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LESSON 6 POSITIVE LIVING FOR PLHIV (Facilitator EN)

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Learning objectives

By the end of the lesson, participants will be able to:

  1. describe the importance of each of the Positive Living Behaviours for maintaining or achieving good nutrition and good health
  2. describe practical dietary and other strategies to manage symptoms of HIV
  3. understand what good communication skills are and how these relate to counselling
  4. use the Positive Living cards to counsel PLHIV about the problems that they have, and how to live well to prevent illness
  5. decide which Positive Living cards are appropriate for a counselling session, depending on the circumstances of PLHIV

Duration: 4 hours 20 minutes

Methods

  • Presentation of cards
  • Participatory Lecture
  • Discussion
  • Game
  • Demonstration
  • Role Play

Materials

  • Large paper and markers
  • Large paper Monitoring Form (same as in Lesson 5)
  • Paper and pen/pencil for each participant
  • Blank A4 papers
  • Large paper or white board
  • Bag of beans (at least 15 beans per participant)
  • Prize(s) for the winner(s) of the game (Learning objective 5), if it is possible to conduct a hand washing demonstration:
    • Clean water (or cistern with scoop)
    • Soap and/or ash

Introduction

  • Note to facilitator

    Lesson 6 takes approximately 6 hours. We suggest a break in the morning and in the afternoon and plenty of energizers!

There are many simple things that PLHIV can do to stay healthy, treat common symptoms and keep a good weight/growth. “Positive Living” means that PLHIV can live active and healthy lives by taking good care of themselves, and by avoiding certain behaviors that are harmful to them and their families. In this lesson, we will learn some of the key, simple behaviors that PLHIV can do to protect their health. We will also learn counseling skills, and how to choose the messages that are appropriate for the person we are counseling. We’ll practice using the “Positive Living” cards and we’ll practice the skills for effective counseling.

Does anyone have questions about what you have heard?

Presentation of learning objectives

The facilitator shows the learning objectives (written on the large paper) and asks one participant to read the objectives aloud to the group. Discuss each objective with participants to make sure they understand.

By the end of the lesson, participants will be able to:

  1. describe the importance of each of the Positive Living Behaviours for maintaining or achieving good nutrition and good health
  2. describe practical dietary and other strategies to manage symptoms of HIV
  3. understand what good communication skills are and how these relate to counselling
  4. use the Positive Living cards to counsel PLHIV about the problems that they have, and how to live well to prevent illness
  5. decide which Positive Living cards are appropriate for a counselling session, depending on the circumstances of PLHIV

Learning objective 1 and 2:

Participants will be able to:

  • Describe the importance of each of the Positive Living Behaviors for maintaining or achieving good nutrition and good health.
  • Describe practical dietary and other strategies to manage symptoms of HIV

Methodology: Demonstration, Plenary Discussion

  • Step 1: Present the Positive Living Cards

Explain that, There are 25 different positive living cards in the set . We’ve talked about these a little already because, as you know, these cards can be used throughout the counseling process. Now we will go over each card in detail. On the back of each card is written (1) the name of the topic, (2) some questions to begin counseling, (3) the key messages for that topic, and (4) some questions to help PLHIV plan what they will do to solve their problem. The discussion points are a guide to the conversation and help counselors create two-way conversation with PLHIV while allowing them the opportunity to modify the advice to meet client’s situation and current practices. As we cover each positive living card we will also learn some more background information about each of the “Positive Living” Topics.

Explain to participants that Positive Living Cards (number 1 to 20) from this set of cards are written for use with PLHIV, including children and their parents and families. However there are special cards for use with pregnant and/or breastfeeding women (number 21 and 25) and special cards for use with caregivers according to the age of their child (number 22, 23, 24).

Explain that there are “Instructions for Using the Positive Living Cards” and a “Card Selection Table” (Annex 15) which provides guidance about possible cards to be used in a counseling according to the target groups. There are 25 cards in the set that include:

  • “General Situation Cards” – practical strategies to enhance health of PLHIV
  • “Specific Situation Cards” – practical strategies to manage symptoms of HIV
  • Step 2: Participatory Lecture and Discussion

Provide a brief description of the asymptomatic phase of HIV infection.

Explain that, As soon as HIV enters the body, it replicates quickly. This rapid replication requires energy and nutrients, which the virus takes from the body. Some PLHIV may not have symptoms at this stage (asymptomatic phase) but they need to eat more to meet increased energy and nutrient needs. The length of the asymptomatic phase varies and may last several years, depending on the person’s health and nutritional status before HIV infection and during the initial years of infection.

Activity – Group Discussion: Health Maintenance

Duration: 5 minutes

Instructions for activity:

Divide the participants into small groups (or pairs) and ask them to discuss recommendations for health maintenance in PLHIV

Bring the groups back together and ask a volunteer from each group to feedback the results of their small group discussion

Ask for a volunteer to write down the issues offered each group on the whiteboard.

  • Step 3: Discussion and Demonstration

Explain, Now we will go over each Positive Living Card that contains messages for health maintenance for PLHIV.

Facilitator Instructions:

  • Note to Facilitator

    Key information – Health maintenance for PLHIV

    Answer might include:

    • Eat a variety of foods
    • Three meals and two snacks
    • Drink plenty of water
    • Regular exercise
    • Avoid smoking
    • Maintain a healthy weight
    • Good oral health
    • Minimize alcohol and drugs
    • Ensure good personal and food hygiene

Review positive living card #1 on hand washing with the group using the following steps:

  • Ask participants to look at the picture and tell you what they think the picture is about.
  • Have one participant read the key messages.
  • Ask participants why this behavior is important?
  • List all the reasons participants feel that this behavior is important, especially for PLHIV.

More information is provided on hand washing below. After the participants have a chance to discuss why they think hand washing is important summarize the information to cover any points that were not already mentioned.

Hand washing

Bacteria (germs) are all around us and inside us. They are too small to see but they are very powerful. Some bacteria are helpful, and some are harmful. If we eat the bad bacteria, or breathe them into our throats or lungs, or if they get into an open wound, they can multiply and cause an “infection” that can result in vomiting, diarrhea, fever, swelling, nose or throat soreness, congestion, coughing, or a wound that does not heal.

Hand washing with soap or ash can kill the bad bacteria on our hands before they can get into our mouths, noses, throats or cuts in our skin. Bacteria also live in feces, so when we go to the toilet or clean a baby’s bottom, bacteria can get on our hands. This is why hand washing is recommended before cooking, before eating, after using the toilet and after cleaning a child’s bottom.

Soap is expensive for many families, but ash is something that almost every household has from the cooking fire. Ash is sterile (it does not have any bacteria) because it has been burned by the fire, and rubbing it on wet hands will remove the bacteria on the surface of the hands. The ash will rinse off easily, it does not leave the hands dirty or black.

Demonstrate the correct way to wash hands following these directions written on the big paper.

To summarize positive living card #1 on hand washing:

  • Ask all participants In what situation would you use this card for counseling?
  • Possible answers for when to use the card: if the client has diarrhea, if the counselor observes poor hygiene, if the counselor is doing a session on food safety.
  • Ask participants, What steps might the client take to be able to carry out this action?
  • Does anyone have questions about this?

Facilitator instructions:

Review positive living card #2 on food safety using the following steps:

  • Ask participants to look at the picture and tell you what they think the picture is about.
  • Have one participant read the key messages.
  • Why is this behavior important?
  • List all the reasons participants feel that this behavior is important, especially for PLHIV.

More information is provided on food safety below. After the participants have a chance to discuss why they think food safety is important summarize the information below to cover any points that were not already mentioned.

Food Safety

Food hygiene and safety is one of the main ways of preventing infection in PLHIV. All foods can make you sick if they are not prepared or looked after correctly. Vegetables and fruit can become contaminated with bacteria during growth and handling, so they must be cleaned well before cooking or eating them fresh. Fresh vegetables and fruit are good for PLHIV because they contain vitamins, but they need to be washed very well. Bacteria can also live in water, so the water used to clean vegetables must be boiled and cooled first, to kill the bacteria that is present. Encourage families to keep a kettle or container of boiled/cooled water in the kitchen for washing food and drinking. Meat and eggs have a high risk of making you sick, so ensure they are well cooked before eating. Ensure eggs are hard before eating.

Drinks, especially milk drinks like soy milk and infant formula, can grow bacteria very quickly. These drinks should be drunk as soon as possible from the time they are made up from a powder or opened.

Bacteria can grow quickly on leftover food, so it is important to re-cook foods (such as soup, and rice) very well before eating them again. The longer a food sits, the more bacteria can grow. Try not to leave at room temperature for more than two hours. Cover leftover food to protect it from dust, insects and animals. Re-cook leftover food (boil or fry) for at least 10 minutes before eating it.

Ensure that fresh foods are not mixed with cooked foods, for example ensure raw meat does not go near food that has already been prepared for eating.

To summarize positive living card #2:

  • Ask all participants, In what situation would you use this card for counseling?
  • Possible answers for when to use the card: If the client has diarrhea, if the counselor observes poor hygiene around the house, if there are young children living in the household, if the counselor is doing a session on food safety.
  • Ask participants, What steps might the client take to be able to carry out this action?”
  • Does anyone have questions about this?
  • Step 4: Small Group Breakout and Presentations

Instruction for activity:

To review the remaining cards divide the participants into small groups and assign each group some of the following positive living cards until all cards have been assigned.

3 – Oral Hygiene

4 – Plan ahead!

5 – Exercise

6 – Limit alcohol, avoid smoking

7 – Health and weight check every month

12 – Drink plenty of fluids

13 – Three meals, two snacks, every day!

Give each small group time to study their card, discuss the information on the card, and read the background information (provided in the lesson). Then bring the group back together and have each small group present their positive living cards.

The groups must present the following:

  • What the picture is about
  • The key messages
  • Why the behavior is important (including the information from the lesson)
  • The situation in which a counselor would use this card
  • The steps a client might take to be able to carry out this action.

Continue with the short lecture. Explain that, PLHIV may experience some symptoms due to untreated HIV infection or side effects of medications. Dietary management of HIV and ARV-related side effects can help to:

  • enhance nutrition status and promote immune function
  • complement and strengthen medical treatment, including improve medication compliance
  • improve quality of life
  • Note to facilitator

    If the small group does not present all of the background information on the positive living card be sure to cover the points missed. This is also the time to correct any misinformation. Allow participants to ask questions about each topic to make sure they understand everything.

Activity – Group Discussion: Managing symptoms associated with HIV

Duration: 5 minutes

Instruction for activity:

  • Divide participants into small groups and ask them to identify common symptoms that PLHIV experience.
  • Bring the groups back together and ask a volunteer from each group to feedback the results of their small group discussion
  • Ask for a volunteer to write down the issues offered by each group on the whiteboard.
  • Note to facilitator

    Key Information – Health maintenance for PLHIV

    Answer might include:

    • Weight loss
    • Nausea and vomiting
    • Diarrhea
    • Poor appetite
    • Sore mouth
    • Oral thrust

Background information for Positive Living Practices

1. Hand washing.

Bacteria (germs) are all around us and inside us. They are too small to see but they are very powerful. Some bacteria are helpful, and some are harmful. If we eat the bad bacteria, or breathe them into our throats or lungs, or if they get into an open wound, they can multiply and cause an “infection” that can result in vomiting, diarrhea, fever, swelling, nose or throat soreness, congestion, coughing or a wound that doesn’t heal. Hand washing with soap or ash can kill the bad bacteria on our hands before they can get into our mouths, noses, throats or cuts in our skin.

Bacteria also live in feces, so when we go to the toilet or clean a baby’s bottom, bacteria can get on our hands. This is why hand washing is recommended before cooking, before eating, after using the toilet and after cleaning a child’s bottom.

Soap is expensive for many families, but ash is something that almost every household has from the cooking fire. Ash is sterile (it does not have any bacteria) because it has been burned by the fire, and rubbing it on wet hands will remove the bacteria on the surface of the hands. The ash will rinse off easily, it does not leave the hands dirty.

How to wash hands:

  • Wet the hands
  • Rub the hands together with soap or ash for 20 seconds (count from 1 to 20).
  • Rub the soap or ash between the fingers, and on the front and back of the hands.
  • Rinse the hands with running water.
  • Let the hands air dry, or dry them with a clean cloth. Do not dry them on your clothes or a dirty cloth (where there are bacteria).

In what situation would you use this card for counseling?

If the client has diarrhea, if the counselor observes poor hygiene, if the counselor is doing a session on food safety.

2. Food Safety.

Food hygiene and safety is one of the main ways of preventing infection in PLHIV. All foods can make you sick if they are not prepared or looked after correctly. Why is cleaning food important? Vegetables and fruit can become contaminated with bacteria during growth and handling, so they must be cleaned well before cooking or eating them fresh. Fresh vegetables and fruit are good for PLHIV because they contain vitamins, but need to be washed well. Bacteria can also live in water, so the water used to clean vegetables must be boiled and cooled first, to kill the bacteria present. Encourage families to keep a kettle or container of boiled/cooled water in the kitchen for washing food and drinking.

Drinks, especially milk drinks like soy milk and infant formula, can grow bacteria very quickly. These drinks should be drunk as soon as possible from the time they are made up from a powder or opened.

Bacteria can grow quickly on leftover food, so it is important to re-cook food (such as soup, and rice) very well before eating it again. The longer food sits, the more bacteria can grow, try not to leave at room temperature for more than two hours. Cover leftover foods to protect them from dust, insects, and animals. Re-cook leftover food (boil or fry) for at least 10 minutes before eating it.

In what situation would you use this card for counseling?

If the client has diarrhea, if the counselor observes poor hygiene around the house, if there are young children living in the household, if the counselor is doing a session on food safety.

Ensure that fresh foods are not mixed with cooked foods, for example ensure raw meat does not go near food that has already been prepared for eating.

3. Oral Hygiene

Bacteria grow quickly in warm dark places (like the inside of the mouth), and like people, bacteria need food to grow. Bacteria living in our mouths can grow on the small pieces of food that remain after eating. Toothpaste contains anti-bacterial ingredients that help to keep the inside of the mouth clean. PLHIV should try to brush with toothpaste at least twice a day or if possible after every meal. Encourage children to brush their own teeth from an early age (after one year old), but keep helping the child to brush their teeth until they are about 8 years old.

The gums should be brushed very gently, so as not to cause irritation or break the skin.

In what situation would you use this card for counseling?

If the client has sores in their mouth or thrush, if the counselor notices poor hygiene in the house, if the counselor is conducting a general session on personal hygiene.

4. Plan Ahead for Food Security!

What months of the year are considered the “lean season” in this area? (the time of the year when less food is available). What do poor families normally eat during this period? There are several foods that can be stored for months, and eaten throughout the lean season. Dry beans can be stored for one year and pumpkins can be stored for several months. Ask PLHIV what other things can be stored. Does the family have a dry safe place for storage? What quantity would they need to last throughout the lean season? How could they store this quantity? What kind of containers would they need? When (what month) should the family begin to prepare and store the food? Help them to make a plan for storing food.

The easiest to get a variety of nutritious foods on a daily basis is from your garden. Encourage PLHIV to start a home or community garden where PLHIV can grow different varieties of vegetables and fruits for harvesting at different times of year. A home garden can be easily set up even on a very small amount of land or in scattered plots around the house such as backyard, under the house, new the cow shed or in front of the house. It is possible to produce a large number of nutritious local varieties of vegetables and fruits all year round – such as amaranth, kangkong, pumpkin, wax gourd, papaya, and coconut –without significant amounts of money, time and land.

In what situation would you use this card for counseling?

If the client complains of poor food security, if client is underweight or has lost weight. The client can be encouraged also to gather foods like water cress, ivy leaves, frogs, crabs, shrimp, small fish, snails from the rice fields etc., and to plant a small garden or a few vegetables in pots.

5. Exercise

One of the biggest challenges for PLHIV is keeping a positive and hopeful attitude. Exercise is good for a person’s physical, mental and emotional well-being. It can also help to increase appetite. Encourage PLHIV to have a regular exercise routine that involves friends or family members. Continuing routine work activities is also important – it is good for the mind and the body, and it helps their families. If PLHIV are not feeling well, a small amount of gentle exercise such as a slow 5 minutes walk, can help them feel better. What are some of the barriers to regular exercise? How can these be overcome?

In what situation would you use this card for counseling?

If the client complains of being weak or shows signs of depression or poor mental health, if the counselor is running a session on positive living.

6. Limit alcohol, avoid smoking

The money available for food is reduced when there are one or more smokers and drug users in the family. Smoking can also decrease appetite. Alcohol consumption can be harmful if it is excessive and cause dehydration. However, alcohol is often part of cultural celebrations (weddings, ceremonies, etc), and avoiding it entirely may create social stigma for PLHIV. This is why we counsel PLHIV to “limit” alcohol consumption. However pregnant women and children should ensure they do not drink any alcohol, and breast feeding women should only drink very small amounts on special occasions.

One serious consequence of smoking and drugs is the cost. Smokers are more likely to have problems breathing or working, to get diseases of the mouth and lungs (like cancer), and to lose teeth. When the mouth becomes sore, eating becomes painful and difficult.

All other drugs, both injectable and non-injectable should be avoided. If the PLHIV has a drug problem, it is important to refer them to a service that can help them.

In what situation would you use this card for counseling?

If clients are regular smokers, people who are known to get drunk or use drugs on a regular basis, or are pregnant/breastfeeding women etc.

7. Health and weight checks every month

Why is it important for PLHIV to go for a health and weight check every month? Why so often? The immune defense of a PLHIV does not function as well as that of a person who does not have HIV. If a PLHIV becomes sick or loses weight, the situation can develop very quickly into a potentially serious or deadly illness. This is why it is important to monitor the health and weight of PLHIV every month at a health centre, OI/ART site or referral hospital. Weight loss can be a clear sign to the client that they have an infection or that something is wrong.

It is important for PLHIV to get weighed regularly to make sure they are not losing or gaining too much weight. If weight is monitored, any unintentional weight loss or weight gain can be more easily detected and something can be done sooner about the situation.

Why is it important for pregnant women to receive regular checkups (at least 4 times) during pregnancy? Visiting a HCallows the health staff to monitor the health of the mother and the growth of the baby. A pregnant woman with HIV will need special health care because HIV infection can be passed from the mother to her baby so it is important that a pregnant woman should get tested for HIV during her first trimester of pregnancy. Pregnant women with HIV need counseling from a trained health worker on how to reduce the risk of infection to the newborn baby and she needs to understand the options for feeding their newborn baby and decide the safest way to feed their baby.

In what situation would you use this card for counseling?

All clients should be counseled to have their weight monitored, including: someone who has experienced weight loss or has a low BMI; all pregnant and breastfeeding (but especially if they have had malnutrition) women; someone who has missed their monthly check-up several times; someone who has just learned that they are HIV-positive; and someone who is often dealing with OIs or who has just recovered from an OI.

8. Seek immediate care for infections

The person in the picture on this card has swelling in the jaw, perhaps due to a tooth infection. This is just an example; the correct advice is to seek immediate care at the HC or OI clinic for any kind of infection. Common infections/illnesses include bed sores, diarrhea, mouth sores, fever, etc. The natural immune defense of a PLHIV does not function as well as that of a person without HIV. So any kind of infection or illness is dangerous for PLHIV and can become serious very quickly.

Another message from this card is the importance of regaining the weight that is lost during illness. This is particularly important in children, pregnant and breastfeeding women.

As we discussed in the beginning of the training, illness and infections make the body use a lot of energy to fight them, causing it to lose weight. Once the body loses weight the person is then more susceptible to infection again, thus creating a never-ending cycle of malnutrition and illness. To break this cycle, it is important for our clients to regain the weight that they lose after illness. Any time we are dealing with illness or infection we should always advise the client to increase food intake during the recovery period until the weight that was lost has been regained. What were the seven ways of gaining weight we talked about at the beginning of the training? Improving frequency and quality as indicated on the monitoring forms are strategies we can promote with our clients.

In what situation would you use this card for counseling?

If the client complains of any kind of infection or illness, or if the client is recovering from any kind of infection or illness (particularly the messages on regaining weight).

9. Take medicine as directed

PLHIV who take medicine on time, all pills, no missed doses, have lower levels of the HIV virus in their bodies. When taken as directed the medicine continues to work well and fight the virus. If medicine is not taken as directed the virus can grow stronger and the medicine will not work as well as before. It is important for PLHIV who take medicine to eat well because good nutritional practices help the medicine to work well. Some medicine may require special attention to ensure the medicine works effectively, for example taking them with foods or on an empty  stomach. Encourage PLHIV to discuss interactions between medicines and foods with their doctors.

The transmission of the HIV virus to the baby can be greatly reduced if medicines are taken correctly in pregnancy and during breastfeeding. It is important for babies exposed to HIV to take any medicines as directed by the health staff to protect them from HIV and also other illnesses. For children with HIV, it is important for them to take medicines so they can be healthy (i.e. to ensure normal growth and development).

What are some of the challenges for PLHIV to take their medicine as directed? (Possible answers – they forget, they feel nausea, they don’t have enough food, they are confused by the doctor’s instructions, etc).

In what situation would you use this card for counseling?

If the client indicates that they are not taking medication appropriately, if the client is pregnant or breastfeeding, if the client complains of side-effects, if the counselor is running a general session on positive living practices.

10. Manage side effects of ARV drugs

It is important for PLHIV to know that like other medicines, side effects are normal when they first start taking medicines and that they will go away after a time. Some possible short term side effects of ARV drugs are poor appetite, nausea, vomiting, abdominal pain, diarrhea, headache, dizziness, lethargy and change in taste. Encourage PLHIV who are having problems with side effects to talk to other PLHIV who have been through this experience already, to talk to their medical provider at the OI/ART clinic, and most importantly to keep taking their drugs as directed.

It is important for PLHIV to keep eating even when they are not feeling well because of the side effects. But they should not eat in a way that makes them vomit. Encourage them to rest and drink plenty of fluids, which will help the drugs to work well.

In what situation would you use this card for counseling?

If the client indicates that they are not taking medication appropriately, if the client complains of side-effects, if the counselor is running a general session on positive living practices.

11. Danger signs of weight loss/poor growth

As we learned in Lesson 2, PLHIV who are not sick need about 10% more energy every day than people who do not have HIV. PLHIV, who are ill (symptomatic), need about 20-30% more energy (than people who do not have HIV). We also leant that children, pregnant and breastfeeding women with HIV have even higher energy needs. This is because the body needs energy to fight infection. Food is the only thing that can add calories (energy) to our bodies. The things that can take away energy from our bodies are infections, and very heavy workloads. Moderate work and exercise are good because they help keep the body strong, but the harder a person works, the more they must eat to maintain a good body weight.

Weight loss, or wasting, is one of the most common symptoms of untreated HIV infection, and can occur at any stage of infection. It needs to be taken seriously because malnutrition can reduce the strength of the immune system.

PLHIV and their families must be trained to recognize the danger signs of weight loss/poor growth. This is important, and even if the PLHV is being weighed every month, the person and the family should still watch for the danger signs and make sure the person eats more as soon as they think they might be losing weight or having poor growth if they are a child. Try to make sure that other family members are also present to receive this information.

Losing weight, or staying the same weight, from one month to the next, is a sign that the child is in poor health. It is important to refer the child to the HC for follow up and counseling.

In what situation would you use this card to counsel PLHIV?

If the client complains of any kind of infection or illness, if the client is recovering from any kind of infection or illness, if the client shows signs of weight loss/poor growth, low BMI etc., if the counselor is running any session on self care at home and positive living.

12. Drink plenty of fluids

What is dehydration? Dehydration is when the body does not have enough fluid inside it to function well. The body needs plenty of fluid inside it to fight disease and for drugs to be effective. Children also need to have lots of fluids, so ensure they are regularly drinking all day. Pregnant and breastfeeding women also need to drink more fluids. Many people, especially people who live in a hot climate, are dehydrated and don’t even know it. Thirst is a sign that your body is already dehydrated. This is why all people, especially PLHIV, should drink regularly, even before they feel thirsty. Another sign of dehydration is dark yellow urine with a very strong smell.

Most drinks add to the liquid inside our bodies, and this is good. But some drinks actually cause us to urinate more than others, so in fact they are reducing the overall amount of liquid in the body (they dehydrate us).

Dehydrating drinks include carbonated sodas with caffeine in them like cola, alcohol, and strong coffee and tea. These drinks should be taken in moderation.

Adults should drink about 2 liters of liquids every day. This is about four large cups, or eight small cups. Encourage PLHIV to measure 2 liters in the cup that they normally drink from.

This advice to “Drink plenty of fluids” is good information for all PLHIV, and also for people who do not have HIV. You do not need to wait for a special circumstance to use this card.

Clients who have experienced weight loss or poor growth or are malnourished should drink fluids with energy in them, such as soy milk, cows milk, juices etc.

In what situation would you use this card for counseling?

All clients would benefit from this card, in addition: if the client indicates during the assessment that they drinks less than 2 liters of water per day; if the client has an illness or is recovering from an illness like diarrhea or fever; or if the client shows signs of lost weight/poor growth or malnutrition. This card can be used with the blue small cards to explore various fluid options to entice the client to drink more.

13. Three meals, two snacks, every day

group (white), Body-Building group (red), and Protective group (yellow/green) (we learned this in Lesson 2). Many people in Cambodia normally eat only two meals per day (midday and early evening). Many PLHIV start to eat three meals (adding breakfast) at the time they start taking ARV drugs. This is good, but in fact all PLHIV should eat three meals and two snacks or more every day. Doing this is one of the simplest ways to ensure that PLHIV are getting the extra food they need. Another way to increase energy intake is by increasing the amount of food served at each meal or snack. Each meal should contain foods from the three major food groups – Energy group (white), Body-Building group (red), and Protective group (yellow/green) (we learned this in Lesson 2).

This card is a good reminder for anyone, but it is especially useful for PLHIV who are not eating the recommended number of meals and snacks each day because PLHIV need to eat more food than people who do not have HIV. If the body’s requirement for energy is not met, body will break down fat and muscle, leading to weight loss.

In what situation would you use this card for counseling?

All clients would benefit from this card, in addition: if the client indicates during the assessment they eat less than three meals or two snacks per day; if the client has an illness or is recovering from an illness like diarrhea or fever; and if the client shows signs of lost weight and low BMI.

14. Enhancing your appetite

“Comfort foods” are different for every person. Some people like porridge, some like soup, and some may prefer desserts, drinks or fried fish. As a counselor, you will need to ask (not tell) the PLHIV: What foods do they enjoy eating the most? What foods make them feel happy or better when you are ill? The answers could be different for every person, and every answer is okay. The important thing is for PLHIV to identify the food they enjoy the most, and to make that food as nutritious as possible. This will help PLHIV to keep eating, even when they do not feel hungry.

For children, the “comfort foods” are more likely to be fluids such as breast milk, milk or fruit. When a breastfed baby is unwell it is especially important to continue to encourage breastfeeding. Breastfeeding provides comfort to a sick baby.

This message is important not only for PLHIV but also for their family members and care givers who can help cook and encourage them to eat.

In what situation would you use this card for counseling?

If the client indicates that they are not taking medication appropriately, if the client complains of side-effects, if the client has an illness or is recovering from an illness like diarrhea or fever, if the client shows signs of lost weight and low BMI, or if the counselor is running a general session on positive living practices.

15. Dietary strategies for managing diarrhea

Diarrhea is dangerous because it can dehydrate a person very quickly. This is especially dangerous in children, and can cause death. It can also be very painful. If a PLHIV has diarrhea, give them an oral rehydration solution (ORS) and specific instructions for how to prepare it (1 package mixed with 1 liter of boiled water). It is very important to use the correct amounts of ORS powder and water. If possible, demonstrate to the PLHIV and their families how to make the ORS using a 1-liter water bottle that is typically found in the villages.

In children, the most important thing is getting enough fluid into the body; make this the focus when a child is very sick. During diarrhea, ensure that ORS is provided after the child passes a stool. Give liquids such as soup, thin porridge, coconut water and boiled water. Keep giving liquids until the diarrhea stops. If the child is breastfed, increase the number of times each day the breast is offered. Breastfeeding can reduce the severity and frequency of diarrhea. It prevents dehydration and malnutrition and helps replace lost fluids. It is also important to encourage the child to keep eating even he or she has diarrhea.

  • Note to facilitator

    Show participants the BFCI flipchart number 19 and 20, and explain that these pages show what a mother should do when her child is sick. It can be used during the counseling session with a mother/caregiver when the child has diarrhea.

Blood in the diarrhea indicates a serious illness or infection, and PLHIV should seek treatment at the HC immediately. If diarrhea continues for more than four days, PLHIV should also go for treatment at the HC. The client needs to take ORS after each occasion of diarrhea.

In an infant or young child with diarrhea has more than 3 loose stools a day for two days and/or blood in the stools and shows signs of dehydration (sunken eyes, dry lips and tongue, and not passing urine), take them immediately to the closest health centre.

In what situation would you use this card for counseling?

If the client indicates that he/she has diarrhea or if a child in the household has diarrhea.

16. Dietary strategies for managing nausea and vomiting

Vomiting, like diarrhea, can also dehydrate a person very quickly. It can be dangerous in pregnant and breastfeeding women and children. It also prevents the person from wanting to eat, or getting the benefits of the food that cannot stay in their stomach. Sometimes taking medicine makes a person vomit. In this case, we do not know if the person has vomited the medicine or not. Do not tell the person to take more medicine; this could be dangerous. However, if a PLHIV is vomiting for more than a day, he/she should seek treatment from the HC or the doctor at the OI clinic. If a child keeps vomiting (i.e. cannot keep anything down), he/she should be taken to the nearest health centre.

In what situation would you use this card for counseling?

If the client indicates they are nauseous or have been vomiting, if the client indicates that they are not taking medication appropriately, if the client complains of side-effects, if the client has an illness or is recovering from an illness like diarrhea or fever.

17. Dietary strategies for managing thrush

Thrush is common among PLHIV because their bodies are often not able to resist this kind of infection. The “germ” that causes thrush (yeast) is all around us. Sometimes people who do not have HIV also get thrush in the mouth, especially babies or older people. Babies with oral thrush may experience difficulty feeding. Thrush can also infect the vagina or penis. Thrush grows well in warm, dark places. Thrush and mouth sores can be painful and prevent PLHIV from eating. Encourage PLHIV to keep their mouths clean as instructed on the card.

In what situation would you use this card for counseling?  

If the client complains of thrush.

18. Dietary strategies for managing fever

Fever is another symptom of illness that can rapidly dehydrate a person, because the body loses fluid through sweating. There are many things that can cause fever, but the important thing is for PLHIV and their families to know when they should seek treatment (as described in the key messages) and to drink plenty of fluids during the bouts of fever. If a child exposed to or infected with HIV has a fever, take them to the HC as soon as possible.

In what situation would you use this card for counseling?

If the client indicates they are nauseous or have been vomiting, if the client has an illness or is recovering from an illness with fever, if the counselor is doing a well-being session on positive living.

19. Anemia

Certain groups of people are more prone with anemia. These include babies and young children (6 months to 3 years old), pregnant and breastfeeding women, women of child bearing age and adolescent girls. Babies are born with iron stores. For the first six months of life, the best source of iron is breast milk. Most breastfeed babies receive enough iron from breast milk to keep the stores they were born with topped up. Around about 6 months, babies should have iron rich complementary foods (enriched bobor). Young children have higher iron needs because their bodies and brains are growing fast. Women and adolescent girls should have more iron-rich foods than men because they lose iron during menstruation. During pregnancy, the body makes more blood because pregnant women and their babies are growing.

The body needs iron to make healthy blood. Anemia is also a common complication of HIV, including for pregnant women with HIV, especially for those on ART.

To prevent anemia, it is important to encourage most at risk PLHIV to eat iron rich foods. There are two different types of iron in food. Iron from animal foods and iron from plant foods. If PLHIV get their iron from an animal, such as pork, beef, animal organs, chicken, shellfish, fish or frog, their body can use it very easily because is very similar to the iron in their own bodies. Remember that iron from plant foods, such as dark leafy vegetables, green broccoli, tofu, beans, is not taken up by the body as well as iron from animal foods. To help the body use iron from vegetables, eat these foods with vegetables and fruits rich in vitamin C (iron helpers) such as tomato, tamarind, chili peppers, mango, papaya or orange.

Unfortunately there are foods that make it harder for body to use iron (called iron blockers). If PLHIV have, or are prone to anemia, encourage them to drink tea, coffee, cola drinks between rather than with meals. Drinking these drinks with meals reduces the absorption of iron we get from the foods in that meal. Do not give tea to babies and children.

In what situation would you use this card for counseling?

If the client looks pale (pale palm of hands, pale nails, pale inner eye lids) and indicates that he/she feels weak and tired, if the counselor observes the client not eating enough high iron foods. If the counselor is doing a session with babies and young children (6 months to 3 years old), pregnant and breastfeeding women, women of child bearing age and adolescent girls.

20. Eating well

Eating well helps PLHIV to stay healthy longer. Different foods protect or strengthen the body in different ways. Each type of nutrient has a specific function and the nutrients work together as a team. Therefore it is important for a PLHIV to consume a variety of foods on a daily basis for growth and to maintain optimal health. As much as possible, encourage PLHIV and their families to eat local foods and foods that are in season. By taking care to choose foods that are in season and locally available, eating can be enjoyable, healthy and affordable.

A good meal should include foods from the three food groups and a drink. An example of a mixed meal of optimal variety is one made up of rice, fish, pumpkin and dark green leafy vegetables. This could be exchanged with other foods in other meals on other days.

For example, rice can be eaten with other body building foods such as frogs, eggs, eel or tofu, instead of fish. In addition, try to buy fruits and vegetables that are in season, such as, mangoes and traditional green leafy vegetables, to add variety. Fruits and vegetables can also be grown at home. Remember to drink enough clean boiled water every day. Eating well helps fight illness and infection and improves response to treatment. HIV increases the body’s need for energy (i.e. food). Failing to meet a body’s nutritional needs will lead to poor nutritional status. Eating well helps a PLHIV to meet their body’s nutritional needs.

This message is important not only for PLHIV but also for their family members and care givers who can help prepare and cook meals. As a counselor, when suggesting food to a person, you will need to ask (not tell) the PLHIV: What foods are grown or produced in the area? Which foods in the card are considered “too expensive” for regular use? Which foods are seen as affordable for you?

In what situation would you use this card for counseling?

All clients (adults and children) would benefit from this card, in addition – if the counselor observes during assessment the client does not eat meals that have a variety of food types.

21. Eat well when you are pregnant or breastfeeding

Pregnant women have extra nutritional needs due to the changes in their bodies and the needs of their growing baby. This is the same for all pregnant women, whether they have HIV or not. Breastfeeding women need extra foods to recover from their delivery and to produce sufficient quality and quantity breast milk for their babies. As we learned in lesson 2, pregnant or breastfeeding women with HIV need even more energy – 35% extra energy for the baby’s growth and breast milk production – as well as for fighting the virus.

Encourage pregnant and breastfeeding women to eat a variety of foods to ensure that they get all nutrients they require. Many pregnant and breastfeeding women in Cambodia eat only two meals per day, so it is important to encourage them to eat more food, more often.

It is easy to start with the foods that are commonly eaten in the community, are usually well liked, and are easy to grow. Ensure pregnant and breastfeeding woman drink plenty of fluids.

  • Note to facilitator

    If the participants are not working with children, pregnant or breastfeeding women with HIV, Positive Living Card 21 to 26 may be left out of the training.

During pregnancy, women are storing food for their body to use during pregnancy, at birth and during the first months of the baby’s life. It is important for pregnant women to gain enough weight during pregnancy. If a woman’s weight after delivery is lower than her weight before pregnancy, even she is eating well, her continued weight loss may be a sign of illnesses associated with HIV. Refer mothers who are losing weight and not feeling well to the nearest HC.

If a pregnant woman experiences heartburn and nausea as well as a change in taste or appetite, she should eat small amount of foods at frequent intervals (i.e. eat 5 or 6 meals a day) and should drink fluids between, rather than with meals. A small bowl of sweet mung bean porridge is an example of a light meal or snack. See also card 14 and 16 for practical dietary strategies for improving appetite and managing nausea and vomiting.

There are some specific beliefs and practices about foods during pregnancy and breastfeeding. It is important that expectant mothers/mothers should be counseled and informed about food taboos, beliefs and practices that may be beneficial, neutral or harmful as well as suggestions on ways to help them change those misconceptions (see Lesson 3 for some common misconceptions about food related to pregnancy and breastfeeding).

In what situation would you use this card for counseling?

All pregnant, post partum or breastfeeding women with HIV would benefit from this card. If the counselor observes a pregnant or breastfeeding woman eat less food than usual, if the expectant mother complains of morning sickness, nausea, heartburn, if the counselor detects during assessment that the pregnant/breastfeeding woman does not eat more meals.

22. Starting foods with your baby (6-24 months)

After 6 months, breast milk alone cannot provide enough nutrients for the rapid growth and development of the child. The child needs other foods in addition to breast milk. However it is also very important that they continue to breastfeed because the nutrients in the breast milk help them to grow and to fight diseases. A mother should continue to breastfeed after complementary foods are introduced and for as long as the mother and baby want to, but at least until the child is 1 year old. Breastfeeding  should be offered before other foods, to be sure the infant takes plenty of breast milk every day.

Relative to body size, children need more food than adults but young children have small stomachs, so they need more frequent meals. The complementary food should be well cooked, soft, and mashed. A 6 month old child is not accustomed to eating food yet, therefore a mother must be patient to encourage the child to try the new foods.

Start by providing only one type of food to the child. When the child gets used to eating that food, introduce another kind of food. Mother needs to choose one of the following recipes:

  • 1-Rice bobor + chopped meat + green leafy vegetables + oil, or
  • 2-Rice bobor+ fish + green leafy vegetables (+ orange vegetable) + oil, or
  • 3-Rice bobor + egg + green leafy vegetables (+ orange vegetable) + oil, or
  • 4-Potatoes (or taro or beans or tofu) + ground nuts + green leafy vegetables (+ orange vegetable) + oil

When starting giving complementary foods, encourage mothers/caregivers to think about frequency, amount, thickness, variety, responsive feeding and hygiene. Like adults, children need a variety of foods from the three food groups. Responsive feeding describes the way of feeding a child: be patient and actively encourage baby to eat; don’t force baby to eat; give the baby time to get used to eating foods other than breast milk; and use a separate plate to feed the baby to ensure they eat all the food given. Good hygiene (cleanliness) is important to avoid diarrhea and other illness.

As we learned in Lesson 2, babies and young children living with HIV (i.e. have had a positive HIV test result) also need more energy and nutrients to grow and fight infections so they need more food than children without HIV. It is important that children living with HIV should increase energy intake to prevent weight loss and promote growth. A baby with HIV who is not sick should receive at least one extra feed per day. A baby with HIV who is sick and/or losing weight should be fed twice as much compared with what a healthy baby should eat [see also Lesson 2 (participant manual) for the daily food guide for babies and children with HIV (6-24 months)].

Sick children should be given small frequent meals, preferably of their favourite foods, and more fluids, including breast milk (if they are breastfed infants, do not commence mixed feeding in this situation). After illness children should be given more food more food than usual.

In what situation would you use this card for counseling?

If clients are mothers or caregivers with children 6 to 24 months of age, discuss the appropriate complementary foods using the appropriate age.

Note for the counselor

This information is important for non-breastfed children who are between 6 and 24 months. Sometimes young children (6-24 months) are not breastfed. Reasons could include that their mother has died or that their mother is HIV-positive and has chosen not to breastfeed her baby. These children need extra food to compensate for not receiving breast milk, which can provide half of their energy and nutrient needs from 6 to 12 months and one third of their needs from 12-23 months. A minimum of 2 cups of milk each day is recommended for all children under 2 years old who are not breastfed or no longer breastfeed. This milk can be either commercial infant formula, that is prepared according to directions, or animal milk, which should be boiled for children less than 12 months old. Remember that if children are not breastfed, they need the same amount of food and snacks as the breastfed children of the same age plus 1-2 extra meals and 2 cups of milk each day.

23. Feeding school-aged children and youth (nutrition for children over 5 years old)

School-aged children and youth need to eat healthy and balanced meals. It is especially important that girls eat well so that when they are women, they are well nourished and can produce healthy babies. Healthy eating and physical activity help children grow, learn, and build strong bones and muscles. The need for most nutrients increases as girls and boys reach puberty because they are growing so quickly and often gain half of their final body weight during adolescence (10-19 years). Adolescence is a period of transition between childhood and adulthood which involves a period of rapid growth, physical and psychological development and maturation.

This growth and development creates increased needs for energy and nutrients. Inadequate energy and nutrients can stop or slow linear growth (stunting) and delay sexual maturation.

Adolescent boys have high energy needs and that is why they often feel hungry and eat large quantities of food. Adolescent girls need more iron rich foods when they start to menstruate. If a teenager becomes pregnant, she has even higher nutrient needs to support both her growing baby and her own continued growth and physical development. These can be met by giving larger or more frequent nutritious meals and snacks. If her nutritional needs are not met, her baby may be born with low birth weight or health problems.

In what situation would you use this card for counseling?

If clients are school-aged children, teenage girls/boys and/or their parents/caregivers.

24. Promoting good growth for children living with HIV

All children grow and develop at different rates. It is important to monitor a child’s growth and development so that any possible concerns can be identified and treated as early as possible. Many of the things that we have learned in this training will help children to grow and develop to their full potential: good breastfeeding and complementary feeding practices. Babies and children should attend regular growth monitoring and promotion sessions, particularly for the first two years of life, to make sure they are growing well and identify any nutrition problems the children may have, such as severe thinness or swelling. Regular growth promotion and monitoring prevents malnutrition.

A healthy child who is growing well should gain a certain amount of weight every month. Malnutrition happens when a child does not receive enough food and care to grow healthy and strong. If the child is not gaining or losing weight as he/she gets older, there is a problem. Refer the child to the HC as necessary. Malnutrition and growth failure (poor growth) usually strikes a child between one to two years of age, because at this time, children are often being weaned and can be easily affected by a lack of food and poor hygiene. It is important to address poor growth and poor nutrition quickly, as soon as they are identified. Malnutrition is dangerous because it affects both the physical and mental development of children.

In children with HIV, malnutrition and growth failure (poor growth) is extremely common and is often seen before a child becomes sick with illnesses such as lung infections and ongoing diarrhea. It can indicate rapid disease progression if it is seen in HIV-exposed infants before the laboratory diagnosis of HIV infection can be made. HIV positive children with severe acute malnutrition should be urgently evaluated at the nearest Pediatric AIDS care site or admitted to hospital for treatment.

Encourage the mother or care giver to take the child for regular growth monitoring and promotion. During growth monitoring and promotion sessions, the mother or caregiver can ask questions about the child’s growth, health and nutrition. Immunization is important for babies because it can protect the baby against several diseases. Encourage the mother to ask about her baby’s immunization schedule and follow the recommendations from the National Immunization Program. The policy recommends that Bacillus Calmette–Guérin (BCG) vaccination should not be given to a child with HIV.

In what situation would you use this card for counseling?

All children with HIV under 5 years of age would benefit from this card, in addition – if the counselor observes during assessment the mother/caregiver not taking the child for regular monitoring and promotion, if the child is not gaining weight or losing weight.

25. Tips for breastfeeding – Breastfeeding when the mother is living with HIV

Infant feeding recommendations are given to the mother at the health facility. The National Guideline for the Prevention of Mother-to-Child Transmission of HIV (Ministry of Health, 2011) recommends that exclusive breastfeeding is the primary option encouraged both for the general population and for mothers living with HIV. Exclusive breastfeeding means that a baby receive ONLY breast milk during the first 6 months of life – no other foods, drinks (i.e. no tea, no fruit juice, no honey, no sugar, no rice water, no milk formula), or even water are required. However drops and syrups of medicines can be given when medically prescribed.

Benefits of breastfeeding:

  • Breast milk is the perfect food for babies, it contains everything (i.e. nutrients and water) a baby needs for the first 6 months.
  • Breast milk protects babies from many diseases, especially diarrhea and lung infection.
  • Breast milk is free, always available, and does not require any preparation.
  • Exclusive breastfeeding for the first six months together with ARV for either mother or baby greatly reduces the risk of passing HIV.
  • Exclusive breastfeeding helps mothers recover from childbirth and protects them from getting pregnant again too soon

Encourage HIV positive mothers who have not breastfed before to ask trained breastfeeding counselors or health staff who know about breastfeeding (especially for HIV positive women) to teach them about breastfeeding before they have their baby.

Mixed feeding (feeding a baby both breast milk and any other milks or foods including water, rice water, juices, diluted condensed milk/canned milk) is very dangerous and should always be avoided because it greatly increases the chances of passing HIV to the baby. It also increases the chances of the baby suffering from other illness such as diarrhea and lung infection because he/she is not protected through breast milk). A baby less than 6 months old has immature intestines. Other food or drinks than breast milk can cause damage to the baby’s intestines (causing “small holes”), which then makes it easier for HIV and other diseases to pass into the baby.

If a mother with HIV get breast problems such as sores, bleeding and/or cracked nipples, encourage her to seek advice and treatment immediately. She can continue breastfeeding on the demand from the uninfected breast or may be encouraged to express and heat treat her breast milk so that it can be fed to her baby while she is recovering.

Once a baby with HIV reaches 6 months of age, the mother with HIV should introduce complementary feeding and continue to breastfeed (along with ART for mother and child) up to 24 months or longer. If a mother decides to stop breastfeeding before 12 months of age, breastfeeding should only stop when a nutritionally adequate diet can be achieved without breast milk. The child should be weaned gradually over 1 month rather than abruptly. Stopping breastfeeding abruptly can cause consequences such as poor growth and diarrhea.

If an HIV positive mother is working or has to be away from her baby, expressed breast milk can be given to the baby. It is important that the mother knows how to express breast milk and store it correctly. Expressed breast milk (kept in a clean, covered container in a cool place) can be stored for up to 8 hours at room temperature or in a refrigerator for 24 to 48 hours. Always feed the baby using a clean open cup. DO NOT use bottles, teats or spouted cups. They are difficult to clean and cause the baby to become sick. The mother should express breast milk before she leaves home and while she is away from the baby. This will keep the milk flowing and prevent breast swelling. She should breastfeed exclusively and frequently for the whole period that she is with her baby.

In what situation would you use this card for counseling?

If the client is an HIV positive pregnant woman who has decided to breastfeed her baby, an HIV positive breastfeeding woman.

Note to facilitator

The new guidelines of the Ministry of Health on mother-to-child prevention states that, to treat all mothers with ART upon confirmation that they are HIV positive.

All babies exposed to HIV should be breastfeed for 6 months, receive vaccination according to the national program, and recieve ART in accordance with the PMTCT program.

Policy for the use of Pediatric ART in Cambodia was published in November 2011, by National Center for HIV/AIDS, Dermatology and STD (NCHADS).

Learning objective 3:

Participants will be able to understand what good communication skills are and how this relates to counseling

  • Step 1: Participatory Lecture

Explain that, Good communication is not just telling a person what they should do; instead it is a way of working with people to help them decide for themselves what they think is best to do in their situation. There are many factors that work together to contribute to good communication. The communication skills that we will review can also be called “counseling skills”. Good communication skills can lead to positive behavior changes, whether its nutrition related or for improved quality of life.

  • Step 2: Brainstorming

Instructions for activity: Ask participants to brainstorm factors that contribute to good communication. Write the answers on flipchart paper.

  • Step 3: Participatory Lecture

Skills to facilitate good communication

Explain that, When someone comes to you for advice, good communication skills are essential to help build a relationship based on trust and confidence. This ensures you can gather relevant information and the individual can build confidence to address the issues they face in a constructive way. The two types of communication skills we will be addressing now are listening and learning skills, and skills for building confidence and support.

Skills to facilitate the counseling process

Skills for listening and learning

  • Helpful non-verbal communication
  • Effective verbal communication
  • Responses and gestures that show interest
  • Empathy
  • Avoid judgmental words

Skills for building confidence and giving support

  • Accept what a client thinks/feels
  • Recognize and praise good work
  • Practical help
  • Relevant information
  • Simple language
  • Suggestions rather than comments

Source: Adapted from Nutritional care and support for people living with HIV/AIDS training course participant manual, WHO 2009

Skills for listening and learning

Skill 1 – Non-verbal communication is a way of expressing attitudes and thoughts through expressions without the use of words. If we can use good non-verbal skills when talking to an individual, this will help enforce a positive environment. It is not only what you say but HOW you say it!

Ask participants how they would feel if someone:

  • Stands over you when talking?
  • Keeps looking at their watch as you are talking?

Following are five non-verbal means of communication, various forms of which can either help or hinder communication:

TO DO

NOT TO DO

Posture

Head is level with the other person’s

Stand with your head higher than the other person

Demonstrate attention

Make eye-contact where appropriate or direct gaze to an acceptable location

Be distracted

Barriers

Remove table or notes

Sit behind a table or take notes throughout

Taking time

Make the person feel you are not rushing, wait for them to start

Hurry the meeting along, show signs of impatience, look at your watch

Touch

Touch the person appropriately

Touch the person inappropriately

Adapted from Nutrition care support for people living with HIV/AIDS training course participant manual, WHO 2009

Skill 2 – Verbal communication is also very important. The type of questions and the way the questions are asked can also affect how comfortable the individual feels.

  • Appropriate questioning helps us understand the client’s situation and it help us to assess the client’s conditions. When asking questions:
    • DO ask one question at a time
    • DO be brief and clear
    • DO use questions to help the client talk about their feelings and behaviors
    • DO use the questions to explore and understand issues and to heighten awareness
    • DO NOT ask irrelevant questions to simply satisfy curiosity. It may cause people to feel pushed or reluctant to answer
  • Open ended questions are very helpful because they allow the person to give information. These questions require more than a one word answer.
  • Open ended questions start with “How? What? When? Where? Why?”
    For example: How are you feeling? What are you eating?
  • Closed questions are less helpful. They only allow for a yes/no answer and do not elicit sufficient information to identify whether there are problems to be addressed. Closed questions start with Are you? Or Does he/she? For example: Are you feeling well? Are you eating well?
  • Paraphrasing: involves repeating in your own words what the person has said to show you are listening. It assists the client to focus on their situation more clearly. For example, if a client says: I feel so helpless. I cannot eat and put on weight. My mouth gets sore every time I eat or drink. You could say: It sounds like you are having difficulty eating because your mouth gets sore.

Skill 3 – Use responses and gestures to show interest.

It is important to let the individual know you are interested and listening to what they are telling you. This can be achieved by using gestures and responses. Gestures such as maintaining eye contact where appropriate; smiling and nodding show to the individual that you have been listening to what they have been saying. When using responses, be mindful that your responses are neutral and not leading in any way. Things like “I see” and “Aha” are neutral responses.

Skill 4 – Showing empathy.

Empathy is the ability to share another person’s emotions and feelings, and involves trying to understand how that person views themselves or their world. Demonstrating empathy helps build rapport, and assists the client to feel comfortable to discuss their thoughts and feelings.

Skill 5 – Avoid words which sound judgmental.

Using words that can be perceived as judgmental can make the individual feel uncomfortable and lose trust in you. Examples include: right/wrong, good/bad, well/badly, enough, properly. E.g. instead of: Do you eat well?, ask: How are you eating?

Skills for building confidence and giving support

It is easy for PL HIV to lose confidence and fall to pressures around them. It is important in counseling to build self-confidence and well-being to resist pressures presented. The following points can help build confidence and give support to individuals.

Skill 6 – Accept what an individual thinks or feels.

Respond to the individual in a neutral way – don’t agree or disagree with a statement. By responding to the individual in a neutral manner, we are ensuring we are not putting forward our own views.

For example: Client says: “I can’t eat fish, it’s bad for people with HIV”. You could respond in a neutral way by saying: “I see, could you explain the reasons for your thinking”.

Skill 7 – Recognize and praise good work.

The notion is to not look at the things an individual is doing wrong and correcting them, it is important to first recognize what they are doing right and giving them praise for their good practices. By focusing on the good, individuals will be more likely to listen to suggestions in the future.

Skill 8 – Give practical help.

When there is a problem to solve, walk the individual step-by-step through the process. This gives the individual confidence to solve the problem in a constructive way. By giving practical help you can guide someone through the steps needed to solve a problem in a constructive way. For example:

Client says “I heard eating seafood is bad for people living with HIV.”

You ask: “Why do you think seafood is bad for PLHIV?” and

You could inform the individual that “Seafood is a good protein food, people can be allergic to seafood but this is not related to HIV. However, seafood should be cooked well before eating”.

Skill 9 – Give relevant information.

When giving information, try to give it in the context of now; give them information they can use immediately. It is no use giving information that can’t be applied for another week. Also remember when giving the information to present it in a positive way. You don’t want the individual to feel like they are being criticized or they have done something wrong. Build an individual’s confidence before presenting new information. Try to give only one or two pieces of information at a time.

Skill 10 – Use simple language.

In order for the individual to understand what you are saying, try to use simple language and avoid medical language or jargon. For example: A client may not necessarily understand the term “exclusive breastfeeding”. Therefore, when informing the client about this practice you could talk about “giving a baby ONLY breast milk and no other foods, drinks, not even water”.

Skill 11 – Make a few suggestions rather than commands.

Ensure you do not command or tell someone to do something. This can make the individual feel unworthy or lose confidence. Examples of command words include always, never, should, and must.

An alternative is giving the individual options so they can decide what works for them. Examples of phrases:

  • Have you thought about…….. instead of…..
  • Would it be possible……..
  • You could choose between…… and…….
  • What about trying ……….to see if it works for you?
  • Would you be able to….

As a group, ask participants an alternative way of saying “you must eat more fruit and vegetables”.

Ask participants, Does anyone have questions about what you have discussed?

Explain, Now we will discuss some practical considerations for nutrition counseling.

Problem identification helps the individual to tell their story and allows the individual to discuss the problem by describing it and locating its cause and effect. How do we do this?

  • Allow individuals to express needs and wants.
  • Empathize with individuals.
  • Conduct discussions in a non-judgmental way – be aware of body-language!
  • Active listening is important to obtain accurate information about a client as well as to demonstrate that the person and their problem is important and the counselor wants to help.
  • Communicate information according to the individual’s needs and what they already know. Always explain why you are giving the information.

Considering options can help the individual consider all options for what can be done to solve the problem. Informed decision making ensures the individual has all the necessary information and is aware of all consequences before making a decision. How do we do this?

  • Help the individual come up with a plan that works for them
  • Be aware of cultural values and beliefs that impact decision making
  • Help make informed decisions
  • If there are signs for behavior change, suggest one change at a time and ensure goals are realistic

Developing action plan can help the individual to develop the steps needed to implement their chosen option. Review the plan together and ensure individual has knowledge and skills to carry it out. How do we do this?

  • Use recall to help the individual remember what was discussed
  • Help individual build confidence through praising and reaffirming positive steps taken
  • Ensure individual is aware of support available
  • Have a follow-up plan in place
  • Step 4: Recap – Good communication skills

Ask participants to tell you what good communication means. Write the answers on flipchart paper. Fill in the gaps, using the information below:

  • Listening to and understanding what the client is saying about their problem;
  • Exploring with the client all the possible options available to solve a problem;
  • Providing a client with the necessary information to make informed decisions;
  • Evaluating with the client the options available to solve a problem;
  • Helping the client reach the best decision to solve the problem they face;
  • Providing skill-building, coaching or mentoring to ensure the client solves the problem successfully;
  • Identifying the help or support needed and determining the next steps;
  • Following-up with the client to evaluate how the action plan is proceeding; and
  • Helping the client modify or change the action plan if necessary.

    Adapted from Nutritional Care and Support for People Living with HIV/AIDS -A Training Course, WHO, 2009

Wrap up by saying, For counseling to be effective, good communication skills are very important. These skills can be used in many situations with individuals. Good communication is not just telling or advising a person what they should do. It is a way of working with the client to help them decide for themselves what they think is best to do in their situation. A discussion may also include other family members however it is the decision of the clients themselves as to whom to include in the discussion. In nutrition, we could use good communication skills to:

  • Gather information on nutrition practices
  • Explore challenges the client faces
  • Praise good practices
  • Give information on healthy eating practices, infant or young child feeding practices and suggest changes if needed.

Remember that the client’s decision may depend also on a number of influences such as other people/family member’s beliefs, opinions and needs, local culture, the health status of the client, who controls the household money and resources etc. We will practice these skills later when we do an activity to conduct a full counseling session.

Learning objective 4:

Participants will be able to use the positive living cards to counsel PLHIV about the problems that they have, and how to live well to prevent illness

Methodology: Participatory Lecture, Discussion, Demonstration, and Role Play

Explain: Now that we’ve covered all of the information provided in the positive living card we will talk about some steps to take when counseling PLHIV on positive living.

  • Step 1: Participatory Lecture and Discussion

Explain that, The counseling cards are written so that we first ask PLHIV questions, and have a discussion about their current practices, before we share correct information (key messages) with them.

Why do you think a counselor should ask questions first before providing information?

Write the answers on the big paper. Possible answers include: PLHIV like it when someone wants to listen to them; the counselor should try to understand the reasons behind the current behavior of PLHIV; and people are more likely to trust a person that shows interest in their lives.

Explain that there are five steps to using the positive living cards. Refer participants to the Lesson 6 (participant manual) or to the information on the big paper. Ask one participant to read aloud all five steps.

Five Steps to Using the Positive Living Cards

  1. Select the appropriate Positive Living Card.
  2. Ask questions and LISTEN!! People trust others who show interest in their lives.
  3. Provide correct information (Key Messages).
  4. Discuss what is possible. Help PLHIV and their families find the realistic solution and make a plan for it.
  5. Keep a record of the Topics you have discussed. Write on the Monitoring Form which cards you discussed and choose the key suggested actions that the PLHIV will take to solve his/her problem. This will enable the counselor to follow up at the next visit.
  • Step 2: Demonstration and Role Play

Now I will demonstrate the five steps using the Positive Living cards.

Ask one volunteer to pretend to be the PLHIV while the facilitator pretends to be the counselor. Choose one of the Positive Living Cards. Give the volunteer a moment to think about their answers to the questions that you ask (the questions are on the back of the card). The facilitator (“counselor”) and the volunteer (“PLHIV”) should demonstrate the proper process for counseling. Be sure to follow all five steps!

Ask participants to look at the “Key suggestions provided by the counselor” box at the bottom of the end page of the Monitoring Form. Describe and demonstrate how the counselor should record the Positive Living Topic in this box question on the big paper Monitoring Form. They should choose the plan/suggestions that they have discussed with PLHIV and their family through the process of negotiation.

Say: Let’s look at another example together. Let’s imagine that a counselor is meeting with a client name Ms. Saroen. Ms. Saroen currently does not brush her teeth every day and she has an infection in her mouth. The counselor has selected Positive Living Topic 3 (Oral hygiene) and Positive Living Topic 8 (Seek immediate care for infections) to counsel Ms. Saroen. Ms. Saroen agrees to brush her teeth two times every day and to visit the HC for treatment for the infection in her mouth. How will we record the discussion and the plan of action?

The facilitator writes the following information on the big paper Monitoring Form (used in the previous lesson), so that participants can see the example.

“Positive Living” Counseling

Card number and Topic

Background information – Negotiated plan of action

 #3 Oral Hygiene

1. Ms. Saroen will keep a bottle of boiled water and a cup near to where she keeps her toothbrush. She will ask her sister, to bring her toothpaste from the market whenever she needs it.

#8 Seek immediate care for infections

2. Ms. Saroen has an infection in her mouth. Today she has enough money to get a moto dop to the HC. She will go this afternoon for treatment.

Thank the volunteers for demonstrating in front of the group.

Activity:

Give participants 30 minutes to practice using some of the “Positive Living” cards to counsel each other, negotiate changes, and record the appropriate information on their Monitoring Forms. They should alternate the role of “counselor” and “client.”

Facilitators should walk around the room, observing the counseling technique of each participant and providing feedback on their ability to “negotiate”. Praise good skills and gently correct any mistakes.

After the 30 minute practice in pairs, choose one or two pairs of participants to demonstrate their technique to all the participants, using two to four different topics. Ensure the topics include all target groups (i.e. adult PLHIV, HIV-positive pregnant and breastfeeding women, HIV-exposed infants, and young and older children with HIV). Invite comments and feedback from the group, with questions like “What is being done well here? What could be better?”

Note: If there are enough facilitators, each person attending the training could be assessed for their ability to use the Positive Living Cards, see Annex 16for a sample assessment form.

Learning objective 5:

Participants will be able to decide which positive living cards are appropriate for a counseling session, depending on the circumstances of the PLHIV.

Methodology: Game

The facilitator introduces and explains the game:

We can see that it takes a long time to discuss all of the Positive Living topics. You should not try to discuss them all during a single counseling session! Choose one or two topics to discuss with PLHIV and their families during any one visit. More than two topics contain too much information to remember at once. Two contain the right amount of information to remember. Also remember that some of the positive living cards will be used during the dietary assessment and negotiation portion of the session.

How do you think you will know which topics to discuss? We will play a game where you will practice choosing which Positive Living topics and cards to use. I will read to you seven stories about four PLHIV. There are certain Positive Living messages that are appropriate for each person. I will read each story twice. After I read the story, you should choose which cards you would use to counsel, and write the numbers of those cards on your paper.

For example, if I tell you that Ms. Sovun has a white growth in her mouth, which card would you choose to counsel her? You would write the number “17” on your paper, because card 17 is about Managing Thrush. I will give you a bean for each correct answer. There is a prize for the person who has the most beans at the end of the game!

First, each participant should write these names down the left side of their paper like this:

Rattana

Sina

Dara

Saroen

Bopha

Sokha

Nary

Now I will read the story of the four PLHIV, one at a time. Listen carefully!!

Story 1:

Mr. Rattana recently started receiving support from the home-based care team in his area. He received a kit from the HBCT that included soap, toothpaste and a toothbrush, and some food like instant noodles, iodized salt and fish sauce. When you visit Mr. Rattana and his family at their home, you notice that the food is in the kitchen and that it is being used. But the soap, toothbrush and toothpaste are still in the bag from the HBCT. They have not been opened. What cards would you select to counsel Mr. Rattana and his family?

Give the participants a few minutes to choose the cards they would use and write the numbers on their paper next to “Rattana”. Check each participant’s answers as they are written on the paper, and give one bean per correct answer. The correct card numbers are:

1 (Handwashing)

3 (Oral hygiene)

Story 2:

Ms. Sina found out that she is HIV-positive only three months ago. She is depressed and does not want to eat; she says she does not feel hungry. Last week she cut her foot while walking home from work and the cut has become swollen and red. She has not been for a health check since she learned that she is HIV-positive. What cards would you select to counsel Ms. Sina and her family?

Check the participants’ answers and give one bean per correct answer. The correct card numbers are:

14 (enhancing appetite)

8 (seek immediate care for infections)

7 (health and weight check every month)

13 (three meals and two snacks, every day!)

11 (danger signs of weight loss)

Story 3:

Mr. Dara and his wife are both HIV-positive. They both recently started taking ARV drugs, and the wife has no problem with the drugs but Mr. Dara says that they make him feel dizzy and nauseous. You ask him how many times a day he normally eats since starting to take the drugs. He answers that his wife cooks once per day (around 11am), and that they normally eat twice per day – once at 11am and again at 5pm. They usually eat the same rice and soup at both meals so that the wife does not have to cook twice. What cards would you select to counsel Mr. Dara and his wife?

Check the participants’ answers and give one bean per correct answer. The correct card numbers are:

10 (Managing side effects of ARV drugs)

13 (Three meals, two snacks, every day!)

2 (Food safety)

16 (Managing side effects of nausea and vomiting)

9 (Take medicines as directed)

Story 4:

Ms. Saroen is a single mother living with HIV. Her husband died and she has two children aged 7 and 9. They are farmers. Ms. Saroen has lost about 4kg of body weight in the past three months because she says that it was the lean season and she ate less to make sure that her children could eat enough. She and her children have been eating rice and thin soup three times a day and fruit that they can find around their home as snacks. Now, there is enough food again, and some money from the harvest, but Ms. Saroen knows that she needs to regain her weight, and she is worried about not having enough food again during the lean season next year. What cards would you select to counsel Ms. Saroen?

Check the participants’ answers and give one bean per correct answer. The correct card numbers are:

4 (Plan ahead)

7 (Health and weight check every month)

11 (Danger signs of weight loss)

13 (Three meals, two snacks, everyday!)

Story 5:

Ms. Bopha is HIV positive and 3 months pregnant with her first child. She has not yet visited the HC. She tells you that she has nausea and finds it difficult to eat. She is not taking ARV drugs. She also complains about being tired. You ask her how many times a day she normally eats. She answers that she usually eats two main meals a day without any snacks. During the discussion you notice that Ms. Bopha looks very pale. What cards would you select to counsel Ms. Bopha?

Check the participants’ answers and give one bean per correct answer. The correct card numbers are:

7 (Health and weight check every month)

9 (Take medicines as directed)

16 (Managing side effects of nausea and vomiting)

14 (Enhancing appetite)

19 (Anemia)

21 (Eat well when you are pregnant or breastfeeding)

Story 6:

You visit Ms. Sokha, a 25 years old HIV positive mother who has a 5-month-old baby and tell you that she is currently exclusively breastfeeding her daughter. Her baby seems to be crying often and wanting to feed more. She is thinking of introducing rice water to the baby because she feels her milk is decreasing. Ms. Sokha also tells you that her husband now has a new job and he tells her that he will be able to afford some commercial infant formula for the baby. She is planning to give her baby formula when her husband brings it home. She also feels she has lost weight because her clothes fit loosely. Sometimes she has nausea and diarrhea and she notices that she has these symptoms since she starts taking the ARV drugs. What cards would you select to counsel Ms. Sokha?

Check the participants’ answers and give one bean per correct answer. The correct card numbers are:

7 (Health and weight check every month)

10 (Managing side effects of ARV drugs)

11 (Danger signs of weight loss)

21 (Eat well when you are pregnant or breastfeeding)

25 (Tips for breastfeeding)

Story 7:

You are visiting Ms. Nary at her home. Ms. Nary has a baby who is 6 months old. Her baby has had an positive HIV test result. She tells you that her baby is recovering from illness and has started eating well but is still losing weight. She gives her only thin liquid porridge because she thinks that meats like beef, eggs should be avoided during illness because these foods can cause the illness to relapse. The baby seems small for his age. Ms Nary breastfeeds her son only at night. You also notice poor hygiene around kitchen area. What cards would you select to counsel Ms Nary?

Check the participants’ answers and give one bean per correct answer. The correct card numbers are:

1 (Hand washing)

11 (Danger signs of weight loss/poor growth)

22 (Starting foods with your baby)

25 (Tips for breastfeeding)

24 (Promoting good growth for children living with HIV)

Ask all participants to count and show their beans. The participant with the most beans (correct answers) wins the prize. There may be more than one winning participant! Try to have a prize for all the winners, even if you have to give it to them later in the training. It is important to reward good performance!

Congratulate participants for learning how to counsel PLHIV for Positive Living!

Summary:

The Lesson 6 is long, and contains a lot of information. Ask participants to keep and study the rest of the lesson when they have free time.

Give out the test questions. Have the participants spend no more than 10 minutes answering them. Each person should work by themself. Go over the answers as a group. Answer any questions the participants have.

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