participant is key.

The first part of this chapter focuses on setting the tone and atmosphere for the workshop with formal introductions and exercises to determine participant expectations, and to create group norms. The first substantive session, The Impact of HIV/AIDS, attempts to explore the above- mentioned issues by encouraging participants to think about their own personal experiences with HIV/AIDS. By sharing stories about friends and family members touched by the pandemic, participants focus on the personal, educational, social, and economic issues surrounding the disease in their own lives. The trainer then guides the group through an analysis of these issues, and gradually expands them so that participants can see the affects of the disease in their own lives, in their local communities, their nation, the subregion or continent, and finally, on a global scale. By beginning with the personal, participants are urged to identify with their own motivation for fighting HIV/AIDS and for participating in this workshop.

Trainers are encouraged to obtain current information and statistics for the world and for individual countries and regions. See the UNAIDS website at http://www.unaids.org/

Impact of HIV/AIDS 1-5 Chapter 1: Impact of HIV/AIDS

Objectives

By the end of this class, participants will be able to— • State the overall goal of the workshop • List participants’ expectations for the workshop • List the group norms for the workshop • Relate their personal experiences with HIV/AIDS • Discuss the experiences of other participants in relation to HIV/AIDS • Describe the impact of HIV/AIDS on the local community, the nation, the region, and the world

1-6 Family Planning Plus Overview

When a workshop begins, it is important to assess the strengths and weaknesses of participants. It is also helpful to get an idea of what the participants expect to get out of the workshop to make the experience a good and productive one for all involved. This will also help the facilitator get to know the participants as well as the participants to be comfortable with each other. It is important to foster a sense of belonging within the group and to establish a set of ground-rules that all participants can agree to for the workshop duration.

Impact of HIV/AIDS 1-7 Chapter 1: Impact of HIV/AIDS

Training Schedule Schedule Day One Day Two Day Three Day Four Registration Review Game Review Game Review Game 30 minutes 30 minutes 30 minutes 30 minutes Class Chapter 1 Chapter 3 Chapter 5 Chapter 7 Introductions Epidemic Game Story of Esi and Yao, HIV/AIDS in Our Ground Rules Prevention Facts Part II Community Goals and Expectations 1 hour Disease Progression 1 hour Diagram 1 hour 1 hour 30 minutes Break 15 minutes 15 minutes 15 minutes 15 minutes Class Chapter 1 cont. Chapter 3 cont. Chapter 5 cont. Chapter 7 cont. Impact of HIV/AIDS Universal Precautions Mother-to-Child HIV/AIDS in Our 1 hour 30 minutes Biological Transmission Community (cont) Vulnerability of Girls Living Healthy Testing the Waters and Women 1 hour 40 minutes 1 hour 45 minutes 1 hour 30 minutes Lunch 1 hour 1 hour 1 hour 1 hour Class Chapter 2 Chapter 3 cont. Chapter 5 cont. Chapter 7 cont. Myths and Facts Condom Carousel Co-Factor Tug-of-war Evaluation Story of Esi and Yao, Condom Chapter 6 Closing: Head, Heart, Part I Demonstrations The Loss Exercise Feet Transmission Facts 1 hour 30 minutes 45 minutes 1 hour 40 minutes 2 hours Break 15 minutes 15 minutes 15 minutes Class Chapter 2 cont. Chapter 4 Chapter 6 cont. What’s the Fluid? Elephants and Lions Panel or Discussion Where’s the Door? Game with People Living Gender Toss/ Social Immune System Facts with HIV/AIDS and Processing Discussion Vulnerability to Immune System Role- HIV/AIDS play 2 hours 30 minutes 2 hours 10 minutes 1 hour 50 minutes Evaluation 15 minutes 15 minutes 15 minutes

1-8 Family Planning Plus Sample Lesson Chapter 1: Impact of HIV/AIDS Plan

Sample Session Design

Time Content Methodology Materials Needed Evaluation

30 Introductions and Official opening Possibly head table, None minutes Opening of the flowers, water for Introductions of all Meeting the speakers, etc. participants using peer Local practices interviews or traditional should guide the introductions opening of the meeting

20 Goals and Trainer distributes a half Colored paper Participants’ minutes Expectations sheet of paper to each expectations will be Markers participant. Trainer asks used to evaluate the (Also see Alternative participants to consider the Tape entire training Activity: What I single most important thing Prepared signs on workshop. Trainers Bring/What I Want to they want from this colored paper can move the written Take Away, workshop and write that expectations into an page 7-186) expectation in large print - Expectations Expectations Met on the paper. Participants - Expectations met section as each of the read their expectations and topics gets covered then tape to an throughout the four Expectations wall in the days. training area.

10 Group norms Trainer leads group Flipchart Abiding by the group minutes brainstorm for the norms throughout the Markers workshop ground rules. As workshop participants offer each Tape point, the trainer seeks agreement from the rest of the group before noting the norm on the flipchart.

Impact of HIV/AIDS 1-9 Time Content Methodology Materials Needed Evaluation

90 Exchanging Stories: Participants relate a story in Flipchart Active participation minutes The Impact of which HIV/AIDS has in the activity. Markers HIV/AIDS affected their own lives. Motivation to fully Tape Personal experiences Participants choose stories participate in the with HIV/AIDS to share with larger and workshop. larger groups, until two or Group sharing around three representative stories personal experiences are left. Discussion of the Trainer expands the stories effects of HIV/AIDS to make larger links to the on the local effects of HIV/AIDS on community, the economics, education, nation, and the world. agriculture, and so on.

1-10 Family Planning Plus Chapter 1: Impact of HIV/AIDS

Activities and Handouts for Impact of HIV/AIDS

• Opening of the Meeting and Introductions

• Goals and Expectations

• Group Norms

• Exchanging Stories: The Impact of HIV/AIDS

Impact of HIV/AIDS 1-11 Activity Opening of Meeting and Introductions Objective By the end of the activity, participants will be able to— • Introduce another participant to the group by name • State several basic facts about another participant

Time allotted 30 minutes

Preparation Local practices should guide the opening of the meeting. You may want to have a local official or religious leader formally open the meeting with a speech or prayer.

Facilitation 1. Have each participant pair up with another, either by turning to the person steps next to them, or by some other method.

2. Explain that they will take turns interviewing each other.

3. The interviewer should learn their name, the name they prefer to be called by during the workshop, their position title (if applicable), personal data (age, marital status, number of children, etc.), likes/dislikes, etc. After about 5 minutes, the participants should switch roles. The trainer may also wish to participate. (Depending on the size of the group, you may want to limit the amount of information the interviewer should get from the interviewee, and reduce the time of interviews.)

4. After about ten minutes, invite volunteer pairs to introduce each other to the group.

Wrap-up After everyone has been introduced, trainers should introduce themselves, if they have not participated in the activity.

1-12 Family Planning Plus Activity Goals and Expectations Objective By the end of the activity, participants will be able to— • State the overall goal of the workshop • Name one important outcome of the workshop for themselves

Time allotted 30 minutes

Preparation Make a flipchart with the workshop goal written on it from Step 1 below. Prepare three flipcharts, one with “Expectations” written at the top, one with “Expectations Met” at the top, and one with “Parking Lot” at the top. Markers, colored paper, tape.

Facilitation 1. Start by referring to the flipchart with the workshop goal on it. “To steps provide NGO staff and community members a deeper understanding of the dynamics and impact of HIV/AIDS, and to sensitize them to the current issues and challenges that PLWHA face.” Say that this is the overall goal of the workshop. (You may need to modify this goal to reflect the actual goal you want to reach with your participants.)

2. Acknowledge that we all have our own hopes, ideas and expectations about what we wish to take away from this workshop. If you had to choose one thing that is most important for you to take away from this workshop, what would it be?

3. Distribute pieces of colored paper to each participant. Have each person write his or her expectations on the pieces of paper. (Some may want to write more than one.)

4. Next, have participants read their expectations aloud as they post them on the Expectation flipchart.

5. Distribute copies of the workshop schedule. Have participants refer to the workshop schedule. Summarize the expectations listed and indicate which sessions are likely to address these expectations. Explain that you will post both flipcharts on the wall.

6. If unexpected topics are listed, use this time to negotiate with the participants regarding a time or means to include that topic in the workshop. Introduce the idea of a “parking lot” and post the Parking Lot flipchart on the wall. This is a place where participants can post concerns, questions, and ideas that weren’t covered to their satisfaction during

Impact of HIV/AIDS 1-13 sessions (anonymously, if they want). The Parking Lot should be revisited regularly through the course of the workshop to answer the question/concerns, perhaps during the recap in the morning, at the lunch break, or at the end of the day.

Wrap-up Explain that throughout the course of the workshop (during breaks), when participants feel their expectations have been met, they should move their expectation from the Expectations flipchart to the Expectations Met flipchart. (You may want to periodically refer to the flipcharts and remind people to move their expectations over.)

1-14 Family Planning Plus Activity Group Norms Objective By the end of the activity, participants will be able to— • State the workshop norms agreed to by the group

Time allotted 10 minutes

Preparation Create a flipchart with “Group Norms” written on top. Markers.

Facilitation 1. Start by suggesting that for the duration of workshop we will be working steps together on some sensitive issues and that participants may have strong emotional reactions to them. This training needs to be a safe place where we can discuss things openly, and support each other in the process. It is important to establish some ground rules so that our work is productive and enjoyable.

2. Lead a brainstorm to establish group norms. As participants suggest each rule or norm, be sure that all participants agree to it before writing it on the flipchart. Examples of norms the group might suggest include, for example, being on time, encouragement for everyone to participate, confidentiality, respect for each person’s opinion, etc.

Wrap-up When all the rules have been agreed to and written on the flipchart, explain that you will post it on the wall. Throughout the course of the workshop, if participants feel that a norm or rule is being broken, they should remind the group to adhere to the norm.

Impact of HIV/AIDS 1-15 ctivity Exchanging Stories: The Impact of A 1 HIV/AIDS

Objective By the end of this session, participants will be able to— • Relate their personal experiences with HIV/AIDS • Discuss the experiences of other participants in relation to HIV/AIDS • Describe the effects of HIV/AIDS on the local community, the nation, the region, and the world

Time allotted 90 minutes

Preparation Arrange the chairs in a circle, leaving a small gap for the trainer and a flipchart stand.

Facilitation 1. Invite participants to think about the importance of the topic of this steps workshop in light of the toll HIV/AIDS has been taking on the community. Suggest that in these difficult times, HIV/AIDS has touched each of us in very personal ways. Perhaps we have cared for someone who has been infected with HIV or sick with AIDS. Maybe we have lost friends or relatives to the disease. Perhaps we are caring for orphans in our homes. Maybe it has become the focus of our work. Perhaps we have tested positive for HIV ourselves, or are living with AIDS. In some way, each of us has a story to tell about the impact of HIV/AIDS on our own lives.

2. Ask participants to take a quiet moment to think about their personal experiences with HIV/AIDS. Ask them to choose one particular story that best indicates the effect that HIV/AIDS has had on their own lives. Allow a long pause while participants think of their most important story. Remind participants that personal information that participants choose to share should be treated as confidential; that is, it should not be discussed with others outside the safe space of the training room.

3. Invite participants to turn to a partner and share their stories. Allow about five minutes for each story. Be sure to tell the pairs when to switch.

4. After all participants are finished telling their stories, ask each pair to choose one of the two stories to share with a larger group.

1 The “Exchanging Stories: The Impact of AIDS” session was adapted and reprinted (with permission of Peace Corps) from the Life Skills Manual, pp. V 25–26.

1-16 Family Planning Plus 5. Each pair will then join up with another pair for a total of four people, and the foursome will read aloud the two stories.

6. After the two stories have been told, each group of four will choose the single story they most want to share with others. They will then join up with another set of four, each set telling one story. Continue in this way, adding two groups together, until only two or three groups remain. (The number of times this occurs will depend on the number of participants in the training.)

7. Finally, have one representative of each of the remaining groups stand up and tell the large group the story chosen to be shared. Two or three stories will be told one from each of these larger groups.

8. After all stories have been told, thank all participants for sharing their stories. Sometimes, one or two other participants still want a chance to tell their stories. Invite them to do so at this time.

9. In high-prevalence countries, the stories told by the participants will often have some common themes, both negative and positive. These may include the following—

- The loss of many family members or friends in a relatively short period of time

- A number of orphans left after the death of a loved one, and the family’s inability to cope with the orphans

- The courage of infected/affected who are “living positively”

- The strength of families in continuing to care for their members

- Feelings of helplessness or powerlessness (e.g., inability to afford medication or particular foods to strengthen patient, and so on)

- Loss of income (or agricultural outputs) due to illness

- Hardships that women face in terms of the double burden of care and greater vulnerability to HIV

- Number of funerals making it impossible to work regularly

- The efforts of faith-based and other groups in the community to help PLWHA and their families

10. Using the stories that were told by the participants, attempt to draw connections to the wider effect of HIV/AIDS on the community and on the nation. Brainstorm these points with the group and list them on a flipchart. Some of the connections may include—

Impact of HIV/AIDS 1-17 - Loss of professionals needed to build the nation, such as teachers, health workers, government officials, and so on

- Burgeoning number of orphans, many with no support. The issue of street children in urban areas, and the extraordinary vulnerability of young girls, may also be raised here

- The downward spiral of poverty and vulnerability of women leading to more spread of infection and greater poverty

- Loss of agricultural production

- Helplessness or powerlessness leading to a fatalistic response to the epidemic. (For example, “We’re all going to die anyway, so why protect myself?)

Take the opportunity to weave some of the latest statistics or case studies about the impact of the pandemic throughout this portion of the session.

Wrap-up At the end of the session, summarize with the following points— • We have all seen firsthand the effect of HIV/AIDS on our families, our friends, and the local community. This exercise has reminded us that we are not alone in dealing with these issues. Many of us in this room have experienced the same problems, and we can serve as a source of energy and strength for each other throughout the workshop as we learn more about ways to cope positively with this disease in our community. • As we imagine our personal stories multiplied by the numbers of people in our nation, we begin to see the enormous effect that HIV/AIDS can have on our efforts to grow and develop as a nation. Working together to stem the tide of this disease can help our entire country, and indeed our region, to grow stronger. Let’s keep this in mind throughout our time together so that we may gather and share as much new information as we can to help our communities combat this disease.

1-18 Family Planning Plus Note to Trainers: • This exercise works best in high-prevalence countries, because most of the participants will have some personal story around HIV/AIDS. If you are working in a low-prevalence country, consider other ways to address the topic of the effect of HIV/AIDS—perhaps by showing a video or presenting global statistics. • At times it may be painful to recount personal stories about HIV/AIDS, so be prepared to respond sensitively to participants’ reactions to the stories. Be sure that everyone understands confidentiality in the training room. • This exercise is designed to allow participants to “pass” if they would not like their story shared with a larger group (by not choosing their story to continue to pass up through the larger groups). However, sometimes participants feel that they have “lost” their story because it was not chosen. For this reason, it is important to provide time at the end of the storytelling for any of the participants to share if they would like to. • Where Internet access is available, it can be helpful to look up the latest statistics and case studies for HIV/AIDS in a particular country and to share these with participants during the processing of the exercise. Perhaps the best source for such information is http://www.unaids.org/

Impact of HIV/AIDS 1-19 Chapter 2

Transmission of HIV/AIDS

“By 2005, bearing in mind… that globally, women and girls are disproportionately affected by HIV/AIDS [UNGASS will] develop and accelerate the implementation of national strategies that promote the advancement of women and women’s full enjoyment of all human rights, promote shared responsibility of men and women to ensure safe sex, empower women to have control over and decide freely and responsibly on matters related to their sexuality to increase their ability to protect themselves from HIV infection” (paragraph 59), and eliminate “all forms of discrimination, as well as all forms of violence against women and girls, including harmful traditional and customary practices, abuse, rape, and other forms of sexual violence, battering and trafficking in women and girls.”

— (PARAGRAPH 61). DECLARATION OF COMMITMENT ON HIV/AIDS SPECIAL SESSION OF THE UN GENERAL ASSEMBLY, JUNE 2001. Table of Contents Family Planning Plus Chapter 2: Transmission of HIV/AIDS

Chapter 2 Transmission of HIV/AIDS Introduction...... 2-23 Objectives...... 2-26 Important Terms...... 2-28 Sample Session Design ...... 2-29 Activities and Handouts for Transmission of HIV Sample Session ...... 2-32 Myths and Facts about HIV/AIDS ...... 2-33 The Story of Esi and Yao, Part I ...... 2-35 Transmission Facts...... 2-37 What’s the Fluid? Where’s the Door?...... 2-39 Gender Toss...... 2-40 Social Vulnerability to HIV/AIDS...... 2-41

2-22 Family Planning Plus Chapter 2: Transmission of HIV/AIDS

Key Questions

• What bodily fluids contain HIV?

• How is HIV transmitted from person to person?

• How can I know whether I have been at risk of HIV transmission?

• Do social and cultural issues influence HIV transmission?

• What cultural and social expectations and roles make women more vulnerable to HIV/AIDS? Which make men more vulnerable?

Introduction

The HIV/AIDS pandemic has resulted in the deaths of thousands of parents, teachers, and doctors—the very people who were in the best position to teach young adults and children how the disease is transmitted and how to stop the chain of transmission. In recent years, nations and communities all over the world have allowed the HIV prevention message to decline, and they must once again step up these efforts. These educational activities must focus on the ways that HIV can be transmitted, along with life skills for adolescents and behavior change programs that promote abstinence; being faithful with a faithful, tested partner; reducing the number of sexual partners; and using condoms correctly and consistently.

HIV can be transmitted through blood, semen, vaginal fluids, and breast milk. (HIV can also be transmitted through other fluids such as amniotic fluid, but this generally poses a risk only to health workers and others who attend births, and will not be addressed in this session.)

Transmission of HIV/AIDS 2-23 HIV can be transmitted from person to person in the following ways— • Vaginal or anal sex • Possibly oral sex • Sharing needles or other sharp equipment such as razors • Through blood transfusions of untested blood • From mother to infant during pregnancy, during delivery, or through breastfeeding

The following chart indicates the main modes of HIV transmission in various parts of the world.

Region Main Modes of Transmission Sub-Saharan Africa Heterosexual North Africa and Middle East Heterosexual, injecting drug use South and Southeast Asia Heterosexual, injecting drug use East Asia and Pacific Injecting drug use, heterosexual, men who have sex with men Latin America Men who have sex with men, injecting drug use, heterosexual Caribbean Heterosexual, men who have sex with men Eastern Europe and Central Asia Injecting drug use Western Europe Men who have sex with men, injecting drug use North America Men who have sex with men, injecting drug use, heterosexual Australia and New Zealand Men who have sex with men

Source: UNAIDS: AIDS epidemic update, December 2001; http://www.unaids.org

Because HIV is transmitted primarily through sexual contact, it cuts right to the core of intimate, personal relationships. Effective HIV prevention messages require that we look at many of the expectations that societies place on men and women because of their gender roles, many of which are deeply rooted in the cultural expectations of men and women, and boys and girls.

2-24 Family Planning Plus For example, the following social stereotypes and cultural expectations may place men and boys at risk for HIV infection— • The assumption that men and boys should be risk-takers may make them more likely to have sexual intercourse without a condom, or more likely to participate in injecting drug behavior • The stereotype that men and boys are always seeking sexual activity or that they need sex to survive may make them take a number of sexual partners or have sex when they have a sexually transmitted infection (STI) • The idea that men should always be strong may keep them from visiting a doctor or clinic when they are showing signs of a STI. Because these types of infections greatly increase the risk of HIV transmission, this places men and their partners at higher risk for contracting HIV

Cultural expectations also place women and girls at risk. Consider the following examples— • In cultures where women and girls are considered subordinate to men, they may not have the right to make decisions regarding when to have sex, with whom, whether or not to use a condom, whether or not to get pregnant, and so on • Some cultures have taboos associated with not breastfeeding one’s baby, which makes it difficult for a mother with HIV infection to choose not to breastfeed

HIV/AIDS is not just a public health concern, it also includes issues of gender, socioeconomic status, educational levels, and cultural practices. In an effort to address these issues, this session introduces the story of Esi and Yao, a typical family in sub-Saharan Africa, and describes how HIV/AIDS has touched their lives. This session explains the basic process of transmission and it explores the socio-cultural backdrop of transmission through Esi and Yao’s experiences. It is important that each community adapt the story to better reflect the ways in which HIV is transmitted in the area, along with the social, economic, and cultural issues surrounding the disease in that community.

Transmission of HIV/AIDS 2-25 Chapter 2: Transmission of HIV/AIDS

Objectives

By the end of this class, participants will be able to— • Identify common myths about HIV/AIDS • Identify key facts about HIV/AIDS • Discuss the effects of HIV/AIDS on one family • Define transmission • Identify at least five ways in which HIV is transmitted • Define portal of entry • Determine whether or not HIV can be transmitted by specific activities • List activities that can transmit HIV and activities that cannot transmit HIV • List common stereotypes and expectations about men and women in this community • List at least five reasons that women may be vulnerable to HIV/AIDS due to their expected social roles • List at least five reasons that men may be vulnerable to HIV/AIDS due to their expected social roles • List at least two aspects of the expected roles of men and women that can be used to help in the fight against HIV/AIDS • Discuss some of the challenges for women and men who seek VCT services

2-26 Family Planning Plus Family Planning Plus: HIV/AIDS Basics

Transmission of HIV/AIDS 2-27 Important Terms

Transmission Passing a virus (such as HIV) from one person to another

Portal of Entry An opening in the skin or tissue that HIV can pass through; a “door” into the body; examples include cuts, sores, or the soft tissue of the vagina, penis, and so on

2-28 Family Planning Plus Sample Lesson Chapter 2: Transmission of Plan HIV/AIDS

Sample Session Design

Time Content Methodology Materials Needed Evaluation

60 Myths and Facts Participants move under Prepared signs Active minutes about HIV/AIDS “True” or “False” sign in participation in -True response to trainer’s the activity Clarification of statements about -False common myths about Verbalized HIV/AIDS. HIV/AIDS List of myths and facts understanding of the “correct” Provision of a few answers basic facts about HIV/AIDS Needs assessment to assist trainer in understanding participants’ level of HIV/AIDS knowledge

30 The Story of Esi and Participants watch the Props for role-plays (or Referring to the minutes Yao, Part I story of Esi and Yao cutouts, photographs, or story throughout unfold. The story can be pictures of all characters all the The experience of one told through presentation and signs indicating the information- family with HIV/AIDS, of a long role-play, or by following dates— based sessions. including the husband’s using cutouts, pictures, or Early 1993, late 1993, initial infection with the photos and narrating the 1992, early 1994, virus, transmission to story. early 1995, 1997, 1998, the wife, first child not late 1998, late 1999 becoming infected, second child dying of AIDS, and finally, the husband’s death.

Transmission of HIV/AIDS 2-29 Time Content Methodology Materials Needed Evaluation

30 Transmission Facts Trainer introduces the Flipchart Proper placement minutes concept of of the cards in Introduction to Markers “transmission,” then the next exercise “transmission” leads a group brainstorm Tape Modes of transmission regarding ways in which Prepared flipcharts Introduction of What’s HIV is transmitted from with— the Fluid? Where’s the one person to another. - Pictures of a door and Door? Test Trainer introduces the a drop of blood with Discussion of “portal of “What’s the fluid? the phrases, “What’s entry” Where’s the door?” test, the fluid?” and and describes “portal of “Where’s the door?” entry.”

30 What’s the Fluid? Participants are asked to One card for each Proper placement minutes Where’s the Door? reach under their chairs participant marked with of the cards and and to remove the card a Transmit/Does Not correct Review of specific that was placed there. Transmit activity. identification of activities and Participants are asked to the fluid and the discussion of whether Tape walk up to the front of portal of entry. they pose the risk of the room, one-by-one, Flipcharts with headings transmitting HIV and place the cards under - Transmits HIV the proper heading. While doing so, they - Does not Transmit should answer, “What’s HIV the Fluid? Where’s the Door?”

10 Gender Toss Trainer tosses a ball to Ball Active minutes participants and asks participation in Flipchart them to complete a the exercise sentence “Women are…” Markers or “Men are…” Tape

2-30 Family Planning Plus Time Content Methodology Materials Needed Evaluation

90 Social Vulnerability to Participants form mixed Flipchart Paper Lists created by minutes HIV/AIDS groups. These groups list groups Markers some of the expectations Social/cultural their culture places on Tape expectations of men specific gender/age and women groups. The participants Positive aspects of then list ways in which those expectations these expectations might Ways in which make them more expectations make men vulnerable to HIV/AIDS. and women vulnerable After processing, the to HIV infection groups list ways that some of these STIs and HIV/AIDS expectations can be Issues associated with changed or used to help VCT, and violence fight HIV/AIDS.

Transmission of HIV/AIDS 2-31 Chapter 2: Transmission of HIV/AIDS

Activities and Handouts for Transmission of HIV

• Myths and Facts about HIV/AIDS

• The Story of Esi and Yao, Part I

• Transmission Facts

• What’s the Fluid? Where’s the Door?

• Gender Toss

• Social Vulnerability to HIV/AIDS

2-32 Family Planning Plus Activity Myths and Facts about HIV/AIDS2 Objective By the end of this session, participants will be able to— • Identify common myths about HIV/AIDS • State key facts about HIV/AIDS

Time allotted 60 minutes

Preparation Compile a list of basic facts and common myths about HIV/AIDS, as your community knows them. It is best to develop your own list from the experiences of your community, but to help you get started, an example is provided in the tools for trainers on pages 2-46 to 2-48.

Next, prepare two signs, with the headings True and False. Hang them on opposite sides of the room, and ensure that the space between them is open and will accommodate the movement of the participants.

Facilitation 1. Remind participants of some of the issues discussed in the session called steps Impact of HIV/AIDS. Suggest that because HIV/AIDS is such an important and sensitive issue, that community members may often hold a number of false ideas or myths about the disease. It is important to be able to recognize these myths, and to help our fellow community members understand the real facts about the disease so that we may all better protect ourselves and care for those who are infected. Say that this short activity will help us to begin to think about the myths and facts about HIV/AIDS.

2. Point out the words on the wall. Indicate that you will read out a statement about HIV/AIDS, and if the participants believe that the statement is true, they should stand near the True sign. If they believe the statement false, they should stand near the “False” sign. There is no middle ground and they must defend their position.

3. Read the first statement, and give all participants a chance to choose their answer. When all have chosen, invite a few participants from the “False” side to explain why they have chosen that answer. Do the same for those under the True sign. Allow some debate to develop—this will help the trainer gauge the level of HIV/AIDS knowledge in the group, and will point out some of the key issues that need to be clarified in the sessions to

2 The “Myths and Facts about AIDS” session was adapted and reprinted (with permission of Peace Corps), from the Life Skills Manual, pp. II-27 to II-30.

Transmission of HIV/AIDS 2-33 follow. In addition, this exercise will help the trainer to understand the personalities of the group leaders, as they emerge during the debate.

4. After all debate has been exhausted, clarify the “correct” answer to the statement and explain it. Ask for questions and ensure that all participants understand before beginning the process again with the next question. (It is not necessary to go into great detail regarding each answer, because all the issues will be addressed in the sessions to follow.)

5. Continue in this way until all questions are exhausted, the time for the exercise is exhausted, or the participants are exhausted (from moving around).

Wrap-up At the end of the activity, suggest that participants keep some of these myths and facts in mind throughout the sessions to follow. Point out that sometimes facts about HIV/AIDS can be confusing, and it is important that we all feel free to ask questions throughout the workshop in order to make clear anything that we do not understand. Invite the participants to have a seat and prepare to begin our journey of understanding the facts about HIV/AIDS by watching the story of Esi and Yao.

2-34 Family Planning Plus Activity The Story of Esi and Yao, Part I Objectives By the end of the exercise, participants will be able to— • Discuss the impact of HIV/AIDS on one family. This family’s story will serve as a backdrop for all remaining sessions.

Time allotted 30 minutes

Preparation Before the session (perhaps even the day before) ask five participants to take part in the role-play (pages 2-49 to 2-51). Spend some time with them before the sessions or over the break to rehearse the scenes. Ensure that any necessary props are available to the actors (e.g., a bundle of clothes or a doll to represent baby, radio, etc.) (Note: Be sure to adapt this story to a typical example of how HIV/AIDS is affecting a family in your culture.) Alternatively, have the trainers prepare and perform the role-play.

Facilitation 1. Remind participants of the discussion during the Impact of HIV/AIDS steps session. Although the effects of HIV/AIDS are felt throughout the community, the nation, and the continent, HIV/AIDS is first an issue for an individual family.

Point out that many issues need to be covered when discussing HIV/AIDS. In the next four days, we will discuss many of these topics, from transmission and prevention to the immune system, disease progression, and ways to live a healthy life with the virus. To help us get started, we are going to follow one family through their experiences with HIV/AIDS.

Invite participants to watch the role-play.

2. Narrate the role-play as the performers act it out. (If your actors are comfortable, they can use dialogue to tell the story, but this will require more practice and preparation.)

Wrap-up After the role-play is finished, thank all the actors and invite them to have a seat. Ask that participants keep the Story of Esi and Yao in their minds as we move through the information on HIV/AIDS in the next four days. Their story will help us to see the different stages of HIV/AIDS in the life of a family.

Transmission of HIV/AIDS 2-35 Note to Trainers: Depending on the circumstances and the learning styles of your group, you may choose to deliver the story in one of three ways. • Role-play • Cutouts of figures • Pictures or photographs

2-36 Family Planning Plus Activity Transmission Facts3 Objective By the end of this session, participants will be able to— • Define transmission • Identify at least five ways in which HIV is transmitted • Define portal of entry

Time allotted 30 minutes

Preparation Prepare two flipcharts; on the first one write, “What’s the Fluid?” and have a colorful drawing of a drop of blood on the top. On the second chart write, “Where’s the Door?” and have a colorful drawing of a door on the top.

Facilitation 1. Remind participants of the Story of Esi and Yao. Ask them to guess which steps points in the story represent the transmission of HIV from one person to another. Correct answers will include Yao sleeping with the woman at the bar, Yao transmitting HIV to Esi after their marriage, and Esi transmitting HIV to their second child. Be sure to briefly discuss that HIV was not transmitted to Yokaana, their first child. After the discussion, ask participants for a good definition of “transmission.” You may come up with something such as, “how HIV passes from one person to another.”

2. Point out that despite the myths surrounding HIV, we know how HIV is transmitted, and we know how it can be prevented. Ask participants to brainstorm which fluids in the body are capable of transmitting HIV. Record the correct answers on the “What’s the Fluid?” flipchart. For responses with fluids cannot transmit HIV, record them in a separate box at the bottom of the page; these will be addressed later.

The correct answers include blood, semen, vaginal secretions, and breast milk. (Other secretions include amniotic fluid, synovial fluid, cerebral- spinal fluid, etc., but these will probably come up only in sessions with health workers or others who attend births.) Fluids that do not transmit HIV include vomit, diarrhea, saliva, tears, sweat, and urine. After the correct answers have been given, be sure to stress that, whereas fluids such as vomit, diarrhea, saliva, tears, sweat, and urine do contain HIV, there is not enough HIV in them to transmit the virus from one person to another.

3 The “Transmission Facts” session was adapted and reprinted (with permission of Peace Corps), from the Life Skills Manual, pp. II-51 to II-55.

Transmission of HIV/AIDS 2-37 However, many of these fluids may transmit other diseases, so care should be taken with them.

3. Next, point out that in addition to a fluid infected with HIV, it also needs an entry point into the body. This “door” is sometimes called a “portal of entry.” It is a place at which the virus may enter. Ask participants to think of possible doors that may allow HIV into the body, and write the answers on the “Where’s the Door?” flipchart. Some suggested answers include cuts, sores, needle punctures, soft tissues of the vagina, tip of the penis, anus, mouth, eyes, or nose.

4. State that we can always tell whether or not it is possible for HIV to be transmitted by asking ourselves two questions.

What is the fluid?

- Is one of the fluids present that can transmit HIV?

Where’s the door?

- Is there a portal of entry for the virus to pass through?

5. Ask participants to brainstorm some of the most common ways for HIV to be transmitted. These include—

- Vaginal or anal sex

- Possibly oral sex

- Sharing needles or other sharp equipment such as razors

- Through blood transfusions of untested blood (emphasize that most countries now test blood for HIV so most sources are safe)

- From mother to infant during pregnancy, during delivery, or through breastfeeding

Wrap-up Summarize the activity by emphasizing that it is clear how HIV is transmitted. Review the fluids that can transmit HIV, and the doors through which HIV might enter. Remind participants that they can now put any activity to the “What’s the Fluid? Where’s the Door?” test if they are unsure whether the activity may place them at risk for HIV transmission. In the next exercise, we will practice this test by reviewing a number of activities that may or may not transmit the virus.

2-38 Family Planning Plus Activity What’s the Fluid? Where’s the Door?4 Objective By the end of this exercise, participants will be able to— • Determine whether or not HIV can be transmitted by specific activities • List activities that can transmit HIV and activities that cannot transmit HIV

Time allotted 30 minutes

Preparation Create cards with a number of different activities on them. (Suggested activities are listed at the end of this chapter. See tools for trainers on page 2-52.) Ensure that each participant has one card. Before the session (preferably before the day begins or during the break), tape the cards under the participants’ chairs or just distribute cards to each participant at the start of the session. Tape two signs at the front of the room, one labeled “Can Transmit HIV,” and one labeled “Cannot Transmit HIV.”

Facilitation 1. Remind participants of the transmission facts that we have just learned, steps and say that we will now practice using the “What’s the Fluid? Where’s the door?” test. 2. Ask participants to reach under their chairs and pull out the activity cards taped there, or distribute the cards to each participant. Explain that the cards were placed randomly and the situations have nothing to do with them personally. Give participants a moment to read their cards. Ask them to think about whether or not that activity might transmit HIV. 3. Invite participants to come up to the front of the room, one by one, with their activity cards. Each participant should read his or her card, explain what fluid is present that might contain HIV, and what door is present through which HIV might pass. The participant should then tape the card to the Can Transmit HIV or Cannot Transmit HIV sign. After the participant chooses, ask for feedback from the entire group. Clarify any questions or incorrect answers. 4. Repeat this process until all participants have completed the exercise.

Wrap-up Summarize the activity. Say that participants can always decide whether or not an activity is a risk behavior for HIV transmission by using this simple test.

4 The “What’s the Fluid? Where’s the Door” session was adapted and reprinted (with permission of Peace Corps), from the Life Skills Manual, pp. II-51 to II-55.

Transmission of HIV/AIDS 2-39 Activity Gender Toss Objective By the end of this warm-up, participants will be able to— • List common stereotypes about men and women in this community

Time allotted 10 minutes

Preparation Provide a ball, or a bunch of scrap paper balled up and covered in tape. Create a flipchart with two columns, labeled Men and Women. Ask a volunteer to record the responses from participants in the appropriate column once the warm-up begins.

Facilitation 1. State that we have spent some time discussing some of the major facts and steps issues surrounding HIV/AIDS. No matter how much we know about HIV/AIDS, sometimes our ability to act on that knowledge can be influenced by other factors in our situation; for example, by the cultural and social roles expected of us because of our gender. For this reason, we will spend the next activity exploring the effect of gender on HIV/AIDS. We will discuss the effect of social roles on our abilities to prevent HIV infection or to lessen the effects of HIV/AIDS on our lives.

2. Say that we will first begin with a short warm-up exercise. State that you will toss a ball to different participants while calling out one of two sentences, either “Women are…” or “Men are…” When the participant catches the ball, he or she must immediately complete the sentence and then toss the ball back to the trainer. Stress that the exercise must go very fast, so they should say the first thing that comes into their heads and then toss the ball back to the trainer. As we play the game, our volunteer will record what we have said on the flipchart.

Wrap-up After the activity, review the words listed on the flipchart with the participants. Some possible responses will include “Women are sexy,” “Men are strong,” “Women are kind,” “Men work hard,” etc. Ask a few participants why they said what they did to describe men and women. You may want to probe the more controversial answers. Ask that the group keep this exercise in mind as we move on to discuss some of the reasons that we can become vulnerable to HIV infection.

2-40 Family Planning Plus Activity Social Vulnerability to HIV/AIDS5 Objective By the end of this session, participants will be able to— • List some common social and cultural expectations for men and women in this community • List at least five reasons that men may be vulnerable to HIV/AIDS because of their expected social roles • List at least five reasons that women may be vulnerable to HIV/AIDS because of their expected social roles • List at least two positive aspects of the expected roles of men and women that can be used to help in the fight against HIV/AIDS • Describe the importance of treating STIs to preventing transmission of HIV • Discuss some of the challenges of VCT for women and men

Time allotted 90 minutes

Preparation Before the session, prepare flipchart paper and markers for each group. Clear a large space of wall for posting flipcharts as groups report out.

Facilitation 1. Refer to the Gender Toss and suggest that every culture and community steps assign certain roles to people on the basis of whether they are a man or a woman. In addition, roles and expectations can be assigned depending on a person’s age.

2. Divide participants into four groups mixed by gender and age. Provide each group with an ample supply of flipchart paper and markers.

3. Indicate that each group will have about 20 minutes to discuss the roles and expectations that their society or culture places on a specific age or gender group. Assign each group of participants to discuss one of four gender/age groups.

5 The “Social Vulnerability to HIV/AIDS” session was adapted and reprinted (with permission of Peace Corps), from the Life Skills Manual, pp. II-63 to II-68.

Transmission of HIV/AIDS 2-41 - Group 1 will discuss expectations of older men

- Group 2 will discuss roles of older women

- Group 3 will discuss the expectations of girls and young women

- Group 4 will discuss the roles of boys and young men

The groups should list these ideas on a flipchart. In addition, they should think about how the age and gender of their assigned group makes people of that age and gender particularly vulnerable to HIV. They should list these ideas on a flipchart, as well.

4. After about 20 minutes, provide each group an opportunity to briefly report—

- Their ideas to the larger group. Post all the flipcharts on the wall as groups

- Their discussion

5. Lead a discussion around these issues of vulnerability based on cultural and social expectations. Attempt to make a link between the expectations that participants list and the list of vulnerability to HIV. For example, the expectation that women should accept a man’s authority may lead to an inability to negotiate safe sex or go to obtain VCT services.

6. Depending on the community, the following issues might be relevant to women. If these issues are not raised and you believe they may still be pertinent, ask the participants whether these are issues in the local area.

- Women do not have as much decision-making authority as men, and sometimes may not be able to make decisions regarding whether or not to have sex; whether or not to use a condom; whether or not to get pregnant; and whether or not to be tested for HIV or other STIs

- Fear of violence from men, which may keep a woman from being tested for HIV or from reporting her HIV test results to her partner

- Sexual violence against women, including trafficking in women, rape, and the lack of access to HIV prophylaxis after rape

- Girls’ initiation rites that may include female genital cutting (circumcision) or sexual initiation by an older man

- Taboos related to speaking about sex

- Men’s preference for dry sex, which may encourage women to insert drying agents in the vagina that can cause tearing or tiny cuts 2-42 Family Planning Plus - Denial of homosexuality and bisexuality, which may cause men who have sex with men to continue to have sex with their wives or girlfriends in order to protect themselves from reproach or disclosure

- Bride price, dowry, or marriage rites that place a property value on women

- Early marriage for girls

- In areas where virginity has great importance, girls may engage in anal sex in order to preserve their virginity

- Inheritance laws that deny women land or resources when their husband dies

- Wife inheritance/funeral customs that include sexual relations with the brother of the deceased

- Extreme poverty that encourages the exchange of sex for money, school fees or food

- The expectation that women should care for others before themselves may lead to lack of treatment seeking for STIs, including HIV

- Lack of economic resources and power that may lead to an inability to purchase condoms

- Lack of SRH education for women

- Lack of access to family planning and health services

- Lack of mobility to access and use health services

- Lack of availability of female-controlled prevention methods, such as the female condom or microbicides

- Acceptance of multiple partners for men or women

Be sure to spend some time discussing each of these issues, perhaps by referring to Esi. You may wish especially to focus on issues of violence against women, which may lead to fear of VCT or fear of negotiation around sexual and reproductive decisions. Be sure to point out that being faithful did not protect Esi; being married was a risk factor for her, as it is for many women.

7. Depending on the community, the following issues may be relevant to men. If these issues are not raised by the group and you believe they may

Transmission of HIV/AIDS 2-43 still be pertinent, ask the participants if these are important issues in the local area.

- The expectation that men should be risk-takers and have many sexual partners may increase the chance of HIV infection because men feel pressured to have many partners, to have partners outside of marriage, or to have sex without a condom.

- The expectation that men should always be strong may keep a man from going to the doctor or to a health clinic because it may be perceived as a sign of weakness. This can mean that a man is infected with a STI for a long time without knowing it or without receiving treatment for it, which greatly increases the risk of HIV infection or transmitting it to a partner. Briefly remind the group of the reasons that STIs greatly increase the risk for associated HIV infection, which will be covered in more depth later. (See pg. 2-48) Remind them that whenever there is an infection, more white blood cells are present (the kind of cells that HIV can enter and take over), which provides a greater chance of passing on HIV. Also, the sores and lesions brought on by STIs greatly increase the portals of entry through which the virus can enter the body.

- The expectation that men should have sex only with women may keep men who have sex with men from getting access to the information and services they need.

- The acceptance or belief that men need or desire multiple partners.

- The expectation that men should be the decision-makers may keep the family from making decisions that might be more healthy for the family, such as avoiding frequent pregnancy, practicing family planning methods, using condoms to protect against HIV infection, or getting VCT to learn whether the partners are infected with HIV.

8. After thoroughly discussing the possible sources of vulnerability to HIV infection, ask participants to again review the lists of expectations posted on the wall. Can any of these expectations be used to help fight HIV/AIDS in our communities? Can any positive aspects of these roles and expectations be beneficial in our fight against HIV/AIDS? Some examples may include—

- The expectation that men should be the protector of the family can mean that men will do everything they can to protect the family from HIV, including condom use, and seeking VCT, and medical services

2-44 Family Planning Plus - Initiation rites for girls can be changed to include some kind of symbolic rite (instead of female genital cutting), followed by education about HIV/AIDS, and so on

Wrap-up Summarize the session by suggesting that differences in power and status between the sexes can make both women and men more vulnerable to HIV. These gender issues often lead to expectations that differ on the basis of productive and reproductive roles, with a woman’s productive roles being overlooked and undervalued because they are considered part of her reproductive roles as wife and mother. Women are also more vulnerable because of a lack of access to information and resources. But there are ways to work within the community to maintain our social and cultural traditions while still protecting ourselves against HIV. Beginning an honest dialogue with community members and family members about these issues may go a long way toward protecting our people from HIV/AIDS.

Transmission of HIV/AIDS 2-45 Tools for Myths and Facts about HIV/AIDS Trainers

This tool is meant for use with the Myths and Facts about HIV/AIDS activity on pages 2-33 and 2-34. It is important that trainers spend time before the workshop compiling a list that represents some of the common myths and facts of HIV/AIDS in the local community. The examples listed here are suggestions to help you begin. Each statement is followed by a brief explanation to assist with discussion after the participants have decided whether the statement is true or false.

Myths

You can be cured of HIV/AIDS if you have sex with a virgin.

False. Having sex with a virgin greatly increases the risk of transmitting HIV to young girls and boys, and also places them at risk for coercive sex and rape. (The origins of this myth are not clear, but are based on an idealized female character of virgin purity, and it reinforces the idea of the male as predator.)

Mosquitoes can transmit HIV/AIDS.

Mosquitoes do not transmit HIV, but because they may take blood from more than one person, it is often believed that they can do so. There are many things that a trainer can say to refute this myth. • Mosquitoes do not inject blood into a person when they bite • Mosquitoes take blood into the “stomach,” and it does not remain in their stingers • HIV stands for Human Immunodeficiency Virus, a virus that can survive only in humans—once it is taken in by a mosquito, the virus dies. • If HIV were transmitted in this way, people of all ages would have AIDS—from infants to grandparents, the way malaria occurs in all ages. Instead, most cases of HIV/AIDS occur among sexually active people of reproductive age

Some new medicines can cure AIDS.

Although new medicines, called anti-retrovirals and protease inhibitors, can help someone to live a great deal longer with HIV, these medicines are not a cure. A person with the virus will always have the virus in their body, although it may be at undetectable levels. The virus may still be replicating at very low levels in the bone marrow of the person infected. Thus, the new medicines do not kill the virus; they simply suppress it.

2-46 Family Planning Plus Myths and Facts about HIV/AIDS, continued

A condom has small holes in it that HIV can pass through.

Because male and female condoms are manufactured products, they may not be 100% perfect and they may occasionally break or tear, usually because they are handled or used incorrectly. By and large, however, condoms have proven to be very effective in preventing the transmission of HIV. In studies in which one partner was infected and the other was not, and when they used condoms consistently and correctly, the other partner did not become infected.

A baby born to an HIV-infected mother will always get HIV.

Almost all babies born to an HIV-infected mother will test positive for HIV at birth, but this is because the mother’s antibodies have been passed to the baby. It may take up to 18 months to be sure if the virus itself has been passed to the baby. Many babies are born to HIV-infected mothers and do not, themselves, become infected. This can depend on a number of factors, including the amount of HIV in the mother’s system at the time of pregnancy, and other issues that we will discuss in a later session.

Drinking local gin can cure AIDS.

There is no cure for AIDS. Drinking alcohol can lead to poor judgment and risky behavior, such as unprotected sex. HIV weakens the immune system, and drinking alcohol may hasten the onset of AIDS.

Facts

Although many people do not have access to expensive drugs to treat HIV/AIDS, there are medicines that can be used to slow down the disease and to keep us healthier longer.

Medicines used to treat infections and diseases such as tuberculosis, malaria and sexually transmitted infections can help us to remain healthier for a longer time with HIV/AIDS. It is very important to promptly seek treatment for any illness; doing so helps to keep the body stay strong to fight HIV infection.

Transmission of HIV/AIDS 2-47 Myths and Facts about HIV/AIDS, continued

Someone with an untreated sexually transmitted infection (STI) has a higher risk of becoming infected with HIV.

Untreated STIs greatly increase one’s risk of becoming infected with HIV for a number of reasons. • Sores and lesions from STIs create more “doors” for HIV to pass through. • Having a discharge that occurs with gonorrhea or chlamydia, for example, means that more white blood cells are present. Because white blood cells are hosts for HIV, it means that more virus can be transmitted or received when a discharge is present. • Women are at an even higher risk for HIV because they often don’t have symptoms of STIs, or they can’t see lesions or sores because they are inside the vagina.

A person can have a negative test for HIV and still be infected with the virus.

The HIV test checks for antibodies, not for HIV itself. Because it can take anywhere from two weeks to three months for most people to develop antibodies against HIV, a person may test negative during those weeks before the body has been able to produce antibodies. This is called the “window period,” and it is the time when someone is most highly infectious.

Using a condom during pregnancy and breastfeeding can help an HIV-infected mother to reduce the risk of passing HIV to her baby.

A pregnant woman who uses condom has a better chance to avoid a STI or reinfection with HIV. This substantially reduces the risk of passing HIV to her baby, because the amount of HIV in the woman’s body can be a factor in transmitting HIV to an unborn baby (fetus) or an infant.

You cannot know whether someone is HIV-positive.

The only way to determine whether someone is HIV-positive is by performing an HIV antibody test.

2-48 Family Planning Plus Tools for The Story of Esi and Yao6 Trainers

It is important to adapt this role-play so that the situations and characters are appropriate and recognizable to your audience. Feel free to add other family or community members to the cast.

Preparation: Set up a mock bottle store (or bar) to the right, and a mock health clinic in the middle of the room. In a corner on the left, arrange a gravesite.

The trainer stands in the center of the room, with Esi to the right and Yao to the left.

Esi is chatting with friends.

Narrator: It is early 1993. This is a young woman, you know her, she lives just near. She is good, kind, and smart. Her name is Esi, and she is finishing school soon. Her parents are proud of her, and they know she will have a good life.

Yao is standing alone. As narrator speaks, he begins to walk toward the bottle store props.

This good man is Yao. He is doing well in his business—the shop down the road. You know him. He makes his friends laugh, and he is generous.

Show Yao drinking at the bottle store. A woman walks up and chats with him—they leave arm- in-arm.

Last year, in 1992, he went to the city for business. It was a lonely time in the city; he stayed at a rest house and knew no one there. One night he drank some beers and he found a woman to ease his loneliness. He does not remember her name.

Esi and Yao walk toward the center of the room, and other actors join them. Show a marriage celebration, with Esi and Yao arm-in-arm, and family and friends all around.

At the end of 1993, Esi and Yao are married—there is a big celebration. Soon Esi and Yao are living in their home, and both help to run the business.

The group disassembles, and Esi is left standing alone. She acts sick, lies down, then recovers and walks away.

Early in 1994, Esi becomes a bit sick. She doesn’t feel well one day—it isn’t important, it just feels like the flu. Yao makes her rest, and in a few days, she recovers and returns to work. She feels fine.

6 The “Story of Yulia and Mukasa” (Esi and Yao) was adapted and reprinted (with permission of World Health Organization), from AIDS Home Care Handbook, pp. 21–28. Copyright WHO, 1993.

Transmission of HIV/AIDS 2-49 The Story of Esi and Yao, continued

Esi and Yao cross the room together, carrying a baby. They walk offstage.

Early in 1995, Esi and Yao are blessed with a child. A boy, named Yokaana, is born. He is very healthy and grows well.

Esi and Yao return to the center of the room, carrying a baby and guiding a small child.

By 1997, things have gone very well for this family. The business is going fine, and they feel very lucky. They are blessed with another baby.

Yao and the small child walk offstage. Esi holds the baby with great concern.

But by 1998, Esi becomes very worried about her new baby. He doesn’t look well. He has fevers and diarrhea, and he doesn’t seem able to gain weight. Esi buys medicines for the baby, but he doesn’t seem to get better. Finally she becomes afraid—the baby cannot eat without vomiting, and he has diarrhea again. She takes him to the doctor at the local health clinic.

Esi walks to the prop of a health clinic. A doctor sits behind the desk and talks with her as she holds the baby. (Trainer: you may choose to narrate the next segment, or if the actors are feeling confident, have them perform it.)

The doctor is very concerned. He asks Esi many questions about the baby, and he asks questions about her and her husband. He asks questions about their health and about their private life. She is embarrassed—no one has ever asked her questions about sexual things before. But this day is bad: the doctor tells Esi he believes the baby could have AIDS. He says he cannot tell from the test until the baby is 15 months old. He tells Esi to have a blood test herself and talks with her about this. Esi cannot believe what she hears, and her mind refuses to accept what the doctor says. But she agrees to the test so the doctor will not be angry. The doctor says her husband should also come to the clinic to be tested.

While she is having her blood taken in the clinic, Esi is worrying and does not know how she can talk to Yao about this or what to do. She is afraid to tell Yao, because he might be angry with her for getting tested without his permission, he may beat her, or even throw her out of the house. The doctor gives Esi medicine for the baby to help with the vomiting. He also tells her many things but she cannot remember much. She is told to return in two weeks for the result of the test.

2-50 Family Planning Plus The Story of Esi and Yao, continued

Esi walks away from the clinic with the baby. Yao meets her and they talk as they give medicine to the child. Both walk offstage.

At home, Esi cannot tell her husband what the doctor said. She is sure that the doctor is wrong. She has known too many women and families destroyed by this disease and she tells Yao that the doctor gave her medicine for the baby to make him well. She does not go to find out the result of her test.

In the corner of the room, Esi crouches, crying over her baby’s grave. Yokaana stands beside her.

One night in late 1998, the baby dies. He got a fever and was suddenly gone. The family is very unhappy, but luckily, Yokaana is healthy and tries to help his mother with her sorrow.

Yao stands to the other side of the stage, hunched over and looking ill. He walks toward the health clinic, receives medicines, and gradually acts out his recovery.

Poor Yao. It seems like he is always coughing now and he says he feels tired all the time. He goes to the doctor and is given medicines for tuberculosis. He is instructed how to take the medicines. Yao follows the instructions and after some time he feels better and even returns to work.

Esi is seen working at the shop and minding Yokaana. Yao walks over and sits in a chair, looking tired. When the narrator stops speaking, they all walk offstage.

Esi is having to do more and more at the shop. Yao is often ill and too tired to help with the work. He loses weight and keeps having diarrhea. Esi has so much to do looking after the shop and the home as well. Yao gets medicines from the doctor and they help for a time, but he soon falls ill again.

Esi and Yokaana walk over to the corner and crouch next to a grave.

In late 1999, Yao died. The six months before he died were very hard for Esi. Yao was very ill and often harsh and irritable. It was a lot of work caring for him and Yokaana, and trying to run the business. She is now scared, tired, and sad. She feels well, but in her heart she now knows that her family has been found by this terrible disease that has taken so many of their friends and neighbors. She is afraid for herself, but even more for her child—what will happen to him and how will they support themselves?

Transmission of HIV/AIDS 2-51 Tools for What’s the Fluid? Where’s the Door? Trainers

Below are some suggested activities for the “What’s the Fluid? Where’s the Door?” activity. Be sure to write out one card for each participant.

Can Transmit HIV • Vaginal sex • Direct blood transfusion of untested blood • Sharing needles • Contact with blood of an HIV-infected person • Breastfeeding • Mother to child during delivery • Mother to child during pregnancy • Contact with semen • Contact with vaginal fluids • Cleaning up blood without using gloves

Cannot Transmit HIV • Living with a person with HIV infection • Eating from the same dish as an HIV-infected person • Hugging a person with HIV • Kissing a person with HIV • Shaking hands with a person with HIV • Proper use of a condom during sex • Sharing a drinking cup with an HIV-infected person • Letting someone cry on your shoulder • Stepping on a nail outside • Cleaning up vomit or diarrhea with gloves on

2-52 Family Planning Plus Chapter 3

HIV Prevention

“Everyone who is not yet infected must know what they need to do to avoid infection. We must give young people the knowledge and power to protect themselves. We need to inform, inspire, and mobilize them, through an awareness campaign such as the world has never seen— using radio, television, and professional marketing techniques, as well as more conventional tools of education. That campaign must reach girls as well as boys. At present, in sub-Saharan Africa, adolescent girls are six times more likely to be infected than boys. That is something, which should make all of us African men deeply ashamed and angry. And once they know what they need to do, young people must have the means to do it. That means they must have support from their families and communities, as well as access to voluntary counseling and testing and—when appropriate—to condoms.”

—KOFI ANNAN Table of Contents Family Planning Plus Chapter 3: HIV Prevention

Chapter 3 HIV Prevention Introduction...... 3-55 Objectives...... 3-57 Important Terms...... 3-59 Sample Session Design ...... 3-60 Activities and Handouts for HIV Prevention Sample Session...... 3-63 Review Game ...... 3-64 Epidemic Game ...... 3-65 Prevention Facts ...... 3-68 Universal Precautions...... 3-71 Biological Vulnerability of Women and Girls ...... 3-74 Condom Carousel...... 3-76 Condom Demonstrations...... 3-78 Alternate Activities and Handouts ...... 3-90

3-54 Family Planning Plus Chapter 3: HIV Prevention

Key Questions

• How can HIV be prevented?

• What biological factors make women and girls more vulnerable to HIV/AIDS?

• What are the steps for proper use of a condom?

• How can mother-to-child transmission be prevented?

• What are “universal precautions?”

Introduction

Perhaps the greatest hope associated with HIV/AIDS is that it is 100% preventable. Understanding the ways that HIV/AIDS is transmitted and the ways that it can be prevented is important. But one must also have access to the means of prevention, and be able to use those means without being criticized or looked down upon by the community. Then it is possible to remain HIV-free for a lifetime. Unfortunately, what seems to be a short list of things needed for prevention is made much longer by social, economic, and cultural factors that get in the way of preventing HIV/AIDS. The loss of teachers, doctors, and parents can slow information, education, and communication activities that teach people the basics of transmission and prevention. Even once these basics are taught, people may have difficulty obtaining access to the means of prevention. For example, if condoms are not widely and consistently available at an affordable cost, or if young people are not permitted to purchase them, or if anti-retroviral drugs are not available to pregnant women.

Making prevention more difficult are numerous social and cultural taboos—from not being able to discuss sexual matters, to the repression of women and girls that makes it impossible for them to make their own decisions regarding sexuality and reproductive health. There may also be

HIV Prevention 3-55 cultural taboos regarding the use of condoms or that prevent HIV-positive women from choosing not to breastfeed their infants.

Economic, social, and environmental factors may encourage migration from rural to urban areas and between countries, thereby splitting up families. In many areas, war or conflicts make prevention difficult because it reinforces a false sense of power and invulnerability in men, and it makes women and children even more vulnerable.

Because of the many social, economic, environmental, and cultural issues involved with sexual and reproductive behavior, the prevention of HIV represents many complex negotiations between men and women at the personal level. In addition, prevention of HIV requires a re- thinking of gender issues at the national level as communities struggle to cope with inheritance laws, education for girls, access to family planning, and so forth.

Each culture must address these issues on their own terms and in their own time. The community must begin conversations and negotiations that take gender into account when planning HIV prevention programs.

In addition to these issues, women and men have specific biological concerns. Often, research and educational programs focus only on the issues that are relevant to men, so women and girls may not receive information or prevention methods appropriate to their needs. Issues associated with VCT may also differ for women and men.

So although we may teach the “ABCs” of prevention, we should never delude ourselves that preventing HIV/AIDS is as easy as 1-2-3.

This session focuses on the many ways that HIV/AIDS can be prevented, including— • Modifying sexual behavior by choosing abstinence, being faithful with a mutually faithful, HIV-negative, tested partner, or using condoms • Avoiding MTCT by choosing not to have children if a woman is HIV-positive (using family planning), finding alternatives to breastfeeding, having a caesarian delivery where feasible, and, depending on the stage of the disease, taking anti-retroviral drugs to avoid transmission • Using “universal precautions,” including avoiding contact with blood or bodily fluids, placing a barrier between skin and bodily fluids, washing soiled garments so as not to spread disease, cleaning up spills with care, not recapping needles, and so forth

It is important to be aware of participants’ feelings and attitudes during this session because it explores subjects, such as condom use or a wide variety of sexual behaviors that may sometimes be uncomfortable for people. It is important to address these issues with cultural and interpersonal sensitivity while making it clear that condoms are an important tool in the fight against HIV/AIDS.

3-56 Family Planning Plus Chapter 3: HIV Prevention

Objectives

By the end of this class, participants will be able to— • Describe the ease with which HIV can be spread from one partner to another • Describe the “ABCs” of HIV prevention • Discuss the importance of using condoms to prevent HIV transmission • Define abstinence • Demonstrate comfort in handling condoms • Clarify common questions about male and female condom use • List the steps for proper use of male and female condoms • Demonstrate effective use of male and female condoms on a model • Describe the importance of treating STIs in preventing HIV transmission • List at least three reasons that women and girls are more biologically vulnerable to HIV/AIDS • Define universal precautions • Identify when to use universal precautions • List at least four examples of using universal precautions

HIV Prevention 3-57 Family Planning Plus: HIV/AIDS Basics

3-58 Family Planning Plus Important Terms

Abstinence Making a decision not to have sexual intercourse for a specified time period.

Universal A term usually used by health care workers. It means that you should assume that Precautions everyone, regardless of how they appear, should be considered potentially infected with HIV. This means that whenever you might come into contact with the fluids that carry HIV, you should use barriers to protect yourself.

Protection from pregnancy and STI/HIV either through the use of a condom alone or the use of a condom plus another family planning method. Abstinence Dual Protection also provides dual protection, as does avoiding penetrative sex. (per Jeff Spieler, Supervisory Biologist, Bureau of Global Health, Office of Population/Health/Nutrition, USAID )

HIV Prevention 3-59 Sample Lesson Chapter 3: HIV Prevention Plan

Sample Session Design

Time Content Methodology Materials Needed Evaluation

20 Review Game Questions are written on the Colored cards with Successfully minutes back of colored cards and questions answering Review of yesterday’s attached to the wall. Numbers questions sessions Candy or other prizes are written on the front. regarding Participants form teams and Flipchart yesterday’s attempt to correctly answer as Markers sessions many questions as possible to win a prize. Tape Watch or clock

30 Epidemic Game Participants are given a small, One card for each Active minutes folded card and asked not to participant participation Speed with which HIV look at it. Participants are in the activity can be transmitted - About 10% of the asked to greet three people and cards should have Answers to Inability to determine return to their seats. Trainer an “X” on them the questions when a partner is instructs participants to look at at the end of infected their cards. Those with an “X” - About 5% of the activity cards should have Effectiveness of are asked to stand; they a “C” on them condoms in reducing represent people infected with risk HIV. Anyone who greeted - The remaining those standing must also cards should be stand; they are also infected. blank. Finally, those with a “C” on their card are instructed to sit Flipchart down; they have used a Markers condom and are not infected.

30 Prevention Facts Trainer presents the “ABCs” Flipchart paper Success in minutes of prevention of sexually answering “ABCs” of prevention, Markers transmitted HIV, and briefly questions including Abstinence, discusses issues associated Tape during the Being faithful with a with testing. Glove Game faithful, tested partner, and Condom use

3-60 Family Planning Plus Time Content Methodology Materials Needed Evaluation

60 Universal Precautions Trainer briefly defines Latex gloves, plastic Correct minutes universal precautions. bags answers given Brief definition of during the universal precautions, Trainer guides participants Flipchart paper Glove Game and discussion of through possible ways HIV Markers appropriate steps for might be transmitted in a universal precautions. home care or hospital Tape situation, including ways to The Glove Game is used protect oneself in such as an evaluation of the situations. Prevention session. The Glove Game is played as an evaluation of the Universal Precautions session. Participants are given one latex glove and invited to place it on one hand. Trainer will read out situations, and participants will raise the gloved hand if some kind of “universal precaution” or prevention method is necessary in that situation.

30 Biological Trainer leads group in a Flipchart Active minutes Vulnerability of brainstorm of reasons why participation Markers Women and Girls women and girls are in the exercise particularly biologically Tape Biological issues that vulnerable to HIV/AIDS. make women and girls more vulnerable to infection

20 Condom Carousel Participants form a circle. Radio or tape player Correct minutes Trainer passes the condom with audiotape answering of A game that emphasizes around the circle to the sound the condom the strength of condoms, Condom Carousels of music, as on a carousel. questions allows participants to When the music stops, - 5 to 6 condoms develop comfort with whoever is holding the blown up as touching condoms, and condom balloon must break it balloons with clarifies some common and answers the question questions written questions about condom inside it. on folded strips of use. paper inside

HIV Prevention 3-61 Time Content Methodology Materials Needed Evaluation

70 Condom Trainer discusses male and Condoms (enough Observation minutes Demonstration female condoms and invites a for each participant) of proper participant to come up and condom use How to use male and Penis models or other demonstrate their proper use. during female condoms representative such practice Pairs of participants practice as banana or bottle Brief discussion of the handling and using the (Checklists for female condom Handouts: “How to condom. training of Use Male and Female trainers) Condoms”

3-62 Family Planning Plus Chapter 3: HIV Prevention

Activities and Handouts for HIV Prevention

• Review Game

• Epidemic Game

• Prevention Facts

• Universal Precautions

• Biological Vulnerability of Women and Girls

• Condom Carousel

• Condom Demonstration

HIV Prevention 3-63 Activity Review Game7 Objective By the end of this activity, participants will be able to— • Demonstrate an understanding of the information and concepts provided in yesterday’s sessions

Time allotted 20 minutes

Preparation This exercise should be adapted and used every morning to review the previous day’s lessons. Prepare a series of questions on colored cards. (Examples of some questions follow this chapter on page 3-81 and 3-82. Remember to adapt the questions to reflect material you covered the day before.) Number the front of the cards. Place the prepared cards randomly on a wall at the front of the room. Prepare a flipchart to serve as a scoreboard. Provide a prize large enough for a team of about five people, perhaps candy or fruit.

Facilitation 1. After greeting all participants and finishing any housekeeping or warm-up steps tasks, prepare the group for the day’s sessions by briefly reviewing the schedule. Suggest that yesterday’s sessions were packed with new information and concepts, and it may be wise for us to spend a few minutes reviewing some of them before we move on to the business of the day. 2. Divide the group into teams of no more than five participants. Have each team gather in one area, and ask each team to choose a name. Write the names of the teams on the scoreboard. 3. Taking turns, each team chooses one of the numbered cards. The trainer reads the question, and the team has 30 seconds to provide the correct answer. If the team provides the correct answer in less than 30 seconds, give them a point. If the answer is incorrect or not provided in time, they do not receive a point. 4. Continue to move from team to team until all questions have been asked. Be sure to keep the game lively and competitive! Clarify any questions that participants may have from yesterday’s sessions.

Wrap-up Briefly summarize the concepts that were covered in yesterday’s sessions. Indicate that we will now turn our attention to today’s topics.

7 The “Review Game” was adapted and reprinted (with permission of Peace Corps), from the Life Skills Manual, pp. II-36.

3-64 Family Planning Plus Activity Epidemic Game8 Objective By the end of this activity, participants will be able to— • Describe the ease with which HIV can be spread from one partner to another • Discuss the importance of using condoms to prevent HIV transmission

Time allotted 30 minutes

Preparation Create one small card for each participant. About 10% of the cards should be marked with an X (if you know the prevalence of HIV in your country, use that percentage instead). About 5% should be marked with a C. Leave the remaining cards blank. Fold all the cards.

Facilitation 1. Explain that we will play a brief game to preview some of the issues steps associated with transmission and prevention of HIV. Invite all participants to stand.

2. Distribute all the cards—one to each participant. Remind participants that they are not to look at their cards until you tell them to do so.

3. Ask participants to mill about the room and greet three different people. Everyone should take care to remember who they greeted. They should not look at each other’s cards, nor should they look at their own. They should simply greet three people and then sit down.

4. When everyone is seated, invite participants to look at their cards. Ask everyone who has an X on his or her card to stand. Tell the participants that all of those standing are considered infected with HIV for the purposes of this exercise.

5. Ask the participants to take a look at those standing. If someone that they greeted is currently standing, they should also stand. They have also been infected with HIV.

8 The “Epidemic Game” was adapted and reprinted (with permission of Peace Corps) from the Life Skills Manual, appendixes 25 and 26.

HIV Prevention 3-65 6. Ask those who have remained seated to look again at the people standing. If someone that they greeted is standing, they should also stand. Continue this for a time or two until almost everyone is standing. Remind the group that, for the purposes of this exercise, those standing are infected with HIV.

7. Next, ask all of those who have a C on their cards to sit down. Indicate that these people have used a condom, so they are not infected after all.

8. The entire group can now sit down.

9. Ask the people with the X on their cards how they felt to discover they were HIV-positive. Ask the participants with a C on their cards how it felt to find out that they were not infected after all.

Wrap-up Ask the group what we can learn from this game. Write the answers on a flipchart. Possible answers may include the following. • HIV can be transmitted very quickly and easily. • You cannot determine whether someone has HIV. • Using a condom can reduce your risk for HIV. • Having contact with one person is the same as having contact with all the partners of that person.

Lastly, ask the group how they might have avoided infection during this game. Possible answers may include the following. • They could have refused to play (abstinence). • They could have insisted on seeing their partner’s cards before shaking hands or greeting them (testing). • They could have greeted only one partner. (Risk reduction—being faithful.) Remind the group that they must first check the card before being faithful with that partner (testing).

3-66 Family Planning Plus Note to Trainers: • It is important to emphasize that this is a representative exercise. People cannot transmit HIV by simply greeting each other. They would have had to have sex (or other contact with bodily fluid). Also, be careful that this exercise does not set a negative tone regarding people living with HIV/AIDS. • This exercise can also be facilitated using beans or colored water. When using beans, find two different colors of beans (for example, red for HIV positive, and white for uninfected) and place a small pile of beans into each person’s hand. When participants greet each other, they should exchange half of the beans in their hands. At the end of the session, any red bean in a participant’s hand indicates that they were infected. When using water, give most participants a glass of water, but give about 10% of the participants a glass filled with tea, coffee, or another colored liquid. When participants greet each other, they exchange half the liquid in their class. This adaptation is particularly effective when trying to explain the amount of virus in the blood, because some glasses will be very dark, whereas others will have only a tiny amount of colored fluid.

HIV Prevention 3-67 Activity Prevention Facts Objective By the end of this activity, participants will be able to— • Describe the ABCs of HIV prevention • Define abstinence

Time allotted 30 minutes

Preparation At the front of the room, post the flipcharts from the previous session to indicate the ways that HIV is transmitted. Post blank flipcharts beside them.

Facilitation 1. Suggest that the last activity was a brief introduction to the issues steps associated with HIV prevention, and that the remainder of the session will address the topic in more detail.

2. Briefly review the ways that HIV is transmitted, referring both to the flipcharts from the last session and to the Story of Esi and Yao. Review each of the ways that HIV is transmitted, and brainstorm with participants about possible ways to prevent such transmission.

3. Begin with transmission through blood contact and brainstorm some suggestions for preventing such transmission. Indicate that this topic will be covered further at the end of the session, when we discuss universal precautions.

4. Move on to discuss mother-to-child transmission. Allow a few suggestions here, but indicate that we will also cover that topic later. We are putting off this discussion until that time because this is one of the more complicated topics in HIV prevention. It will be easier to understand the issues associated with MTCT after we have talked more about the immune system and how it is affected by HIV/AIDS.

5. Say that because it can be difficult to discuss sexual matters openly, often conversations and even education or information about HIV/AIDS focus more on the non-sexual ways that the virus is transmitted and prevented. Although these issues are certainly important, we must be realistic and understand that the majority of HIV infections come from sexual contact. (Use the statistics for your country.) For this reason, we will devote most of this session to preventing the transmission of HIV through sexual activity.

3-68 Family Planning Plus 6. Ask participants to think about ways to prevent sexual transmission of HIV and note these ideas on a flipchart. Suggest that it has been helpful for some communities to remember the “ABCs” of HIV prevention. Brainstorm this concept on a flipchart.

A = Abstinence

B = Being Faithful (with a faithful, tested partner)

C= Use a condom correctly, every time, all the time

7. Ask participants for a good definition of abstinence. They may come up with something like “not having sex at all,” “never having sex,” or “waiting to have sex until you are married.” Agree on one definition and write it on the flipchart. Spend a few minutes discussing abstinence. What is the percentage chance that someone might be safe from infection with HIV if they use abstinence? (100%) How comfortable are most people with abstinence as a prevention method? Is it easy for people to remain abstinent? Brainstorm some ideas for ways to help people remain abstinent and write them on a flipchart. Possible answers may include masturbation of self or partner, hugging, kissing, cuddling, massaging, etc. Are there particular groups who might be most comfortable using abstinence for prevention? Possible answers include youth, couples in which one partner is HIV positive, etc.

8. Move on to discuss being faithful. Remind the group of Esi’s story. Was she faithful to her husband? Did her faithfulness prevent HIV infection? What is the percentage chance that someone who practices being faithful can contract HIV? (50%) Discuss the problems and advantages of “being faithful” as a prevention method. (Examples. Problems: being faithful is only 50% safe because one can only really be sure of one’s own faithfulness, testing is not forever, places married women at risk, etc. Advantages: if you are sure your partner and yourself are HIV-negative and faithful, then there is no need to use condoms, a woman can get pregnant if that is what the couple wants, etc.) What factors must be in place for this method to work? (Examples might include trusting that one’s partner is also faithful, getting tested before deciding to use this method and testing again in three months to make sure one is not infected before having unprotected sex, and so on). Say that we will discuss testing a bit more in upcoming sessions.

HIV Prevention 3-69 9. Finally, move on to a discussion of condom use. Think again about the story of Esi and Yao. Would condom use have helped in their situation? (Possible answers might be that Yao could have used a condom when he was with the stranger in the city, or condom use within their marriage would have prevented Esi’s infection, but then she may not have been able to get pregnant.) How effective are condoms in preventing transmission of HIV infection if they are used correctly and consistently? (Although they are not 100% effective in reducing risk of transmission, more than a few studies show that condoms greatly decrease risk of transmission—greater than 90% effective.) What are some of the advantages and disadvantages of condom use? Suggest that we will talk about condoms more later in the session.

Wrap-up Summarize the activity by suggesting that each of the ABCs may be appropriate for various people at various points in their lives. The important thing is to always actively practice one of them. Sometimes we can think of it as three boats in a raging sea that is HIV infection. We can change boats, but we must always be in one of the boats or another—Abstinence; being faithful with a faithful, tested, HIV-negative partner; or condom use—correctly, every time, all the time.

3-70 Family Planning Plus Activity Universal Precautions9 Objective By the end of this activity, participants will be able to— • Define universal precautions • Identify when to use universal precautions • List at least four examples of using universal precautions

Time allotted 60 minutes

Preparation Be sure to have at least one latex glove for each of the participants for use in the Glove Game (see the tools for trainers on page 3-83). It is also helpful to have some heavy plastic or metal container fashioned into a “sharps container” to use as a visual aid. This can be an actual “sharps” container or simply an old coffee container. Punch a hole in the plastic top large enough to insert a needle. Finally, provide at least one example of a plastic barrier available in the local community that can be used if latex gloves are not available (for example, plastic bags).

Facilitation 1. Briefly summarize the session up to this point—review all of the steps suggested ways to prevent HIV. We have now discussed sexual transmission of HIV at length, and we have decided to postpone our discussion of preventing MTCT until a later time. We can now turn our attention to ways to protect ourselves from transmission of HIV through contact with blood or bodily fluids.

2. Ask whether participants have ever heard the term “universal precautions.” Can anyone give a definition for this term? Write any suggestions on the flipchart. Summarize the suggestions as follows—

“Universal precautions” is a term usually used by health care workers. It means that you should assume that everyone, regardless of how they appear or seem, should be considered potentially infected with HIV. This means that no matter who you are working with, you should use barriers to protect yourself as if you were protecting yourself against the virus that causes AIDS.

9 The “Universal Precautions” session was adapted and reprinted (with permission of Peace Corps), from the Life Skills Manual, pp. II-69 to II-73.

HIV Prevention 3-71 So whenever you are handling blood or body fluids (blood, semen, vaginal fluids, breast milk, vomit, feces, and so on), you must create some kind of a barrier between that fluid and your skin. Proper disposal of the barrier is also very important, as is washing your hands thoroughly after the event. These precautions will protect you from HIV and any other blood-borne disease such as Hepatitis B, as well as many other infectious diseases carried in bodily fluids.

3. Ask participants to brainstorm some possible ways to form barriers between their own skin and blood or other fluids. Record their answers on the flipchart. Be sure that by the end of the discussion, the following points have been covered.

- Use latex gloves or plastic barriers if gloves are not available. (Be sure to pass around some latex gloves so participants can handle them. Also have some examples of other plastic barriers available in the local community—for example, plastic bags.)

- Clean up blood spills immediately using gloves or plastic barriers and wipe with a bleach and water solution (mix household bleach, one part to 20 parts water) then dispose soiled items in plastic bags.

- Wash your hands thoroughly with soap and water after handling blood or bodily fluids.

- Place used injection needles in puncture-proof containers. (Pass around the “sharps” container or other sample container.) Do not place the cap back on the needle after use, because this is the most common way that health workers have infected themselves.

- If a person you are working with begins to bleed, hand them a cloth to stop the bleeding themselves, if they can, until medical help arrives.

- If you are in a situation in which blood or other fluids may splatter into your face, for example, if helping with childbirth, cover your eyes with glasses and your nose and mouth with a mask or piece of cloth (if possible). The placenta should be handled with gloved hands, placed in plastic, and burned or buried deeply enough that animals or children will not dig it up.

- Keep a first aid kit with latex gloves or plastic barriers, bandages, and antiseptic available at your school, home, or work site.

3-72 Family Planning Plus - If you do become exposed to potential HIV infection, contact a medical officer immediately for possible HIV prophylactic treatment. Be sure that you do not treat the person whose blood or fluid you have touched only as a possible infector, but show concern for their health as well by offering compassion, information, and possible testing.

4. After clarifying any questions participants may have about preventing HIV infection, indicate that we are now going to play a game to review all of the information we have been discussing in this session. This game is called the Glove Game.

5. Provide each participant with a latex glove (or other plastic barrier). Indicate that they should place that barrier on one of their hands, while leaving the other free. State that you will read different situations or activities aloud. Participants should raise their gloved hand if the situation requires protection against HIV using some kind of barrier or universal precaution. They should raise their bare hand if no barrier or protection is required. A suggested list of situations can be found at the end of this chapter on page 3-83.

6. Read out situations. Answer any questions participants may have.

Wrap-up Summarize the session up until this point. Briefly review the ways to prevent HIV infection, perhaps by indicating situations in the lives of Esi and Yao in which such measures might have helped. Say that we will now examine specific biological reasons that women and girls are vulnerable to HIV infection.

HIV Prevention 3-73 ctivity Biological Vulnerability of Women and A 10 Girls

Objective By the end of this activity, participants will be able to— • List at least three reasons that women and girls are more biologically vulnerable to HIV/AIDS

Time allotted 30 minutes

Preparation Arrange flipchart stand so that participants can see it clearly.

Facilitation 1. Remind participants that we are all vulnerable to HIV infection. We have steps considered some of the social reasons that women are even more at risk for HIV/AIDS. Indicate that we are now going to spend a few moments talking about some of the biological reasons that women and girls are more at risk for HIV infection than men and boys.

2. Lead participants in a group brainstorm regarding some of the reasons why women and girls may be more biologically at risk than men and boys. Some suggestions include the following.

- Women receive greater quantities of possibly infected fluids during a sexual encounter.

- Women have a surface area of mucous membrane (portal of entry) that is greater in size than that of men.

- Because the vagina is an internal organ, women are less likely to know that they have sores from a STI, which could facilitate HIV transmission.

- STI that can facilitate HIV transmission often don’t produce symptoms in women.

- Very young women have more risk of infection during sex both because the cells in the underdeveloped vagina are more likely to receive the virus, and because tearing may cause bleeding, which increases the risk for infection.

10 The “Biological Vulnerability of Women and Girls” session was adapted and reprinted (with permission of Peace Corps), from the Life Skills Manual, pp. II-63 to II-68.

3-74 Family Planning Plus - If a woman has undergone female genital cutting (circumcision) or uses natural substances to dry out her vagina, the smaller or drier area may more easily rupture or tear during sex, creating a portal of entry for the virus to pass through.

- Coerced or forced sex (rape) increases the risk of tearing the vaginal tissues, thereby increasing the risk of transmission.

- Anemia, malaria, pregnancy complications, lack of access to family planning, and both safe and unsafe abortions place women at risk for needing blood transfusions, another mode of HIV transmission.

Wrap-up When summarizing this brief activity, suggest that women and girls are especially at risk for HIV infection for many biological and social reasons. Protecting women and girls from HIV infection is thus not simply a matter of education and health care, but a social issue for the entire community. As we will see in the remainder of the workshop, many of the issues surrounding prevention of HIV infection for women can be divisive and raise a great many questions.

HIV Prevention 3-75 Activity Condom Carousel11 Objective By the end of this activity, participants will be able to— • Demonstrate greater comfort in handling condoms • Clarify common questions about condom use • Define dual protection

Time allotted 20 minutes

Preparation Begin by writing common questions about condom use on small slips of paper and folding the paper very small. (Suggestions regarding condom questions can be found at the end of this chapter. See tools for trainers on pages 3-84, 3- 85.) Completely unroll one latex condom for each question. Drop one question into each condom. Blow the condoms up like balloons and tie them off. You will need a radio or tape player. Be sure to have music queued for the activity. If necessary, ask a volunteer from among the participants to be responsible for turning the music on and off.

Facilitation 1. Say that often people rely on abstinence or being faithful even when it steps might not be the method of prevention most likely to protect them from HIV infection. For example, Esi would have been safer using condoms than being faithful. Sometimes this is due to discomfort with the idea of condom use, and sometimes it may come from misinformation about condoms.

2. State that it is natural for anything that is completely new to be a bit uncomfortable to talk about or to use. Before deciding to use condoms, it is important to become more familiar with them. The next two activities are designed to help us to become more comfortable with handling condoms, to gather more information about condoms, and to give us an opportunity to practice their most effective use.

3. Say that the first exercise is the Condom Carousel. This activity will allow us a chance to become familiar with the look, feel, and smell of condoms while we discuss common questions about condom use.

11 The “Condom Carousel” activity was adapted and reprinted from “Condom Time Bombs” (with permission of Peace Corps), from the Life Skills Manual, Appendixes 28 and 29.

3-76 Family Planning Plus 4. Invite participants to stand in a circle. Say that you will circulate a condom blown up like a balloon while the music is playing. Participants should pass it around the circle until the music stops. Whoever is holding the condom balloon when the music stops should break it, take out the slip of paper inside, and answer the question for the group.

5. Clarify any misconceptions about the questions. If a participant finds a particular condom balloon hard to break, be sure to point out how strong condoms are and how difficult it is to break them! Also remember to point out how large the condom can be when it is blown up, and link this to the myth that condoms are too small.

6. Continue until all balloons have been used, then invite the participants to sit down.

Wrap-up When summarizing, take a moment to ask participants how comfortable they felt touching or holding the condoms. For some, this may have been the first time to have such contact. Ask for any comments or questions. Allow time for the participants to express any discomfort or negative feelings they might have about condoms or condom use. When the discussion is winding down, say that we will now move on to a deeper discussion on how condoms are used.

HIV Prevention 3-77 Activity Condom Demonstrations Objective By the end of the activity, participants will be able to— • List the steps for proper use of male and female condoms • Demonstrate effective use of male and female condoms

Time allotted 70 minutes

Preparation Have enough male condoms so that each participant has one. Be sure to provide condom demonstration models (wooden penises, bananas, bottles, and so on)—it works best when there is one model for each pair of participants. Make a copy of the How to Use a Male Condom handout for each participant (pages 3-88 and 3-89).

If female condoms are available, provide one for each participant and at least one female condom demonstration model for each pair of participants (or they can use a clenched fist to simulate the vagina). Make a copy of the How to Use a Female Condom handout for each participant (pages 3-86 and 3-87).

Before the session begins, place one or two male and female (if available) condom packets at each participant’s seat. Place one condom demonstration model (penis/vagina) near each pair of participants. Do not distribute handouts until the end of the session.

Facilitation 1. Move immediately from the Condom Carousel activity to a discussion steps about the proper use of a condom. State that practicing proper use of a condom can often clear up many of the mistaken beliefs and fears about condom use.

2. Invite one of the participants to come to the front of the room and guide us through the proper steps for using a male condom using one of the models. Suggest that fellow participants provide feedback and advice should the volunteer need it. Correct any wrong information about the steps.

3. The trainer should then demonstrate the correct way to put on and remove the male condom, so that all the participants can see its correct use. Be sure to explain each step in the demonstration and answer any questions that participants may have.

3-78 Family Planning Plus 4. Next, ask participants to take a moment to open one of the condoms at their seats. Ask participants to practice the steps for putting on a condom in pairs. Each participant should have one chance to explain the steps for putting on a condom to their partner. Each pair will thus go through the demonstration twice.

5. Move on to a discussion of the female condom. Say that there is a shared responsibility between men and women for condom use, be it for disease prevention or family planning, or both, which is called “dual protection.” Point out that sometimes women do not have the decision-making power in a relationship, and thus they may not be able to convince a partner to use a condom. In cases such as these, the use of a device such as the female condom may give the woman more power over condom use.

6. Encourage each participant to remove the condom from the wrapper and to explore it. Tell them that female condoms are not made of latex like a male condom, but of polyethylene (rubber), which is a stronger material than latex and less likely to break. Show them that the female condom is covered with a lubricant. Explain that an advantage of the female condom is that it may be inserted up to eight hours before a sexual encounter, so that a woman can always be prepared and protected. Also be sure to point out that the female condom covers a wider surface area than the male condom, which may offer women greater protection against STIs.

7. Explain that the female condom has some negative aspects, including a higher cost or a lack of availability in some areas, and the awkwardness of application. Some people have also said that the female condom makes noise during sex, however, this can be reduced if the female condom is inserted several hours before the sexual encounter.

8. Ask if any of the participants would like to volunteer to demonstrate the proper steps in using a female condom on a model or using their fist. This may be the first time that some participants have seen the female condom, so be prepared to demonstrate it yourself. The trainer should then demonstrate the correct way to insert and remove the female condom, so that all the participants can observe its correct use. Be sure to explain each step in the demonstration and answer any questions that participants may have.

9. Distribute female condom demonstration models to ensure that each pair of participants has one (or show them how to clench the fist to simulate the vagina). Encourage the group to follow along with you as you demonstrate, using their own models or fists.

10. Provide some time for the participants to practice in pairs.

HIV Prevention 3-79 Wrap-up To finish up the discussion regarding condom use, distribute the handouts (and checklists from pages 3-91 to 3-96 if this is a session to train trainers) to each participant and review how to put on a male and a female condom. Remind the group that condom use is one of a few ways to protect one’s self from sexual transmission of HIV. Each person must make her or his own decision about which method of protection is best for her or his situation.

Note to Trainers: • You may want to start a discussion about condoms with the reasons that people think they don’t work. Point out that most condom failure is the result of inconsistent or improper use. By demonstrating the steps of proper condom use with real condoms, participants can learn themselves and can teach others how to properly use a condom. This can be empowering, but first, people must be open to new experiences in order to fight against HIV. • If you are training community health workers or peer educators who will in turn be training members of the community in proper condom use, you will need to make sure that their skills are adequate to train others. This session can be expanded to provide time for practice and to be sure that all participants have mastered the skills. You will want to use the Checklists for Use of Male/Female Condoms in the Alternate Activities and Handouts section at the end of this chapter on pages 3-91 to 3-96.

3-80 Family Planning Plus Tools for Review Game—Suggested Questions Trainers

Be sure to write enough questions to give your teams several turns. The following are some suggested questions to help you begin. Make sure that you write only the question and not the suggested answers, shown below italicized. (The questions listed here are taken from throughout the manual, be sure to use questions that cover the material from the previous day’s sessions.)

List two ways that HIV might be transmitted. • Sexual transmission through semen or vaginal fluids • Blood-to-blood contact by using the same needle • MTCT

List three effects of HIV/AIDS on the development of the nation. • Loss of health workers, teachers, and other professionals • Loss of agricultural production • A large number of orphans who may not be educated or able to care for themselves in the future • A greater number of funerals can lead to a decline in production through worker absenteeism and associated factors

List three universal precautions. • Wearing latex gloves or plastic barriers • Using bleach and water to clean up blood spills • Disposing of needles in heavy containers • Using condoms • Washing one’s hands

What is the link between HIV transmission and sexually transmitted infections (STIs)? • The sores or ulcers from some STIs create a portal of entry, or a door, for HIV to enter the body • STIs cause an increase the number of white blood cells in the genital area, making it easier to transmit or contract HIV

HIV Prevention 3-81 Review Game—Suggested Questions, continued

List two of the steps for properly putting on a male condom and a female condom. • See the complete list at the end of chapter 3, pages 3-86 to 3-89

List three reasons that men can be vulnerable to HIV infection due to their expected roles. • Taking risks • Multiple partners • Always being strong • Men should have sex only with women • Men should be the decision-makers

List three reasons that women can be vulnerable to HIV infection because of their expected roles. • Fear of violence from men • Taboos on talking about sex • Bride pricing and marriage rites that assign women a property value • Poverty that leads to transactional or paid sex

List three ways to prevent HIV. • Abstain from sex • Be faithful with a faithful, tested, HIV negative partner • Use condoms, every time, all the time • Use universal precautions

3-82 Family Planning Plus Tools for The Glove Game—Suggested Situations Trainers

When dressing the bleeding wound of a child or young student (glove)

When shaking hands with a person you know to be sick with AIDS (hand)

When cleaning blood away from the floor of your workplace (glove)

When cleaning vomit or diarrhea from the floor of your home (glove)

(Emphasize that gloves in this case are used as a precaution when blood is present in the vomit or diarrhea, whereas usually, not enough HIV is present in vomit or diarrhea to cause infection. Note that other infectious diseases may be present in vomit and diarrhea.)

When wiping the tears from the face of an HIV-positive person (hand)

When having sex (remind participants that in this case the “glove” is a condom)

When lifting a sick person (hand—unless open sores are present, check first)

When cleaning sheets with blood on them (glove)

When bathing a sick person (hand—unless open sores are present, check first)

Changing diapers (nappies) of a sick baby (glove)

(Emphasize that gloves in this case used as a precaution when blood is present in feces or diarrhea, whereas usually, not enough HIV is present in feces or diarrhea to cause infection. Note that other infectious diseases may be present in feces and diarrhea.)

Helping an old woman who has been cut in a car accident (glove)

Tending to a skinned knee on a soccer pitch (glove)

When cleaning the sheets and pillowcases of a person who is HIV-positive (hand)

HIV Prevention 3-83 Tools for Condom Carousel—Sample Questions Trainers

It is important to compile a list from the community of common questions or concerns regarding condom use. The suggestions below are intended merely as examples. Each statement or question should be written on a separate card.

How many times can you use a condom?

A male condom should be used only one time and then thrown away. It is very dangerous to attempt to use a male condom more than once since it will be filled with semen and possibly infected with HIV or another STI.

The World Health Organization (WHO) does not recommend or promote reuse of a female condom. However, recognizing the urgent need for risk reduction, WHO recently released a draft protocol for the reuse of female condoms. The protocol says that a female condom can be disinfected using a 1:20 solution of household bleach and water for 1 minute, then washed with soap and water, hanged to dry, and re-lubricated. This may occur up to five times without damage. Check for leaks by filling with the condom water and observing it. Female condoms can be lubricated with petroleum-based oil. (WHO, 2002)

What is dual protection?

Protection from pregnancy, and HIV and STIs, either through the use of a condom alone or the use of a condom plus another family planning method. Abstinence also provides dual protection, as does avoiding penetrative sex. (Spieler)

Is it safer to wear two male condoms instead of just one, or a male and a female condom at the same time? Is it double the protection?

Condoms should be used only one at a time. Use of two condoms does not offer better protection; rather it worsens the degree of protection. Using two may increase the friction and cause condoms to break. Also, using two condoms may reduce the sensation, and the couple may be tempted not to use condoms at all times.

Petroleum jelly (i.e., Vaseline, or a local brand) is a good lubricant to use with a condom. True or false?

False. Petroleum jelly or any other oil-based lubricant should not be used with a male condom. These substances can cause condoms to break. Use a water-based lubricant, such as (insert local brand).

3-84 Family Planning Plus Condom Carousel—Sample Questions, continued

If a man or a woman uses a condom for more than two years, he can become infertile. True or false?

False. Condom use has never been shown to cause infertility. This is a myth.

Only men can receive free condoms. True or false?

False. Free condoms are available to both men and women at (insert local source for free or inexpensive condoms).

Condoms are too small for men in our area. True or false?

False. Condoms stretch to fit any size penis.

Condoms are too big to be used by adolescents. True or false?

False. Condoms are very elastic and can fit both small and large penises.

Condoms can (and do) sometimes transmit HIV. True or false?

False. Well-made and properly stored latex condoms do not permit HIV cells to pass through them.

Why is it good for married couples to use condoms?

Condoms can be used by married couples for dual protection, both from disease and pregnancy. If one partner has engaged in a behavior that places them at risk for HIV infection, condom use can protect the other partner. Condoms can also be used if one or both partners are HIV-positive, in order to protect the other partner from infection or reinfection, and to possibly reduce the risk of transmission to an unborn child or breastfeeding infant.

Condoms encourage immoral sexual behavior. True or false?

What do you think? This is a common statement used to keep people from talking about or distributing condoms. Do you think it is true? Do young people decide to have sex just because they have a condom? Do married people decide to have sex with someone else just because a condom is available?

HIV Prevention 3-85 Handout How to Use a Female Condom12

1. Open End (Outer Ring)

The open end covers the area around the opening of the vagina. The inner ring is used for insertion and to help hold the sheath in place.

2. How to Hold the Sheath a. Hold inner ring between thumb and middle finger. Put index finger on pouch between other two fingers, or b. Just squeeze.

3. How to Insert the Condom

Squeeze the inner ring. Insert the sheath as far as it will go. It’s in the right place when you can’t feel it. Don’t worry—it can’t go too far, and IT WON’T HURT!

4. Make Sure Placement Is Correct

Make sure the sheath is not twisted. The outer ring should be outside the vagina.

5. Removal

Remove before standing up. Squeeze and twist the outer ring. Pull out gently. Dispose with trash, not in toilet.

Use more lubricant if— Remove and insert a new female condom if— • The penis does not move freely in and out • The female condom rips or tears during • The outer ring is pushed inside insertion or use • There is noise during sex • The outer ring is pushed inside • You feel the female condom when it is in • The penis enters outside the pouch place • The female condom bunches inside the • The female condom comes out of the vagina vagina during use • You have sex again

12 Excerpt from Female Health Company (n.d.) Adapted from the CEDPA Reproductive Health Awareness manual, Chapter 10, p. 21; 2002. Draft.

3-86 Family Planning Plus How to Use a Female Condom, continued

Add lubricant to inside of sheath or to the penis. Start with two drops and add more if desired. • Purchase or pick up female condoms long before you will need them. Make sure they are available in case a sexual encounter occurs. • If you are expecting a sexual encounter, you may insert the female condom up to eight hours before you have sex (optional). • Insert the female condom, before you and your partner begin any sexual activity. • Wash your hands with soap before you begin. • Check the expiration date before opening the package. • Open the package carefully, and be sure not to tear it with your nails or your teeth. • Find a comfortable position, perhaps by standing with one leg up on a chair, or by lying on your back with both legs up, or by sitting with knees apart. • Rub the condom to spread the lubricant over the entire thing. • During sex, hold the outer ring of the condom in place while guiding the penis into the vagina. • To remove the condom after sex, twist the outer ring and pull it out while still lying down. Be careful not to spill any semen. • Tie the condom and burn or bury it in a place where children are not likely to play.

HIV Prevention 3-87 Handout How to Use a Male Condom13

IMPORTANT: Whenever possible, show clients how to put on and take off a condom. Use a model, a stick, a banana, or two fingers to demonstrate putting on the condom. Suggest to a new user that he practice putting on a condom by himself before he next has sex. • Purchase or pick up condoms long before you need them. • Store condoms in a cool place, away from direct sunlight and heat. • Always have condoms available, even when you are not likely to have sex. • Before using any condom, check the expiration date. Do not use condoms beyond their expiration date. • Check that the condom has not been left too long in the sun by feeling for an air pocket in the wrapper. • Open the package carefully. Take care not to use long nails or your teeth to open the packet, as this may cause a tear in the condom. • Pinch the tip of the condom to prevent air from being trapped. Air at the tip can cause the condom to burst. • Hold the condom so that the rolled rim is facing up, away from the penis. • Pull the foreskin back if the penis is uncircumcised. • Place the condom on the tip of the erect penis. • Unroll the condom all the way to the base of the penis. The condom should unroll easily. If it does not, it is probably backward. Turn it over and try again. If using the condom to avoid passing on a STI, throw away the condom that was on backward and start over with a new one. • Any lubricant used should be water-based. Good lubricants include a spermicide (except nonoxynol 9), glycerin, and specially made products. Water can also be used. They help keep condoms from tearing during sex. Natural vaginal secretions also act as a lubricant. Do not use lubricants made with oil, most of them damage condoms. Do NOT use cooking oil, baby oil, coconut oil, mineral oil, petroleum jelly (such as Vaseline), skin lotions, suntan lotions, cold creams, butter, cocoa butter, or margarine. • After ejaculation, hold the rim of the condom to the base of the penis so it will not slip off. The man should pull his penis out of the vagina before completely losing his erection.

13 Adapted from the CEDPA Reproductive Health Awareness manual, Chapter 10, p. 20; 2002.

3-88 Family Planning Plus How to Use a Male Condom, continued • Remove the condom carefully, being careful not to spill the contents on your partner. • Tie a knot at the top of the condom, and throw the condom away in a pit latrine (toilet), burn it, or bury it. Do not leave it where children will find it and play with it. • Do not use a condom more than once. Always use a brand new condom whenever having sex.

Putting on a Condom

Hold the condom with the rim away from the body and unroll all the way to base of the penis

Taking off a condom and disposing of a used condom

Slip off the condom without spilling semen. Burn the used condom and throw it in the latrine or bury it.

HIV Prevention 3-89 Chapter 3: HIV Prevention

Alternate Activities and Handouts

• Condom Checklists (to be used for training community health workers, peer educators, and similar workers)

3-90 Family Planning Plus Tools for Checklist for Use of Female Condom14 Trainers

Name of CHW/Peer Educator:

Date:

Instruction: Rate the performance of each task/activity observed using the following rating scale.

0 Step/task omitted

1 Step/task performed incorrectly

2 Step/task performed correctly but not systematically

3 Step/task performed correctly and with confidence

N/A Step/task not observed

Steps in Use of the Female Condom Dates Observed

1. Create a comfortable and private environment.

2. Greet the woman.

3. Ask about her reason for her visit.

4. Tell her about the female condom. - The female condom is a new, safe, pre-lubricated (covered with oil) contraceptive. (Let them handle and feel it.) - It is made of strong, soft polyethylene (rubber). - When worn, it gently lines (covers) the vagina (private part).

14 Adapted from CEDPA ENABLE/Ghana workshop

HIV Prevention 3-91 Checklist for Use of Female Condom - It is reliable, provides sensitivity for the couple, and is natural and enjoyable. - It acts as a barrier against germs that cause AIDS and STIs. - It also prevents unwanted pregnancy by preventing the male seed (sperms) from reaching the female egg (ovum). - It has a double advantage in protecting a woman’s health by preventing unplanned/unwanted pregnancies and protecting against HIV and other STIs. - It has a flexible ring at each end (show the condom). - The inner ring is used for insertion to help keep the condom in place. - The outer ring remains outside the vagina (female private part), it can be seen, and it covers the outside of her genitals. - It is one size, which fits all women. - It can be inserted up to 8 hours before sex or just before sex. - It should be used only once and then discarded. - Review the female reproductive system.

5. Demonstrate how the female condom is used. - Wash your hands with soap. - Check the manufacture and expiration dates. - Open the package carefully where an arrow points on the top right of the package. Don’t remove the condom with long or rough nails. - Find a comfortable position. - Stand with one foot on a chair or bed. - Sit (knees apart). - Lie down.

3-92 Family Planning Plus Checklist for Use of Female Condom, continued - Rub the condom to spread the oil on it. For extra moisture and comfort, use any water- or oil-based lubricant. For example, dip several fingers into palm oil and apply. - Squeeze the inner ring. - Insert the condom into the vagina (private part) as far as it will go (use a model or half-clenched first). - Push it up with a finger and ensure that it is not twisted. - During sex, guide the penis inside the condom with the other hand. - Hold the outer ring in place. - You will hear noise during sex.

6. Remove the condom after sex. - Squeeze and twist the outer ring and pull it out while still lying down to prevent spilling of semen (sperm). - Tie it. - Wrap the used condom and throw it into dustbin or pit latrine.

7. Encourage the woman to visit you after use and ask any new questions. At follow-up meeting with the woman— - Greet the woman - Inquire about her health - Ask about any problems encountered - Counsel again if necessary - Go through the steps with her - Counsel her about changing her dual protection methods (protection against both unwanted pregnancy and HIV/STI) if necessary

HIV Prevention 3-93 Tools for Checklist for Use of Male Condom15 Trainers

Name of CHW/Peer Educator:

Date:

Instruction: Rate the performance of each task/activity observed using the following rating scale.

0 Step/task omitted

1 Step/task performed incorrectly

2 Step/task performed correctly but not systematically

3 Step/task performed correctly and with confidence

N/A Step/task not observed

Steps in Use of the Female Condom Dates Observed

1. Greet the client with respect. 2. Briefly explore the purpose of his or her visit.

3. Ask about the client’s reproductive goals. 4. Explain the health benefits of family planning.

5. Determine what the client already knows about condoms.

6. Address myths and misconceptions about condoms appropriately.

15 Adapted from CEDPA ENABLE/India checklist.

3-94 Family Planning Plus Checklist for Use of Male Condom, continued

7. Briefly explain. - A condom is a thin, rubber sheath worn by men during sexual intercourse. - Condoms protect from pregnancy because the semen is trapped inside the condom and cannot enter the woman’s body. - The benefits of condoms (easy to use, cheap, easily available, offers protection from HIV, STI, and cancer of cervix). - Limitations of condoms (male partners must use them correctly each time).

8. Instruct the client on correct use of condoms. - Shows a packet of condom to the client.

9. Offer instructions on how to use the condom. - A new condom should be used every time one has sex. - If condoms are not used each time, pregnancy can occur and both partners are at risk for HIV and STIs. - A condom should be put on an erect penis before the penis enters the vagina.

10. Explain how to put on a condom. - Tear the packet from one side and take out the rolled condom, taking care not to tear the condom. - Hold the rolled rim of the condom on the outside, away from body. - Hold tip of condom between fingers to expel air. - Roll it down the penis. - Do not use oil or Vaseline as lubricant. Only use water- based lubricants.

11. Explain how to take off a condom. - Withdraw the hard penis immediately after ejaculation to avoid spilling semen into the vagina. - Hold the rim of the condom while pulling out the penis.

HIV Prevention 3-95 Checklist for Use of Male Condom, continued

12. Explain how to dispose a condom. - Tie a knot on the upper portion of the condom. - Wrap the condom in paper and either bury it, burn it, or throw it in a pit latrine so that children will not find it and play with it.

13. Check that the client understands how to use condom by— - Giving a condom to the client and asking him or her to explain the correct use of condom. - Encouraging him or her to offer correct answers and repeating any points the client forgot. - Encouraging the client to ask questions about the correct use of a condom.

14. Explain how to look after condoms before using them. - Keep in a cool, dark place. - Keep away from direct sunlight or heat. - Check the date of expiry on the packet. - Take care when handling condoms. Fingernails and teeth can tear them. - Do not unroll condoms before using them. An unrolled condom may be weakened and is difficult to put on. - Ask the client whether she or he has more concerns and responds appropriately.

3-96 Family Planning Plus Chapter 4

HIV/AIDS and the Immune System

“…We must put care and treatment within everyone’s reach. Even a year ago few people thought that effective treatment could be brought within reach of poor people in developing countries. Those already infected with HIV were condemned to be treated like lepers in earlier times—as people from whom the healthy had to be protected, but for whom nothing could be done. Now, however, there has been a worldwide revolt of public opinion. People no longer accept that the sick and dying, simply because they are poor, should be denied drugs which have transformed the lives of others who are better off.”

—KOFI ANNAN Table of Contents Family Planning Plus Chapter 4: HIV/AIDS and the Immune System

Chapter 4 HIV/AIDS and the Immune System Introduction...... 4-99 Objectives...... 4-101 Important Terms...... 4-103 Sample Session Design ...... 4-105 Activities and Handouts for HIV/AIDS and the Immune System Sample Session...... 4-106 Elephants and Lions Game...... 4-107 Immune System Facts ...... 4-110 Immune System Role-play ...... 4-114

4-98 Family Planning Plus Chapter 4: HIV/AIDS and the Immune System

Key Questions

• What is the difference between HIV and AIDS?

• What is the function of the immune system? How does it work?

• How does a healthy immune system respond to disease?

• How does the immune system respond to HIV?

• How does an HIV-infected immune system respond to disease?

Introduction

Besides raising issues of social and cultural taboos, the topic of HIV/AIDS is often difficult to talk about because it is perceived as a highly medical or technical subject. The technical language that has developed around HIV/AIDS has grown more and more complex, and community members may often feel put off by the words used to discuss the disease. Some of the past education programs and written information about HIV/AIDS have only made this problem worse by focusing on the most advanced information, sometimes in words that are beyond the understanding of most people.

Although there are new findings about HIV/AIDS almost every day in the medical and scientific communities, it is important to assure participants that this level of information is not necessary for their own health or that of their fellow community members. Trainers should avoid using highly technical language because this not only confuses some people, but it also makes the entire topic of HIV/AIDS seem remote and unreal. Whenever possible, members of the local community should share HIV/AIDS knowledge, rather than someone from the outside. Local trainers are usually much more culturally appropriate, more easily understood, and more widely accepted than an outside trainer, or worse, a so-called expert.

HIV/AIDS and the Immune System 4-99 It is not necessary for every participant to remember specific medical or biological facts about HIV/AIDS (unless you are training community health workers, peer educators, etc., who will be training others). As a trainer, it is much more important to focus on participants’ understanding of the general concepts being presented. It is important to relate these concepts to what people can do to protect themselves and each other, and for them to understand why doing those things will protect them.

The HIV/AIDS and the Immune System session is presented to help participants understand some of the basic effects of HIV on the body. Although the specifics are not important, a general understanding of the reaction of the immune system to HIV can help in the discussion regarding prevention of MTCT, living healthy with HIV/AIDS by slowing disease progression, and so forth. Whereas this session may be one of the most difficult for some groups, it is an important building block session for the remainder of the workshop, and should therefore be presented with simple language and evaluated carefully using the final Immune System Role-play.

4-100 Family Planning Plus Chapter 4: HIV/AIDS and the Immune System

Objectives

By the end of this class, participants will be able to— • Describe the difference between HIV and AIDS • Describe the role of the immune system • Discuss the effect of HIV on the immune system • List five parts of the immune system • Describe the function of five parts of the immune system • Describe a healthy immune system’s reaction to disease • Describe the reaction of a damaged immune system to disease • Demonstrate a healthy immune system’s reaction to disease • Demonstrate the reaction of a damaged immune system to disease

HIV/AIDS and the Immune System 4-101 Family Planning Plus: HIV/AIDS Basics

4-102 Family Planning Plus Important Terms

Cell The smallest basic unit of a plant or animal.

Immune System The body’s way of fighting disease. The system is made up of many different kinds of cells, all of which are white blood cells.

Macrophage As part of the immune system, this cell is the first line of defense. It eats an antigen or invader, and sends a signal to the “captain” of the immune system (T4 Cells) that an invader is present and that the immune system army must be called to respond. (Macro = big, phage = eater; “the big eater”

T4 “Helper” Cells; The “captain” of the immune system. These cells receive messages from also called CD4 macrophages when an invader (antigen) is present and orders two more types of Cells cells, the B cell and the T8 cell, to destroy the invader. The T4 helper cell is also the cell that HIV attacks and destroys.

B Cell B cells work together as a factory to identify the shape of the invader (antigen) and to make antibodies (like keys) that attach to the antigen and serve to “lock” the antigen. If the antigen comes back into the body, the antibodies will recognize it, and the antigen will not be able to make the person sick again.

T8 “Killer” Cells; This cell is also called by the T4 cell to respond to the antigen. It attacks and kills also called CD8 or the invader. Cytotoxic Cells

Antigen A foreign invader or germ that enters the body. It can be a virus, a bacterium, fungus, protozoan, and so forth.

Antibody Created in response to an invading antigen. Antibodies are produced by B cells. They work like “keys,” fitting the shape of the antigen, and “locking” the antigen. When an antigen enters the system again, it is recognized, “unlocked,” and disarmed by the antibodies. The antigen is then unable to make the body sick.

Acquired The advanced stage of HIV infection. This is the name given to represent a ImmunoDeficiency cluster of opportunistic infections brought on by an immune system weakened by Syndrome (AIDS) HIV.

Human The virus that causes AIDS. This virus is an antigen unlike any other. It attacks Immunodeficiency and takes over T4 cells, and reproduces inside, making more and more HIV. Virus (HIV) These new viruses then invade other T4 cells. Over time, this cripples the immune system, causing AIDS.

HIV/AIDS and the Immune System 4-103 Reinfection Being exposed to new doses of HIV. Each time HIV reenters the immune system (such as after sex with an HIV-positive person when both partners are HIV- positive), more T4 cells come out to fight. This gives HIV a greater chance to reproduce because it takes over those T4 cells and makes more and more HIV out of them. A person who is HIV-positive should avoid reinfection in order to live healthier and longer.

Viral Load The amount of HIV in the body. A high viral load means that HIV has crippled a large number of T4 cells, making the immune system weaker and more susceptible to diseases.

4-104 Family Planning Plus Sample Lesson Chapter 4: HIV/AIDS and the Plan Immune System

Sample Session Design

Time Content Methodology Materials Needed Evaluation

20 Elephants and Lions Participants act out a role- None Active minutes Game play to illustrate the effect participation of HIV on the immune in the activity Effect of HIV on the system immune system Successfully performing Difference between HIV the Immune and AIDS System role- play at the end of session

45 Immune System Facts Using cutouts, the trainer Cutouts of Parts of Active minutes leads participants through a the Immune System participation Discussion of parts of the discussion of each aspect of in the exercise immune system, including - macrophage the immune system, macrophage, T4 cell, B Successfully followed by the effect of - T4 cell cell, T8 cell, antigen, and performing HIV on the immune system antibodies - T8 cell the Immune System role- Effect of HIV on the - B cell play at the end immune system - Antibodies of the session Introduction of - Antigen opportunistic diseases and reinfection - HIV Flipchart paper Markers Tape

45 Immune System Role- Participants divide into One set of Parts of Successfully minutes play groups and act out the parts the Immune System performing of the immune system and cutouts for each the Immune Practice describing the then the effects of HIV on participant System role- parts of the immune system the immune system play at the end and the effects of HIV on of the session the immune system

HIV/AIDS and the Immune System 4-105 Chapter 4: HIV/AIDS and the Immune System

Activities and Handouts for HIV/AIDS and the Immune System

• Elephants and Lions Game

• Immune System Facts

• Immune System Role-play

4-106 Family Planning Plus Activity Elephants and Lions Game16 Objective By the end of this activity, participants will be able to— • Describe the difference between HIV and AIDS • Describe the role of the immune system in one’s body • Discuss the effects of HIV on the immune system

Time allotted 20 minutes

Preparation Ensure that the chairs are arranged in a large circle, with plenty of room inside the circle for a group of participants to move around. Have several Post-It notes or pieces of tape (enough for each “lion” to have three or more). Make signs that read, Body, Immune System (enough for each of the adult elephants), and several with names of diseases on them, including Tuberculosis, Malaria, Diarrhea, Syphilis, Gonorrhea, etc. (but not HIV) enough for all the lions to each have one. Tape.

Facilitation 1. Begin by reminding participants about the story of Esi and Yao. Talk a bit steps about Yao’s illnesses and his HIV infection. Remind the group about Esi’s health and the brief illness she had. Suggest that we have been discussing how HIV is transmitted and ways to prevent such transmission. Now we will move to a deeper discussion of precisely what happens once HIV has already entered the body.

2. Suggest that we will do a short activity to get us started and to help us to think more clearly about the effects of HIV on our bodies. This activity is called the Elephants and Lions Game.

3. Stand in the center of the circle, and ask for one volunteer. Have the volunteer stand in the center of the circle with you. Indicate to everyone that this person is the baby elephant.

16 The “Elephants and Lions Game” was adapted and reprinted (with permission of Peace Corps), from the Life Skills Manual, Appendixes 26 to 28.

HIV/AIDS and the Immune System 4-107 4. Ask for six more volunteers (This number can be higher, depending on the size of your group). These volunteers are the adult elephants. Their job is to protect the baby elephant. They should form a circle around the baby elephant, facing out, away from the baby elephant, and link arms or join hands. To show them the importance of their job, the trainer should try to touch the baby elephant—you will find that the adult elephants quickly get the point and close ranks to avoid attack.

5. Now, ask for four or five more volunteers (or more depending on the size of your group). These people are the lions. Give each lion several Post-It notes or pieces of tape. Their job will be to attack the baby elephant—they should try to put the Post-It notes or pieces of tape onto the baby elephant.

6. When the trainer says, “Go!” the lions should try to attack the baby elephant. Let this go on for about 30 seconds—until the baby elephant has at least one note or piece of tape stuck to it from the lions—but the baby elephant should not be hurt.

7. Now ask the following questions (the participants should stay where they are).

What is the baby elephant? What does the baby elephant represent?

- Answer: The baby elephant is the human body. (Tape the sign with word Body to the baby elephant. Point out that this could be any human body; man, woman, young, old.

What are the adult elephants? What do they represent?

- Answer: The adult elephants are the immune system. Their job is to protect the body from invading diseases. (Tape Immune System signs to the adult elephants.)

So, what are the lions? What do they represent?

- Answer: The lions stand for the diseases, illnesses, and infections that attack a person’s body.

There may be a few people who say that the lions represent HIV. That is not so. Ask another person to try to tell you the meaning of the lions.

8. Now go very dramatically to each of the lion volunteers—one by one.

Say, “These diseases, such as tuberculosis (give the volunteer the Tuberculosis sign), malaria (give another the Malaria sign), diarrhea (give another the Diarrhea sign, and so on,) attack the human body, but are they able to kill the human body?”

4-108 Family Planning Plus The answer should be “No.” Diseases or germs attack the human body every day, but the immune system (point to the adult elephants) manages to fight them off and protect the body. The human body might get sick (such as the Post-It note or piece of tape that reached the baby elephant), but it does not die, because the immune system is strong.

9. The trainer continues, “But suppose I am HIV. I come to this body (touch the baby elephant) and I attack and kill the immune system.” At this point, the trainer should touch three of the adult elephant volunteers and ask them to sit down. Touch each person as you remove him or her, acting as if HIV is killing the immune system.

10. The trainer continues, “Now, what will happen to the baby elephant when the lions come?” The answer should be that the baby elephant would be hurt even more when the lions come back. Remind the group of Yao’s illness with tuberculosis. He became sicker and sicker, but he took medicines and did not die.

11. Again the trainer moves from one adult elephant volunteer to another, acting as if HIV is killing the adult elephant and telling the volunteers to sit down. Do this until only one or two are left. Indicate that HIV has continued to attack this body’s immune system, until only a very little bit of it is left. Ask participants what will happen now when the lions return? Will the remaining adult elephants, what is left of the immune system, be able to protect the baby elephant, or the body?

12. Once more, tell the lions to attack (putting Post-It notes or tape onto the baby elephant) on the word, “Go!” The lions are now able to easily get to the baby elephant. Make sure the volunteer doesn’t get hurt! Stop the attack.

13. Thank all participants and ask them to sit down.

Wrap-up Summarize the activity by reminding participants that HIV has killed the immune system. This lack of an immune system makes it possible for many common diseases such as tuberculosis, diarrhea, and so forth, to attack a person’s body at once. Gradually, all these diseases come together to cause a person’s death rather than just make the person sick. This is called AIDS.

To be sure people have understood, you might ask, “Does HIV kill a person?” They should say, “No—the diseases kill a person.” Or “No, HIV kills the immune system.” Finally, have someone describe the difference between HIV and AIDS.

HIV/AIDS and the Immune System 4-109 Activity Immune System Facts17 Objective By the end of this session, participants will be able to— • List five parts of the immune system • Describe the function of five parts of the immune system • Describe a healthy immune system’s reaction to disease • Describe the reaction of a damaged immune system to disease • Define the terms reinfection and viral load

Time allotted 45 minutes

Preparation This session is fairly complex and may be most appropriate for health workers, college students, and other well-educated audiences. It could be optional, depending on your audience, but it is an important building block for understanding the progression of HIV/AIDS. Prepare a set of Parts of the Immune System to use as visual aids (see tools for trainers on page 4-116). Put tape on the backs of each so that they may be attached easily to the flipchart as you are facilitating.

Facilitation 1. Move immediately from the Elephants and Lions game to a deeper steps discussion of Immune System Facts. We have discussed the difference between HIV and AIDS, and we have seen a visual image of what happens to the immune system when HIV has attacked it. Now we will examine the immune system in even greater detail.

2. Remind participants that it is not necessary that they become experts at the immune system. They should not feel that they have to memorize all the words they are about to hear or that forgetting one concept means that they do not understand HIV/AIDS. (If you are training trainers, it is more important for them to remember the precise words and phrases.) Rather, they should try to understand the general ideas. Understanding some basic facts about the immune system can help us learn both how to prevent disease and how to help slow down disease progression in someone who is already infected.

17 The “Immune System Facts” session was adapted and reprinted (with permission of Peace Corps), from the Life Skills Manual, pp. II–33 to II–49.

4-110 Family Planning Plus 3. Engage in the following dialogue with the participants. As each particular part of the immune system is discussed, write key points and phrases on the flipchart, and attach the drawing of that part beside it. Also, it may be helpful to act out the parts of the immune system as you are discussing them. This will make it more easily understandable and keep it livelier.

Describe again what is meant by the immune system.

- The immune system is the body’s way of fighting disease.

Tell participants that the body is made up of cells.

- A cell is the smallest basic unit of a plant or animal.

Our blood cells are labeled by what two colors?

- Red and white.

Which of those make up the immune system?

- The white blood cells, called leukocytes, are our immune cells. The immune system is made up of white cells that protect us from diseases. Some of the main cells in the immune system are—

- The Macrophage: Macro = Big; Phage = Eater; the Big Eater

This cell eats the invaders or germs (called antigens) and sends a signal to the “captain” of the immune system that an invader is present and that the immune system “army” needs to respond.

- The T4 helper cell (CD4 cell): The “captain” of the immune system.

It receives the message from the macrophage when an invader (antigen) is present and orders two more cells (the B cells and the T8 killer cells) to search for and destroy the invader. The T4 helper cell is also the cell that HIV attacks and destroys. (T cells are called “T” because they mature in the thymus gland.)

- The B cell

It works like a factory to identify the shape of the invader (antigen) and to make antibodies (like keys), which fit the antigen and lock it. If the antigen ever returns to the body in the future, the antibody will recognize it, and it will not be able to cause the illness again.

HIV/AIDS and the Immune System 4-111 - The T8 (CD8) or cytotoxic or killer cell

Also called by the T4 helper cell to attack the invader and kill it directly.

What is an antigen?

- An antigen is a foreign invader or germ that enters the body. It can be a virus, a bacterium, a fungus, a protozoan, or a similar microorganism. Have the group name an antigen common in their community besides HIV. (Examples might include the bacterium that causes tuberculosis or the virus that causes the common cold.)

What is an antibody?

- An antibody is created in response to an invading antigen. B cells produce antibodies. They work like “keys,” fitting the shape of the antigen “locks.” When an antigen enters the system again, it is recognized and attacked by antibodies.

What is HIV?

- HIV is also an antigen, the human immunodeficiency virus. It is a virus that attacks the T4 helper cells. When it cripples enough T4 helper cells, the rest of the immune system is not called into action. Other antigens invade the body and cause disease. At this point, the infected person develops AIDS.

4. Remind the group of what happened to the immune system in the Elephants and Lions Game. Using the cutouts as cues, brainstorm with the participants exactly what happens when an antigen such as the bacterium that causes diarrhea enters a healthy immune system. The antigen enters and is eaten by the macrophage. The macrophage then calls for help from the T4 helper cell. The T4 cell confronts the antigen and calls for the T8 cells and the B cells. The B cells begin to create antibodies against this antigen to protect against any later invasion. The T8 cells attack and kill the antigen. Throughout this period of time, a person may feel sick while his or her immune system battles with the disease, but after the immune system has done its job, the person will usually recover.

4-112 Family Planning Plus 5. Now hold up the drawing of HIV. Ask participants how all of this changes when HIV is the antigen that is invading. Indicate that the macrophage still eats HIV and still calls for the T4 cell, the captain of the immune system. But this time, HIV takes over the macrophage and changes it so that HIV is now in control. When the T4 cells arrive, HIV invades them, as well, but not before the T4 cells have had time to call out the B cells and the T8 cells. But the T4 cell is exactly what HIV has come to the body to look for. HIV needs the T4 cells in order to duplicate itself. So HIV continues taking over more and more T4 cells, making more and more copies of the HIV virus in the body. Without their captain, the B cells and the T8 cells are confused. The B cells still make antibodies, but this time the antibodies are not strong enough to ward off the virus when it comes back again. The T8 cells are not able to kill HIV.

6. Imagine that HIV is waging this kind of war in your immune system— killing all of the captains, confusing all of the “soldiers,” like the B cells and T8 cells. Now, when the bacteria that causes diarrhea comes into the body, the immune system tries to respond. It sends out some T4 cells to meet the diarrhea-causing bacteria. But what do you think happens when the T4 cells come out? HIV enters them and reproduces in them, as well. So every time someone with HIV gets sick, HIV gets more of a chance to reproduce because more T4 cells are called out. This is one of the reasons that people who are HIV-positive should do their best to avoid any infections or illnesses, especially reinfection with HIV. Every time more HIV is dumped into the system of someone who is already HIV-positive, more and more T4 cells come out to try to deal with the new invaders, and that gives HIV more of a chance to reproduce in the body. The amount of HIV in the body is called the viral load.

7. Now, remind the group of what happened in the Elephants and Lions Game once HIV began attacking the immune system. It made it easier and easier for the other diseases to make the person sicker and sicker. It made it possible for more diseases to attack the body, and finally to kill the body.

Wrap-up Ask one of the participants to use the cutouts to summarize the attack of an antigen on a healthy immune system. Ask another to demonstrate the attack of HIV on an immune system, and then the invasion of another antigen into that unhealthy immune system. Clarify any questions, and indicate that we will practice our new knowledge by acting out these attacks on the immune system.

HIV/AIDS and the Immune System 4-113 Activity Immune System Role-play18 Objective By the end of this session, participants will be able to— • Demonstrate a healthy immune system’s reaction to disease • Demonstrate the reaction of a damaged immune system to disease

Time allotted 45 minutes

Preparation Be sure to have one set of Parts of the Immune System cutouts for each group (see page 4-116). (This session is follows on from Immune System Facts; if you have chosen not to do Immune System Facts, do not do this activity.)

Facilitation 1. Indicate that we will now practice some of the concepts that we have just steps discussed in the last exercise. Ask participants to gather in groups-of-six. Distribute one set of Parts of the Immune System cutouts to each group. Each person in the group should take one of the cutouts.

2. Suggest that everyone spend a few moments looking at their cutout and reminding themselves of the function of that part of the immune system.

3. Groups should begin by having everyone in the group state the name and function of their cutout. Other members of the group should provide feedback and advice whenever there are questions.

4. When all group members have stated the purpose of their part of the immune system, the group members should then work together to create a role-play acting out an attack of a disease on a healthy immune system. Provide about 10 minutes for the creation of this role-play.

5. After practicing the role-play of the healthy immune system, have the group act out and practice the attack of HIV on the immune system, and then the attack of diseases on the disabled immune system.

6. When all participants seem comfortable with both role-plays, combine two groups and have them act out their role-plays for each other. For example, the first group can act out the attack of a disease on a healthy immune system, while the second group can act out the attack of HIV on an immune system followed by the attack of diseases.

18 The “Immune System Role-play” was adapted and reprinted (with permission of Peace Corps), from the Life Skills Manual, pp. II-35 to II-36.

4-114 Family Planning Plus Wrap-up Ask all the participants to come back to the larger group, and summarize the session. Now that we have seen what happens inside the body when HIV first attacks, we can move on to how HIV acts over time within the body. The next activity, Disease Progression, will focus on the behavior of HIV from the time of infection until the person dies of AIDS.

HIV/AIDS and the Immune System 4-115 Tools for Parts of the Immune System Trainers

Antigen

Macrophage—The “Big Eater” T4/CD4 Helper Cell—”The Captain”

B Cells—the Antibody T8/CD8 Cytotoxic (Killer) Cells Factory

Antigen Human Immunodeficiency Virus (HIV)

4-116 Family Planning Plus Chapter 5

Disease Progression

“People who know their HIV status are more likely to change their behaviour to protect themselves and others,” said Health Minister Brian Chituwo on Zambian President Kenneth Kaunda’s decision to go for an HIV/AIDS test. “Voluntary counselling and testing also helps to break the stigma linked to HIV/AIDS and provides a link to care and support services for those who are HIV-positive.”

—UNKNOWN Table of Contents Family Planning Plus Chapter 5: Disease Progression Chapter 5 Disease Progression Introduction...... 5-119 Objectives...... 5-121 Important Terms...... 5-123 Sample Session Design ...... 5-124 Activities and Handouts for Disease Progression Sample Session...... 5-126 Story of Esi & Yao, Part II...... 5-127 Disease Progression Diagram...... 5-129 Mother-to-Child Transmission...... 5-137 Living Healthy...... 5-143 Co-Factor Tug-of-war ...... 5-145

5-118 Family Planning Plus Chapter 5: Disease Progression

Key Questions

• How does HIV progress to AIDS in the body?

• What are some of the “symptoms” of HIV or AIDS?

• What is the “window period?” The “honeymoon period?”

• Are there ways to prevent mother-to-child transmission by understanding disease progression?

• What are the recommendations for the prevention of mother-to-child transmission?

• Can certain behaviors lengthen the time that an HIV infected person can live healthily with the virus?

• How can people with HIV/AIDS live longer and healthier lives?

Introduction

Whereas transmission and prevention are arguably the most important topics for those seeking to prevent HIV infection, the Disease Progression session is perhaps the most important topic for PLWHA and those who care for them. Understanding the progression of HIV/AIDS in the body can offer a great deal of hope to those coping with HIV infection, because it explains the following crucial links to a longer, healthier life.

Disease Progression 5-119 • The significance of the “honeymoon period” (the time before HIV develops into AIDS) • The influence of co-factors in moving HIV infection more quickly into AIDS, and especially how to live more positively and lengthen the honeymoon period • The significance of avoiding reinfection with the virus and avoiding infection with opportunistic diseases, especially STIs • The prevention of MTCT by avoiding reinfection with the virus during pregnancy and while breastfeeding • The effect of frequent pregnancies on the honeymoon period and the importance of family planning • Ways to lengthen the honeymoon period, even without access to anti-retroviral (ARV) drugs

The tone of this session should be one of empowerment. In many communities, the lack of access to expensive ARV drugs has left PLWHA feeling helpless and disempowered in the face of their HIV infection. Although ARV drugs certainly lead to longer, healthier lives for those infected with HIV, there are still many ways for infected people to control the progression of the virus in their bodies using locally available resources. Information about disease progression, along with an understanding of the many aspects of positive wellbeing, can help those living with HIV/AIDS and those who care for them to regain control of their own health. Early VCT can be an important entry point into care and support services, and preventive behavior. This session represents that powerful new direction for communities that have been hit hard by the pandemic, as they continue the fight for access to ARV therapy.

5-120 Family Planning Plus Chapter 5: Disease Progression

Objectives

By the end of this class, participants will be able to— • Define the terms window period, honeymoon period, incubation period, AIDS, opportunistic diseases, and co-factors • Describe the stages of HIV progression in the body • List some co-factors that can make an HIV-positive person develop AIDS faster • State three ways to help prevent MTCT • List at least three recommendations for preventing MTCT of HIV • Describe at least two issues or potential problems associated with those recommendations in the local community • State five aspects of wellbeing • List positive behaviors that can lengthen the honeymoon period and keep an HIV- positive person healthy longer • Describe the importance of treating opportunistic infections to staying healthy

Disease Progression 5-121 Family Planning Plus: HIV/AIDS Basics

5-122 Family Planning Plus Important Terms

Infectious Disease A disease likely to cause infection or to spread to or affect others.

Window Period The time between infection with HIV and when a person develops enough antibodies to produce a positive HIV test. Around 95% of people develop enough antibodies to be detected by the test within 2 weeks to 3 months after being infected; however, it can take up to 6 months in some people. During this time, a person has a high viral load and is very infectious because no antibodies are controlling the virus. The person’s test is still negative at this time because this person does not have enough antibodies for the test to detect. The test measures levels of antibodies, not the virus.

Honeymoon This is the time between the end of the window period and the beginning of Period disease symptoms associated with AIDS. It is called the honeymoon period because a person may live in relative harmony with their virus. An infected person may have a few minor symptoms, but usually they do not look sick. During this time, they have lots of antibodies (“high antibody load”), and a small amount of HIV (“low viral load”). Although a person can still pass the virus to others, they are less infectious. During this time, pregnant women have less chance of passing HIV to their babies.

Incubation Period The time between infection and the development of disease symptoms associated with AIDS. This could take many years. It includes both the window and honeymoon periods.

AIDS Acquired Immuno Deficiency Syndrome. The advanced stage of HIV infection. This is the name given to represent a cluster of opportunistic infections brought on by an immune system weakened by HIV.

Co-Factors Factors that can shorten an HIV-positive person’s honeymoon period and move that person more quickly into AIDS. Some examples are poor nutrition, reinfection with HIV, infection with sexually transmitted or other infections, pregnancy, stress and isolation, smoking, drinking too much, and using drugs.

Opportunistic Infections or diseases that affect an HIV-positive person. These occur because Infections the germs take the “opportunity” of the weakened immune system to attack the body. Some examples include pneumonia, tuberculosis, Kaposi sarcoma, and cervical cancer.

Disease Progression 5-123 Sample Lesson Chapter 5: Disease Progression Plan

Sample Session Design

Time Content Methodology Materials Needed Evaluation

20 Story of Esi & Yao, Participants act out final Props for the role-play Refer to the role- minutes Part II part of the role-play or cutouts, play at appropriate illustrations, or times during the One family’s journey photographs day’s sessions with HIV/AIDS Wife fights HIV infection and teaches others

70 Disease Progression Using ribbons or tape on Three different colors Proper placement minutes Diagram the wall, participants of ribbon or tape of the cards craft a diagram showing throughout the Definition of concepts: Masking Tape the progression of HIV in exercise window period, a body over time. Prepared cards: honeymoon period, Answers in co- Participants affix key incubation period, co- - Window period factor tug-of-war terms on the diagram at factors, and reinfection. - Honeymoon period the appropriate points - Incubation period Phases of HIV infection - Chills in the body over time - Fever Effects of opportunistic - Cough diseases - Weight loss - Diarrhea Prevention of MTCT - Yeast infections - Cervical cancer - Herpes zoster (shingles) - Tuberculosis - Dementia - Pneumonia - Kaposi sarcoma -AIDS Blank cards

40 Mother-to-Child Trainer leads debate Flipchart Active participation minutes Transmission regarding MTCT. in the exercises Markers, tape Preventing MTCT

5-124 Family Planning Plus Time Content Methodology Materials Needed Evaluation

60 Living Healthy Chart Participants brainstorm Prepared wellbeing Answers provided minutes factors that may keep an chart posted on the for the Living Various aspects of HIV-positive person wall Healthy chart and wellbeing and how to healthier longer to the Co-Factor Tug- remain healthy with Markers complete the Living of-war HIV infection Healthy chart Tape

15 Co-Factor Tug-of-war Tug-of-war game Participants Answers provided minutes brainstorm co-factors for the exercise and ways to live positively. Those stating negative co- factors take one end of the rope, while those suggesting positive behaviors take the other end. Participants then fight in a tug-of- war.

Disease Progression 5-125 Chapter 5: Disease Progression

Activities and Handouts for Disease Progression

• The Story of Esi & Yao, Part II

• Mother-to Child Transmission

• Disease Progression Diagram

• Living Healthy Chart

• Co-Factor Tug-of-war

5-126 Family Planning Plus Activity Story of Esi & Yao, Part II Objective By the end of this session, participants will be able to— • Describe one family’s fight to live healthier and longer with HIV/AIDS

Time allotted 20 minutes

Preparation The day before the role-play, review it with the participants who have volunteered to play the roles of Esi, Yokaana, the counselor, and some of the patients. You may wish to rehearse it with the group once or twice. On the day of the role-play, set up the room as described in the tools for trainers section at the back of this chapter (see page 5-146).

Facilitation 1. Remind participants of the Story of Esi and Yao that we saw yesterday. steps Suggest that Yao died without knowing about his HIV infection, and that Esi was left alone with Yokaana to carry on. We will now watch a bit more about Esi and her family, so that we may refer to it as we talk about disease progression and living healthy with HIV/AIDS throughout the day.

2. View the role-play together.

3. After the role-play, ask a few questions about the story, for example—

- Why did Esi decide to get the results of her HIV test this time?

- What did you notice about the counselor’s discussions with Esi? What are some of the things that you think are most important for the counselor to consider when delivering test results?

- What were some of the decisions Esi made about her HIV status?

- How might the testing procedures have been different if Esi’s husband was still alive? Why didn’t Esi talk to Yao about her having been tested before? Is it difficult for wives to decide to get tested on their own? Do they usually need to ask the husband for permission? Are wives sometimes afraid to report the results of such tests to their husbands? Why?

Disease Progression 5-127 - On who does responsibility for care for the sick, dying, bereaved, and orphans usually fall? Who manages the greater economic burden and food insecurity?

Wrap-up After leading a brief discussion on the role-play, ask that participants keep Esi’s story in mind as we talk about disease progression and the rights of people living with HIV/AIDS.

5-128 Family Planning Plus Activity Disease Progression Diagram19 Objective By the end of this session, participants will be able to— • Define the terms window period, honeymoon period, incubation period, AIDS, opportunistic infections, and co-factors • Describe the stages of HIV progression in the body • List some co-factors that can make an HIV-positive person develop AIDS faster • State two ways to help prevent MTCT

Time allotted 70 minutes

Preparation Prepare cards with the following phrases written in large print on them. Window Period, Incubation Period, Honeymoon Period, AIDS, Herpes Zoster, Cervical Cancer, Tuberculosis, Pneumonia, Dementia, Cough, Chills, Fever, Weight Loss, Diarrhea. Either tape these cards under participants’ chairs or distribute them before the exercise. Arrange the chairs in a semicircle around a prominent wall. Ensure that the wall is completely blank, or use several blank flipcharts taped together, so that the Disease Progression Diagram may be constructed on it (see tools for trainers on page 5-147). Have three different colors of tape or ribbon available, perhaps red, blue, and green. When constructing the diagram, make everything big and bold so that all participants can see it.

Facilitation 1. Remind participants of the Story of Esi and Yao. Suggest that we have steps seen the effects of HIV on the immune system, but we will now turn our attention of how it acts in the body once someone has been infected.

2. Stretch a length of the green tape (or ribbon) in a horizontal line along a large stretch of wall, or on the flipcharts taped together. ( ) Suggest that this is a timeline and that it represents the time from the moment Esi got infected to when she develops AIDS and beyond. Ask participants to remember when Esi was first infected. When was that? It was shortly after her marriage to Yao. Make a large X with the red tape on the time line to the far left. (X ) Indicate that this X represents the day that Esi was infected with HIV.

19 The “Disease Progression Diagram” session was adapted and reprinted (with permission of Peace Corps), from the Life Skills Manual, pp. II-75 to II-79.

Disease Progression 5-129 3. Ask participants to remember the Elephants & Lions Game, and the Immune System Facts. What happens in the body when HIV first enters? Allow participants to discuss the effect of HIV on the immune system. Remind them of the definition of viral load. Ask how much her viral load might be in Esi’s system when she is first infected.

4. Say that when a person is first infected, they have a high viral load because the immune system has not had a chance to fight the virus. Beginning at the red X, use the red tape to draw a line at about a 70-degree angle from the timeline. Indicate that this line represents the HIV viral load in Esi’s body when she is first infected.

Viral Load ( X ) Infection Timeline 5. Ask participants what happens with the immune system when all of this virus is dumped into the body. The T4 cells are taken over, but still call for the T8 cells and the B cells. The B cells begin to make antibodies to fight the HIV in Esi’s system. Use the blue tape to represent the climbing antibody count in Esi’s system. The tape should begin at the red X at about a 5-degree angle, and steadily climb until it is at about a 45-degree angle from the timeline.

Viral Load Antibodies

( X ) Infection Timeline

6. Ask participants what they think will happen to Esi’s viral load when the antibodies are beginning to fight the virus like this. They should indicate that the viral load will decline as the antibodies fight the virus. Use the red tape to illustrate this, taking it down from the peak and dropping it toward the timeline. It should intersect with the blue antibody line about halfway up from the timeline. Do not allow the HIV viral load to go completely down, but level it off until it is parallel with the timeline. (See the sample Disease Progression Diagram on page 5-147)

5-130 Family Planning Plus Antibodies

Viral Load Antibodies

Viral Load

( X ) Infection Timeline

7. Indicate that the antibody count will climb and level off as well. Use the blue tape to draw a parallel line well above the red HIV viral load line.

8. Point to the intersection between the red and the blue lines. Indicate that this is a very important time for an HIV-positive person. Ask if anyone knows why. Explain that before this point is when a person can test negative for the virus. Remind participants that the HIV test can only pick up antibodies to HIV—the test cannot find HIV itself. So at first, if someone has the virus and goes for testing, it may appear that he or she is not infected. But in fact, the person is infected but has not yet developed enough antibodies to be spotted on the test. This time period is known as the window period. Ask the participants to take a look at the cards in their hands or under their chairs. If someone has the Window Period card, he or she can come up and place it on the timeline now.

9. Talk about the window period a bit. Ask participants why the window period is such an important time. Sample answers follow.

- A person does not know that they are infected, so they may keep engaging in risky behavior

- A person has a high viral load at this time, and this is the time when he or she is the most likely to infect someone else

- If a person gets the test at this time and does not come back to be tested again, he or she may think that there is no HIV infection

10. Point out that another big issue about the window period involves mother- to-child transmission (MTCT) of HIV. If a woman becomes or is pregnant during the window period, her body will have a high viral load, so she will be more likely to transmit HIV to her infant. Also, if a woman is breastfeeding during the window period, she is more likely to transmit HIV to her infant. What does this tell us about some of the ways to lessen the risk of MTCT of HIV?

Disease Progression 5-131 - A woman should either abstain from sex or use a condom when she is pregnant or breastfeeding in order to reduce the risk of MTCT

11. Before moving on, ask participants if they know how long the window period is likely to last. Write their answer on a card and paste it in the window period section of the diagram. The answer should be 2 weeks to 6 months, although 95% of people will test positive if they have been infected after 3 months. Why is this important to remember for VCT?

A person who has engaged in risky behavior needs to act as though they have been infected; that is, not continue the behavior and practice safer sex, and get tested. Even if they test negative, they will need to continue to practice safer behavior until they have a second test 3 to 6 months after the risk behavior, in order to make sure that they are HIV-negative.

When and why should someone get tested? Answers may include—

- If they or their partner has engaged in unprotected or unsafe sex

- If they have had sex with multiple partners

- If they have been cut by a knife or needle used by someone who is possibly infected

- If they, their partner, or their children are unexplainably or chronically sick

- If they are afraid they have been infected; some people just want to know

What are the benefits of being tested?

- To learn their antibody status, if they are HIV-positive or HIV- negative

What are the consequences of knowing your status?

- An HIV-positive person can take measures to live positively, make plans for the future of their family, and take precautions to not infect others and to take care not to be re-infected.

- An HIV-negative person may have a sense of relief, and they can change their behavior so as not to become infected in the future.

5-132 Family Planning Plus What are the consequences of not knowing your status?

- You may always be worried that you may be infected, and may not know what precautions to take, and may not be able to plan for the future

- Believing that you are positive when in fact you are negative

- Believing that you are negative when in fact you are positive

(Ask participants to compare and contrast the effects of these last two scenarios.)

12. Ask participants to look at their cards again. Would Esi or another HIV- positive person have had any symptoms of HIV infection during the window period? If any of the participants have cards showing such symptoms, they should come up and place them on the timeline now. Remind participants that Esi felt a bit sick and weak right after her infection, and Yao made her lie down. It only felt like a cold or flu, though, and she quickly recovered. Some of the possible symptoms of initial HIV infection might be chills, fever, or cough. But remind participants that these are symptoms for many different illnesses, so it is very difficult to realize that HIV might be involved. Most people do not notice these symptoms very much at all.

13. Again draw participants’ attention to the diagram. At this point in the diagram, the antibody count has risen, and the viral load has dropped. Ask participants to think about Esi’s story. What time in her life do they think this represents? Remind the group that Esi was healthy and well for years after her infection. This is because the body is battling HIV infection and for the time being the antibodies are winning. Ask participants if they know the name for this time period. It is called the honeymoon period, because this is a time when people are living in relative harmony with the virus. A person may get sick, but the immune system is still able to fight of the infection. Ask the person with that card to come up and place it on the timeline now.

14. During the honeymoon period, a person looks and feels as healthy as any other person. Why is this an important thing to remember? Some answers follow.

- Because a person looks and feels healthy, others might think that they are not infected and decide not to protect themselves against HIV.

Disease Progression 5-133 - Because a person looks and feels healthy, he or she might not protect himself or herself against new infections or other diseases.

- They might not plan for the future.

It is important to remember that during this time, a person will test positive for HIV on a test.

15. Suggest that sometimes the names that scientists give to these phases are not easy to think about or to remember. Are there better ways to think about infection, the window period, or the honeymoon period? One possibility is to think about infection as planting the seeds. For a time, there is no evidence that seeds have been planted—this is like the window period. Before we begin to see sprouts, the seeds germinate. This is like the honeymoon period. And just like with planting seeds, sooner or later a bud and then an entire plant comes up. In terms of our timeline, that period is known as AIDS.

16. Invite participants to think now a bit about Yao when he first started to get a bit sick. What illness did he get? He got tuberculosis, got treatment for it, and got better. But later he got sick again. What do you think was happening in Yao’s immune system at this time? (If necessary, remind participants of the Elephants & Lions Game.)

17. Suggest that now, the virus starts to win the battle against the antibodies. The viral load again begins to climb, and the antibody count begins to drop. Use red and blue tape to illustrate this on the diagram. The red line should begin to climb, and the blue line should begin to drop.

Antibodies Viral Load

Viral Load Antibodies ( X ) Infection

18. Point to this new point on the diagram, where the rising red line intersects with the falling blue line. Ask participants to tell you the name of this time period. This is when Yao has begun to develop AIDS. Ask the person with that card to come up and place it on the timeline now.

5-134 Family Planning Plus 19. Say that when the viral load starts to climb, it means that the antibodies are dropping. The T4 cells are losing their battle and the immune system is getting weaker and weaker. Ask participants what will begin to happen to Yao now. They should say that he will begin to get sick with different infections such as diarrhea, tuberculosis, malaria, and so on, because his immune system is not strong enough to stop those diseases. Ask participants with such diseases on their cards to come up and place them on the timeline. Indicate that these diseases are often called opportunistic infections, because HIV has given them the opportunity of the weakened immune system to take a hold of the person’s body.

20. You may need to take some time to describe each of the opportunistic infections. Diseases such as herpes zoster (shingles), Kaposi sarcoma, tuberculosis, pneumonia, cervical cancer, and dementia should be placed on the part of the timeline that represents AIDS. Other cards, such as weight loss, yeast infections, and so on, should be placed toward the end of the honeymoon period. These symptoms may be present at that time as the body gets weaker. Also, any STIs that you chose to place on the cards would be sprinkled throughout the honeymoon period and the AIDS period on the diagram.

21. Remind participants that Yao got sicker and sicker at this point, until the various diseases in his system finally caused his death. Ask the participant holding the Incubation Period card to come up and place it on the timeline now. Where should it go? The incubation period is the time from initial infection until the person actually develops AIDS. The incubation period thus stretches from the red X all the way to when AIDS develops.

22. Now that the diagram is almost finished, ask participants how long the honeymoon period lasts. Listen to a variety of answers based on people’s experiences. (Answers could be anywhere from 2 to 10 years or more.) Finally, indicate that the honeymoon period is the hopeful part of this diagram. This is the part of the diagram at which people have the most control over what happens to their bodies. A number of factors can shorten the honeymoon period, and make people become sick with AIDS-related infections faster. And there are a number of ways that people can lengthen their honeymoon period, so that they remain healthier longer.

Disease Progression 5-135 23. Ask participants to brainstorm some of the things that can make people develop AIDS faster. Write ideas on individual cards and paste them in the honeymoon period section of the diagram. Some examples are reinfection with HIV, STIs, infection with other diseases (such as malaria, diarrhea, and so on), pregnancy, poor nutrition, poor water quality, lack of exercise, smoking, drinking too much, stress and isolation, using drugs, and so on. Indicate that these are called co-factors; they are factors that can lessen the honeymoon period and move an HIV-positive person more quickly into AIDS. Take time to clarify any co-factors that are unclear for participants.

Wrap-up Ask a participant or two to guide the group through a summary of the Disease Progression Diagram. Ask other participants to define some of the terms, such as window period, honeymoon period, incubation period, AIDS, viral load, co-factors, and so on. Say that just as there are ways to shorten the honeymoon period and make someone sicker faster, there are also ways to lengthen the honeymoon period. We will soon discuss how to keep ourselves healthy for a long period of time with HIV infection.

5-136 Family Planning Plus Activity Mother-to-Child Transmission20 Objective By the end of this session, participants will be able to— • List at least three recommendations for preventing MTCT • Describe at least two issues or potential problems associated with these recommendations in their local community

Time allotted 40 minutes

Preparation Prepare a flipchart with the table shown in step 2 below. Using one flipchart for each statement, write the following ideas in large letters on a flipchart paper. • Avoid getting pregnant if you are HIV positive • Use a condom if you are pregnant or breastfeeding • Have a caesarian delivery • Start treatment with AZT or Nevirapine during pregnancy • Get counseling on breastfeeding options if HIV positive

Facilitation 1. Ask participants to review with you the ways that HIV can be prevented. steps Remind the group that we have discussed prevention from sexual contact and from blood contact with the virus, but that we have not yet discussed the prevention of mother-to-child transmission. We have chosen to wait until this point so that we would have the greatest amount of information to understand the progression of the disease, and also so that we would be able to keep in mind the social issues associated with mother-to-child transmission. Although these issues are medical and technical in some ways, many social issues and beliefs that affect a woman’s ability to use these methods of prevention surround them.

20 The “Mother-to-Child Transmission” session was adapted and reprinted (with permission of Peace Corps), from the Life Skills Manual, pp. II-63 to II-68.

Disease Progression 5-137 2. Suggest that we begin with prevention of mother-to-child transmission. Remind participants of the story of Esi and Yao. Discuss Esi’s two pregnancies. Esi did not transmit HIV to her infant son Yokaana, and he was born HIV negative. Yet Esi’s second child was born HIV-positive. Why is it possible for one child to be born negative and the other positive? Review the disease progression diagram and discuss some of the reasons why this may have been the case. Examples include—

- Esi was still early in the honeymoon period when she was pregnant with Yokaana, so she would have had less HIV and more antibodies in her system.

- Yao was nearing the end of his honeymoon period at this time and his viral load was probably higher. He may have repeatedly re- infected Esi with the virus when she was pregnant with or breastfeeding the second baby.

Post a flipchart with the following table on it.

Mother-to-Child Transmission of HIV during Breastfeeding and with No Anti-Retroviral Drugs

Postpartum Antenatal Labor and Delivery (0–24 months)

Chance of Transmission

5–10% 10–20% 10–20%

Explain the chart by saying that these are the average rates of transmission that have been determined through observation and study in various countries. The risk of transmission is influenced by many factors.

- The mother’s health status, or at which point she is in the disease progression, may be the most important factor. If she has been infected for some time, her immune system is weak and her viral load is going up, she will be more likely to pass on the disease.

- If she were to be infected by her husband or partner during pregnancy or while she is breastfeeding, the viral load in her blood and breast milk would be very high until her immune system built up enough antibodies to fight the infection (remember the window period). There is an even higher risk of transmission in this case.

5-138 Family Planning Plus - It is important to remember that overall, only about one-third of all pregnancies in HIV-positive women result in an HIV-positive child.

3. Post the first flipchart, “Use a condom if you are pregnant or breastfeeding.” Indicate that this is one of the recommendations to help reduce the transmission of HIV from mother-to-child. It is important because if the mother’s viral load is high, there is a greater chance of transmission to the child through her blood, birth fluids or breast milk.

Using Esi as an example, ask participants to list some of the reasons that this would have been difficult for Esi during her pregnancy. Some possibilities might include that Esi and Yao did not know that they were HIV-positive, or any taboos on using condoms among married couples, and so on.

Are there traditional periods after birth (40 days) or during breastfeeding when couples abstain from sex? Is it common for men to look elsewhere for sex during these periods? Point out that if this happens, the man may become infected (if he is not already), or he may be re-infected, or be infected by another strain of HIV (super-infection). Should any of these occur, the man’s viral load will be very high and the chances of infecting or re-infecting his wife when they do have sex are higher, as well. This would in turn lead to a greater chance of the child becoming infected through the mother’s breast milk.

Lead a discussion about the likelihood of this recommendation being used in this particular community. What makes this a positive recommendation? Are there any reasons that it will be difficult to put this recommendation into practice here? How can they be overcome? What about encouraging men to use a condom if they go elsewhere for sex, so that they can protect the health of their children and their wives?

4. Now post another flipchart that reads “Avoid getting pregnant if you are HIV-positive.” Lead a similar discussion with the group. How easy is it to follow this recommendation in the community? What are some of the social factors around gender that have an impact on this recommendation?

- Who decides whether and when to have sex?

- Who decides whether and when to have children?

- What is the responsibility of the woman? Of the man?

Disease Progression 5-139 - Emphasize that dual protection, or using a condom or a condom plus another form of birth control, or abstinence or non-penetrative sex, protects against both pregnancy and disease, which can prevent reinfection and the strain on the woman’s body that comes with pregnancy.

- Point out that it is difficult for married couples to just stop having sex when they find out that one or both partners are HIV-positive. Sexual relations are a vital part of a relationship, so there must be other alternatives for a couple to remain intimate with each other. Brainstorm with the group some creative ways couples could do this. Some suggestions may include hugging, kissing, bathing together, non-penetrative sex, massage, masturbation, etc.

5. Lead a similar discussion with the next flipchart, “Have a caesarian delivery.” Discuss the availability and safety of caesarian deliveries in this area. Is this a feasible choice for most women in this community? Why does a caesarian delivery reduce MTCT? (Because most cases of such forms of transmission occur during delivery. Obstetrical procedures such as deliberately rupturing the membrane or invasive delivery techniques that increase the likelihood that the baby will be exposed to the mother’s blood, or the presence of STIs, make the risk of infection greater.) New research has suggested, however, that a caesarian section is much more likely to result in serious complications (infection) for HIV positive women, and that the risk increases the more advanced the disease is. The best thing that a couple could do in this situation is to discuss the risks and benefits with their provider. They should then make the decision together based on availability of high quality surgical facilities, an experienced provider, the stage of disease and general health of the mother, and other personal preference issues.

6. Continue with the next recommendation, “Start treatment with AZT or Nevirapine during pregnancy.” Make sure that everyone understands that AZT and Nevirapine are names for the new AIDS drugs (anti-retrovirals) that can help prevent MTCT. The most common regimen is that a woman takes a single dose of Nevirapine at the onset of labor and the baby is given a single dose within 72 hours of birth. In order to take these drugs, one must be tested for HIV. Is VCT available? Are these drugs available in this community? Are they affordable? Is this a viable option for women here? Who would make the decision to get these drugs or to get tested, the woman or the man? What could members of the community do to see that these drugs are made available in their community? (Advocacy.)

5-140 Family Planning Plus 7. Finally, discuss the last flipchart, “Get counseling on breastfeeding options if HIV positive.” Point out that different breastfeeding advice can be offered depending on the availability of healthy, affordable breast milk substitutes in the area. Lead a discussion about breastfeeding. Is there a stigma associated with not breastfeeding one’s infant in this area?

- The facts are that breastfeeding can increase the overall risk of HIV transmission by 14 percent in women who test HIV-positive before giving birth. The risk increases to at least 29 percent (and possibly much greater) if the woman is first infected with HIV during breastfeeding because her viral load is so high.

- Breastfeeding is important for a baby’s health and protects babies from other diseases. In many countries where infant mortality is high, it is recommended that a mother continue to breastfeed even if she is positive, especially if she cannot find a source of non- contaminated milk.

- In some areas, women who work outside the home will let another lactating woman breastfeed her child in her place, also known as “wet-nursing.” This practice runs the risk that the wet-nurse may be HIV-positive, and this is not recommended unless her status is known to be negative and remains negative.

- If an HIV-positive mother chooses to breastfeed or must breastfeed, it has been shown that it is safer to breastfeed exclusively (“exclusively” means no other food or liquid is given to the baby at all, not even water) and to wean abruptly after three months. One of the reasons for this is that when a baby begins to eat foods, he or she may develop small tears in the esophagus that can serve as a portal of entry for HIV transmission.

- It is important for the mother to practice good breastfeeding techniques so as to avoid infections such as mastitis, which can greatly increase the amount of HIV in the breast milk. Lactation counseling and support from the family and community can help.

- It is also important for the mother to take good care of her breasts, because the risk of transmission is higher if the nipples are cracked or raw, and they may bleed, thereby exposing the baby to a high concentration of virus.

Disease Progression 5-141 8. Summarize the discussion of MTCT. Suggest that there are no easy answers, because many health recommendations carry social consequences and many social norms carry health consequences. In some countries, some of these decisions can be made only by the male partner in a relationship and thus a woman may feel that she has little control over her own health or the health of her infant. It is important to involve men in these discussions so that they can understand the risks associated with MTCT, and the importance of them changing their own behavior to prevent such transmission and protect their children.

Wrap-up Remind participants that although HIV/AIDS is a health concern, it fundamentally affects all aspects of our lives. Suggest that HIV/AIDS has called into question some of the most basic things that we believe about ourselves and our culture including some of the gender stereotypes, roles, or expectations that we might be used to. It is important to begin to dialogue about the effects of HIV/AIDS and to come up with some creative solutions to address HIV/AIDS in our communities.

5-142 Family Planning Plus Activity Living Healthy21 Objective By the end of this session, participants will be able to— • State five aspects of wellbeing • List positive behaviors that can lengthen the honeymoon period and keep an HIV-positive person healthy longer • Describe the importance of treating opportunistic infections to staying healthy

Time allotted 60 minutes

Preparation Create the Living Healthy chart on a very large sheet of paper, or two flipcharts taped together, leaving the outer circle blank and only the five aspects of wellbeing listed. (An example of the chart is provided in the tools for trainers at the back of this chapter, see page 5-148.) It should be big enough to fit completely over the honeymoon period section of the Disease Progression Diagram.

Facilitation 1. Remind participants about the Disease Progression Diagram exercise and steps suggest that we will now discuss positive behaviors. Remind the group that we have discussed a number of co-factors that can shorten the honeymoon period, but many behaviors can lengthen the period.

2. Take the Living Healthy chart and hang it directly over the honeymoon period section of the Disease Progression Diagram. Review the five aspects of wellbeing written on the chart. Point out that often when we think of treatment for a disease or infection, we think about medicines we can get from the doctor or herbs or treatment we can get from a traditional healer. But there are many aspects to protecting one’s health and strengthening one’s body to fight disease.

3. Begin by discussing General Health Maintenance. What are some ways that we keep ourselves healthy every day? Pass out several colored cards to each participant. Ask them to write some ideas on the cards. Invite participants to come up and tape their ideas to the chart. Possibilities include rest, good nutrition, exercise, vaccinations, avoiding drugs and alcohol, proper sanitation, washing one’s hands, and so on.

21 The “Living Healthy” session was adapted and reprinted (with permission of Peace Corps), from the Life Skills Manual, pp. II-81 to II-85.

Disease Progression 5-143 4. Then move on to discuss Psychological Wellbeing. Have participants write their ideas on the colored cards. Invite participants to come up and tape some answers in this category. Possibilities include having a positive attitude, building one’s self-esteem, counseling, and reducing stress.

5. Next discuss Spiritual Wellbeing. Ask participants to come up and add some ideas to this section. Some possibilities are prayer, meditation, visualizing a positive future, attending church or mosque, and so on.

6. Then move on to discuss Social Wellbeing. Ask a few participants to tape up some ideas in this section. Possible answers include having the comfort and support of a spouse, partner, or family; support groups with other HIV-positive people; activism; protection from discrimination; meaningful work; and so on.

7. Finally, discuss Physical Wellbeing. Indicate that often we think that this means access to the new AIDS drugs, but it can mean so much more. Divide this section into three parts, and suggest that we can think of three different aspects to our Physical-Medical health. We can—

- Use treatments, drugs, or herbs to strengthen the immune system. These might include herbs from a local pharmacist or traditional healer that boost the immune system (such as Echinacea or the African potato)

- Immediately seek treatment for any infections or diseases. Most local health centers have treatments for tuberculosis, pneumonia, STIs, and so on. Getting treatment for these helps the immune system to concentrate on fighting HIV, and it also reduces the number of T4 cells that would otherwise come out for HIV to attack

- Use anti-retroviral therapy and protease inhibitors such as AZT, D4T, Indinavir, and Nevirapine (not yet available everywhere). These drugs can greatly reduce the amount of HIV in bloodstream and keep a person healthier longer. These drugs also substantially reduce the risk of MTCT if taken during pregnancy. Sometimes drugs to reduce the risk of MTCT are available as part of trial studies in local hospitals

Wrap-up Invite participants who have any ideas that have not been put up to do so now. Summarize the entire Living Healthy chart, and remind the group that we can take control of our health, even if we are already infected with HIV. Esi decided she wanted to do just that. She went for the test and began to practice these healthy behaviors so that she might live a longer, healthier life.

5-144 Family Planning Plus Activity Co-Factor Tug-of-war22 Objective By the end of this session, participants will be able to— • List co-factors that make an HIV-positive person develop AIDS faster • List positive behaviors that can delay the onset of AIDS and lengthen the honeymoon period

Time allotted 15 minutes

Preparation Clear a large area in the room, hallway, or outside of the training area. Have a long, strong, tug-of-war rope available.

Facilitation 1. Continue on immediately from the Living Healthy exercise. State that we steps are going to see just how powerful positive behaviors are in fighting against HIV infection.

2. While holding the tug-of-war rope, ask participants to brainstorm co- factors that might shorten someone’s honeymoon period and positive behaviors that might lengthen it. All those who mention co-factors should get on one end of the rope, while all those who mention positive behaviors should get on the other. Usually, people can brainstorm many more positive behaviors, but if they are tending toward listing co-factors, playfully urge them to think of some other positive behaviors. Keep it lively and fun!

3. When all participants have chosen a side, indicate that each side should try as hard as they can to pull down the other. Usually, the positive behaviors are stronger, and they will pull down the negative behaviors or co-factors.

Wrap-up Congratulate the winning team (which should be the positive behaviors) and remind the group how our positive behaviors can powerfully fight HIV infection.

22 The “Co-Factor Tug of War” activity was adapted and reprinted (with permission of Peace Corps), from the Life Skills Manual, pp. II-77 to II-78.

Disease Progression 5-145 Tools for The Story of Esi & Yao, Part II23 Trainers

Preparation Set up a mock health clinic at the back center of the room, and a small gravesite to the left of the room. To the right, set up Esi’s shop. Set up a makeshift bed (just some sheets) at the front center of the room.

The trainer stands at the center of the room. The scene opens with Esi and Yokaana standing hand-in-hand at Yao’s gravesite. Now let us join Esi and her family again where we left off before. It is late 1999, and her husband has just died. Esi decides she must know what is happening to her family. Esi guides Yokaana offstage, then walks toward the health clinic. An empathetic counselor is seated at a chair, and Esi sits directly across from her in a chair. The two act out the blood test and counseling session as the narrator speaks. (If your actors are comfortable, they can act out this scene instead of hearing it from the narrator.) Shortly after Yao’s death, Esi goes to a clinic and asks for a blood test for HIV. The people in the clinic talk with her a long time about her life and what the test means. Her blood sample is taken and she is told to return to the clinic in two weeks. Esi returns to the clinic and meets a woman who tells her that the test is positive, that she is infected with the virus. They talk for a long time. The woman is very kind and tells Esi she must fight this virus and live as long as she can for Yokaana’s sake. The woman says there are many things she can do, and that there are many people who will help her. Esi moves from the health clinic to her shop. She is seen caring for Yokaana, running the shop, visiting the health clinic, and visiting the sick. Since Esi’s test, she has been working hard to fight her infection. Sometimes Esi does not feel well and she goes to the clinic for treatment. She has been able to keep working in the shop. Recently she took a training course offered by an AIDS organization from the capital city and now she has been trained to provide help to people who are sick—especially those with AIDS. She learned about coping with the problems of AIDS and how to help people with AIDS and their families manage. Esi tries to eat well, get plenty of rest, and talk about her troubles to friends. She visits people in their homes. She takes her son with her and he helps with simple chores for these other families. She talks in the community about AIDS and about health. She gives both her knowledge and her hope. She says she can live with AIDS and that when she dies the virus in her will die too.

23 The “Story of Yulia & Mukasa” “Esi & Yao” was adapted and reprinted (with permission of World Health Organization), from AIDS Home Care Handbook, pp. 41–43. Copyright WHO, 1993.

5-146 Family Planning Plus Tools for Disease Progression Diagram Trainers

Incubation Period

Window Period Honeymoon Period

3–6 months AIDS

Antibodies

Viral Load

Timeline

Disease Progression 5-147 Tools for Living Healthy Chart Trainers

Traditional herbs, Support of Acupuncture partner/spouse

Gender Protection Equity from Anything that Treatment of discrimination enhances the opportunistic Advocacy work immune system infections (TB, pneumonia, diarrhea, fever) Extended family support Peer support/ Anti-retroviral friendships drugs and protease Productive inhibitors work Physical Social Good nutrition Wellbeing Wellbeing

Meditation Rest and relaxation General Avoid smoking, drugs and alcohol Belief in a higher Spiritual Health power Wellbeing Maintenance Avoid STIs, Family Reinfection Planning with HIV Faith Psychological Prayer Wellbeing Exercise Positive attitudes Counseling Stress reduction

Support groups Building Building self-esteem interpersonal skills

5-148 Family Planning Plus Chapter 6

Living with HIV/AIDS

“The experiences of Uganda, Senegal, and Thailand, have shown that serious investments in and mobilization around these actions, make a real difference. Stigma, and discrimination, can be stopped, new infections can be prevented, and the capacity of families and communities to care for people living with HIV and AIDS can be enhanced.”

—NELSON MANDELA, SPEAKING ON PREVENTING THE FURTHER SPREAD OF HIV Table of Contents Family Planning Plus Chapter 6: Living with HIV/AIDS

Chapter 6 Living with HIV/AIDS Introduction...... 6-151 Objectives...... 6-153 Important Terms...... 6-155 Sample Session Design ...... 6-157 Activities and Handouts for Living with HIV/AIDS Sample Session...... 6-158 The Loss Exercise ...... 6-159 Panel Discussion with People Living with HIV/AIDS ...... 6-163

6-150 Family Planning Plus Chapter 6: Living with HIV/AIDS

Key Questions

• What are some of the feelings associated with testing HIV positive?

• What are some common responses to a positive HIV test for an individual? A family? The community?

• What does it mean to live positively with HIV/AIDS?

• How can reducing the stigma against people living with HIV/AIDS lead to prevention of HIV?

Introduction

Voluntary Counseling and Testing (VCT) can be a powerful tool in the fight against HIV. It can help prevention efforts and be an important entry point for obtaining care services and support. It can also help reduce stigma and discrimination against PLWHA. It is difficult to make the decision to be tested for HIV, but it is also a powerful motivation for prevention. When people test negative for HIV, they may feel relief and they may be motivated to change their risk behavior. When someone tests positive, they may change their risk behavior to keep from infecting others or from being re-infected.

Testing positive for HIV can, however, prove to be a traumatic and life-altering experience in the life of an individual. In addition to raising issues of mortality and chronic illness, HIV/AIDS may represent potential rejection by the family and community, fear of discrimination, and the downward spiral of poverty. Because of the stigma associated with HIV/AIDS, those who test positive may fear to tell their loved ones about the infection, may refuse to seek medical care, and may grow more and more isolated in their illness. Sometimes, the test result can lead to

Living with HIV/AIDS 6-151 anger and even violence, as the newly diagnosed seek to find someone to blame for their condition.

Although this is the unfortunate situation over much of the world, there is an alternative to this debilitating culture of silence. Many nations and communities are trying to overcome the discrimination and stigma associated with the disease, so that PLWHA can receive the support and services they need and potentially become the strongest educators in the fight against HIV/AIDS. Counseling programs, support groups, access to health care, appropriate human rights protections, and new inheritance laws are reducing the discrimination and stigma associated with HIV/AIDS. This environment is helpful to the care of PLWHA, as those who have support, and access to services, are more likely to live longer, healthier lives. But this atmosphere is also crucial to prevention, because the heightened community attention to the disease makes it easier to be tested, to receive condoms, to receive treatment, and to hear the stories of those who have become infected with the virus.

The Living with HIV/AIDS session seeks to help participants to explore their own reactions to the losses associated with a positive test result, so that they may become more empathetic to the situations of PLWHA. Further, it encourages a dialogue with infected people themselves, so that participants can better understand the feelings and challenges associated with testing positive; seeking services; and revealing HIV status to partners, family members, and the community. Finally, it provides an opportunity for living with HIV/AIDS to discuss how to live a healthy and positive life with the virus, in the hopes that participants will feel more comfortable about knowing their own HIV status.

This session can sometimes be painful or emotional for participants, trainers, and PLWHA alike, but it has often represented a true turning point for participants of HIV/AIDS workshops.

6-152 Family Planning Plus Chapter 6: Living with HIV/AIDS

Objectives

By the end of this class, participants will be able to— • Describe some of the feelings associated with discovering one is HIV-positive • Describe some common responses to a positive test result for HIV • Describe what it means to live positively with HIV/AIDS • Describe how their own feelings about PLWHA have changed after the session • Discuss some of the challenges associated with VCT for women and men

Living with HIV/AIDS 6-153 Family Planning Plus: HIV/AIDS Basics

6-154 Family Planning Plus Important Terms

Shock A common reaction to a positive result to an HIV test. The person may be so surprised and confused that they may not know what to do. It is important that the person have someone that they trust around at this time.

Denial Another common response to a positive result. Sometimes a person may not believe that the result is true or that they are really HIV-positive. This may be a subconscious way to protect oneself from the fear and pain associated with the threats posed by HIV/AIDS. It is important not to become angry or impatient with such a person, but to help him or her to understand the test and its results.

Anger A response to an HIV-positive test that may include blaming oneself, blaming the person suspected of infecting you, blaming of the person delivering the result, or even blaming God. This may be the most difficult reaction to cope with, but it is important to try not to take it personally, but to help the person talk about their feelings.

Bargaining A person with HIV or AIDS may try to bargain, thinking, “God will cure me if I stop having sex,” or “I won’t ever be unfaithful again if I get well.”

Fear People with a positive result may fear death, losing a job, losing children, discrimination, and other things. Talking with the person or referring them to a support group may help him or her to work through these fears.

Loneliness or A common reaction to a positive HIV test result. This feeling may come and go Isolation and may be lessened by support from family, friends, and the community.

Self-consciousness Another possible reaction to a positive test result. The person may feel that everyone is looking at them or talking about them. They may want to hide or feel unworthy. Encourage them to get involved in community events and to stay active. Remind them that people with HIV/AIDS are valuable members of the community like everyone else.

Depression A common response to learning one is HIV-positive. Symptoms may include sleeping a lot, not wanting to eat, not wanting to talk, crying, and sadness. Depression can cause weakness in mind and body. It is important to recognize the signs of depression and try to get the person to visit with friends, stay busy with important things, to do something to help others, and think about their children and friends who still need them. If the symptoms of depression do not go away or they become worse, it may be necessary to refer the person to a doctor or a counselor.

Living with HIV/AIDS 6-155 Acceptance A person with a positive result will eventually accept their situation. Acceptance helps people feel better and to take better care of themselves.

Hope Hope is an important part of lengthening one’s honeymoon period and remaining healthy longer with HIV/AIDS. Persons living with HIV/AIDS can hope for many things— • To live a long time • To remain healthy a long time • To hope for better medicines to fight the disease • To hope for success on their jobs or with their activities • To hope for a happy life after death; and so on

6-156 Family Planning Plus Sample Lesson Chapter 6: Living with HIV/AIDS Plan

Sample Session Design

Time Content Methodology Materials Needed Evaluation

30 The Loss Exercise Trainer leads Paper for each Discussion at the end of minutes participants through a participant the exercise (See Alternative series of questions to Activities: Rights Pen or pencil for illustrate the Exercise, page 7-187) each participant emotions associated Empathy for PLWHA with learning one is Flipchart Rights and needs of HIV-positive. Markers PLWHA

2 hours Panel or Discussion Invite a group of Possibly, head table Active participation in 30 with PLWHA PLWHA to speak to for the speakers the discussion with the minutes the participants from speaker. Experiences of local Glasses of water for a local group. PLWHA, including the speakers Any positive change of Participants’ positive living with the attitude toward PLWHA questions will follow Possibly, tissues virus, possible stories expressed during the the discussion. of discrimination or processing session. acceptance, and so on

Living with HIV/AIDS 6-157 Chapter 6: Living with HIV/AIDS

Activities and Handouts for Living with HIV/AIDS

• The Loss Exercise

• Panel Discussion with People Living with HIV/AIDS

6-158 Family Planning Plus Activity The Loss Exercise24 (See the end of the sessions for an Alternate Activity, the Rights Exercise, page 7-187.)

Objective By the end of this exercise, participants will be able to— • Describe some of the feelings associated with discovering one is HIV-positive • Describe some common responses to a positive test result for HIV • Discuss some of the challenges associated VCT for women and men

Time allotted 30 minutes

Preparation Gather participants in a circle, with a head table at the front for the next aspect of the session, the People Living with HIV/AIDS Panel.

Facilitation 1. Suggest that up until this point, we have talked a great deal about the steps various facts and information surrounding HIV/AIDS. We know a great deal now about transmission and prevention. We have explored at great length how the immune system responds to HIV/AIDS, the progression of the disease in the body, and the ways to strengthen one’s body to live healthier with the disease. We have also discussed the effects of HIV/AIDS on our lives and our nation, and we have watched HIV/AIDS at work in the lives of our fictional story of Esi and Yao. But many of us know from our own lives that HIV/AIDS is not about facts and information as much as it is about feelings, hopes, and fears. It is an intimate, personal issue for many of us, for our friends and family members, and for the strong men and women who have agreed to speak with us at the second half of this session today.

2. To prepare us for their visit, and to bring us back to our own personal feelings about HIV/AIDS, we are going to do a short activity, called the Loss Exercise.

3. Ask participants to completely clear their desks of everything except a sheet of paper and a pen or pencil. Tell the participants to number 1 to 5 on their papers. Explain that you are going to read five statements, and they will respond to those statements on their papers.

24 The “Loss Exercise” was adapted and reprinted (with permission of Peace Corps), from the Life Skills Manual, Appendixes 21 to 23. The responses to a positive test result are adapted and reprinted (with permission of World Health Organization) from AIDS Home Care Handbook, pp. 45-48. Copyright WHO, 1993.

Living with HIV/AIDS 6-159 4. It is important to emphasize that no one else in the room will see their papers—they will not be collected. They will not be used at any later time—the papers are the personal, private property of the participants.

5. Read the statements slowly and seriously, one by one, and ask the participants to write their responses on their papers. Reinforce that it will not be shared with others.

6. First, ask participants to write down the name of the personal possession that they love the most. Maybe it is your house, or a special item your grandmother gave you, or a book, or anything else. Write that thing as #1.

7. Next, ask them to write down the part of their body that they value the most. Perhaps you enjoy your ears the most because they help you listen to music, or you value your legs, because you are able to walk with them. Write down the one part of your body that you value the most as #2.

8. Third, say that they should write down the name of the activity that they most enjoy doing. Maybe it is going to a religious event, or dancing, or playing football, or any other activity. What do you most enjoy doing in the whole world? Write that activity as #3.

9. Next, ask the participants to write down one secret or very confidential thing about yourself that no one else or few people in the world know. What very private thing would you not want many other people to know about? Write that secret or confidential thing as #4. (Remind the group that no one else will see these papers.)

10. Lastly, write down the name of the person whose love and support means the most to you in the world.

11. After everyone has finished, explain that you will now go through the list again. As you go through each statement, they should imagine that they are living through what you are saying.

- Imagine that something terrible happens that causes you to lose the possession that you love most. Either a theft occurs or a loss of some kind that takes this thing away from you completely. You will never again see the thing listed on #1. Take your pen or pencil and cross out #1 now.

- Imagine that an accident or other unfortunate occurrence causes you to lose the part of your body that you value the most. This part of your body is gone, and you will never have it again. Cross out #2 now with your pen or pencil.

6-160 Family Planning Plus - Imagine that this same accident or unfortunate occurrence makes it impossible for you to do your favorite activity ever again. You will never again be able to do the activity listed on #3. Cross out #3 with your pen or pencil now.

- Imagine that because of all the above situations, your secret has been exposed. Everyone now knows and is talking about what you wrote on #4. It has become public knowledge—everyone is talking about it. Circle #4 with your pen or pencil now.

- Finally, because of all of these changes (losing your possession and your body part, not being able to do your favorite activity, and everyone knowing your secret), the person that you love most in the world leaves you forever. You will never again see this person that you love and who is your most important source of support. Cross out #5 with your pen or pencil now.

12. Allow a few silent moments for the participants to think about the activity. Sometimes, the participants may be a bit upset or uncomfortable at this point. Allow a bit of time for the processing of these feelings.

13. Now, ask participants to describe in one word or phrase what they are feeling. Write the words on a flipchart. Keep brainstorming until all the ideas are exhausted. The list may include sadness, grief, feelings of suicide, hopelessness, feeling alone, rage, misery, depression, anger, blaming others, and so on.

14. Ask participants to take a look at the list that you have created. Ask them to imagine how these feelings might relate to testing positive for HIV/AIDS. Discuss the links between this exercise and testing positive. Suggest that they have placed themselves in the position of a person living with HIV/AIDS and allowed themselves a fictional experience of some of the powerful emotions that may come up for a PLWHA. Discuss what this might mean for the support that they might provide for someone in this situation.

15. Ask participants to consider how the consequences and feelings may differ for a woman or a man who tests positive.

- A woman may feel sad and grief-stricken, but she may also be fearful. The consequences for her may include loss of her children, marital strife, violence, or abandonment. She may have no resources or skills with which to support her in such a situation.

- A man may feel sad and grief-stricken, he may fear losing his job, his family, or the respect of others.

Living with HIV/AIDS 6-161 16. Suggest that people may have common responses when they test positive, or when they learn any shocking news. These responses include shock, denial, anger, bargaining, fear, loneliness, self-consciousness, depression, acceptance, and hope. Briefly discuss these common responses to a positive test result. Were such feelings a part of this exercise? Have participants experienced these emotions in the past?

17. Suggest that someone with a positive result may have one or more of these feelings, or may have each of them in phases. Someone may feel hopeful one day and angry the next. This is normal, and these feelings should not be avoided. It is important to provide the person a chance to talk about such feelings.

Wrap-up Remind participants that this exercise was not real, but simply an activity. Take them through every step again, giving them back their favorite possession, body part, and activity, indicating that no one knows their secret, and that the person they love still loves them. Suggest that they keep these feelings and the possible responses to an HIV-positive test in mind as we talk with our speaker or speakers in the next activity.

6-162 Family Planning Plus ctivity Panel Discussion with People Living with A 25 HIV/AIDS

Objective By the end of this session, participants will be able to— • Describe what it means to live positively with HIV/AIDS • Explain how their own feelings about PLWHA have changed after the session

Time allotted 2 hours, 30 minutes

Preparation At least a week before the session, visit local organizations and support groups of PLWHA and find out if they have a speaker’s component. Get to know their philosophy and the experiences of their members speaking publicly about their personal experiences living with HIV/AIDS. Talk to some of the speakers, explain your purpose, and select the speakers that most closely fit your group (ensure that at least one man and one woman is selected, because their experiences will differ and add a gender perspective to the discussion). It is important to select speakers who are honest, prepared, and eager to speak with groups, and who can model what it means to live positively with HIV. Offer a stipend or a meal, along with transportation to and from the venue. Also ask the speakers to provide you with a list of any questions or topics that they would not feel comfortable discussing, so that you may lead the discussion away from those issues should they arise.

Facilitation 1. Move from the discussion regarding common responses to a positive test steps result to this panel of PLWHA. Indicate that no matter how much we educate ourselves about HIV/AIDS, perhaps the best source of information and understanding comes from talking and working with people who are living positively with HIV infection every day. (You may want to set ground rules regarding what topics/questions that the panelists do not wish to discuss, and remind participants that the panel discussion should remain confidential.)

2. Introduce the speakers, and provide time for all participants to introduce themselves.

25 The “Panel Discussion with People Living with HIV/AIDS” session was adapted and reprinted (with permission of Peace Corps), from the Life Skills Manual, pp. II-87 to II-89.

Living with HIV/AIDS 6-163 3. Provide a specific time for each speaker to tell his or her story. After all stories have been told, provide time for the participants to ask questions.

4. Spend about an hour and a half in this dialogue with the speakers.

Wrap-up After the panel discussion, when the panelists have left, provide some processing time (1 hour or more) for participants to discuss their feelings about the session. Often, this session can raise powerful emotions for the participants, and they may want some time to discuss the experience with the group.

Note to Trainers: This session can be a transformational one for many participants, because it debunks some stereotypes about the disease and can break through denial about personal risk. Many community groups have been powerfully changed by such a session, and it is hard to overstate the benefits of this conversation with people living with HIV/AIDS, especially with groups in which people still express some denial about HIV/AIDS. However, in some areas there has been a certain “tokenizing” of such speakers, meaning that people living with HIV/AIDS are brought into a community just for a session like this one, and they have to tell their stories over and over for groups like these. In some cases, this can be painful for the speakers, especially if such sessions are not followed up by more meaningful partnerships among the speakers and community groups. It is important to recruit speakers from credible, recognized organizations of people living with HIV/AIDS. Every situation is different, so only your facilitation team can determine whether or not the benefits of a session like this outweigh the possible cost to the speakers. Before deciding to have this session, weigh the needs of your group and the goals of the session against any possible problem that the session might raise for the speakers living with HIV/AIDS. It is also helpful to prepare the group beforehand by talking about the types of questions that may be especially difficult for the speakers, and by reminding participants that the panel discussion should remain confidential.

6-164 Family Planning Plus Chapter 7

HIV/AIDS in Our Lives and Our Community

“The challenge is to move from rhetoric to action, and action at an unprecedented intensity and scale. There is a need for us to focus on what we know works. We need to break the silence, banish stigma, and discrimination, and ensure total inclusiveness within the struggle against AIDS. We need bold initiatives to prevent new infections among young people, and large-scale actions, to prevent mother-to-child transmission, and at the same time we need to continue the international effort of searching for appropriate vaccines. We need to aggressively treat opportunistic infections, and we need to work with families and communities to care for children and young people to protect them from violence and abuse, and to ensure that they grow up in a safe and supportive environment.”

—NELSON MANDELA Table of Contents Family Planning Plus Chapter 7: HIV/AIDS in Our Lives and Our Community

Chapter 7 HIV/AIDS in Our Lives and Our Community Introduction...... 7-167 Objectives...... 7-169 Sample Session Design ...... 7-171 Activities and Handouts for HIV/AIDS in Our Lives and Our Community Sample Session...... 7-173 HIV/AIDS in Our Community...... 7-174 Risk Behavior: Testing the Waters...... 7-176 Workshop Final Evaluation...... 7-179 Closing: Head, Heart, Feet ...... 7-181 Alternate Activities and Handouts ...... 7-185 What We Bring/What We Want to Take Away...... 7-186 The Rights Exercise...... 7-187

7-166 Family Planning Plus Chapter 7: HIV/AIDS in Our Lives and Our Community

Key Questions

• What are the statistics for HIV/AIDS in your country, and your local community? How many people in your area are estimated to be infected with HIV/AIDS? How many orphans are living in your country?

• What is being done to prevent HIV/AIDS in your country? What care and support programs are available?

• What is your personal risk for HIV infection?

• What new facts have you learned in this workshop? What new feelings or attitudes do you hold?

• What action are you going to take to fight HIV/AIDS in your own lives and in your communities?

Introduction

The preceding six chapters have explored many aspects of HIV/AIDS from transmission to prevention, from disease progression to living healthy with HIV or AIDS, and to the gender issues at work around HIV/AIDS. Although many topics have been explored in technical terms and through the Story of Esi & Yao, for the most part, participants have looked at HIV/AIDS through a general lens and at arm’s length.

The goals of this final session are to help the participants to apply everything that they have learned about HIV/AIDS to the situations in their own countries and to the situations in their own lives. Participants will learn about the current state of the epidemic in their local areas from a

HIV/AIDS in Our Lives and Our Community 7-167 health official, along with testing locations, support groups and services for PLWHA. It is recommended that you enlist the help of a local health worker or a staff member from the Ministry of Health for this part of the session. Often it can be difficult or painful to learn of the HIV/AIDS statistics in one’s own area, and this can lead to feelings of judgment, disbelief, and blame. Having a local health official deliver this information can lessen any feelings of judgment or blame for the participants.

In addition, care of people living with HIV/AIDS, widows, and orphans requires a re-thinking of gender issues at the national level as communities struggle to cope with inheritance laws, education for girls, access to family planning, and so forth. Each culture must address these issues on their own terms and in their own time. The community must begin conversations and negotiations that take gender into account when planning HIV prevention and care programs.

Last, this session urges participants to examine their own risk for HIV infection. By applying the lessons learned in the workshop to their own lives, participants are given an opportunity to explore and modify their own risk behaviors. This exercise also serves as a review and evaluation of the information disseminated in the sessions.

The session will conclude with an activity that encourages participants to assess new knowledge, attitudes, and feelings gained from the sessions, and offers them an opportunity to commit to take action in the fight against HIV/AIDS.

7-168 Family Planning Plus Chapter 7: HIV/AIDS in Our Lives and Our Community

Objectives

By the end of this class, participants will be able to— • State the current percentage of the country’s population believed to be HIV-positive • State the estimated number of orphans in the country • Describe the government’s response to the epidemic • List testing resources for HIV/AIDS • List support services for PLWHA • Identify their own levels of risk for HIV infection

HIV/AIDS in Our Lives and Our Community 7-169 Family Planning Plus: HIV/AIDS Basics

Training Schedule Schedule Day One Day Two Day Three Day Four Registration Review Game Review Game Review Game 30 minutes 30 minutes 30 minutes 30 minutes Class Chapter 1 Chapter 3 Chapter 5 Chapter 7 Introductions Epidemic Game Story of Esi and Yao, HIV/AIDS in Our Ground Rules Prevention Facts Part II Community Goals and Expectations 1 hour Disease Progression 1 hour Diagram 1 hour 1 hour 30 minutes Break 15 minutes 15 minutes 15 minutes 15 minutes Class Chapter 1 cont. Chapter 3 cont. Chapter 5 cont. Chapter 7 cont. Impact of HIV/AIDS Universal Precautions Mother-to-Child HIV/AIDS in Our 1 hour 30 minutes Biological Transmission Community, cont. Vulnerability of Girls Living Healthy Testing the Waters and Women 1 hour 40 minutes 1 hour 45 minutes 1 hour 30 minutes Lunch 1 hour 1 hour 1 hour 1 hour Class Chapter 2 Chapter 3 cont. Chapter 5 cont. Chapter 7 cont. Myths and Facts Condom Carousel Co-Factor Tug-of-war Evaluation Story of Esi and Yao, Condom Chapter 6 Closing: Head, Heart, Part I Demonstrations The Loss Exercise Feet Transmission Facts 1 hour 30 minutes 45 minutes 1 hour 40 minutes 2 hours Break 15 minutes 15 minutes 15 minutes Class Chapter 2 cont. Chapter 4 Chapter 6 cont. What’s the Fluid? Elephants and Lions Panel or Discussion Where’s the Door? Game with People Living Gender Toss/ Social Immune System Facts with HIV/AIDS and Processing Discussion Vulnerability to Immune System Role- HIV/AIDS play 2 hours 30 minutes 2 hours 10 minutes 1 hour 50 minutes Evaluation 15 minutes 15 minutes 15 minutes

7-170 Family Planning Plus Sample Lesson Chapter 7: HIV/AIDS in Our Lives Plan and Our Community

Sample Session Design

Time Content Methodology Materials Needed Evaluation

2 hours HIV/AIDS in Our Health official presents Depending on the Active Community national statistics for HIV needs of the health participation prevalence, number of official, may in the session Current national orphans, and other pertinent include— HIV/AIDS statistics statistics. Official then provided by health - Flipcharts, provides summary of testing official markers, and tape resources and services Summary of testing available for PLWHA. - Overhead projector resources and services Participants are invited to ask - Computer available for PLWHA questions. presentation Description of the equipment government’s response - Photocopies of to the epidemic resources for testing services for PLWHA

45 Risk Behavior: Testing Participants identify which Four signs Active minutes the Waters activities they are engaged in, participation - Plunger and then review all activities in the exercise Assessment of personal for risk of HIV infection. - Wader risk for HIV infection Correct -Tester answers to the Review and evaluation assessment of of HIV transmission and - Delayer risk activities prevention facts One handout for each participant - Activities Prepared flipchart - Activities

HIV/AIDS in Our Lives and Our Community 7-171 Time Content Methodology Materials Needed Evaluation

1 hour Workshop Evaluation Trainers explain the Copies of the Final Active importance of feedback from Evaluation form and participation the participants to improve posttest in filling out future training. Participants questionnaire. Pens, forms complete a questionnaire and envelope to collect evaluation forms to assess forms their learning and the workshop

40 Closing: Head, Heart, Participants state one way that Large drawing of a Feedback minutes Feet the workshop has provided body with head, from new information, one way that heart, and feet clearly participants Validation and it has changed feelings or visible. reflections upon the attitudes, and one action that workshop Three different colors they are committed to doing of Post-It notes after the workshop. Markers

7-172 Family Planning Plus Chapter 7: HIV/AIDS in Our Lives and Our Community

Activities and Handouts for the HIV/AIDS in Our Lives and Our Community

• HIV/AIDS in Our Community

• Risk Behavior: Testing the Waters Review Activity

• Workshop Final Evaluation

• Closing: Head, Heart, Feet

HIV/AIDS in Our Lives and Our Community 7-173 Activity HIV/AIDS in Our Community Objective By the end of this session, participants will be able to— • State the current percentage of the country’s population believed to be HIV-positive • State the estimated number of orphans in the country • Describe the government’s response to the epidemic • List testing resources for HIV/AIDS • List support services for PLWHA

Time allotted 2 hours

Preparation A few weeks before the workshop secure a speaker for the session, preferably an official from the Ministry of Health, the National AIDS Control Program, or other bureau responsible for HIV/AIDS at the national government level. It is important to choose a charismatic, lively speaker who is positioned to have access to the most current information regarding HIV/AIDS statistics and services. Meet with the speaker to describe your participants and to discuss your hopes and expectations for the session. You may wish to specifically ask his or her office to prepare a list of testing services, and support services for PLWHA, along with copies of any national strategy for AIDS control that may be available.

Facilitation 1. Summarize the entire workshop up to this point. Suggest that we have steps discussed many of the general facts and issues of HIV/AIDS, but that up until now we have not specifically addressed all of the issues around HIV/AIDS in this country. Suggest that we are now equipped with enough knowledge to ask specific questions about HIV/AIDS in our country, and that this session provides us with the opportunity to do so.

2. Introduce the speaker, and facilitate an introduction of all the participants.

3. Provide the speaker with enough time to detail the current situation of HIV/AIDS in the country, including the projected number of infections, the estimated number of orphans, and so on. It would also be useful for the speaker to present any other information that he or she may have regarding the effects of HIV/AIDS on the country. The speaker should also cover the government’s response to the epidemic.

7-174 Family Planning Plus 4. Be sure that testing services are reviewed, including their cost and the locations of testing centers, as well as sites of free condom distribution, and so on. You may wish to prompt participants to ask specific questions about the quality of counseling at testing facilities. Finally, be sure the speaker discusses any support services or groups open to PLWHA.

5. Provide participants with enough time to ask questions. Clarify any concepts or terms that are raised that may not have been covered in the sessions.

Wrap-up Thank the speaker for coming, and provide time for the participants to do the same. After the speaker has gone, suggest that we have discussed the current situation of HIV/AIDS in our country, now we will turn our attention to the risk for HIV/AIDS in our own lives.

HIV/AIDS in Our Lives and Our Community 7-175 Activity Risk Behavior: Testing the Waters26 Objective By the end of this session, participant will be able to— • Identify their own levels of risk for HIV infection

Time allotted 45 minutes

Preparation Prepare four signs, one for each corner of the room. Plunger, Wader, Tester and Delayer. Provide one copy of the Activities handout for each participant, and write the list of activities in large print on a flipchart. (Suggested activities are listed at the end of the chapter, see page 7-183.)

Facilitation 1. Say that we are now in possession of all the knowledge that we need to go steps out into our communities and work to stem the HIV/AIDS epidemic; either by teaching others how HIV can be prevented, or by helping those who are HIV-positive to live a longer, healthier life, or by working with a group of orphans or PLWHA to lessen the effects of the disease on the community. But first and foremost, we now have enough information to think about our own levels of risk for HIV/AIDS and to begin to do something to prevent HIV infection in our own lives or to address any possible current infection with HIV/AIDS.

2. Begin the session by asking participants, “If you went to a lake, and you really wanted to get cool in the water, what is the most likely way for you to get into the water? Would you—

- Just run toward the lake and dive in? (Plunger)

- Walk in slowly, wetting your body bit-by-bit and getting used to the temperature? (Wader)

- Dip your toes in the water, then decide if you will go in? (Tester)

- Stand on the beach looking at the view and surroundings, and consider what you will do next? (Delayer)

(You might act out these actions as you are saying them, to make the exercise livelier. Do not, however, use the descriptive words Delayer, Plunger, Tester, Wader.)

26 The “Risk Behavior—Testing the Waters” session was reprinted (with permission of Peace Corps), from the Life Skills Manual, pp. V-55 to V-59.

7-176 Family Planning Plus 3. Point to the four different corners of the training area, repeating one action described above for each. Ask participant to move to a corner depending on the action that best describes their approach to getting into the water.

4. Once everyone in the group has moved to a corner, give each type of response a title—plungers, waders, testers, and delayers. Have the group put their title/sign on the wall. Ask participants to think about the good and bad things about each of these types of behavior. Brainstorm some of the positive and negative things about each type of behavior. (Gender and age are important aspects of this activity. Be sure to note if women or men, or young or older people go to a particular corner. That is, if all the men or young people go to the “plunger” corner, point out that they might need to be more careful, to be more like a “delayer,” whereas if the women all go to the “delayer” corner, you may suggest they need to be a bit more assertive, to be more like a “plunger,” to be able to protect themselves.)

5. Now ask all participants to sit down. Ask them to consider whether the type of behavior they chose is their most common way of behaving. Is this their usual style? What implications might that style have in terms of being at risk for STIs and HIV? (Allow that just because this may be their personal “style” in general, it may not be their way of dealing with issues around STIs and HIV/AIDS.)

6. Next, distribute the handout and post the Activities flipchart. Ask participants to take a few minutes to read the list and to check off those activities that they are currently engaged in or have done in the past. Urge the participants to be completely honest when answering—this list is only for their private, personal information and will not be collected or shared with other participants.

7. When all participants seem to have finished, remind the group briefly of our discussions regarding HIV transmission. (What’s the fluid? Where’s the door?) Suggest that some of the activities posted have no risk at all, whereas others are low risk, and still others pose a high risk for HIV infection (in situations in which a fluid and a door are both present). Make sure that everyone understands these levels of risk before you go on. You may wish to write them on a flipchart paper.

No Risk

- No risk of getting HIV/AIDS—there is no receipt of blood, semen, vaginal fluids, or maternal body fluids.

HIV/AIDS in Our Lives and Our Community 7-177 Low Risk

- Low risk of getting HIV/AIDS—there is a slight possibility of exchange of blood, semen, vaginal fluids, or maternal fluids.

High Risk

- High risk of getting HIV/AIDS—there is a strong possibility of exchange of blood, semen, vaginal fluids, or maternal fluids.

8. Next, have all participants count off, from one to the number of participants there are. Indicate that when you say, “GO!” all participants should come up at once to the flipchart, and write the level of risk next to the statement corresponding to their number. For example, if your number were 5, you would write “High Risk” on the flipchart next to statement five. Restate that they are not to write anything personal, such as whether or not they engage in this activity. They should merely write whether the activity is high risk, low risk, or no risk. Say “Go.”

9. After everyone has finished writing the risk level, go through each statement with the group. Reach an agreement on the levels of risk, and change any of the answers that are incorrect.

10. Invite the participants to think about the statements they noted on their own private lists. Are any of them high-risk activities? Are they currently engaging in high-risk or low-risk activities that may place them in danger of contracting HIV? Ask participants to reflect on their levels of risk silently.

Wrap-up Summarize the activity and suggest that it can be very difficult to honestly assess one’s own risk for HIV infection. But we must begin with ourselves if we are to hope to stem the tide of this epidemic. Invite participants who would like to talk with you at greater length about their own personal risk, or about the possibilities of getting an HIV test, to talk with you after the session.

7-178 Family Planning Plus Activity Workshop Final Evaluation Objective By the end of this activity, participants will be able to— • Evaluate their own learning in the workshop using the questionnaire • Evaluate the workshop structure and facilitation using the evaluation form

Time allotted 1 hour

Preparation Make enough copies of the Workshop Final Evaluation forms and “What We Know about HIV/AIDS” posttest questionnaires for all participants. (Locate these in Appendix II.) Have two envelopes for collecting the evaluations and posttests, and have pens/pencils.

Facilitation 1. Invite participants to sit where they can write comfortably. Say that we steps have almost finished our work together, but now we must look carefully at what we have learned in this workshop.

2. Explain that it is important that we evaluate this workshop. We need to examine both what we have learned, and how well the information has been presented by the trainers. We also need to know whether the content was appropriate for participants. This is crucial in order to improve future training.

3. Refer to the Expectations/Expectations Met flipcharts. All the Post-It notes should have been moved over during the course of the workshop. If there are still some that have not been moved over, take this time to address the final expectations. If there are some expectations that have not been met, ask the person to see you after the close of the workshop to arrange some kind of follow-up.

4. Explain that the Workshop Final Evaluation form is anonymous. We do not need the participant’s name on it. This will enable them to be honest and candid with their answers. It is important that participants answer as fully as possible.

HIV/AIDS in Our Lives and Our Community 7-179 5. Say that in addition, participants will receive a questionnaire just like the one they filled out during the registration at the beginning of the workshop, “What We Know about HIV/AIDS.” Participants should answer all the questions as best they can. This is an important way for you, the trainers, to determine how well you presented the material in the workshop. The participants should put their name on this one (or the same sign that they used on the first questionnaire).

6. Distribute copies of the Evaluation form and posttest questionnaire.

Wrap-up Ask participants to place completed evaluation forms in one envelope and questionnaires in another envelope.

7-180 Family Planning Plus Activity Closing, Head, Heart, Feet27 Objective By the end of the activity, participants will be able to— • State one new fact that they have learned in the workshop • State one new feeling, attitude, or emotion that has come out of the workshop • State one concrete action that they will take as a result of the workshop

Time allotted 40 minutes

Preparation Create a very large outline of a person on several flipcharts taped together. You may do this easily by having someone lie down on the flipcharts, and then tracing that person’s body. Draw a large heart in the chest of the outline. Post the drawing in the middle of the wall, and arrange a ring of chairs around it. Distribute three Post-It notes to each participant—one of each color.

Facilitation 1. Provide a brief summary of the previous workshop sessions. Indicate that steps we have spent four intense days together discussing a subject that can often be difficult for people to address. We have honestly and candidly discussed all the issues associated with HIV/AIDS—the terrible effects it has been having on our families, communities, and our countries. We have discussed how it is transmitted and ways to prevent it. We have traced its effect on our immune systems, and we have discussed the progression of the disease from infection, to honeymoon period, to AIDS, to death. We have discussed gender and its influence on HIV/AIDS, and we have talked about living with HIV/AIDS. Finally, we have reviewed the effects of HIV/AIDS on our own countries and communities, and we have bravely assessed its possible effects on our own lives.

2. State that as we close the workshop, we would like to provide some time for everyone to reflect on the past four days. Think about all the sessions, what you learned, what you felt, what you feel committed to doing now.

3. Instruct the participants to take out one of the Post-It notes. Ask them to think about one new fact or piece of information that they learned in the workshop. There may have been a few, but ask them to identify the one that was the most important new learning for them. They should write that in bold letters on the Post-It.

27 The “Head, Heart, Feet” exercise is reprinted (with permission of Rick Arnold et al.) from Educating for a Change, p. 106. Copyright 1991, Between the Lines and the Doris Marshall Institute for Education and Action.

HIV/AIDS in Our Lives and Our Community 7-181 4. When all participants have finished, invite them to think about how this workshop made them feel. Have they changed their minds about anything as a result of these two days? Have they formed any new attitudes or opinions? Ask them to write their most important new feeling, attitude, or opinion on the next Post-It note.

5. Last, ask participants to think about one thing that they are committed to do after this workshop. We often come to such sessions, learn a great deal, and leave without allowing our lives to be changed too much by the content of the sessions. But we have discussed powerful issues in these past four days. What do we intend to do with this new knowledge? Ask the participants to write the one thing they are most committed to doing on the final Post-It note.

6. After all participants have finished, refer them to the large outline on the wall. Ask that participants come up to the outline, in turn, and read their statements. First, they should tell us their most important new learning, and then they should stick that note on the head of the outline. Then they should tell us their most important new attitude, feeling, or opinion, and they should place that note on the heart of the outline. Last, they should tell us what one thing they are most committed to doing about HIV/AIDS after the workshop, and they should place that note on the feet of the outline.

7. Continue in this way until all participants have had a turn. The trainer may wish to end the session by discussing his or her own “head, heart, feet.”

Wrap-up The “Head, Heart, Feet” exercise often moves participants to a profound or intimate mood. You may wish to end the workshop immediately after this session, or go on to any closing ceremony that you have planned to officially close the workshop.

7-182 Family Planning Plus Tools for Risk Behavior—Testing the Waters Trainers

Suggested Activities

Edit this list so that there are exactly as many activities as there are participants in this session.

1. Using toilets in a public washroom (No Risk)

2. Touching or comforting someone with HIV/AIDS (No Risk)

3. Having sex without a condom (High Risk)

4. Dry kissing (No Risk)

5. Having sex using the same condom twice (High Risk)

6. Swimming with an HIV-positive person (No Risk)

7. Sharing needles for drugs, ear piercing, or tattooing (High Risk)

8. Abstaining from sexual intercourse (No Risk)

9. Going to school with an HIV-positive person (No Risk)

10. Cutting the skin with a knife used by others (High Risk)

11. Being bitten by a mosquito (No Risk)

12. Giving blood (No Risk)

13. Having sex using a condom properly (Low Risk—unless the risk of breakage exists)

14. Eating food prepared by an HIV-positive person (No Risk)

15. Body-to-body rubbing with clothes on (No Risk)

16. Having sex with a condom and the condom breaks (High Risk)

17. Back rub or massage (No Risk)

18. Riding on the bus with an HIV-positive person (No Risk)

19. Cleaning up spilled HIV-positive blood without wearing gloves (High Risk)

HIV/AIDS in Our Lives and Our Community 7-183 Risk Behavior—Testing the Waters, continued

20. Wet (deep) kissing (Low Risk, only if blood or open sores in the mouth—usually No Risk)

21. Touching or comforting someone living with HIV/AIDS (No Risk)

22. Receiving a blood transfusion (No Risk or Low Risk—depending on the country)

23. Getting an injection at a private clinic that cleans its needles with water (High Risk)

24. Having sex with your husband (High Risk)

25. Having sex with your wife (High Risk)

26. Spending the evening drinking with friends (High Risk)

7-184 Family Planning Plus Chapter 7: HIV/AIDS in Our Lives and Our Community

Alternate Activities and Handouts

• What We Bring/What We Want to Take Away (Alternative for Chapter 1: Expectations)

• The Rights Exercise (Alternative for Chapter 7: The Loss Exercise)

HIV/AIDS in Our Lives and Our Community 7-185 Activity What We Bring/What We Want to Take Away

Objective By the end of the activity, participants will be able to— • List the ways in which they may serve as a resource for others • List the most important outcomes of the workshop for themselves

Time allotted 20 minutes

Preparation Provide two half-sheets of paper (two different colors) for each participant. Arrange a sign on one wall that reads “What We Bring” and one on another wall that reads “What We Want to Take Away.”

Facilitation 1. Suggest that we all come to the workshop with valuable knowledge and steps experiences from our own lives, and that as such, we can serve as a powerful resource for each other during the workshop. Ask participants to think about the knowledge, skills, or experiences that they can offer to the rest of the group and to write one or two of them on the first half sheet of paper.

2. When participants are finished, indicate that we all have our own hopes and expectations regarding what we wish to get out of this workshop. If you had to choose one thing that is most important for you to take away from this workshop, what would it be? Write your most important expectation on the second half-sheet.

3. One by one, participants should come to the front of the room. They should read what they bring to the rest of the group, and then tape that paper under the “What We Bring” sign. They should then read their expectation, and tape that paper under the “What We Want to Take Away” sign.

4. Continue until all participants have had a turn. The trainer may also wish to participate.

Wrap-up Summarize the expectations listed under the “What We Want to Take Away” and indicate which sessions are likely to address these expectations. If there are unexpected topics listed, use this time to negotiate with the participants regarding a time or means to include that topic in the workshop.

7-186 Family Planning Plus Activity The Rights Exercise28 Objective By the end of the activity, participants will be able to— • Define the term human rights • Identify at least five human rights that are important to their own lives • Identify a link between the protection of human rights for PLWHA and the prevention of infection • Identify gender differences in the loss of rights and the consequences of disclosure of positive status

Time allotted 30 minutes

Preparation Cut small slips of paper, five for each participant.

Facilitation 1. Ask the group to think about what the term “human rights” means to them. steps What human rights do they have? Brainstorm with the group what they consider to be basic human rights for all people regardless of their health status. Ideas might include the right to medical care, employment, housing, religion, education, reproductive rights, and so forth.

2. Distribute five slips of paper to each participant. Invite them to write down five rights that are most important to them, one of each piece of paper.

3. When participants have finished, ask them to hold up their rights like a hand of cards—with the written words facing them. The trainer should then move among the group with a small basket, randomly taking slips of paper from the participants and placing them in the basket. The trainer may skip some participants altogether and take all five from another.

4. Have the participants look at their papers and think about the rights that they lose. What will their lives be like without those rights? How did it feel to lose them? Did they think that the selection process was fair? Why or why not?

28 The “Rights Exercise” was adapted and reprinted (with permission of Peace Corps), from the Life Skills Manual, pp. II-87 to II-88.

HIV/AIDS in Our Lives and Our Community 7-187 5. Ask participants how such an exercise is related to HIV/AIDS. Do people with HIV/AIDS stand to lose their rights in this same manner? Is it fair that they be forced to lose basic rights because of a health condition? Would the loss of rights be different for men and women? How? If they thought they might be infected with HIV and they knew that they would probably suffer discrimination like this, would they want to get tested? If they knew they were HIV-positive, would they tell their partner or potential partner? Might this decision be different for women and men? Why? If they choose not to tell their partner, how might this effect transmission of HIV in our community?

Wrap-up Summarize the activity by suggesting that it is much easier to prevent transmission of HIV in a community when people feel free to divulge their health status without feeling that they will be discriminated against, will lose their rights, or even suffer violence. Why is this so? Because those who are HIV-positive will feel supported, safe, and able to protect themselves and others by practicing precautions to prevent HIV transmission. Therefore, it is important for all of us to fight for the rights of PLWHA, and to work against discrimination in our communities.

7-188 Family Planning Plus Appendices Table of Contents Family Planning Plus Appendices

Appendix I: References and Resources...... I-191 Appendix II: Evaluation...... II-193

I-190 Family Planning Plus Appendix I: References and Resources

References

AIDS Epidemic Update. United Nations Joint Programme on HIV/AIDS; December 2001. Available at: http://www.unaids.org/

AIDS Home Care Handbook. World Health Organization; Avenue Appia 20 1211 Geneva, 27 Switzerland, 1993.

Arnold R., Bev Burke, Carl James, D’Arcy Martin, and Barb Thomas. Educating for a Change. Between the Lines and the Doris Marshall Institute for Education and Action; 1991.

The Center for Development and Population Activities. Reproductive Health Awareness: An Educational Approach. Washington, DC: CEDPA; unpublished draft, 2002.

Life Skills Manual. Washington, DC: Peace Corps; 2000.

The Safety and Feasibility of Female Condom Reuse: Report of a WHO Consultation. Geneva: World Health Organization; January 2002.

Resources

Gender and HIV/AIDS: Leadership Roles in Social Mobilization. Addis Ababa, Ethiopia: African Development Forum; December 2000.

Gender or Sex: Who Cares? Skills Building Pack on Gender and Reproductive Health for Adolescents and Youth Workers. IPAS and Health and Development Networks; 2001.

Resource Packet on Gender & AIDS. UNAIDS and Sociometrics Corporation; 2001.

Facing the Challenges of HIV/AIDS & STDs: A gender based response. KIT, SAFAIDS, and WHO; 1995.

Fact Sheet on Gender & HIV/AIDS. United Nations Development Fund for Women. Available at: http://www.undp.org/unifem/human_rights/facts.html.

Gender, HIV/AIDS & Human Rights: A Training Manual. United Nations Development Fund for Women; 2000. Appendix II: Evaluation

Key Questions

• How do we know whether the participants have learned the content?

• How do we know whether the trainers have successfully presented the material?

• How do we know whether we met the objectives of the training?

It is important to evaluate our training in order to produce meaningful outcomes that we can integrate into programs. We need to determine whether we the trainers have done our job, and how well we did. We also need to know whether the participants have learned the information and skills we intended to teach them. This is crucial to improving our training in the future. In an effort to capture that information, this appendix contains an example of a pretest/posttest and a final evaluation for a workshop. You will need to adapt these to cover the specific content of your training.

You can distribute the pretest questionnaires to participants during the registration period, before the workshop starts. It is important for trainers to carefully review these early on the first day so that they can tailor the training to the participants’ needs. The posttest can be given as part of the Workshop Final Evaluation session. KEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEY

Name______

Today’s Date______

Training Site______KEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEY What We Know about HIV/AIDS

Many of you may already know a great deal about HIV/AIDS. You may have heard about it on the radio, or read about it in the newspaper, or you may have had some personal experience of the disease by caring for orphans, or if someone you know has had the disease. This is a tool to help the trainers to get a sense of what you already know, to better meet your needs. You are not expected to know everything, or even most things on this form. We will use this to measure how well we the trainers have presented the information, in order to become better trainers in future workshops.

1. Name two ways in which HIV can be transmitted.

Vaginal or anal sex Possibly oral sex Sharing needles or other sharp equipment such as razors Through blood transfusions of untested blood From mother to infant during pregnancy, during delivery, or through breastfeeding

2. Name two reasons that women are vulnerable to HIV infection due to their expected societal roles.

Women do not have as much decision-making authority as men Fear of violence from men Sexual violence against women Girls’ initiation rites Taboos on speaking about sex Men’s preferences for dry sex Bride price or marriage rites Extreme poverty Lack of availability of female-controlled prevention methods

KEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEY

II-194 Family Planning Plus KEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEY

3. Name two reasons that men are vulnerable to HIV infection due to their expected societal roles.

Men should be risk-takers Men should have many sexual partners Men should always be strong Men should have sex only with women, so men who have sex with men don’t have access to information and services they need Men should be the decision-makers

4. Name two reasons why women and girls are more biologically vulnerable to HIV/AIDS.

Women receive greater quantities of possibly infected fluids during a sexual encounter. Women have a surface area of mucous membrane (portal of entry) that is greater in size than that of men. Because the vagina is an internal organ, women are less likely to know that they have sores from STIs, which could facilitate HIV transmission. Very young women have more risk for infection during sex both because the cells in the vagina are underdeveloped in young women and are more likely to receive the virus, and because tearing may cause bleeding, which increases the risk of infection. Anemia, malaria, pregnancy complications, lack of access to contraceptives, and safe and legal abortions put women at risk of needing blood transfusions, another mode of HIV transmission.

5. Give two reasons why it is important to treat STIs to prevent transmission of HIV.

Sores and lesions from STIs create a larger “door” through which HIV can pass. A discharge, which may occur with gonorrhea or chlamydia infection, means that more white blood cells are present. Because some specific white blood cells are hosts for HIV, it means that more virus can be transmitted or received when discharge is present. Women often don’t have symptoms of a STI or they can’t see lesions or sores because they are inside the vagina, which places women at even higher risk.

KEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEY

Evaluation II-195 KEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEY

6. Name two of the feelings or responses to testing positive for HIV.

Shock Denial Anger Bargaining Fear (see list of Important Terms in chapter 6)

7. Name two positive behaviors that a PLWHA can do to prolong their life.

Traditional herbs Rest Exercise Eat well Avoid alcohol Meditation (see Living Healthy Chart in chapter 5)

8. Name two of the stages of HIV progression in the body.

Infection Window period Honeymoon period Incubation period AIDS: Acquired Immune Deficiency Syndrome

9. List two ways for preventing MTCT.

Avoid getting pregnant if you are HIV-positive Use a condom if you are pregnant or breastfeeding Have a caesarian delivery Start treatment with AZT or Nevirapine during pregnancy

10. List two of the steps for proper use of a male condom.

See “How to Use a Male/Female Condom” in chapter 3

KEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEYKEY

II-196 Family Planning Plus Name______

Today’s Date______

Training Site______

What We Know about HIV/AIDS

Many of you may already know a great deal about HIV/AIDS. You may have heard about it on the radio, or read about it in the newspaper, or you may have had some personal experience with the disease, by caring for orphans, or by knowing someone who has had it. This is a tool to help the trainers to get a sense of what you already know, to better meet your needs. You are not expected to know everything, or even most things on this form. We will use this only to measure how well we the trainers have presented the information, in order to become better trainers in future workshops.

1. Name two ways in which HIV can be transmitted.

2. Name two reasons that women are vulnerable to HIV infection due to their expected roles.

3. Name two reasons that men are vulnerable to HIV infection due to their expected roles.

4. Name two reasons why women and girls are more biologically vulnerable to HIV/AIDS.

5. Give two reasons why it is important to treat STIs to prevent transmission of HIV.

Evaluation II-197 6. Name two of the feelings or responses to testing positive for HIV.

7. Name two positive behaviors that a PLWHA can do to prolong their life.

8. Name two of the stages of HIV progression in the body.

9. List two ways for preventing MTCT.

10. List two of the steps for proper use of a male condom.

II-198 Family Planning Plus Family Planning Plus: HIV/AIDS Basics

Workshop Final Evaluation Form

Location: Date:

The final evaluation form consists of several questions intended to determine your assessment of the workshop, including the content, structure, and methodology of the training. Please answer the questions as fully as possible, and we invite your honest and candid opinions. Your input will be important for improving future workshops.

1. Following are the workshop objectives. Please rate how well you think the objective was achieved on a scale of 1 to 10, with 10 being “fully achieved” and 1 being “did not achieve.” By the end of the workshop, the participants will be able to—

a. Describe the effects of HIV/AIDS on the local community, the nation, the region and the world.

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b. Identify at least five ways in which HIV is transmitted.

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c. Determine whether or not HIV can be transmitted by specific activities.

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d. Identify at least five reasons that men and women can be vulnerable to HIV/AIDS due to their expected social roles.

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e. Describe the ABCs of prevention.

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f. List the steps for proper male and female condom use.

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g. Define universal precautions and identify when to use them.

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Evaluation II-199 h. Identify at least three reasons that women and girls are more biologically vulnerable to HIV/AIDS.

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i. Describe the importance of treating STIs for preventing transmission of HIV.

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j. Describe the difference between HIV and AIDS.

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k. Describe the role, parts, and functions of the immune system and the effects of HIV on it.

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l. Describe the stages of HIV progression in the body.

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m. Describe ways to prevent MTCT and discuss issues surrounding it.

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n. Describe aspects of wellbeing and the importance of positive living behaviors to PLWHA.

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o. Describe some of the feelings and responses to testing positive for HIV.

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p. List testing resources and support services in the community for PLWHA.

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q. Identify participant’s own levels of risk for HIV infection.

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II-200 Family Planning Plus 2. Please rate each session on a scale of 1 to 10, with 1 being the lowest and 10 being the highest possible rating, by writing the number in the space provided after the session title. Rate each session according to how important and useful the session was to you.

Session Rating

1. Introduction/Ground Rules/Expectations ______

2. Impact of HIV/AIDS ______

3. Myths & Facts about HIV/AIDS ______

4. The Story of Esi & Yao—Part I ______

5. What’s the Fluid? Where’s the Door? ______

6. Gender Toss/Social Vulnerability to HIV/AIDS ______

7. Epidemic Game ______

8. Prevention Facts ______

9. Biological Vulnerability of Women and Girls ______

10. Condom Carousel/Condom Demonstration ______

11. Universal Precautions ______

12. Review Game ______

13. Elephants & Lions ______

14. Immune System ______

15. Impact of HIV on the Immune System ______

16. Immune System Role-play ______

17. Story of Esi & Yao—Part II ______

18. Disease Progression Diagram ______

19. Mother-to-Child Transmission ______

20. Living Healthy ______

21. Co-Factor Tug-of-War ______

Evaluation II-201 22. The Rights Exercise ______

23. Panel or Discussion with People Living with HIV/AIDS ______

24. HIV/AIDS in Our Community ______

25. Risk-Behavior—Testing the Waters ______

26. Closing: Head, Heart, Feet ______

3. Please make comments or suggestions about how specific sessions could be improved.

4. If you rated any session a “5” or below, please indicate the session and briefly explain why.

5. Overall, I found the workshop

Very Useful

Useful

Not Useful

Comments

II-202 Family Planning Plus 6. Which topics did you find most useful?

Comments

7. Which topics did you find least useful?

Comments

8. Which training activities helped you learn the most?

Comments

Evaluation II-203 9. Was the time adequate for the workshop objectives?

Just Adequate

Too Short

Too Long

Comments

10. Are there specific ideas, tools or skills that you did not get from this training workshop that you need to improve yourself?

Yes No

If yes, list them

11. Do you have any further comments on any other aspect of the workshop?

(Feel free to use additional paper if necessary)

II-204 Family Planning Plus MAIN OFFICE NEPAL 1400 16th Street, NW, Suite 100 Gairidhara Washington, DC 20036, USA G.P.O. 8975, EPC 5316 Tel: 202-667-1142 Kathmandu, Nepal THE CENTRE FOR DEVELOPMENT Fax: 202-332-4496 Tel: 977-1-427-739 AND POPULATION ACTIVITIES E-mail: [email protected] or 977-1-417-071 Fax: 977-1-421-696 EGYPT E-mail: [email protected] Headquartered in Washington, DC, CEDPA 53 Manial St., Suite 500 is an international nonprofit organization Manial El Rodah NIGERIA that seeks to empower women at all levels Cairo 11451, Egypt 18A &B Temple Road of society to be full partners in development. Tel: 2-02-365-4567 Off Kingsway Road Founded in 1975, CEDPA supports programs or 2-02-531-8149/8150 Ikoyi, Lagos, Nigeria and training in leadership, capacity building, Fax: 2-02-365-4568 Tel: 234-1-260-0020 advocacy, governance and civil society, E-mail: [email protected] Fax: 234-1-260-0022 youth participation and reproductive health. E-mail: [email protected] GHANA The Enabling Change for Women's P.O. Box CT 4977 RUSSIA Reproductive Health (ENABLE) project Cantonments The Latin American Institute of the Accra, Ghana Russian Academy of Sciences works to strengthen women's capabilities Tel: 233-21-234-175 21/16. Bolshaya Ordinka St. for informed and autonomous decision Fax: 233-21-251-063 Moscow, Russia making to prevent unintended pregnancy E-mail: [email protected] Tel: 7-095-951-0087 and improve reproductive health. Initiated Fax: 7-095-951-1059 in 1998, ENABLE seeks to increase the GUATEMALA E-mail: [email protected] capacity of non-governmental organization 2a Avenida 9-42 #4, Zona 9 (NGO) networks to expand reproductive Guatemala City 01009 SENEGAL health services and to promote a supportive Guatemala BP 259 Dakar Liberté environment for women's decision making. Tel: 502-360-7252 1917 Sicap Liberté 3 or 502-334-6047 Dakar, Senegal Fax: 502-331-3482 Tel: 221-864-3705 E-mail: [email protected] Fax: 221-824-2071 E-mail: [email protected] INDIA 50-M Shantipath SOUTH AFRICA Gate No.3, Niti Marg Kutlwanong Democracy Centre Chanakyapuri, 357 Visagie Street 0002 New Delhi, India 110021 P.O. Box 11624, The Tramshed Tel: 91-11-26886172 Pretoria 0126, South Africa Fax: 91-11-26885850 Tel: 27-0-12-320-2067 E-mail: [email protected] Fax: 27-0-12-320-5943 E-mail: [email protected] MALI ENABLE is funded by the Office of BP 1524 Population and Reproductive Health, Rue 939 Bureau for Global Health, U.S. Agency for Quizambougou, Zone Industrielle International Development, under the Bamako terms of Cooperative Agreement No. Mali HRN-A-00-98-00009-00. Tel: 223-21-5429 Fax: 223-21-0246 E-mail: [email protected]

denotes countries with ENABLE projects