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LESSON 6 POSITIVE LIVING FOR PLHIV (Participant EN)

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HOW TO COUNSEL PLHIV ON POSITIVE LIVING BEHAVIORS

  1. Select the appropriate “Positive Living” cards
  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 realistic solutions, and make plans for them.
  5. Keep a record of the Topics you have discussed. Write on the Monitoring Form which cards you have 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.

INTRODUCTION TO COMMUNICATION SKILLS

WHAT IS COUNSELING?

Counseling is an interactive process designed to help people cope or adapt to different situations they may face. Counseling therefore involves:

  • Helping a person share their problem by expressing their concerns
  • Giving relevant information about a problem
  • Guiding a person through various options available to solve the problem
  • Exploring a possible plan of action
  • Helping a person to make informed decisions

Counseling is NOT:

  • Giving advice to a person on what to do
  • Suggesting to a person what to do
  • Making judgments or recommendations or promoting the counselor’s own opinions

FOUR STAGES OF COUNSELING

  1. Comfortable environment
  2. Problem identification
  3. Considering options
  4. Action plan

For counseling to be effective, good communication skills are very important. These skills can be used in many situations with individuals.

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

POSITIVE LIVING TOPICS

  1. Hand washing
  2. Food Safety
  3. Oral Hygiene
  4. Plan ahead!
  5. Exercise
  6. Limit alcohol, avoid smoking
  7. Health and weight check every month
  8. Seek immediate care for infections
  9. Take medicine as directed
  10. Manage side effects of ART
  11. Danger signs of weight loss
  12. Drink plenty of fluids
  13. Three meals, two snacks, every day!
  14. Enhancing your appetite
  15. Managing diarrhea
  16. Managing nausea and vomiting
  17. Managing thrush
  18. Managing fever
  19. Anemia
  20. Eating well
  21. Eat well when you are pregnant or breastfeeding
  22. Starting foods with your baby (6-24 months)
  23. Feeding school age children and youth
  24. Promoting good growth for children living with HIV
  25. Tips for breastfeeding

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.

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

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. 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. 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

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 “comfortfoods” 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.

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.

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.

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.

WHO WILL BE COUNSELED

GENERAL SITUATION CARD

(POSITIVE LIVING – HEALTH MAINTENANCE)

CARD #

SPECIFIC SITUATION CARD

(POSITIVE LIVING – SYMPTOMS MANAGEMENT)

CARD #

Adult PLHIV (man and non pregnant woman)

Hand washing

1

Eat well when you are pregnant or breastfeeding

8

Food safety

2

Manage side effects of ARV

10

Oral hygiene

3

Danger signs of weight loss

11

Plan ahead for security

4

Enhancing appetite with “comfort foods”

14

Exercise

5

Managing diarrhea

15

Limit alcohol, avoid smoking

6

Managing nausea and vomiting

16

Health and weight check every month

7

Managing thrust

17

Take medicine as directed

9

Managing fever

18

Drink plenty of fluids

12

Anemia

19

Three meals, two snacks every day

13

Eating well

20

Pregnant woman living with HIV

Hand washing

1

Eat well when you are pregnant or breastfeeding

8

Food safety

2

Manage side effects of ARV

10

Oral hygiene

3

Danger signs of weight loss

11

Plan ahead for security

4

Enhancing appetite with “comfort foods”

14

Exercise

5

Managing diarrhea

15

Limit alcohol, avoid smoking

6

Managing nausea and vomiting

16

Health and weight check every month

7

Managing thrust

17

Take medicine as directed

9

Managing fever

18

Drink plenty of fluids

12

Anemia

19

Eat well when you are pregnant or breastfeeding

21

WHO WILL BE COUNSELED

GENERAL SITUATION CARD

(POSITIVE LIVING – HEALTH MAINTENANCE)

CARD #

SPECIFIC SITUATION CARD

(POSITIVE LIVING – SYMPTOMS MANAGEMENT)

CARD #

Mother with HIV who

has chosen exclusive breastfeeding for the first six months

Hand washing

1

Eat well when you are pregnant or breastfeeding

8

Food safety

2

Manage side effects of ARV

10

Oral hygiene

3

Danger signs of weight loss

11

Plan ahead for security

4

Enhancing appetite with “comfort foods”

14

Exercise

5

Managing diarrhea

15

Limit alcohol, avoid smoking

6

Managing nausea and vomiting

16

Health and weight check every month

7

Managing thrust

17

Take medicine as directed

9

Managing fever

18

Drink plenty of fluids

12

Anemia

19

Eat well when you are pregnant or breastfeeding

21

Tips for breastfeeding

25

MOTHER/FATHER/GRANDPARENT/CAREGIVER WITH

Child 0 – 6 months living with HIV and exclusively breastfed

Hand washing

1

Eat well when you are pregnant or breastfeeding

8

Take medicine as directed

9

Danger signs of weight loss

11

Tips for breastfeeding

25

Managing diarrhea

15

Managing nausea and vomiting

16

Managing thrust

17

Managing fever

18

WHO WILL BE COUNSELED

GENERAL SITUATION CARD

(POSITIVE LIVING – HEALTH MAINTENANCE)

CARD #

SPECIFIC SITUATION CARD

(POSITIVE LIVING – SYMPTOMS MANAGEMENT)

CARD #

Child 6 up to 24 months living with HIV

Hand washing

1

Eat well when you are pregnant or breastfeeding

8

Food safety

2

Danger signs of weight loss

11

Oral hygiene

3

Enhancing appetite with “comfort foods”

14

Take medicine as directed

9

Managing diarrhea

15

Starting foods with your baby (6-24 months)

22

Managing nausea and vomiting

16

Promoting good growth for children living with HIV

24

Managing thrust

17

Managing fever

18

Anemia

19

Child 2 up to 5 years living with HIV

Hand washing

1

Eat well when you are pregnant or breastfeeding

8

Food safety

2

Danger signs of weight loss

11

Oral hygiene

3

Enhancing appetite with “comfort foods”

14

Take medicine as directed

9

Managing diarrhea

15

Promoting good growth for children living with HIV

24

Managing nausea and vomiting

16

Managing thrust

17

Managing fever

18

Anemia

19

Child >5 years and adolescents living with HIV

Hand washing

1

Eat well when you are pregnant or breastfeeding

8

Food safety

2

Danger signs of weight loss

11

Oral hygiene

3

Enhancing appetite with “comfort foods”

14

Take medicine as directed

9

Managing diarrhea

15

Drink plenty of fluids

12

Managing nausea and vomiting

16

Three meals, two snacks every day

13

Managing thrust

17

Eating well

20

Managing fever

18

Feeding school age children and youth

23

Anemia

19

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