April 2008, Last Facilitator Guide - Adult3

Course Director/ Facilitator Guide
for the National Comprehensive HIV Care/ Antiretroviral Therapy (ART) Training Course
Based on the Chronic HIV Care with ARV Therapy and Prevention; and Acute Care guideline modules
Federal HIV Prevention and Control Office Ministry of Health, Ethiopia
April, 2008
Foreword
The Ethiopian Health Policy takes decentralization as a principle that guides the efforts to improve quality and coverage of preventive and curative health services. In this effort, the role of health workers assumes a central position. It is well known that a large segment of the Ethiopian population gets primary care from these health workers. While we are decentralizing the HIV/AIDS services down to the primary health care settings, we need to shift some of the tasks including Antiretroviral Therapy (ART) prescription to Health Officers and Nurses. Building their capacity thus becomes a critical intervention. There fore, these comprehensive HIV care/ART training manuals are primarily intended to develop the capacity of nurses and health officers at all levels so that they can be confident enough to initiate ART and follow patients on chronic HIV/AIDS care. It is our hope that health workers, managers and trainers will benefit from these manuals. Finally, I would like to express our sincere thanks to World Health Organization (WHO) Country Office for technical and financial support so that these standard training manuals will be realized; I also thank a lot to the Presidents Emergency Plan for AIDS Relief (PEPFAR-Ethiopia) and Clinton Foundation HIV/AIDS Initiative (CHAI-Ethiopia) for their enormous technical support.
Yibeltal Assefa, MD, MSc Head, Health Programs Provisional Department Federal HIV/AIDS Prevention and Control Office
Acknowledgements
The Federal HIV/AIDS Prevention and Control Office (FHAPCO)/ Ministry of Health (MoH) would like to thank all those who actively participated in the standardization of these comprehensive HIV/AIDS care and treatment training manuals, modules and guides. In particular, FHAPCO/MoH wishes to acknowledge the inputs of the following individuals:
Dr Mulugeta Workalemahu Dr Yigeremu Abebe Dr Altaye Habtegiorgis Dr Eshetu Gezahegne Dr Hamza Adus Dr Jilalu Asmera Dr Kassu Ketema Dr Ayele Zewde Dr Meg Doherty Dr Wondwossen Amogne Dr Degu Jerene Dr Birhanu Tekle Dr Sisay Sirgu Dr Seblewongel Abate Dr Aschalew Endale Dr Jemal Aliy Dr Ghion Tirsite FHAPCO CHAI- Ethiopia FHI-Ethiopia FHI-Ethiopia I-TECH I-TECH/Gondar University WHO Country Office Columbia University-ICAP-Ethiopia JHU-TSEHAI JHU-TSEHAI FHAPCO/WHO JHU-TSEHAI WHO Country Office WHO Country Office FHAPCO/WHO FHAPCO/Tulane University WHO Country Office
Table of Contents
Title Page
Course Director/Facilitator Preparation for the National Comprehensive HIV Care/Antiretroviral Therapy (ART) Training Courses....6 Course Agenda.......................7 Instructional Materials, Supplies, Venue, Timetable.................9 Facilitator techniques common to all courses15 Chapter 1: Overview of HIV/AIDS in Ethiopia.18 Chapter 2: Integrating Prevention with treatment. 19 Chapter 3. Introduction to chronic HIV with ART........... 21 Chapter 4: Introduction to HIV/AIDS Pathogenesis and Immunology............28 Chapter 5: Opportunistic infections (OIs) and WHO Clinical staging.29 Chapter 6: OI Prophylaxis........ . 32 Chapter 7: Assess (clinical review of symptoms and signs, medication use, side effects, complications, targeted physical exam) and provide clinical care..................................................................................34 Chapter 8: Introduction to the Ethiopian National HIV Care/ART Patient Intake and FollowUp Forms..................................................................40 . Chapter 9: Introduction to ART...............41 Chapter 10: Drug Interactions............................................................................ ..44 Chapter 11: Adherence, Adherence Preparation and Resistance......47 Chapter 12: When to start first-line ART in patients without complications.....................51 Chapter 13: Four First Line ARV Regimens...59 Chapter 14: Support ART initiation then monitor, support adherence to ART..61 Chapter 15: TB/HIV............................................................................63 Chapter 16: Special considerations for ART in pregnant and post-partum women.. ..65 Chapter 17: Is ART working? Visit follow up, laboratory monitoring and identifying failure................................................................................................................ 70 Chapter 18: Managing Side Effects of ART and Reporting Adverse Drug Reactions ...72 Chapter 19: Universal precaution and PEP.. .75 Chapter 20: Palliative Care...76 Chapter 21: Medical Ethics77 Review prior to post-test..........................78 Day by day summary of skill stations and card sorts....79
Facilitator Guide for the Acute Care Short Course 1: Management of Key opportunistic Infections.83 Introduction to OI Short Course using IMAI Acute Care....85 Chapter 1. Quick Check for Emergency Signs.87 Chapter 2. Introduction to the IMAI Acute Care Algorithm: Assess Acute Illness/Classify/Identify Treatment..88 Chapter 3. Cough or difficult breathing..91 Chapter 4. Check all patients for undernutrition and anaemia.96 Chapter 5. Look in the mouth of all patients and respond to any complaint of mouth or throat problems..98 Chapter 6. Does the patient have fever?..........................................................................102 Chapter 7. Does the patient have diarrhea?.....................................................................103 Chapter 8. IMAI Approach to Sexually Transmitted Infections (STI)-STI Syndromic Case Management (Short Course)104 Introduction for facilitators................................... 104 Course objective.............................................. 104 Suggested course schedule............................... 105 Pre-Test.............. 107 Introduction to the IMAI STI Short Course........ 107 Introduction to STI.............. 108 Review of IMAI Acute Care Management.......... 111 Signs & Symptoms: Genital or Anal Sore, Ulcer or Wart...... 114 Signs and Symptoms: Male GU Symptoms or Lower Abdominal Pain.. 121 Signs and Symptoms: Female GU Symptoms or Lower Abdominal Pain.. 126 Skill Stations and Card Sort.......... 139 Values Clarification Exercise.......... 145 Educate and Counsel on STIs.......... 146 Rapid Course Review............ 153 Wrap-Up.............. 154 Chapter 9. Skin Problems and Lumps..155 Introduction to the IMAI Neurological and Mental Problems Short Course...156 A. Headache or neurological problem (Chapter 10)..160 If patient has a headache or neurological problem.161 If confused or cognitive problems 167 B. Mental Health Problems (Chapter 11)............................172 If patient has a mental problem .173 If sad, or loss of interest or decreased energy Depression174 If bizarre thoughts or psychosis......................................177 If person is tense, anxious or worrying excessively Anxiety Disorders 180 If more than 21 drinks per week for men, 14 per week for women.. 180 C. Using medication in neurological and mental disorders (Chapter 12)185 Review drills.................... 188 Adult clinical practiceInpatient and outpatient...... 190
Expert Patient-Trainer Cases.......... 198 Photo booklet key... 206
Course Director/ Facilitator Preparation for the National Comprehensive HIV Care/Antiretroviral Therapy (ART) Training Courses
Target audiences: Primarily nurses and health officers. Other similar cadres like mid-wives can also be included when need arises. Medical doctors without other ART training: to introduce them to chronic HIV care/basic ART and to know the approach of the team which they work with or mentor/supervise. (They may also be trained further in clinician ART and more advanced OI management). There are separate modules for pharmacy personnel which go with the comprehensive course. Objectives of training: To prepare nurses and health officers to provide chronic HIV care and basic ART including initiation, support and monitoring. To review common symptom/sign management using the acute care guidelines with an emphasis on opportunistic infections. Purpose of this guide: This guide is used to aid facilitation in conjunction with the Participant Manual for Basic
Chronic HIV Care, Antiretroviral Therapy and Prevention; and the Participant Training Manual for the Acute Care. Along with the course materials, it is helpful to use
the Facilitator's Guide to the Preparation of Expert Patient-Trainers for instructions on set up and use of the skill stations. There are three important types of facilitators: Clinical facilitators (for Basic ART Clinical Course and the Second Level ART and OI course for medical doctors). Counselling facilitators (for the Basic ART Aid Course). Expert patient-trainers (PLHIV who have been trained to be trainers). Expert patient-trainers (EPTs): Involvement of PLHIV as patients who are experts in their own illness can be a valuable educational strategy to support the training of health workers. This is a very effective training intervention, and also addresses the need for increased number of trainers necessary for capacity-building during rapid ART scale up. In both the National Comprehensive HIV Care/ART Course and ART Aid course, PLHIV are trained to present specific HIV cases with the course participants during the skill stations sessions two hours per day in addition to joining small groups during the interactive classroom training. PLHIV trained as Expert Patient-Trainers (EPTs) add much needed experience and reality to instruction of HIV care and ART.
Course Agenda for the National Comprehensive HIV Care/ART Training (nurses, health officers and mid-wives) - adult and adolescent part
Week Week 1 To be covered Participants Manual for the Basic Chronic HIV Care, Antiretroviral Therapy and Prevention (adult and adolescent) Modules: Chronic Care/ART with Prevention Acute care module for cross-reference Palliative Care Module (Cross reference and to be covered with Chapter 20 of Chronic Care Participants Manual) M&E Day Day 1 ( Monday) Activities Opening Pre-test (Adult and adolescent portion) Chapters 1-5 Chapters 6-8 Skill Station: 2 hours in the afternoon Chapters 9-11 Skill Station: 2 hours Chapters 12-15 Skill Station: 2 hours Chapters 16-21 Skill Station: 1 hour Review Off Acute Care/ OIs ( Chapters 1-6) Practicum (HIV Clinical Care/ART Clinic, In-patient and out-patient) -The whole morning will be used for practicum and class continues in the afternoon; - Practice on HIV Care/ART Follow Up form continues, focus on adherence preparation, ART initiation and monitoring -The whole morning will be used for practicum and class continues in the afternoon - Participants should also fill the acute care recording format -Demonstrate OIs(Inpatient or out-patient) or life threatening cases if available Practice on patient monitoring tools after a brief explanation Remark
Day 2 (Tuesday)
Day 3 (Wednesday) Day 4 (Thursday)
Day 5 (Friday)
Day 6 (Saturday)
Whole day; Do all exercises on M & E
Week 2
Acute Care
Sunday Day 7 (Monday)
Day 8 (Tuesday)
Acute Care/OIs (Chapters 7, 9,10, 11, and 12) Practicum (HIV Clinical Care/ART Clinic, In-patient and out-patient; focus on acute care & OI)
PIHTC Short Course
Day 9 (Wednesday) Day 10 (Thursday)
STI Short Course Day 11 (Friday)
Day 12 (Saturday) Clinical Team (MDT) Building
PITC (Chapter 13) Skill Station: 1 hour STI (Chapter 8 of acute care participants manual) Skill Station:1 hour Practicum (HIV Clinical Care/ART Clinic, In-patient and out-patient; focus on acute care & OI) STI continues Skill Station: 1 hour Clinical Team (MDT) Building
Do exercises; focus on education and counselling of STIs; STI recording -Practicum will be in the whole morning and focuses on ART initiation, prescription, refill, managing side effects if cases available and M & E tools. Half day
Week 3
Paediatric Part Sunday Monday Tuesday Wednesday Thursday Friday Saturday Sunday Monday Tuesday Wednesday Thursday Friday Saturday Sunday Off
IMNCI (Paediatric Acute Care)
Off
Week 4
Paediatric Chronic HIV Care/ART
Closing
Half day
NB.
1. Detailed schedules for weeks three and four are also found in the paediatric facilitator guides. 2. EPT training and preparation has to be done before the main course starts. 3. Training for pharmacy personnel starts in the second week and takes six days including the team building session on Saturday.
Instructional Materials, Supplies, Venue, Timetable

A. Instructional Materials Needed by Each Small Group
Each small group will need the following instructional materials to work on the guideline modules in the classroom setting. Some can be used again and again; reusable materials include wall charts, photo booklet, cards for card sorts, and (when available) training videos. Other material is given to each participant and facilitator and used in exercises. You will need a supply of these for each course. When planning continuous training for scale-up, photocopy enough for the first course, make any small corrections identified during the course, then print a large number for subsequent training. Use the checklists below to plan your course. Figure the totals needed and when each item has been reproduced and delivered to you in the quantity necessary, and has been checked for accuracy and readability, check this off as ready in the far right column. All materials should ideally be prepared at least 2 weeks before the course is scheduled to begin to allow time to correct any errors in reproduction. To help with prioritization and because occasionally it is not possible to have everything ready at once, a column is added which gives the time in the course materials are needed. Steps in preparing course materials: 1. Calculate numbers needed, always adding a few extra. 2. Arrange for printing, photocopying and delivery of materials to be finished 2 weeks before training begins. 3. Photocopy manuals on both sides of the page as they are too large to handle singlesided. 4. Check each item for accuracy when finished (are page references correct, are titles correct, has the final version been printed, are any pages missing, are all pages readable, are there a correct number of copies). Check a portion of each item, not every single copy of each item). 5. Put a check in the ready column only when each item is completely finished. 6. Store copies in clearly labelled boxes for transport to the training site.
B. Checklist of Instructional Materials Needed for Both Courses:

Non-Reusable
Items needed by each small group Guideline Modules Chronic HIV Care with ARV Therapy and Prevention Acute Care Palliative Care: symptom management and end-of-life care General Principles of Good Chronic Care National guidelines (ART, PMTCT, HCT, etc.) Participant Training Manuals Participant Manual for the Basic Chronic HIV care /ART Clinical Training Course Participant Manual for Acute Care Training Courses Facilitator Guides Course Director/Facilitator Guides for the National Comprehensive HIV Care/ART Training Course: for both Chronic HIV care ART and Acute care Clinical Courses Facilitator Guide for the Preparation of Expert PatientTrainers Tools for Patient Education Flipchart for Patient Education Number needed per participant, facilitator 1 for each participant and facilitator 1 for each participant and facilitator 1 for each participant and facilitator 1 for each participant and facilitator 1 for each participant and facilitator 1 for each participant and facilitator 1 for each participant and facilitator 1 for each facilitator Total number Day needed Day 1 Day 1 Day 1 Day 1 Day 1 READY
Day 1
Day 1
Day 1
1 for each facilitator
Pre-Day 1
Patient Treatment Cards (Annex D of the Participant Manual for the Basic ART Training Course) Miscellaneous Pretest = Post-test
1 for each participant and facilitator (to be used in class and the skill stations) 1 set of 4 cards for each participant, plus some extra sets 2 per participant plus 1 with answers for each facilitator 30 per participant, plus some extras (for in class use and skill station use) 30 per participant, plus some extras (for skill station use) 5 checklists for each case per group, plus some extras (for skill station use) 10 per participant, plus some extras
Day 2
Day 2-3 (Ch. 11)
Day 1
National HIV Care/ART Follow Up Form Clinical Review Forms (Annex A of Participant Manual for the Basic ART Training Course) Case-specific checklists (for EPT skill stations)
Day 2 (Ch. 6) Day 1, (Ch. 5) Day 1 for EPTs, Day 2 for participants
Acute Care Recording Forms
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Reusable Laminated Wallcharts for Basic ART Clinical Training Course Sequence of Care After Positive HIV Test 1 for each room HIV Care/ART Follow Up Form(nationally 1 for each room adapted if ready) Follow-Up Recording Form 1 for each room The 5 A's 1 for each room General Principles of Good Chronic Care 1 for each room Review of TB Status 1 for each room Clinical Review of Symptoms and Signs, 1 for each room Medication Use, Side Effects, Complications Coordinated Approach to Chronic Care 1 for each room 7 Requirements to Initiate ARV Therapy at First1 for each room level Facility Opportunistic Infections 1 for each room WHO Adult HIV Clinical Staging 1 for each room plus 1 for the skill station WHO Paediatric HIV Clinical Staging 1 for each room Laminated Wallcharts for Acute Care/OI Training Course Quick Check 1 for each room IMAI Acute Care Recording Form front side 1 for each room IMAI Acute Care Recording Form backside 1 for each room Assess Acute Illness/Classify/Identify Treatments 1 for each room (Cough or difficult breathing) Laminated Wallcharts for Patient Monitoring Course HIV Care/ART Follow Up Form (National) 1 for each room Summary form
Pre-ART Register ART Registerpage 1 ART Registerpage 2 Laminated Cards Yes/No Cards (for in class use)
1 for each room 1 for each room 1 for each room 1 set for each group (each participant needs a Yes and a No card) 1 set for each group 1 set for each group + 1 set for skill station 1 set for skill station 1 set for skill station 1 set for skill station 1 set for skill station 2-4 for each group (collect after course)
OI Cards (for in class use) Side Effects Cards (for use in class and skill stations) HIV Clinical Staging Cards (for skill station use) HIV/TB Cards (for skill station use) Drug Name/Abbreviation Cards (for skill station use) Management of side effects cards Miscellaneous Photobooklet including photos for chronic care/ART and Acute Care courses
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C. List of Other Supplies and Equipment Needed in the Classroom

Supplies needed for each facilitator and participant during the course: name tag and holder or adhesive tape (works well to write names on) notebook/stationery folder to organize manuals and loose forms or cloth bag (avoid binders with punching; each guideline module and participant manual needs to be used actively during the course) ballpoint pen 2 pencils eraser Supplies needed for each small group/classroom: white putty or high quality, very sticky tape to fasten large, laminated wallcharts and flipcharts to wall (test this out ahead of timetape is often too weak to hold the laminated posters) 2 rolls transparent tape pencil sharpener scissors stapler and staple remover extra pens extra pencils extra erasers rubber bands paper clips blank flipchart pad or blackboard and chalk set of white board markers (non-permanent so can write on wall charts) Supplies for demonstrations, role plays, and group activities for each small group: pillbox (if available) cotrimoxazole tablets INH tablets (if available) example of pill charts/diaries (if available) nevirapine, efavirenz, zidovudine, stavudine, lamivudine tablets (single or combination tablets, whatever is available locally) 2-3 measuring tapes which cannot stretch per group (for demonstration of MUAC and clinical visits) or, if body mass index (BMI) is substituted during country adaptation of the guidelines, beam scale and measuring tape on wall to measure height in outpatient clinic plus BMI table box of condoms, 2-3 models of the male penis or bananas Near the classrooms, all groups need access to the following equipment and supplies, to be shared by the groups: photocopy machine video player and monitor (once training video developed) computer and printer
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D. Venue
To train 4 cadres simultaneously requires 4 classrooms, a room for skill stations, and a small room for the secretariat (6 rooms). Classes should ideally be from 8 to 15 participants. If more than this are planned for any one cadre, make a second group and plan for extra rooms accordingly.
E. Timetable for preparation

Prepare a realistic timetable, including all the preceding steps. Planning times will vary according to local circumstances. Tasks your timetable needs to include: Task
Estimated Time Needed
Done Comments
1. 2. 3. 4.
Hire a course director Arrange for facilitator/s Arrange for EPTs Arrange permissions for practicum at teaching hospital, OPD 5. Gather or produce training materials 6. Find venue 7. Reserve classrooms 8. Reserve venue 9. Reserve meals, lodging 10. Arrange for transport (lodging to class to clinics) 11. Budget with funds on hand 12. Compile list of participants 13. Send invitation letters to participants and institutions 14. Send travel authorizations to participants and facilitators if needed 15. Design and print course completion certificates 16. Write and print course evaluation form 17. Adapt course pre/ post test and key 18. Once at site, course director and local physician to visit hospital to arrange ward and OPD days and times. One day before OIs course, facilitators visit to meet with ward nurse and choose patients. 19. Arrange for course closing ceremony if desired.
Official letters needed? If venue is unknown, visit to ensure suitability
Experience has shown that important problems with training are skipping or leaving too little time for the steps required before training (for example, community and stakeholder meetings; prior preparation of participants) and arranging for the key elements at the last minute.
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F. Administrative support
Arrange for secretary or administrative assistant to work from 2 to 3 days before the course begins through the end of the course or one day later. Arrange for photocopy machine accessible to classrooms in good working order, with extra toner, and if possible, capable of collating pages.
G. Size of classes
Optimal size of each group is 8 to 15 with 2 facilitators per group over 12.
H. "Housekeeping"
After the first day, set aside about 10 minutes daily to discuss with each group the rules and responsibilities concerning breaks, cell phones, group discussion, set up and breakdown of the classroom, etc.
I. Facilitator meetings
It is important to schedule a daily meeting of all facilitators and the Course Director at the close of each day to review progress, solve problems, and to plan for the following day. This may last from 10 minutes to an hour, depending on the situation and how things are proceeding.
J. Course closing
Arrange for special speaker to close if desired. Be sure to thank patients for the work they have done. Thank all staff and collaborators who have supported the training. Let participants know what future plans are for post training activities and hand out course completion certificates.
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Facilitator techniques common to all courses

A. How to give pre and post test (there are different tests for each cadre)
Explain to participants that the purpose of the pre test is to give facilitators a sense of baseline knowledge of the group, and is not an evaluation. Allow 30 minutes for the test of approximately 50 questions. Decide beforehand if test should be anonymous (in which case participants will not know their scores) and what, if any, feedback will be given on test results. Do not discuss answers to the questions when test is finished, as the same test will be given as the post test, but explain that all material will be covered in the course. At least two persons should score the test on the same day it is given so that facilitators can gear each course to the level of knowledge of participants.
B. How to conduct a drill

1. Gather the participants together and tell them you will conduct a drill. During the drill, they will review how to decide, for example, if a patient has come for an acute problem, follow-up of an acute problem, or follow-up of a chronic problem. Ask the participants why this is an important decision. They should answer that it is necessary in order to determine which guideline module and section of the guidelines to use to care for the patient. 2. Explain the procedures for doing the drill. Tell participants: This is not a test. The drill is an opportunity for participants to practise making this decision. You will call on individual participants one at a time to answer the questions. You will usually call on them in order, going around the table. If a participant cannot answer, go to the next person and ask the question again. Participants should wait to be called on and should be prepared to answer as quickly as they can. This will help keep the drill lively. 3. Ask if participants have any questions about how to do the drill. 4. Allow participants to review the text for a minute or two before the drill begins. Tell the participants they may refer to the text during the drill, but they should try to answer the question without looking. 5. Start the drill by asking the first question. Call on a particular participant to provide the answer. He should answer as quickly as he can. Then ask the next question and call on another participant to answer. If a participant gives an incorrect answer, ask the next participant if he can answer. 6. Keep the drill moving at a rapid pace. Repeat the list of questions or make up additional questions if you think participants need extra practise. The drill ends when all the participants have had an opportunity to answer and when you feel the participants are answering with confidence.
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C. How to provide individual feedback to written exercises

When participants are working: Look available, interested and ready to help. Watch participants as they work and offer individual help if someone looks troubled or is not writing answers or turning pages (clues someone may need help). Encourage questions and requests for help. If important issues or questions arise individually, make a note to discuss later with the entire group. If a question arises which you feel unable to answer adequately, obtain assistance as soon as possible from another facilitator or the Course Director. Written exercises can also be read aloud and discussed in the group.
D. Reading
When the facilitator manual says participants should read part of the manual or guideline module, you can have participants read silently on their own, or ask for a volunteer to read a section in a loud, clear voice. Which method you choose depends on factors such as level of education of the group as a whole, differing levels within the group, their understanding of English, and what the group prefers. Make sure everyone is on the same page before beginning. If you are reading aloud, make sure that all participants who are willing, get chances to read during the course (do not force anyone). Sometimes it is helpful to ask someone to read who seems particularly sleepy or inattentive to wake them up. You may also choose a mixture of silent reading and reading aloud.
E. Explanations and lecturing

At times the facilitator is directed to explain certain important concepts. Explanations should be short and to the point, using a flipchart and/or referring to the manual. Avoid lecturing as this is not an effective way to learn. Occasionally, when pressed for time, it may be feasible to present certain material as a short, interactive lecture, rather than having participants read through a number of pages themselves, but this should not be the norm.
F. How to use the skill stations

Skill stations are a crucial part of competency based training for HIV care. During the approximately 2 hour-long sessions, participants work with individual EPTs and participate in card sort exercises which reinforce learning of material. Participants are introduced to skill stations on the second day of training. Before this time, the Expert Patient Trainers need to have been trained (see Expert Patient Training materials). Complete instructions for the facilitator on skill stations are provided in this Guide on pp. 71 to 76, and for the participants in their Participant Manual. Facilitators need to be present during skill stations to answer questions and give guidance as needed. Objectives: To provide health workers with the chance to practise skills they are learning in class with the PLHIV who will give each health worker feedback. To reinforce learning of new material such HIV staging, ARV names, regimens and side effects, eligibility, and patient management.
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Scheduling of skill stations needs to be done on a daily basis so that each group has the time to work separately. Often 3 groups will be going to skill stations (2 clinician groups and one ART Aid group). MD use of skill stations: It is advisable to have physicians spend at least three full sessions of skill stations with the EPTs as this presents a rare chance for PLHIV to give feedback on physician interviewing skills and address issues of stigma around HIVAIDS experienced from the patient perspective.
G. Singing competition
This is often an effective way to raise group spirits and to reinforce key points. Each group should be told about this and encouraged to enter the competition which takes place during the closing ceremony. In the Masaka, Uganda course, the winning groups sang about the "7 requirements"; another group presented the 5 A's. The facilitators entered a jingle on the first-line ARV regimens (insert) which is helpful to sing during the class to reinforce learning of these regimens. It is useful to have a prize or prizes that can be shared among the winning group.
H. Energizers
Ask individual participants to be responsible for a few exercises or songs during the course of each day to make things livelier when attention is lagging or when people are tired but the day is not over. This should be decided as part of "housekeeping" activities at the start of each day. The facilitators should also have some energizers of their own to offer.
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Chapter 1: Overview of HIV/AIDS in Ethiopia Duration: 90 minutes

(Overview Plus Introduction and Pre-test)
Purpose:
Pre-test as baseline assessment of knowledge Overview of local context of HIV epidemic, prevention, care and treatment Overview of materials for the course
Materials:
Blank flipchart/markers; LCD Projector for the over-view part; pre-test; three modules (acute care, chronic care with ART and palliative care); chronic care/ART participants manual; acute care participants manual
Learning objectives:
Understand the HIV epidemic-global, national and regional, the status of roll out of ART, targets for treatment and training Understand how the different guideline modules and training materials are linked
Content
Introduction to each other, ground rules and expectations Local context
Methods
Interview someone you dont know and introduce to group; Presentations by local facilitators (power point, including global over-view) Written Explanation by the course director
Duration
15 minutes
35 minutes
Pre-test Introduction to the National Comprehensive HIV/AIDS Care and Antiretroviral Therapy (ART) Training Course for Nurses and Health Officers
30 minutes 10 minutes
Agree on group ground rules; list some expectations from participants; Answer questions from participants if there is time.
Reassurances about the pre-test

Before giving the pre-test, let participants know that they are not expected to know all of the answers, as the test cover much of what they will be learning in the course itself. The purpose of the test is to give facilitators a clear idea of what participants already know, and what they need to learn.
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Chapter 2: Integrating Prevention with Treatment
Duration: 60 minutes Materials:

Blank flipchart/markers; Flipchart for Patient Education; Male condoms and model penises or bananas
Purpose: Learn how to integrate prevention with treatment Learning objectives:

List the different ways of getting infected with HIV Explain and demonstrate the most common ways of preventing HIV transmission through sexual contact Learn to efficiently counsel the patient on prevention during every treatment encounter
Content
Linking ART with increased prevention Modes of transmission of HIV
Methods
Reading, discussions, EXERCISE 1 Discussion, Drill, EXERCISE 2 Q&A, EXERCISE 3
Duration
Preparation
Read the chapter and prepare well before the classes start. Counselling patients on prevention at every encounter 20 minutes
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1. Read learning objectives aloud. 2. Ask for volunteers to read through the clinical cases at the beginning of the chapter and discuss the questions. 3. Have them read the story of Aselef and Alemayehu and answer the questions at the end of the story. Then go through the answers together. Aselef and Alemayehu story answers: 1. How and by whom was Alemayehu infected with HIV? 2. How and by whom was Aselef infected with HIV? 3. How and by whom was Mateo infected with HIV? 4. Do you think Mateo died of AIDS? 5. Why didn't Joaquim get HIV?
By the sweet lady Alemayehu Aselef Yes 1 in 3 children of HIV+ mothers will get infected (without prophylaxis) 5 years
6. How much time was there between the infection of Alemayehu and the year he started to have serious symptoms? 7. How much time had passed between the time Alemayehu got infected and the time he died? 8. Why was Aselef sick shortly after marriage?
7 years Acute viral syndrome
4. Read Linking ART with increased prevention and then break into small groups and do EXERCISE 1. 5. Have participants list all the ways of getting infected with HIV and record using the blank flipchart. 6. Drill: Ask each of the participants to say out loud a mode of transmission, until everybody has said a mode of transmission. If the group is big, some modes of transmission will be repeated several times. This will help the class memorize this topic. 7. Do EXERCISE 2. 8. Tell them to practise giving advice about prevention with each other using the Flipchart and not reading it. 9. Remind them about the back side of the Patient Treatment Card (Annex D) and the prevention messages on it.
10. Do EXERCISE 3: Practise demonstrating condoms. 11. Review the objectives at the beginning of this chapter and confirm that they have been met. If you suspect that an objective has not been well understood by all, answer questions and provide further explanation as needed.
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Chapter 3: Introduction to Chronic HIV Care with ART

Blank flipchart/markers; pre-test; HIV clinical staging photo booklet; Clinical review form (Annex A); YES/NO cards Acute, chronic and palliative care modules, Patient treatment card
Purpose:
Introduction to chronic care including ARV therapy
Understand the difference between acute and chronic care Learn the basic principles of good chronic care Define the 5 A's
Content
Introduction of continuum of HIV care/ART Difference between Acute and Chronic care General principles of good chronic care The 5 A's
Methods
Discussion, Q&A
Duration
20 minutes
Discussion, reading Reading, Explanation Discussion Explanation, demonstration with EPT, discussion
10 minutes 25minutes 35 minutes
Wall charts:
Sequence of care; Principles of Good Chronic Care; 5 A's
Preparation:
Meet with expert patient-trainer (EPT) to prepare demonstration
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1. Read the learning objectives aloud to the participants. 2. Introduce the continuum of HIV care/ART. Comprehensive care for people living with HIV requires both clinical care based at the health facility and home-based care involving the patient, family and friends, community health workers, other community-based caregivers, traditional healers, and communitybased organizations such as NGOs and FBOs. We will be talking about an integrated process of chronic care for HIV patients, including ART (point to the wall chart with the sequence of care after a positive HIV test, reading only the titles in bold, but do not go through in detail. Explain which steps we will be learning here and what is for another course for nursing assistants/ART aids). In this course, we will learn all that are on the right side: steps 3, 4, 5,6,7,8,9,10, and 11. We will also learn to refer to guidelines in two other guideline modules: Acute Care and Palliative Care, and how to use Patient Treatment Cards to educate the patient. Show each of these materials to participants. Tell them we need to learn how to provide good chronic care for HIV patients, not just acute care. 3. Ask participants what are the most important elements for HIV care, based on their own experiences and list these on the blank flipchart (E.g. Clinical care, psychosocial support, HBC etc). What is done well? What could be improved? 4. Ask what is chronic care? What is acute care? Have participants give examples of what the difference is between acute and chronic care. 5. Have the participants read the Acute and chronic HIV care and prevention page of chapter 1 which talks about acute and chronic care. Explain that you are training them both as individuals and as a clinical team. Then refer them to the last page in the chapter which shows how the teams can work. Go through how the clinical team works using this diagram and mention that we will meet as clinical teams once. 6. Explain that currently most HIV care is episodic acute care, and this is a different approach from good chronic care. Comprehensive HIV care includes both acute and chronic care. 7. Introduce the General Principles of Good Chronic Care wall chart. 8. Ask a volunteer to read from Introduction to the General Principles of Good Chronic Care up to Assess. 9. Now introduce the 5 As. Use the wall chart.
10. Ask for volunteers to read about the 5 A's from Assess up till Combining acute care, chronic care, palliative care/symptom management, at which point they may stop (you can let them read the rest of the chapter at night). 11. Ask: What step of the 5 As do we tend to skip? Discuss in the group how they already use the 5 As, and to consider how they could help you both in your individual encounters with patients and as a clinical team. 12. Ask: Why are the 5 As helpful for ARV therapy? Which step is the most important? Why? 13. Now introduce the role-play with the expert patient-trainer.
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FACILITATOR INSTRUCTIONS FOR EXPERT PATIENT-TRAINER (EPT) ROLE-PLAY IN TRAINING SESSIONS Learning Objective: To demonstrate how to conduct an effective patient assessment interview. Before the session: 1. Meet with the designated expert patient (EPT) and review the case study. Clarify how the EPT will present his/her case and what information they will provide from their health, personal/social, and treatment history. Answer questions. Practise role-play. Repeat practise until you are both comfortable with it. It should be about ten to twelve minutes. 2. Ask the EPT how he/she would like to be introduced to the students. Note details. 3. Confirm details of demotime, place, etc. Determine any possible time conflicts for the EPT in case your session is behind schedule. During training session: 1. Introduce the EPT to the students as per his/her instructions. 2. Set up the role-play in the front of the room and ensure that everyone will be able to hear the entire role-play. 3. Ask your co-facilitator to time the exercise and to give you a two-minute warning at 10 minutes so you will have time to complete the most important learning objectives of the exercise. 4. At the end of the exercise, ask the EPT to complete the Feedback form out loud with the class as he/she fills it in (have EPT bring the generic feedback checklist with him/her). 5. Process the exercise and the feedback with the class.
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Do two role plays with the expert patient-trainer, showing good and bad use of the 5 A's. Participants should write out the 5 A's on two sheets of paper then record what was done of the 5 A's steps. Ask them to write on the 5 A's wall chart what was done well of the 5 A's and what was done poorly.
Role-play # 1: Good use of the 5 A's

Assess Facilitator (F): Hello, how are you doing today? What is the reason for your visit today? Expert Patient Trainer (EPT): Hello, I would like to talk to you if you have some time. F: Yes, I do. What do you want to talk about today?
EPT: As you know I am HIV-positive. I got married some time ago, and my husband and I would like to start a family and have children. F: This is good, let us start by checking how you are and then we can talk further about this. How have you been since we last met? Can I do a check on your health to be sure we do not to miss anything? (Use Clinical review on H10) Have you had any health problems lately? (EPT: No) Have you had any of the following: Cough? Night sweats? Fever? STI signs? Diarrhoea? Mouth sores? New skin rash? Headache? Fatigue? Nausea or vomiting? Poor appetite? Tingling, numb or painful feet/legs? Sexual problems? (EPT: shakes head no after each symptom) EPT: No, I am fine. I do not have any symptoms. F: Let me just check your eyes, mouth, glands, skin (should go through the motions).
EPT: I do not have any pain or other symptoms anywhere. F: Ok, so that is good. Now, you wanted to talk about having children, is that right? Can you tell me, do you have children at the moment?
EPT: No, but we want to start now. F: I hope you do not mind, but it is important to know if your husband has ever been tested for HIV and if he is positive or not.
EPT: Well, he doesnt know. He hasnt been tested. F: Can you tell me what you know about the risks of having children when you are HIVpositive? Well, I dont know what the risks are. Would I pass HIV on to my child?
EPT:
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Advise F: Well, perhaps it would be helpful if I gave you some information about this, would you like to hear it?
EPT: Yes, please. F: It is possible for you to pass the virus to your baby but not all HIV-positive women pass the virus to their babiesonly about 1 in 3 will have babies born with HIV infection. The infection can happen during pregnancy, birth, or breastfeeding. There are things you can do to reduce the risk. There are drugs that you can take and give to the baby at birth, and taking care with breastfeeding can make a significant difference. There is a clinic here called PMTCT which specializes in preventing mother-to-child transmission. I would suggest that you make an appointment to talk to them about it. Of course, there is also a risk to your partner, if he is HIV-negative, from having unsafe sex in order to conceive. Do you think he understands this? EPT: I am not sure what he understands. Agree F: How would he feel about coming in for a test?
EPT: I could talk to him, I think he would be frightened though. F: Perhaps you might come with him and we could talk together about being tested and having a baby? What do you think?
EPT: Yes, I think that would be all right. F: And, would you like to have an appointment with PMTCT, or shall we leave that until you have come here with your husband?
EPT: Can I leave that until we have talked more? F: Of course. I can make an appointment with them whenever you want me to. Assist F: So, we have agreed that you will talk to your partner about coming in to talk about having a test and the risks of having a baby. Will you have any difficulties with that?
EPT: Yes, I do not really think he will want to come in. F: What do you think you could do to encourage him?
EPT: I think if I tell him that if we try for a baby I might be putting him at risk of HIV infection himself, he might want to talk about it a bit more. F: Well, I would be very happy to talk to him about it.
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Arrange F: EPT: F: So, let's make a date for next Wednesday, if that suits you. Yes, that would be fine. I have an appointment available on Wednesday at 2 or 3pm. Which would be the best for you?
EPT: 3 oclock would be the best. F: OK, here is a note to remind you of the date. My phone number is at the top, please ring me if you have any difficulties and need to cancel it. You can also ring me anytime during work hours if you want to ask any other questions. Do you have any other questions right now? No, thank you. Thank you for coming today and I look forward to seeing you next Wednesday.
EPT: F:
Role Play #2: Poor use of the 5 A's

Assess F: What is the reason for your visit today?
EPT: Hello, I have come for my regular check-up appointment and I would like to talk to you if you have some time. F: Yes, I do. What do you want to talk about today?
EPT: As you know I am HIV-positive. I got married some time ago, and my husband and I would like to start a family and have children. F: This is good, let us start by checking how you are and then we can talk. How are you? How have you been since we last met?
EPT: Fine. F: Have you had any problems lately?
EPT: No, I am fine and I do not have any symptoms F: How are your eyes, mouth, glands, skin?
EPT: They are all fine. F: Ok, so that is good. Now, you wanted to talk about having children, is that right? Can you tell me, do you have children at the moment?
EPT: No, but we want to start now. F: Is your husband HIV-positive as well?
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EPT: He doesnt know. He hasnt been tested. Advise F: Well, you know you can pass the virus to your baby. The infection can happen during pregnancy, during birth or through breastfeeding. You would need to go to the PMTCT clinic for advice. Of course, there is also a risk to your partner, if he is HIV-negative, from having unsafe sex in order to conceive. He should really have a test himself. Do you think he understands this? EPT: I am not sure what he understands. Agree F: EPT: F: So, you will talk to your partner about going to have a test. Is that right? Yes, I will try. And you will go to see the PMTCT clinic for more information.
EPT: Yes, all right. Arrange F: So, I'll make an appointment for you to come back to tell me how things are going. I can make Tuesday at 4 pm. Do you have any other questions right now?
EPT: No, thank you. F: OK see you on Tuesday at 4. Next patient please.
14. Review the objectives at the beginning of this chapter and confirm that they have been met. If you suspect that an objective has not been well understood by all, answer questions and provide further explanation as needed.
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CHAPTER 4: Introduction to HIV/AIDS Pathogenesis and Immunology Duration: 1 hour Purpose: To understand the natural history of HIV/AIDS Learning objectives:
Describe the function of normal immune system Describe the Patho-physiology of HIV Understand the relevance of life cycle of the virus Understand how HIV infection evolves in patients and the association between opportunistic infection(OI) occurrences and CD4 cells decline Explain the disease progression and clinical manifestations of HIV/AIDS. Understand the relevance of life cycle of the virus and use of ARVs.
Materials:
Blank flipchart/markers;
Wallcharts:
None
Content Preparation:
Read the chapter well before the course starts. Normal immune system How HIV attacks our body Explain the disease progression
Methods
Discussion, Reading Explanation, Reading Explanation, Reading
Duration
20 minutes 25 minutes 15 minutes
1. Read the learning objectives aloud. 2. Ask a volunteer to read Understanding the immune system (1-4) Explain briefly about innate and adaptive immunity. 3. Explain the six steps of HIV life cycle using the diagram in the participant manual. Lecture need to be prepared on Life cycle, clinical course and measures of immune status (Clinical, immunological and Virological). Facilitator may also show the diagram of the virus it self on power point presentation (Optional). 4. Using the blank flipchart, have them define these terms: CD4, opportunistic infection, immune system. 5. Ask the group: How long does it take for a person who becomes infected with HIV to get AIDS without ART? 7-10 years
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Chapter 5: Opportunistic Infections (OI) and WHO Clinical Staging
Duration: 90 minutes
Purpose: Understand common OIs and WHO Clinical Staging Learning objectives:
Outline common opportunistic infections; Understand the diagnosis of common opportunistic infections; Describe WHO clinical staging of HIV infection; Stage HIV positive patients
Materials:
Blank flipchart/markers; HIV Chronic Care photos
Content
Outline and diagnosis of common opportunistic infections; Clinical staging
Methods
Discussion, Reading
Duration
30 minutes
Wall charts:
HIV clinical staging
EXERCISE 1, 2
60 minutes
Preparation:
Read well before the course begins.
NB. Tell the participants that they will learn more about integrated management of OIs in the acute care course. Stress on class room practice of WHO clinical staging.
HIV clinical staging

Facilitator needs the HIV Chronic Care photos for this exercise and the HIV clinical stage wall chart. 1. Ask a volunteer to read to the end of WHO Clinical Stages then do photo exercise with wall chart using the clinical staging pages following this section (also point out section 3.4 from the Chronic HIV Care guideline module). 2. Explain how to determine the stage using the wall chart. 3. EXERCISE 1: Hand out individual laminated clinical staging photos A through N to different participants. One at a time, describe the cases below, and have the participant with the photo that matches the description stick the photo on poster by the correct stage. If necessary, ask others to help with the diagnosis, or supply the diagnosis (e.g. photo L is KS).
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The answers are actually in the participant manual in the staging table which you can mention after the exercisealso, this wallchart with the photos should remain on the wall until the end of the course so participants can refer to them). Photo letter K B Case 47 year-old HIV+ thin man with this mass in his mouth. 41 year-old HIV+ woman who comes to the health centre complaining of having cuts on the side of her mouth. 14 year-old HIV + boy who complains of weight loss and these large swellings on his neck. 37 year-old HIV+ woman who complains of this rash on her back. She says that it is itchy. 38 year-old HIV+ woman with painful ulcers as seen in this picture. She says she has had this for a long time. 27 year-old HIV+ woman with multiple of these sores in her mouth. She says that they are painful and that she gets them a lot. 12 year-old HIV + boy who is brought by his mother because he has this itchy rash on his face. 41 year-old HIV+ man who says that he has this whitish patch on the side of his tongue. 30 year-old HIV+ man who says he has some slight swellings under his arms and on his neck as seen. 50 year-old HIV+ man who comes to the health centre because he has this painful rash. 35 year-old HIV+ woman who says that she has lost weight and she has this painful white sore in her mouth. 48 year-old HIV + extremely thin woman with this purple-black rash on her chest. 42 year-old HIV+ extremely thin woman with abnormal vaginal bleeding. 33 year-old HIV + woman who says that she has a whitish discharge. She is frustrated, because she has had it for over a month. Clinical Stage 4 (lymphoma) 2 (angular cheilitis)
M D J
4 (extrapulmonary TB-TB adenitis) 2 (prurigo) 4 (chronic herpes simplex ulcerations) 2 (recurrent mouth ulcers)
2 (seborrhoea)
H A
3 (oral hairy leukoplakia) 1 (PGL)
E G
2 (herpes zoster) 3 (oral thrush)
L M I
4 (KS) 4 (cervical cancer) 3 (vaginal candidiasis)
Tell the participants that the letters in the clinical staging table in the manual correspond to the pictures (at the end of the exercise). 4. EXERCISE 2: Now tell the participants to do the additional written exercise in the manual. Then go over individually to make sure that each understands.
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Answers to EXERCISE 2: 1. An extremely thin HIV + patient has chronic fever for 3 months. 2. An HIV+ patient with pulmonary TB and purple lesions on the skin of the left leg, with oedema of the leg. 3. An HIV+ patient with oral thrush and intermittent diarrhoea for 1 month. 4. An HIV+ patient with TB of the cervical lymph nodes. 5. An HIV + patient with big abscesses of the skin which extend to the muscle, with some yellow pus coming out of them. Stage 4 Stage 4 Stage 3 Stage 4 Stage 3
5. Point out what stage 4 problems can be diagnosed without laboratory. Answers for cases on page 50: Abebech Stage 2 Tulema Stage 4 Ato Gemechis Stage 2
6. Tell the participants that tomorrow (day 2) will be the start of the skill stations where they get to practise the skills they learned today with the expert patient-trainer. The clinical staging will be one of the exercises that they do as a card sort, so it would be a good idea to review this at home tonight.
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Chapter 6: OI Prophylaxis

Acute Care photo booklet; cotrimoxazole tablets (if available)
Purpose: To learn about prophylaxis Learning objectives:

Explain the advantages of cotrimoxazole prophylaxis Decide when to start cotrimoxazole primary prophylaxis Explain the dose of cotrimoxazole prophylaxis Recognise and manage adverse reactions of cotrimoxazole prophylaxis Know how to monitor patients on cotrimoxazole prophylaxis. Follow treatment plan from district clinician for other prophylaxis (INH or fluconazole)
Preparation
Read well before the course begins.
Content
Advantages of cotrimoxazole prophylaxis Management of patients on cotrimoxazoleIndication, dose, side effects, monitoring. INH Preventive Therapy (IPT) and fluconazole prophylaxis
Methods
Reading, discussion.
Duration
15 minutes
EXERCISE 1, Reading, Case discussion
30 minutes
Reading and brief discussion
15 minutes
1. Read learning objectives aloud. 2. Ask for a volunteer to read each of the stories at beginning of chapter. Come back to answering the questions later. 3. Ask for a volunteer to read about prevention of opportunistic infections in the chapter up to Cotrimoxazole side effects. 4. Ask for a volunteer to read page Section 7.2 in the Chronic HIV Care guideline module and then the chapter together using the photo booklet. 5. Look at photos of reaction to cotrimoxazole (rash, fixed drug reaction, Stevens-Johnson reaction). Go over these in photo booklet PUT PHOTO NUMBERS and give explanations.
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6. Ask for a volunteer to read Monitoring in the chapter. Explain when cotrimoxazole can be stopped. 7. Ask participants if they see patients on fluconazole prophylaxis. Look briefly at guidelines in Section 7.3. 8. Have the participants do EXERCISE 1, and then go over each answer individually. Answers for EXERCISE 1: 1. A 25 year-old woman comes to the consultation. She has been referred from the testing centre with a positive test for HIV. She has white patches in her mouth and weight loss. Does she need cotrimoxazole prophylaxis? How many pills will you give to the patient? What will you explain? 2. A 34 year-old comes asking for ART. He has known he is HIV+ for 2 years. He is bothered by seborrhoea and recurrent mouth ulcers. He had herpes zoster 2 years ago. He has no signs of stage 3 or 4. How would you respond? What can be offered?
1. Yes; 32 (assuming her next visit will be in 1 month, HW should schedule visit before meds finish); Cotrimoxazole is important because will help to prevent a brain infection (toxo brain abscess) which can cause paralysis on one side of the body, pneumonias, and some types of diarrhoea 2. Explain to him the benefits of cotrimoxazole prophylaxis and tell him that he is not ready for ART yet. Let him know that ART is not an emergency.
9. Now have participants reread the cases at the beginning of the chapter and answer the questions. Answers for Ato Gemechis in Chapter 6: The health officer tells all she knows about prophylaxis. He agrees to take it, and she gives him a 32-day supply. The health officer arranges a follow-up date in one month, to see if Ato Gemechis tolerates the drug and is adherent. 10. Discuss briefly about IPT. Use section 7.1 of the chronic care module. 11. Review the objectives at the beginning of this chapter and confirm that they have been met. If you suspect that an objective has not been well understood by all, answer questions and provide further explanation as needed.
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Chapter 7: Assess (clinical review of symptoms and signs, medication use, side effects, complications, physical examination) and provide clinical care
Duration: 2 hours Materials:

Clinical review form (Annex A); National HIV Care/ART Follow Up Form
Purpose: To learn to assess the patient and provide clinical care Learning objectives:
Explain why doing the complete assessment is crucial in HIV/AIDS patients Do the complete assessment (including clinical review section 3.1 and 3.2, pregnancy and contraception status, TB status section 5 of Chronic HIV Care guideline module) Know where to refer to in appropriate parts of Acute Care guideline module where indicated in assessment Understand meaning of clinical signs and symptoms in HIV patients not yet on ART Determine what clinical care patient needs, based on assessment in steps 3, 4, and 5
Wall charts:
TB Dial; National HIV Care/ART Follow Up Form
Content
How to do a clinical review Review of functional status Assess family status Review TB status* Provide clinical care
Methods
Reading, Demonstration with EPT Drill Reading, Discussion, Drill Reading, Explanation, Drills Reading, Drill, Explanation and Q&A
Duration
60 minutes 10 minutes 10 minutes 20 minutes 20 minutes
Preparation:
Meet with EPT to prepare demonstration
* NB.-Stress on TB assessment which should be done routinely in the HIV care/ART clinic. - They will learn more on TB/HIV co-infection and comanagement in Chapter 15 of the chronic HIV care/ART participants manual.
How to do clinical review

1. Read through learning objectives aloud. 2. Ask for volunteers to read 3.1 through 3.5 of the Chronic HIV Care guideline module while reading the explanations in the manual. Have them read up to 4: Assess family status. Explain that we will go over how to ask about adherence later.
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Tell the participants that they have an example of the Clinical Review form in the back of their manual (Annex A). 3. Role-play with expert patient-trainer (conducted by a facilitator with an expert patienttrainer). Facilitator should meet with the EPT outside of the class while the participants are reading to discuss the role-play. Tell the EPT to say that s/he has diarrhoea and history of pulmonary TB. The EPT may expand accordingly in the case as well as for the rest of the review. Have the participants use the form as you do the demonstration of the clinical review with the expert patient-trainer of a clinical review of signs and symptoms (NOT including adherence to medications). Tell them to circle the positives i.e. when the EPT says "yes" to diarrhoea or another symptom. Have them decide what clinical stage the EPT is in at the end of the role-play and fill it in the form. 4. Go over the stage together (Clinical stage 3). 5. Review functional status. Explain the 3 different functional status: Work, Amb, Bed. Ask: What status did the EPT had in the role-play? Tell them to circle it in the form. 6. Drill: Facilitator should give the following examples and ask participants to determine the patients functional status: Drill: Functional Status 1. 22 year-old HIV+ man who is attending school. 2. 55 year-old HIV+ man who owns a business and is still running it. 3. 59 year-old HIV+ woman who is a retired teacher but still does the housework. 4. 43 year-old HIV+ thin man who is unable to get out of bed most days because he feels too weak. 5. 29 year-old HIV + woman who is no longer able to work most days. She used to own a business and take care of things at home, but lately she has had to rely on her husband to do this. 6. 37 year-old HIV+ woman who takes care of the children at home and does housework. Answers Work Work Work Bed Amb
Work
7. Assess family status: pregnancy, family planning, and the childs HIV status. Ask a volunteer to read section 4 in the guideline module on how to assess pregnancy status, last menstrual period, use of contraception. Explain that they should also ask questions to explore whether the woman is considering having a child. Explain that they should ask the woman if she does have children, and if so, ask about whether or not her child has been tested yet. Emphasize it is also important to ask these questions to men.
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8. Drill: What is the status and what is the plan? This drill is about how to respond to woman who is: pregnant, not pregnant and on contraception, not pregnant and not on contraception, breastfeeding Drill: Review pregnancy status Section 4 1. What should you ask to any HIV+ woman of reproductive age coming to the health centre? 2. What would you advise to a HIV+ pregnant woman whose partner is HIV+? 3. What would you advise to a HIV+ pregnant woman whose partner is HIV? 4. What would you advise to a not pregnant HIV+ woman on contraception whose partner is HIV+? 5. What would you advise to a not pregnant HIV+ woman on contraception whose partner is HIV-? 6. What would you advise to a not pregnant HIV+ woman not on contraception whose partner is HIV+? 7. What would you advise to a not pregnant HIV+ woman not on contraception whose partner is HIV-? Answers Sexually active? Date of last menstruation? Using contraception? Breastfeeding? If you are sexually active, it is still important to use condoms for protection in order to prevent re-infection. It is important to use condoms for protection in order to prevent passing on HIV to your partner. It is still important to use condoms for protection in order to prevent re-infection as well as other STIs. It is important to use condoms for protection in order to prevent passing on HIV to your partner and to protect both of you from other STIs. Assess if woman is trying to be pregnant. Offer family planning i.e. oral contraceptive pills and stress the importance of condoms to prevent re-infectiondual protection. Assess if woman is trying to be pregnant. Offer family planning i.e. oral contraceptive pills and stress the importance of condoms to prevent passing on HIV to the partner dual protection. Provide or refer for safer infant feeding and PMTCT interventions. Counsel on choice of how to feed her infant and then support her in that choice. Provide good support for exclusive breastfeeding. Continue ARV therapy when breastfeeding. Support replacement feeding if this is her choice.
8. What would you advise to a woman who is breastfeeding?
Provide clinical care:

What to do if: 1. Patient has nausea? 2. Patient has headache? 3. Patient has diarrhoea? Then: Answer Palliative Care guideline module, p. 23 Acute Care guideline module, pp. 46-7 Acute Care guideline module, pp. 28-30; Palliative Care guideline module, p. 27 Chronic Care guideline module, section 9.1;
4. Patient has chronic diarrhoea?
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Palliative Care guideline module, p. 27 5. Patient has fatigue? Acute Care guideline module, pp. 50-52 (could also be anaemia, should make sure i.e pallor?) Acute Care guideline module, pp. 50-52; Palliative Care guideline module, p. 28 Acute Care guideline module, pp. 50-52 Acute Care guideline module, pp. 50-52; Palliative Care guideline module, p. 29 Acute Care guideline module, pp. 50-52; Palliative Care guideline module, P28 Acute Care guideline module, 40-5; Palliative Care guideline module, p. 30 Acute Care guideline module, 24-26; Palliative Care guideline module, P34 Acute Care guideline module, pp. 46-8; Palliative Care guideline module, P15 Acute Care guideline module, pp. 16-17; Palliative Care guideline module, p. 32 Chronic Care guideline module section 11.2; Acute Care guideline module, pp. 18-19; Palliative Care guideline module, p. 23 Use brief interventions to reduce alcohol use; Acute Care guideline module, pp. 50-2; Manage illicit drug use section 9.5 Arrange for PMTCT interventions. Review medications. Switch from EFV to a safe ARV drug, section 8.6
6. Patient has anxiety?
7. Patient has psychosis? 8. Patient has depression?
9. Patient has difficulty in sleeping?
10. Patient has itching?
11. Patient has fever?
12. Patient has pins and needles in arms and legs? 13. Patient has cough and difficult breathing? 14. Patient is losing weight?
15. Patient has hazardous alcohol use?
16. Patient is pregnant?
Review TB status
1. Ask a volunteer to read section 5 on the guideline module on how to Review TB status in all patients on each visit. 2. Explain the TB dial using TB wall chart. 3. Show how to record status on HIV Care/ART Card (Tell participants to look at the back of their manual to the card, Annex A, while the facilitator can use the wall chart) 4. TB Drill: Where does the patient belong on the TB dial? Point to the segment of the dial.
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TB Drill: Part 1 Case Patient has had a cough for 4 weeks. On the last visit sputums were sent. Two sputums are positive. Patient has had fever and is losing weight. You can find no cause for the weight loss other than HIV infection. Patient has no signs or symptoms of TB and is not taking INH. Patient has completed three months of TB treatment. Patient returns for follow-up. Two weeks ago he complained of 2 weeks of cough with yellow sputum. You gave him amoxicillin, and he is no longer coughing. Both sputums are negative. Patient was treated after being referred to the hospital for a large neck node and is now on TB treatment. Patient had TB last year and finished treatment 5 months ago. She has no cough, night sweats, or nodes. Patient has been put on INH prophylaxis and now is in the 3rd month of taking the prophylaxis. He continues to have no symptoms/signs of TB. Answerswhere on dial and what to write on card 1. Suspect TB: Record sputum results + Active TB: TB Rx (start treatment)
2. Suspect TB: Sputums
3. No suspicion of TB: No signs
4. Active TB: TB Rx
6. Active TB: TB Rx
8. No suspicion of TB: INH
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5. TB Drill: Part 2 Now go over how to fill out the TB status on the HIV Care/ART Card. Point to the column where the TB status should be filled in. Emphasize the need to check TB status on every visit. Use the same cases again. Have one participant come to the HIV Care/ART Card wall chart and write the answers as to what should be recorded on the card as his/her colleagues answer each case again.
Review the objectives at the beginning of this chapter and confirm that they have been met. If you suspect that an objective has not been well understood by all, answer questions and provide further explanation as needed.
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Chapter 8: Introduction to Ethiopian National HIV Care/ART Patient Intake and Follow-up Forms Duration: 60 minutes Materials:
Blank flipchart/markers; Copies of National HIV Care/ART Follow Up and patient intake forms.
Purpose: Introduction to using the National HIV Care/ART Patient

Intake and Follow Up Forms
Understand how the HIV Care/ART Card is used Fill out the HIV Care/ART Card *Brief introduction to patient intake form.
Content
How to use the HIV Care/ART card *Brief introduction to patient intake form.
Methods
Reading, Explanation, EXERCISE 1 Demonstration and brief explanation
Duration
Wallchart:
HIV Care/ART Card wallchart
Preparation:
None NB. * They will learn more how to fill the intake form in the patient monitoring (M & E) class (Day 6)
1. Read learning objectives aloud. 2. Show the participants copies of the National HIV Care/ART patient follow up and intake forms. Point out that the follow up form is also found in chapter 8 of chronic care/ART participants manual. 3. Go through the National HIV Care/ART Follow up Form on the wall chart. Have different participants read all sections aloud and explain how to fill it out. 4. Do EXERCISE 1 using the blank follow up form. This exercise should be done as a group. 5. Instruct participants to use the National HIV Care/ART follow up form at the skill stations. 6. Review the objectives at the beginning of this chapter and confirm that they have been met. If you suspect that an objective has not been well understood by all, answer questions and provide further explanation as needed.
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Chapter 9: Introduction to ART Duration: 90 minutes Materials:

Blank flipchart/markers
Purpose: To understand antiretroviral drugs (ARVs) and HAART. Learning objectives:

Name the different classes of antiretroviral drugs (optional); Indicate the classes to which different antiretroviral drugs belong; Explain the basics about how the different ARV drugs classes work; Explain why we need to use a combination of 3 antiretroviral drugs; Explain the difference between a first-line and second-line ARV regimen; Describe the benefits of ART; Describe the goals of ART.
Preparation:
Read well before the course starts
Content
ARVs and HAART The benefits of ART Impact of ART on CD4
Methods
Explanation, Reading, Discussion, EXERCISE Discussion; Reading; EXERCISE Q&A, Discussion, EXERCISE
Duration
1. Read learning objectives aloud. 2. Have the participants do the EXERCISE 1 individually then discuss in group. 3. Ask: What are the benefits of ART? Write them on the flipchart. 4. Then read the chapter through First- and Second-line Regimens. 5. Update the participants on the recent ARV regimen changes in Ethiopia by referring to the revised (new) national guidelines: Guidelines for Management of Opportunistic Infections and Antiretroviral Treatment in Adolescents and Adults in Ethiopia: March, 2008, FHAPCO. 6. Have the participants do EXERCISE 2 and EXERCISE 3. 7. Go over the Answers EXERCISE 2:
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Abbreviation d4T AZT 3TC NVP EFV Circle the one that is included in all 4 1st line regimens. The 2 abbreviations for zidovudine are:
Generic name stavudine Zidovudine (also ZDV) lamivudine nevirapine efavirenz 3TC
AZT, ZDV
Examples of answers for EXERCISE 3 could be as follows (these are brand names and will vary by country): d4T-3TC-NVP AZT-3TC d4T 3TC NVP AZT AZT-3TC-NVP Triomune Duovir Zerit Epivir or Lamivir Viramune Retrovir Duovir-N
8. Ask: Once a patient is on ART, does safe sex need to be practiced? Why? 9. Now have the participants read the section Benefits of ART in the manual to the Figure: showing impact of ART on CD4 and viral load on the following page. 10. Ask: Who can explain this figure? 11. Then, have the participants do EXERCISE 4. Answers EXERCISE 4 1. How many different drugs do we need to take in order to have an effective regimen? 2. Is d4T-3TC-NVP used as a firstline or as a second-line regimen? 3. What are the 2 main goals of ART?
First-line To reduce the number of virus in the blood and increase the number of CD4 as much as possible. Another combination of 3 ARV drugs (usually 2 NRTI and 1 PI) that are used if there is a failure
4. What is a second-line regimen?
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5. What happens if we do not take the combination of several antiretroviral drugs?
of therapy on the first-line regimen. Resistance can occur.
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Chapter 10: Drug Interactions

Blank flipchart/markers nevirapine, efavirenz, zidovudine, stavudine, lamivudine tablets (single or combination tablets, whatever is available locally) other pills such as rifampicin, oral contraceptive pills, methadone, etc. (if possible)
Purpose: To understand common ARV drugs interaction

with other drugs
3 ways ARV drugs interact with other drugs Avoid drug interactions
Content
Drug interaction Interaction with food and herbal medicines
Methods
Reading, Explanation Exercise Explanation, Discussion
Duration
Preparation
Read and prepare well before the course starts.
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1. Read learning objectives aloud.
2. Have the participants read Section 10.2 in the Chronic HIV Care Guideline module Avoid first-line ARV drug interactions. 3. Drill: Now tell them to close their guideline modules and do a drill going through the different medications. Say: patient tells you that s/he is taking this medication and you are giving ART which includes (name the drug which has the interaction). Is this a problem (provide cards with drugs on them and also use real pills if possible, eg. rifampicin, methadone, birth control pills, diazepam, etc.)? Patient is taking: TB treatment (rifampin) Oral contraceptives Diazepam ART to be dispensed NVP NVP EFV
4. Have participants read the corresponding section 10.2 Identify first-line drug interactions in the Participant Manual to the end of the chapter and do the exercises. 5. Go through the answers together. Answers for EXERCISE 1: nevirapine & OCP AZT-3TC-NVP & aciclovir, ganciclovir zidovudine & stavudine AZT-3TC-EFV & phenytoin d4T-3TC-NVP & rifampicin efavirenz & diazepam d4T-3TC-EFV & diazepam d4T-3TC-NVP & AZT, rifampicin; AZT & cotrimoxazole
45
Answers for EXERCISES 2-4: 2. If the patient is a woman who is taking an oral contraceptive, what advice would you give? Avoid a regimen containing NVP or use additional protection or switch to another form of contraception as the efficacy of the estrogen-based OCP is decreased with NVP. Nevirapine Both drugs work on the liver. Rifampicin will cause the blood levels of nevirapine to be lower which can cause HIV resistance. Also, both drugs together can be toxic to the liver. Efavirenz Do not give with diazepam, or other benzodiazepines except lorazepam, phenobarbitol, phenytoin, protease inhibitors (ARV). Avoid eating highly fatty meal with EFV. If on methadone, need to increase dose.
3. If a patient is being treated for tuberculosis with rifampicin, which ARV drug should he avoid? For what reason?
What ARV drugs can he take? 4. If a patient is taking d4T-3TC-EFV, what other advice would you give the patient?
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Chapter 11: Adherence, Adherence preparation & Resistance

YES/NO cards
Purpose: Introduction to preparing a patient for ART

and to understand adherence and resistance
Chapter 11 Section 1- Adherence and Adherence

Preparation
Learning objectives: Preparation:

Read beforehand and prepare well.
Define Adherence Use the 5 A's to prepare patients for ART adherence; Assess the patient's goal for today's visit; Assess the patient's understanding of ART; Assess the patient's interest in receiving ART; Give complete advice to the patient about HIV/AIDS and ART; Check that the patient is willing, motivated, and agrees to ART; Help the patient to develop the resources/support/arrangements needed for adherence; Make arrangements for follow-up after the ART preparation session; Discuss case with clinical team to propose patient to start ART.
Content: Use of the 5 A's to assess readiness for ART Preparation for ART
Methods Demonstration with EPT, EXERCISE 1 Case discussions
Duration 30 minutes
30 minutes
1. Read the learning objectives aloud.
2. Ask participants to define adherence. What is the maximum number of pills a patient can forget per month on the d4T-3TC-NVP regimen? 3 3. Ask for volunteers to read up to Prepare for ARV Therapy 4. Ask for a volunteer to read Section 8.9 in the Chronic HIV Care with ARV Therapy and Prevention guideline module. Explain that the chapter provides additional explanation and examples but what they will rely on is in the guideline module. The guideline module text is highlighted in bold in the participant manual chapter.
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5. Read chapter and discuss on the five As 6. EXERCISE 11.1: Give participants 1 minute to think about an answer to each question. Then discuss each question as a group. 7. Ask: What are conditions that can be a problem for adhering to ART? Write suggestions of the class on the flipchart. Explain what is relevant and what is not. 8. Ask them to choose the 3 most common examples which they most frequently encounter when preparing a patient for adherence to ART. 9. Do the following demonstration: Explain that the facilitators, or one facilitator and one EPT, will do a role play (taking into consideration the examples selected). Role-play with expert patient-trainer: 32 year-old patient, who tested HIV+ three years ago. The patient has been followed at the clinic in the past year. The patient completed TB treatment for lung TB one month ago, and he has had chronic diarrhoea for more than one month which has been helped somewhat by antibiotics. You decide he is medically eligible for ART and you need to assess if he is ready for it. The patient has been on cotrimoxazole in the past but had some problems with adhering to it and sometimes had problems with the TB medications as well. Use this case to demonstrate 5 A's using the examples of problems of adherence that are generated in class. Ask the class to write down at least one example of each of the 5 A's discussed during the role play. Discuss how the 5 A's were used in the role play. ASSESS ADVISE AGREE ASSIST ARRANGE What was skipped? How would they have used the 5 A's differently? 10. Now have the participants read the cases at the beginning of the chapter. Go over as a group possible ways to discuss preparation for ART for these cases.
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Chapter 11

YES/NO cards
Section 2: ARV Drug Resistance Learning objectives:

Describe what resistance means Explain the link between adherence and resistance Explain the consequences of resistance Explain what failure of therapy means Know the maximum number of pills a patient can forget per month for the regimen d4T-3TC-NVP in a fixed drug combination
Preparation:
Read beforehand and prepare well
Content
What happens after we take drug by mouth Mutations and Resistance
Methods
Explanation, Reading, Discussion, Explanation, Reading, discussion and drills
Duration
10 minutes 20minutes
1. Read learning objectives aloud. 2. Then read chapter up to Resistance and discuss 3. Read the chapter and discuss. 4. Do EXERCISE 11.2 and discuss as a group how to best explain resistance and the negative impact on both the individual and the community in your community. 5. Now, do the following adherence and resistance drill: ADHERENCE and RESISTANCE DRILL Materials: need YES/NO cards for this drill Read each statement and tell participants: If you agree with the statement, put your green YES card in the air. If you do not agree, put your red NO card in the air (Right Answers in parenthesis). Adherence and Resistance Drill 1. Being adherent means that you take the correct numbers of pills each day, even if you do not take them always at the same time. 2. HIV can make variations of itself, by accident, even in patients who are not taking ART. 3. Resistance is a change in the virus that makes the antiretroviral drugs ineffective. Answers NO
YES
YES
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4. When a patient is not adherent, the patient will develop failure of therapy and become sick again.
YES
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Chapter 12: When to start first-line ART in patients without complications
Duration: 2 hours Materials:

Blank flipchart/markers Clinical review form with 7 requirements on back (Annex A) YES/NO cards; Laminated treatment cards
Purpose: To learn initiation and management of first-line ARV

regimen at first-level facilities in patients without complications.
Determine medical eligibility for ART Understand why decentralization of ART is important List the 7 requirements to initiate ART in patients without complications Treat/stabilize opportunistic infections before initiating ART
Content
Medical eligibility and 7 requirements for ART at first level facility Starting ART at first level facility Putting it altogether
Methods
Reading, Case discussions and Drills
Duration
60 minutes
Wallcharts:
7 Requirements
Explanation, Reading, Drills Case discussion, EXERCISE 1 and drill 6
60 minutes
Preparation:
Meet with EPT to prepare demonstration
30 minutes
1. Read learning objectives aloud 2. Set the context by asking, What is a first level facility? What would you expect to find there? Put answers on a flipchart. 3. Read through the clinical cases in chapter 9 about Abebech, Tulema, and Mr. Gemechis. Explain that at the end of the chapter we will go over the questions pertaining to Mr. Gemechis. 4. Do a case demonstration with an expert patient-trainer.
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Role-Play Facilitator should go through the 7 requirements using the back of the clinical review form, the ART readiness form. Make sure you tell the EPT to say no to all the exclusion criteria. Patient is a 37 year-old HIV+ woman who was diagnosed 7 years ago. She has a history of pulmonary TB which was treated 1 year ago. She currently is on cotrimoxazole prophylaxis and has been adherent according to your records. Over the last month, she has had recurrent ano-genital ulcerations. She has also lost over 10% of her body weight. She comes to you with yet another flare-up of the ulceration and tells you that she is frustrated. At the last visit, you had started the preparation for adherence, and she was very motivated. Ask: What stage is she? Is she medically eligible? How do we know in which patients the nurse or clinical officer can recommend to start ART at the first-level facility?
7 requirements for ART

5. Ask a volunteer to read the medical eligibility. 6. Explain the rationale for being selective about starting ART; why you can initiate treatment of some patients and some patients need to go to the district clinic for a treatment plan. 7. Read requirements on Section 8.1 of Chronic HIV Care guideline module. 8. Review ART readiness recording form (back of clinical review form-Annex A in manual). 9. Have participants also read Requirements 1 and 2 in the chapter manual. 10. Do Drill 1. Review medical eligibility. Instructions: facilitator reads information on case, and participants each raise a YES or a NO card for medical eligibility. We consider that CD4 is not available, unless mentioned differently. Drill 1: MEDICAL ELIGIBILITY Patient with herpes zoster and no other symptoms. Patient with oral thrush and prurigo Patient with pneumonia and seborrhoea Patient with Kaposi sarcoma Patient with chronic and extensive ulcerations in the ano-genital area Patient without symptoms and CD4 not available Patient without symptoms and CD4 170 cells/mm Patient with repeated otitis media Patient with chronic diarrhoea Patient with weight loss of more then 10% NO YES YES YES YES NO YES NO YES YES
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Review why and why not eligible until each participant understands. 11. Ask a volunteer to read up to Requirement 4. Review Section 8.1 Box 3 in the Chronic HIV Care with ARV Therapy and Prevention guideline module together. 12. Do Drill 2 Reasons from Box 3 for NOT starting ART at first level facility are: 1. A condition requiring referral to district clinician: any severe illness and any stage 4 condition except non-severe oesophageal thrush or chronic HSV ulcerations 2. Is there anaemia? 3. Jaundice or known liver problem 4. Chronic illness such as diabetes, heart disease, kidney disease 5. Prior ARV use except NVP for PMTCT INSTRUCTIONS: First participant states a reason for not starting at first level facility; second participant repeats the first and adds a second reason; third repeats the first, second and a third, etc. Explain use of the recording form for marking eligibility. Point out where would fill out medical eligibility on the HIV Care/ART card. Ask participants: These patients may be medically eligible, but are they eligible for first line treatment at health centre? 13. Do Drill 3. INSTRUCTIONS: Stick card with YES or NO in the air. 'YES' means the patient can initiate ART in the health centre, without further advice. 'NO' means that the nurse needs to call for advice or refer, before starting ART. We consider that all patients in this exercise have medical eligibility (either by history or CD4 count).
53
Drill 3: Initiating ART at the health centre Patient has cryptococcal meningitis Patient has Kaposi lesion Patient has oral thrush and severe pain on the chest when swallowing and able to swallow fluconazole. Patient has TB of the lymph nodes Patient has tingling in hands and feet Patient has yellow eyes Patient is 6 years old Patient has used zidovudine and lamivudine as a therapy since 5 months and now comes to the centre Patient has chronic herpes simplex lesions on the genitals Patient has weight loss of more then 10% and chronic fever Patient has taken 1 tablet of nevirapine for PMTCT Patient has chronic diarrhoea despite empirical treatment Patient has a severe cerebral malaria Patient has a life-threatening pneumocystis carinii pneumonia Patient has oral thrush Patient is diabetic Patient has chronic vaginal candidiasis Patient has recurrent vaginal candidiasis Patient has had two episodes of bacterial pneumonia but has recovered and has occasional problems with skin abscesses despite co-trimoxazole NO NO YES NO NO NO NO NO YES NO YES YES NO NO YES NO YES YES YES
14. Ask for volunteers to read Requirement 4. 15. Do Drill 4. INSTRUCTIONS: Hand out laminated treatment cards. Imagine that all patients mentioned in the exercise below have medical eligibility. Read cases, and participants tell how to treat OI by holding up one of five cards: Green card: Start ART now Yellow card: Treat OI now, and start ART after completing OI treatment Yellow card: Treat OI now, and start ART after observing for 2 weeks (to be sure it is not TB) Yellow card: Treat OI now and do not start ART now Red: Do not start ART and refer
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Drill 4: ON STABILIZING OIs BEFORE STARTING ART What will you do if patient has: bacterial meningitis a non-severe pneumonia persistent fever malaria and is on treatment for it FIRST REFER GIVE ANTIBIOTICS AND WAIT 2 WEEKS BEFORE STARTING ART REFER FOR ASSESSMENT AND TREATMENT COMPLETE MALARIA TREATMENT AND START ART ONLY IF FEVER HAS DISAPPEARED TREAT ORAL THRUSH, THEN START ART TREAT GENITAL SORE, THEN START ART TREAT PHARYNGITIS, THEN START ART TREAT OTITIS, THEN START ART WAIT UNTIL RASH HAS RESOLVED, THEN START ART START ART START ART AFTER TREATMENT WITH FLUCONAZOLE START ART START ART
oral thrush genital sore Pharyngitis Otitis drug reaction (skin rash) chronic itching of the skin oesophageal thrush but still able to swallow drugs persistent diarrhoea that does not respond to empirical treatment a haemoglobin of 9,6 g/dl that is not responding to treatment with iron or folic acid a patient that has been diagnosed with cryptococcal meningitis and is now better, but still has headache a patient with suspicion of resistant malaria, because he has persistent fever, despite chloroquine and Fansidar 16. Read the rest of the requirements
DELAY ART UNTIL SYMPTOMS RESOLVED, THEN CALL FOR ADVICE REFER FOR EVALUATION
17. Have the participants read the rest of the chapter and complete EXERCISE 1. Go over answers together as a group. Answers for EXERCISE 1: 1. An HIV+ patient with chronic fever and a CD4 of 50 cells/mm comes to the health care centre. What will you do? O refer him/her for assessment of the fever before starting ART O start ART now, because the ART will decrease the fever O give antimalarial drugs and start ART at the same time 2. An HIV+ patient has headache and fever since 1 week. His CD4 is 20 cells/mm. What will you do? O refer him for assessment of the headache and fever before starting ART O start ART now, because the ART will decrease the headache and fever O give antimalarial drugs and start the ART next week, even if symptoms have not yet resolved
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3. A patient has oral thrush and chronic diarrhoea. You gave empirical treatment for the diarrhoea and it resolved. You gave miconazole gumpatch for the oral thrush and it disappeared. The CD4 of the patient is 100 cells/mm. He has no other symptoms. What will you do? O refer the patient for assessment before starting ART O start preparing the patient for ART in the health centre O observe the patient regularly, but not start ART yet, because the patient has no criteria to start ART 4. A patient had herpes zoster on the left side of the chest last week. His CD4 are 168 cells/mm. He has no other symptoms, and the herpes lesions start to heal. What will you do? O refer the patient for assessment before starting ART O start preparing the patient for ART in the health centre O observe the patient regularly and give cotrimoxazole prophylaxis, but not start ART yet, because the patient has no criteria 5. An HIV+ patient has been diagnosed with pulmonary TB. His CD4 are 123 cells/mm. What will you do? (They will learn more about TB/HIV Co-Management on Chapter 15) O start TB treatment and start ART after the TB treatment is finished O start TB treatment and call for advice on when to start ART and which ART regimen to use O start ART now, and treat TB later 6. An HIV+ patient has an itchy papular skin eruption, mainly on arms and legs, for several months. He has no other symptoms. You have no CD4 available. What will you do? O start preparing the patient for ART now O not start ART yet, but start cotrimoxazole prophylaxis, because there are not enough criteria to start ART O refer the patient for assessment 7. An HIV+ patient who has been treated for chronic genital herpes simplex comes to the consultation. There are no CD4 counts available in your setting. What will you do? O start preparing the patient for ART now O not start ART yet, because there are not enough criteria O refer for further assessment 8. A new patient comes to the health centre because he is HIV + and says that he needs to start ART right away. He tells you that he had a ''brain infection'' last year. You now have ART available. O start preparing the patient for ART now O ask for written documentation of his HIV test and previous records O refer him for assessment 9. An HIV+ patient recently finished treatment for oesophageal thrush. You start
56
preparing for ART, and she tells you that she took it when she was pregnant so she knows all about it. You should: O refer her to the district clinician O start her on the same ART combination O start preparing her for ART after asking if she was on nevirapine for PMTCT and explaining the difference between PMTCT and ART 10. An HIV+ patient has a CD4 count of 150 and sores at the corner of his lips. He also says that he has lost weight. He tells you that he knows he needs ART, because it helped him put on weight before. What will you do: O refer him to the district clinician O start preparing the patient for the same combination of ART that worked before O give him cotrimoxazole and tell him that he is not medically eligible for ART yet
18. Have participants now reread Mr. Gemechiss case at the beginning of the chapter and answer the questions.
19. Now discuss the following cases in Drill 5.
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Drill 5: What will you do in the following cases: A patient that has Kaposi sarcoma on the leg and has started treatment last month for sputum positive pulmonary TB A patient which has been treated last week for a non-severe pneumonia with amoxicillin. There was oral thrush in the past history A patient with oral thrush and a history of PTB 8 months ago A patient with persistent fever A patient with herpes zoster A pregnant woman that has been diagnosed with smear negative pulmonary TB A patient with chronic itching A patient with persistent but mild anaemia and chronic fever, weight loss and abdominal pain A patient with chronic herpes simplex ulcerations on the genitals A patient with sputum-positive TB that completed treatment last week, who presents with malaria today. Patient had pneumonia last year. A patient who had cryptococcal meningitis 3 months ago but has only chronic diarrhoea right now A patient who was treated for disseminated TB for 5 months and now starts to have anaemia, abdominal pain and weight loss A patient with primary syphilis and CD4 of 170 A patient with recurrent otitis but is symptomfree right now A patient with a toxoplasma brain abscess A pregnant patient with oral thrush. She has PTB last year A patient without symptoms and no history A patient HIV wasting syndrome A patient with a severe respiratory disease
REFER
WAIT FOR 2 WEEKS AFTER COMPLETING ANTIBIOTICS BEFORE STARTING ART TREAT THRUSH AND START ART REFER DOES NOT NEED ART YET START TB TREATMENT CALL FOR ADVICE OR REFER DOES NOT NEED ART YET REFER
START ART ( IF AVAILABLE, AFTER GIVING ACICLOVIR) TREAT MALARIA FIRST, THEN START ART, IF FEVER GONE
START ART
REFER
TREAT SYPHILIS FIRST THEN START ART NO ART NEEDED YET REFER TREAT THRUSH, THEN START ART NO ART YET REFER REFER
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Chapter 13: Four First Line ARV Regimens

Nevirapine, efavirenz, zidovudine, stavudine, lamivudine tablets (single or combination tablets, whatever available locally); Patient Treatment Cards (Annex E)
Purpose: Learn to use the four first-line ARV regimens Learning objectives:
Understand the four first-line regimens Give correct advice on how to take each of four first-line regimens Determine correct dose
Content
First-line ARV regimens Advice to the patient on how to take each of four regimens (Annex E) Dosing
Methods
Q&A Explanation of the card , Drill EXERCISES 1, 2, 3
Duration
Wallcharts:
National HIV Care/ART Follow Up Form (HIV Care/ART Card)
15 minutes
Preparation
Prepared flipchart with Sun/Moon chart for all regimens
First-line ARV regimen instructions

1. Read the learning objectives aloud. 2. Ask for a volunteer to read Section 8.5, in the Chronic HIV Care guideline module, to understand all 4 regimens. 3. Briefly introduce the Patient Treatment Card (Annex E) for each first-line regimen. 4. Explain dose escalation of NVP. Ask: In the first 2 weeks of treatment, how many FDC tabs and separate tablets are given for the regimen d4T-3TC-NVP? 5. Show the examples of sun/moon pill chart for all the regimens that you have drawn on blank flipchart.
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6. Dosing Drill: Give a regimen for a patient. Ask a participant to explain the dose for the patient for one day. Have the participant write the prescription on a sun/moon pill chart for the patient, using a blank sheet from the flipchart. 7. Explain how regimen would be filled out in the HIV Care/ART Card in the upper right hand corner of the card as well as in the dispense section. Use the HIV Care/ART Card wall chart and point out that this will be important to fill out properly when the patient starts on ART. 8. Participants should do EXERCISES 1 through 3 at the end of the chapter. Discuss answers in the group as needed. Answers EXERCISE 1: Write out the full names of the 3 drugs. What is the common name for the combined tablet used in your area? Emma weighs 50kg and is starting on d4T-3TC-NVP. Instructions for the first 2 weeks on how to take the drugs. What instructions should be given to Emma after 2 weeks if she has no problems?
Stavudine-lamivudine-nevirapine i.e. Triomune She needs to take an AM fixed dose combination of d4T-3TC-NVP (30mg for d4T) and PM separate tablets of d4T (30mg) and 3TC (150mg), After 2 weeks she can take AM and PM combined tablets
EXERCISE 2: Show bottles of the drugs. Have the participant arrange and explain the first 2 weeks dose of d4T-3TC-NVP using the pills and including the number of tablets dispensed. If you have other drug regimens available in pill bottles, have participants practise arranging those regimens as well. 9. Review the objectives at the beginning of this chapter and confirm that they have been met. If you suspect that an objective has not been well understood by all, answer questions and provide further explanation as needed.
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Chapter 14: Support ART initiation then monitor and support adherence to ART Duration: 90 minutes Materials:
Blank flipchart/markers ; Pillbox (if available) Checklist for patient counselling
Purpose: Learn to support initiation of ART, then monitoring and

support of adherence
Use a simple pill chart (including pill charts for patients who cannot read) Give several practical tips to the patient on how to remember to take the drugs Assess adherence Understand the importance of constructing a team with other people, to increase your patient's adherence: friends, treatment supporter, home care teams, support groups Explain why safe sex is important, even when taking ART Recognise barriers to adherence Provide solutions for barriers to adherence Know the limitations of each method of assessment of adherence
Preparation
Meet with EPT and prepare demonstration
Content
Support ART initiation Assess adherence
Methods
Reading, Explanation Reading, Explanation, Demonstration with EPT and case discussion Discussion and Q&A
Duration
Practical adherence tips for patients
30 minutes
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1. Read learning objectives aloud. 2. Ask a volunteer to read Support ART Initiation,( read only the bold ones in the participants manual); section 8.9 in the chronic HIV care module 3. Have the participants read the clinical cases at the beginning of the chapter and then discuss them. 4. Ask participants what factors might interfere with adherence for their patients and list these on a blank flipchart. Make sure that all factors listed in their manuals are on the list. 5. Ask participants to list ways to remember taking ART at the right time. Write this on the blank flipchart. 6. Ask for volunteers to read assessing adherence to ART 7. Explain how to assess adherence. Explain how to calculate the adherence percentage on the blank flipchart. Show where adherence is recorded on the HIV Care/ART Card. 8. Show an example of a pillbox, if available 9. Demonstrate how to assess adherence with the expert patient-trainer. Role-play with the expert patient-trainer 56 year old HIV+ patient who was diagnosed 9 years ago. The patient has a history of stage 4 HIV and has been on ART for 3 weeks (d4T-3TC-NVP). S/he describes having nausea initially, but it has resolved. In discussing adherence with the patient, s/he tells you that s/he sometimes forgets to take his medications, but only when he goes out to drink with friends. Also, s/he figures it did not matter because when he remembers, s/he just doubles the next dose (patients treatment supporter is his/her spouse). Ask the EPT, if s/he is on ART, to share his/her experiences with ART. Use the checklist for patient counselling on the back of the HIV Care/ART card. Point the checklist out to the participants. Ask them if they have any questions about it.
10. Have the participants read to the end of the chapter and complete EXERCISE 1. Then discuss what they have written. Review the objectives at the beginning of this chapter and confirm that they have been met. If you suspect that an objective has not been well understood by all, answer questions and provide further explanation as needed.
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Chapter 15: TB/HIV

Blank flipchart/markers; TB wall chart(TB Dial), National HIV Care/ART Card; OI cards
Purpose: Understand the relationship between TB and HIV Learning objectives:

Understand the association between TB and HIV and vice versa; Understand how to screen for TB and how to diagnose active TB; Know the overlapping drug toxicities of TB treatment and ART; Know when to start ART when a person has or develops TB (TB/HIV co-management)
Content
Understanding the relationship between TB and HIV How to diagnose Tb in HIV patients TB/HIV Co-management
Methods
Reading and explanation
Duration
15 minutes
Reading and explanation Explanation, Questions, Drills
Drill What should you do in these cases and what is the TB status? Case HIV + man with cough for 4 weeks and no other symptoms. HIV+ man with fever and weight loss for weeks denies cough. No nodes, not producing sputums. HIV+ woman with cough who has Answers 1. Send sputums (Suspect TB: Sputums) 2. Refer (Suspect TB: Refer:?TB)
3. Record results and start TB
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returned for the results of the sputum test: sputum test is positive. HIV+ woman with cough who has returned for the results of the sputum test: sputum test is negative and patient is still coughing.
treatment (Active TB: TB Rx)
4. Acute Care p. 63Since still coughing, refer to clinician if available, or treat with non-specific antibiotic such as ampicillin. If cough persists, repeat sputums.
HIV and Tuberculosis

1. Ask participants: What is TB? How is TB spread? What is the difference between pulmonary and extrapulmonary TB? What is the difference between TB disease and TB infection? How does HIV affect the risk for getting TB? Is it lower? Is it higher? 2. Then, have them read this section, Correlation Between HIV and Tuberculosis in the manual. Drill : TB MANAGEMENT FOR TB PATIENTS NOT ON ART We consider that CD4 is not available, unless mentioned differently. We consider all patients described in the exercise medically eligible (either by history or CD4 count). The patients have no concurrent OI, unless mentioned differently. What will you do in each case? Patient has chronic cough and 2 positive sputum results Patient has started treatment for TB meningitis 1 month ago Patient has completed the treatment for smear positive pulmonary TB last month Patient has completed treatment for lymph node TB last week Patient has pulmonary TB in month 5 of the treatment and now develops again persistent fever Patient has smear-negative TB and is in month 3 of treatment Patient has smear positive pulmonary TB and the CD4 is 280 cells/mm Patient has smear-negative pulmonary TB and the CD4 is 100 Patient is on treatment for pulmonary TB and loses weight Patient has finished treatment for pulmonary TB last month and now starts to have fever and weight loss, without an evident cause
START AND COMPLETE TB Rx, THEN START ART REFER/CALL FOR ADVICE START ART START ART REFER
CALL FOR ADVICE START TB Rx START ART AFTER INITIATION PHASE START TB Rx START ART ASAP CALL FOR ADVICE ON COTREATMENT REFER REFER
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Chapter 16: Special considerations for ART in pregnant and postpartum women Duration: 90 minutes Materials:
Blank flipchart/markers
Purpose: To learn about special considerations for ART in pregnant

and post-partum women
Define eligibility for ART in pregnant women List ARV drugs pregnant women can take Describe the difference between ART and ARV prophylaxis to prevent MTCT Understand special considerations for ART adherence during pregnancy and post-partum Make sure women get PMTCT interventions Content: Eligibility for ART in pregnant women PMTCT, MTCT interventions ART and ARV prophylaxis Methods Reading, Case discussions Group exercise, brainstorming Explanation, Discussion, EXERCISES 1, 2 Duration 30 minutes 30 minutes
Preparation:
None
30 minutes
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1. Read learning objectives aloud. 2. Have participants read the case about Abebech at the beginning of the chapter, and see if the class knows what to do. Advise them to read special considerations in pregnant women in section 8.6 of the Chronic HIV Care with ARV Therapy and Prevention guideline module. 3. Ask for volunteers to read the chapter in the Participant Manual. When they have read the chapter, discuss how to manage Abebech: The nurse informs Abebech that she should continue the drug. This regimen is not harmful for the baby. Abebech needs the drug to stay healthy, but the drug will also reduce strongly the risk that the baby acquires HIV infection. Abebech is happy about this because it is very important to her that the baby is born negative. The nurse advises Abebech to go to the PMTCT program, to get advice on safe delivery and infant feeding options. The nurse interrupts the cotrimoxazole, and will restart it after the first trimester. 4. Read the box, What is MTCT? What is PMTCT? and the explanations which follow. Make sure participants know what MTCT and PMTCT are. 5. Lead a group brainstorm on PMTCT: Step 1: Ask participants to briefly describe what they do in their clinics to prevent MTCT of HIV. Record on flipchart. Note if they have PMTCT program. Step 2: Ask PMTCT program staff to list the key points of their PMTCT program. Record on flipchart. Step 3: Summarize the exercise by highlighting the PMTCT interventions they are currently providing. Step 4: Conclude exercise by stressing PMTCT gaps in existing services. (Please note that we are not trying to quickly teach PMTCT interventions for safer labour and delivery or counselling on infant feeding choice. We do want to relate what we are teaching in this course to what they may be practising in providing PMTCT interventions, to make them realize ART is a PMTCT intervention, and to be sure pregnant women receive the other PMTCT interventions which are available). 6. Lead the following discussion about other PMTCT interventions: Step 1: Explain the difference between ART and ARV prophylaxis. ART is the provision of a combination of 3 ARV drugs that are prescribed for the life of the patient. It is only appropriate for pregnant women with advanced disease. ARV prophylaxis is the short-term use of one drug, Nevirapine (AZT 300 mg) that is given to the woman starting form 28 weeks of gestation during pregnancy, with AZT (600 mg) - sd-NVP (200 mg) - 3TC (150 mg) at onset of labour, followed by 3TC (150 mg) till delivery. The mother will continue receiving AZT (300 mg) and 3TC (150 mg) for 7 days, postnatal period. The infant should also be started on ARV prophylaxis as soon as possible after birth.
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ARV prophylaxis is appropriate for all pregnant women who are not on ART in order to PMTCT of HIV
Step 2: Stress the need to provide the other PMTCT interventions even if a woman is on ART. Prepare a flipchart with the headings below but without the bullets filled in. Conduct a group brainstorm and ask the group to fill in the correct responses that are listed in bold. At the end of the brainstorm record any responses that were not mentioned. Remind the group that Labour and Delivery and Safer Infant Feeding Counselling require special PMTCT training.
PMTCT in HIV+ Woman on ART**
PMTCT in HIV+ woman not yet medically eligible for ART**
ARV prophylaxis to baby Safer Labour and Delivery Interventions* Counsel on Safer Infant Feeding*
*
ARV Prophylaxis to mother and baby Safer Labour and Delivery Interventions* Counsel on Safer Infant Feeding*
If you have not been trained in infant feeding counselling for HIV-infected women, refer to someone who has been trained ** Adapt to national guidelines (1,2 or 3 drugs) 7. Now have the participants do EXERCISES 1 & 2 at the end of the chapter. Answers for EXERCISE 1: All the regimens without EFV are safe to start in pregnancy in a woman without anaemia for the first exercise. EFV should not be given during the first trimester of pregnancy.
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Answers for EXERCISE 2: 5. A 22-year-old woman comes to the consultation. She has been sent for testing by the antenatal care nurse. She is HIV+, but is very surprised, since she feels very healthy and does not suffer from any disease. The physical exam is normal. She is 4 months pregnant. You assess her and conclude that she is in clinical stage 1. What type of intervention(s) does this woman need? Do CD4 count if possible. If you have limited resource to determine CD4 count, give priority to pregnant women in stage 1 and 2. Explain, advise PMTCT interventions: If she is not eligible for ART Start ARV prophylaxis: AZT 300 mg twice daily starting from 28 weeks of gestation. She will also receive ARV prophylaxis throughout labour and postnatal period (7 days) and to the newborn, counselling on safer labour and delivery (in facility, not at home), arrange for counselling on infant feeding options (if you have not been trained to do these) 6. A 25-year-old woman is pregnant. You think she must be no further than 2 months. She is thin and she had just started TB treatment for smear-negative pulmonary TB. She also had oral thrush 2 weeks ago. What will you do? This woman needs ART for her own health. The nurse should call for advice. The doctor may advise to start AZT-3TC-NVP two weeks after the intensive phase finished. She should still be referred to someone trained in the PMTCT interventions (if health worker is not), for counselling on institutional delivery and infant feeding options. Give CTX prophylaxis starting from 2nd trimester. She does not need ARV prophylaxis as she is on ART. Her baby needs ARV prophylaxis. 7. A 26-year old HIV+ woman is 3 months pregnant. She feels fine and has no problems. On one side of the trunk, you see scars from herpes zoster. What will you do? You decide she is HIV clinical stage 2. Do CD4 count if possible. If her CD4 count is > 200 she is not eligible for ART. If she is not eligible for ART start on AZT 300 mg twice daily at 28 weeks of gestation. Counsel on institutional delivery, arrange for counselling on infant feeding options. Give CTX prophylaxis starting from 2nd trimester. She will be receiving ARV prophylaxis during labour and postnatal period, her baby also need ARV prophylaxis. 8. A 24-year-old woman has been taking ART for 2 years. She tolerates the therapy, and is adherent. Her weight has increased and she did not have any serious OIs within the last 2 years. She was in stage 4 when she started ART. Her regimen is d4T-3TC-NVP. She is now pregnant in her first trimester. What will you do? Inform on the risk of PMTCT. Discuss the advantages of ART in reducing the risk of HIV transmission; explain the risks and benefits of ART during the first trimester. She should still be referred to someone trained in the PMTCT interventions (if health worker is not trained), for counselling on institutional delivery and infant feeding options. She does not need ARV prophylaxis as she is on ART. Her baby needs ARV prophylaxis. If she is concerned about taking ARV drugs in early pregnancy and does not agree with the risk/benefit to continue ART during first trimester, you could interrupt the therapy (all 3 drugs) during the first trimester and then restart.
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9. A woman is taking AZT-3TC-EFV for 6 months. Before, she took d4T-3TC-NVP, but she had to interrupt it because she had a severe rash on NVP. Now she comes to the health centre and tells you she is pregnant in her first trimester. When she started ART, she was in stage 4, but now she feels fine. What will you do? This case should be referred. She needs ART for her own health. She needs to interrupt the EFV containing regimen, but cannot use NVP anymore. The doctor can put her on NFV or may need to stop all the drugs and then restart. She still needs PMTCT interventions. Her baby needs ARV prophylaxis.
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Chapter 17: Is ART working? Visit follow-up, laboratory monitoring and identifying failure

None
Purpose: Learn how to tell if ART is working Learning objectives:

Recognise therapy success and failure Explain frequency of clinical monitoring and its interpretation Explain frequency of CD4 monitoring and its interpretation
Preparation:
Read and prepare well before the course starts.
Content:
How to recognise success and failure of ART Immunologic/CD4 monitoring Clinical monitoring
Methods
Reading, Case discussion Reading, EXERCISE 2
Duration
20 minutes
20 minutes
Reading, EXERCISE 2
20 minutes
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1. Read learning objectives aloud. 2. Ask for volunteers to read through the cases at the beginning of the chapter and then discuss them. 3. Have them read the rest of the chapter. 4. Discuss EXERCISE 1. 5. Have participants do EXERCISE 2 and then discuss answers. Answers for EXERCISE 2: 1. A patient takes d4T-3TC-NVP for 1 year and 6 months. CD4 was measured at baseline (50), month 6 (143), month 12 (247) and month 18 (233). What will you do and why? 2. A patient has been taking d4T-3TCNVP for 3 years now. At first, the weight was increasing, and he did not have a serious OI since he started treatment. Now, the patient develops itching of the skin, he also had herpes zoster last month. He starts to lose a lot of weight. What will you do and why? 3. A patient has been taking d4T-3TCNVP for 6 months. The CD4 has increased from 2 cells/mm3 at baseline to 60 cells/mm3 now. What would you do and why? 4. A patient has been taking d4T-3TCNVP for 2 weeks. He never took ART before. Now he develops fever and cough. Do you think this is a failure of therapy? What would you do?
1. Encourage him to continue adhering to the regimen and tell him that his CD4 is improving
2. This is likely a new OI due to failure of therapy, the HW should call for advice
3. Encourage him to continue adhering to the regimen and tell him that his CD4 is improving. The time it takes to increase the CD4 varies from person to person. 4. This is likely immune reconstitution syndrome, the HW should call for advice.
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Chapter 18: Managing side effects of ART and reporting Adverse Drug Reactions

Blank flipchart/markers; Laminated side effect cards
Purpose: To learn to management of side effects and new symptoms

in patients on first-line ARV regimens.
Describe the most common side effects for each ARV drug used in the first-line ARV regimens Explain the 3 different categories of side effects Give an adequate explanation of the most important side effects to patients Explain to patients what to do if side effects occur Understand the possible explanations when new signs and symptoms develop in a patient taking ART Manage simple side effects List which side effects need advice or referral
Preparation:
None
Content
Common side effects of each drug 3 different categories of side effects Management of side effects
Methods
Reading, Case discussions; EXERCISE 1 Reading, Explanation Reading, EXERCISE 2, 3
Duration
40 minutes
20 minutes
60 minutes
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1. Read learning objectives aloud. 2. Ask those who have been around patients on ARTwhat are the most common side effects you have seen? List them on the flip chart. 3. Read the clinical cases at the beginning of the chapter and discuss the cases. 4. Read up to Clinical Review in Patients on ART. Then look at the table in section 8.12 in the Chronic HIV Care guideline module and discuss usefulness in practise. 5. Do EXERCISE 1 Side Effects Drill: Write the name of each first line drug on a separate page of a flipchart and stick to the wall. Distribute a side effect card to each participant and have the participants match them to the drugs that cause them.
Patient Treatment Card for each regimen

6. Read section 8.7 in the Chronic HIV Care guideline module, Patient/treatment supporter education cards and look at the Patient Treatment Card (Annex E). Point out the sections which talk about what to do with side effects pertaining to the regimen. Also point out the prevention side of the card which is also important for the patient to see. 7. Discuss what you should warn patient about; how to cope and when to seek care.). Give simple instructions.
Clinical review in patients on ART

8. Read in participant manual the strategies for managing aside effects and theoretical explanation of the three possible causes of signs and symptoms, listed under Clinical Review in Patients on ART. 9. Ask participants: What is the general difference between what the patient with HIV and immunosuppression can have versus a patient without HIV? What about the HIV+ patient on ART versus before ART?
Management of side effects

10. Ask for volunteers to read from Immune reconstitution syndrome to the end of the chapter. 11. Ask participants: What you should do in the following cases: Person has nausea Person has nausea for 3 weeks and has stopped eating Person has headache Person has headache for more than 2 weeks Note that the Table in Section 8.12 in Chronic HIV Care guideline module is important because health workers must deal with these very often.
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12. Drill: Instructions: Give a description of a patients symptom and drug regimen using the Table Section 8.12 and ask participant to state a response as to what to do. 13. Have participants do the role-plays in EXERCISE 2 and tell them to use the Patient Treatment Card to explain the regimens and side effects to the patient during the roleplay. If the EPT is available, they can also practise with the EPT otherwise one participant may be the patient and different participants may play the role of the clinical officer or nurse. 14. Do EXERCISE 3 at the end of the chapter. Answers for EXERCISE 3: While doing this exercise, ask: Which drugs cause the side effect? Side effect Type of side effect Drug which causes (* requires urgent care) the side effect Changes in fat Major: occurs with long term d4T treatment Severe belly pain *Major: patient should seek care d4T urgently and needs urgent referralpotentially serious, because could be pancreatitis Tingling or numbness Major: this is neuropathy, should d4T in feet or hands seek advice soon Yellow eyes *Major: patient should seek care NVP or EFV urgently and needs urgent referralthis is likely liver toxicity Skin rash *Major: patient needs to seek care NVP or EFV urgently-It could be a severe reaction to the drug and may require urgent referral. Nausea, vomiting, Minor: patients will need to be all diarrhoea prepared to cope with these side effects
15. Repeat EXERCISE 1 (side effect cards) to review if there is time. 16. Review the objectives at the beginning of this chapter and confirm that they have been met. If you suspect that an objective has not been well understood by all, answer questions and provide further explanation
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Chapter 19: Universal Precautions (UP) and Post-Exposure Prophylaxis (PEP) Duration: 90 minutes Materials:
None
Purpose: To identify Universal Precautions and Post-Exposure

Prophylaxis procedures to use when working with HIV patients and providers

Describe the basic principles and procedures of standard precautions Identify the risks of HIV, HCV, and HBV seroconversion following accidental occupational exposures List the management steps of occupational exposure Describe measures taken to maximize the effectiveness of PEP. Describe the principles of HIV post-exposure prophylaxis
Preparation
None
Content
Universal precautions Post exposure prophylaxisOccupational exposure PEP- Sexual assult
Methods
Reading, Explanation and discussion Reading, Explanation discussion and case studies Reading and discussion
Duration
30 Minutes 40 minutes
20 minutes
1. Have the participants read up to Post exposure prophylaxis. 2. Ask participants to discuss about universal precaution in their context. 3. Ask a volunteer to read Post exposure prophylaxis. 4. Do Exercise: Case 1 and 2 5. Review the objectives at the beginning of this chapter and confirm that they have been met. If you suspect that an objective has not been well understood by all, answer questions and provide further explanation as needed
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Chapter 20: Palliative Care Duration: 30 minutes Materials:

LCD Projector, Lap top
Palliative care module End of life care and Symptom Management.
Purpose: To understand the theory of palliative care and introduce

the operations manual (palliative care module).
Define palliative care and its role in the management of HIV Describe the need for palliative care along the continuum of HIV/AIDS care Describe components of palliative care Discuss challenges of palliative care in the Ethiopian setting
Content Preparation
Read and prepare well before class starts. Definition of palliative care and the different models Challenges and Exercise
Methods
Explanation and discussion or a mini lecture (Power Point Presentation=PPP) Questions, Discussion
Duration
20 Minutes
10 minutes
1. Provide an interactive lecture 2. Explain the need to cross refer the operational manual (Palliative care module End of life care and Symptom Management) 3.. Do the exercise together 4.. Read learning objectives and check whether they are met. NB. Palliative care definitions may vary according to the school of thought.
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Chapter 21: Medical Ethics Duration: 45 minutes Materials:

None
Purpose: To get an over-view on medical ethics with respect to

HIV/AIDS. Learning Objective: Describe concepts, values and principles of medical ethics in general and in relation with HIV/AIDS services in particular.
Preparation
Read well and prepare before hand.
Content
Define medical ethics Values of Medical ethics Case discussion
Methods
Interactive lecture Interactive lecture Exercises
Duration
1. Provide an interactive lecture. 2. Do the exercise together with the class. 3. Further discussions if time is enough. 4. Read learning objectives and check whether they are met.
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Review prior to post-test

INSTRUCTIONS: The following exercise is to help us review for the post-test. Prepare a one-page flipchart with the key points from your chapters. You will have 10 minutes to prepare your flipchart. When you are finished, hang your flipchart on the wall. Review the other flipcharts for 10 minutes. Present a 3-minute summary of your flipchart to the whole group. Assignments (in the Chronic HIV Care guideline module): 1. Principles of Good Chronic Care (H25) 2. Registration and screening (Section 1) and Educate and Support the Patient (Section 2) 3. Assess: clinical review of symptoms etc. (Section 3.1 and 3.2) 4. Pregnancy, family planning (Section 4) & PMTCT (Section 8.6) 5. TB status, diagnosis and treatment (Section 5 and section 8.4) 6. Provide Clinical Carethe 5 As (Section 6.1) 7. Prophylaxis (Section 7) 8. ARV Initiation7 requirements (Section 8.1) 9. ARV Regimens & Doses (Section 8.5) 10. ARV Adherence & Patient Support (Section 8.9) 11. Management of Side Effects (Section 8.12) 12. Manage Chronic Problems (Section 9)
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Day by day summary of skill stations and card sorts

The facilitator for the first skill station of the day should make sure that the card sort exercises are ready for the skill station. Facilitator should also make sure to have enough copies of clinical review forms, HIV Care/ART cards, and case-specific checklists at each skill station.
Introduction and instructions for the EPT skill stations

Starting on Day 2 of the course to the Day 5, the skill stations are 2 hours each day and 1 hour on the last day. Cases that will be practised today are numbers 1-10. The skill station is a way for the health worker to practise the skills that they have learned in class with expert patient-trainers who are PLHIV and have been trained to role-play HIV cases with them. At the end of the role-play they will give the health worker feedback. As facilitators, you are responsible for setting up the skill station, so whoever is the first group to go should be the ones to set it up that day. In order to facilitate setting up and facilitating the skill station it would be helpful to look at ''Section H: Skill Station Procedures'' from the Facilitator Guide for the WHO Basic ART Expert Patient-Trainer Course. This guide also has the facilitator's guide to each case and set up needs of each case. Each case also has a case-specific checklist (found in the Handouts for the Expert Patient-Trainer) and enough copies should be made of each case's checklist for the skill stations. As part of the skill station, there are also card-sorts exercises which are exercises similar to the exercises which are done in the class. As seen in the table below, each day there are different card sorts where cases on the cards or drug abbreviations need to be matched to the appropriate answers. All the cards for the card-sorts are available in the reusable kit. The explanation for each card-sorts exercise is at the back of this facilitator guide in Annex B of the Basic ART section and contains the set up needs for each exercise. Prior to the start of the skill station, the facilitator should introduce the skill station and the skills/materials to be used which will be important to be practised. The facilitator can use the ''Introduction to the health worker,'' Annex 7 of the Facilitator Guide for the WHO Basic ART Expert Patient-Trainer Course to help with the first day introduction. Tell the health worker to bring their manual which has the health worker case book in Annex C of the Participant Manual as well as their guideline module. Explain to the participants that they should be trying to use the materials which are at the skill station even if they have not completed that chapter in class yet (i.e. the first day of the skill station introduces the HIV Care/ART Card and the first group will likely not have done that chapter yet. They can, however, fill out the clinical stage, family status, functional status, and TB status in the card as they learned from the previous day). The participants should practise using the 5 A's during the skill station and use the clinical review forms (available at the skill station). Explain to the participants that they should use the skill stations as an opportunity to put what has been learned into practise. Remind them that this is not a test. It is an exercise of which they should take advantage. The feedback given by the EPT is meant to be non-judgemental and should be taken in a positive manner. The skill stations should be used as a tool to improve their learning.
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Before going to the skill stations on each day, explain to the participants the skills to be practised. They should be practising the 5 A's as in all patient interactions, using the clinical review, giving cotrimoxazole and other prophylaxis as indicated, and filling out the HIV Care/ART Cards. The materials which should be used at the skill stations are their guideline modules (Chronic HIV Care with ARV Therapy and Acute Care), the HW casebook, HIV Care/ART Card (will be available at the skill station) and the Flipchart for Patient Education. The Flipchart should be used during the skill station to practise giving advice and explanations to the patient.
Skill Station Schedule

Day #
1
Case #
Card Sorts
No skill stations
Topics Covered
2 (2 hours for each group)
1-10
HIV Clinical Stages (link the symptoms/signs to the stage)
3 (2 hours for each group)
11-20
TB Testing, Treatment, and Follow-Up Drug Names and Abbreviations Major and Minor Side Effects (link side effect to correct 1st line regimen) Treatment of Side Effects (link correct clinical response to side effect) No card sorts
[Participant Manual Chapters 6-8] Clinical review HIV clinical staging Functional status TB status Prevention Prophylaxis [Participant Manual Chapters 9-11] Opportunistic Infections and Treatment Medical eligibility for ART Adherence Preparation for ART [Participant Manual Chapters 12-15] Preparation for ART ART Initiation Side Effects Assess Adherence on ART
4 (2 hours for each group) 5 (1 hour for each group)
21-30
31-40
[Participant Manual Chapters 17-18] Assess Adherence, Side Effects
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Card Sorts
Actual card sorts material is part of the training course materials and should be found in the Reusable Kit with the other cards. When facilitating the card sorts, remind the participants that it is more important to practise their skills with the EPTs. If an EPT becomes available, they should be working with them over the card sorts exercise.
HIV Clinical Staging (Day 2)

This skill station will include card sorts of patient cases and photos which should be paired to the clinical stage chart. Materials needed: HIV clinical staging wallchart, HIV clinical staging cards. Set up: Place clinical staging wallchart on table and have all the cards in a pile next to wallchart. The cards have an A side and a B side. The A side lists the initial presentation; the B side lists the presentation on the next visit. You will have to tape the two sides together (or laminate them together) to make the cards. Participants should sort cards and group into correct clinical stage on the wallchart. Facilitator should provide feedback. Turn all cards over to look at the B sidedecide if stays in same clinical stage or goes up (re-sort). Identify what medical care (participants can refer to stages in chart) should be provided appropriate to the stage of infection. Another option is to use a blank clinical staging table and then try matching the photos/cases to the appropriate stage through practise.
First-Line Drugs (Day 3)

In this exercise, the participants will need to match the drug abbreviation to the drug name (i.e. EFV to efavirenz). You can also add locally common brand names to the card sort. Materials needed: Blank flipchart paper, Drug name/abbreviation cards, TB/HIV cards, tape. Set up: Tape blank flipchart paper to wall (or table) and write the following directions on it: "Link the drug abbreviation to the corresponding drug name". Tape the drug abbreviation cards to this blank paper in a row. Then put tape on the back of the drug name cards, so participants can place the card next to the proper abbreviation. To make the exercise more interactive and interesting, you can ask the participants to put the abbreviations and the names in the correct first-line regimens once they finish the first part of the exercise.
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TB Testing, Treatment, and Follow-Up (Day 3)

This card sort includes clinical cases about TB and HIV and how the HW at the 1st level facility should manage the patient cases such as whether to treat TB, start ART, or refer. Materials needed: blank flipchart paper, TB/HIV cards, tape. Set up: Tape blank flipchart paper to the wall (or table) and write the following directions on it: "TB/HIV Cases: Match the clinical cases to the correct management plan". Tape the cases to the blank flipchart and put tape on the back of the management plan cards so participants can tape them up on the flipchart next to the correct case. Have the participants refer to section 8.4, p. H25 of their Chronic HIV Care guideline module to do this exercise. Go through each case together and have them decide what is the correct management.
Major and minor side effects on ART and treatment of side effects (Day 4)
This skill station includes card sorts of the side effects of the first-line drugs. Here the participants should practise matching the major/minor side effects with the appropriate regimen. Materials needed: Side effects and drug regimen cards, blank flipchart paper and tape. Set up: Tape blank flipchart paper to wall with the following directions on it: "Major/Minor Side Effects of the 1st-line Drug Regimen: Match the side effect to the correct regimen." Tape each regimen to the flipchart and put tape on the back of the side effects cards, so participants can tape the cards next to the appropriate drug. Have the participants practise matching the side effects to the individual drugs and the regimen.
Treatment of side effects (Day 4)

This skill station includes clinical cases about patients who are on a 1st-line regimen who come to the health centre with side effects and the participants need to match the cases to the appropriate management. Materials needed: Treatment of side effects cards, blank flipchart paper and tape. Set up: Tape a blank flipchart paper to wall with the following directions on it: "Management of Side Effects Match the appropriate treatment plan to the clinical case." Tape the cases to the blank paper and put tape on the back of the management cards, so the participants can tape it on the wall next to the correct case.
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Facilitator Guide for the Acute Care Short Course : Management of key opportunistic infections
A. Introduction for facilitators
Note that this is one of several short courses, concentrating only on opportunistic infections (OI) and when to suspect HIV and TB. For the short course emphasizing OI management in the context of ART scale-up, we will be emphasizing how to use the manual and going over several sections in detail. We will not go over several main symptoms which will need to be taught in a subsequent course or courses. The general approach of this very short course is to introduce the format of the Acute Care guideline module and teach participants how to use the assess, classify and identify treatment approach, concentrating on only a few main symptoms. We limit the time spent reading by having the participants read only the Acute Care guideline module itself (and the second page of the participant training manual), deferring further reading and exercises to after the course. This allows half of the course time to be devoted to outpatient and inpatient practise, using the recording form and the Acute Care guideline module. After this short course, participants will need to study on their own or with their supervisor, or attend further training, to learn how to manage: Diarrhoea especially persistent diarrhoea (management is in Chronic HIV Care) Acute care for mental and neurological problems (including how to use amitriptyline and haloperidol) GU and other STI symptoms Management of fever in an HIV patient beyond suspicion of TB or, if unexplained, suspect complicated OI
B. Suggested course schedule

During the Basic ART Clinical Course, introduce the Acute Care and Palliative Care guideline modules. At the end of course, ask them to read at least p. 3-17 of Acute Care guideline module, in preparation for the course. Give out the Acute Care Participant Manualexplain they can read in the evening and after the course but that they will not read it during the course. Day 1 Morning: Work with Acute Care guideline module in groups (same groups as in Chronic HIV Care if possible) Afternoon: Clinical practise: Inpatient then outpatient if available Day 2 Morning: Clinical practice: outpatient then inpatient Day 3 (if possible) Morning: Clinical practice: outpatient then inpatient
Afternoon: Work with Acute Care guideline module in groups
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Materials needed:
Facilitator material (in addition to this facilitator guide) Many copies of Acute Care Recording Form Wallcharts which are also used in the IMAI Chronic HIV Care course: Clinical stages of HIV Sequence of care Wallcharts specific for Acute Care training: Quick Check Cough or difficult breathing classification table Front and back pages of recording form Photo booklet (sometimes reused by many participants) Demonstrations Photo identification exercises Photos for written and oral case studies Clinical training video (in development) Participants should have: Acute Care guideline module, adapted to country guidelines Chronic HIV Care guideline module (for cross-reference) Palliative Care guideline module or other national acute care guidelines (to refer to for symptom management)
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Introduction to OI short course using IMAI Acute Care
Introduction to the course

Lead a rapid discussion with these questions: Ask: Why do we need to know about acute care if what we are trying to do is to give ARTdidnt we just learn that HIV is a chronic condition that needs good chronic care? Arent all the OIs going to go away with ART? Cannot expect ART effect for months; CD4 climbs slowly; treatment can fail due to failure or non-adherence; need to be able to treat/stabilize OIs in order to start ART! Most patients still will not be on ART. As clinical stage goes up, need to recognise and treat the OIs. Ask: Why is the IMAI Acute Care guideline module only for adolescent and adults? What happened to children? IMCI has the acute care management for children; format is the same. Ask: How many of you have been trained in IMCI? If yes, ask: Do pages 16 to 52 look familiar? Ask for an IMCI volunteer to explain what the pink, yellow, green rows mean. Explain: In order to be able to provide good chronic HIV care, to do clinical staging, and to treat infections in preparation for ART, we need to know how to manage several important and common opportunistic infections. Participants should read page 2 of the participant manual (duplicated below).
Ask:
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Learning objectives
Understand the several possible causes of the same signs and symptoms including common infections and other acute and chronic problems that are not HIV-related, opportunistic infections, ART side effects, and immune reconstitution syndrome. Use the IMAI Acute Care guideline module to assess, classify, identify treatments (and diagnostic tests) in patient presenting with: Cough or difficult breathing (this includes pneumonia and TB; when to refer during follow-up) Undernutrition and anaemia Mouth problems: limited to consideration of thrush and ulcers Skin problems: how to classify lumps, skin infections, and to identify and manage common HIV-related skin problems Headache: when to suspect meningitis Peripheral neuropathy Find and use the treatment instruction boxes and boxes summarizing advice and counselling Know when to suspect HIV infection Know how to encourage HIV testing and counselling and introduce the patient to what is available in chronic HIV care Know the signs and conditions required for clinical staging of HIV infection
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Chapter 1: Quick Check for Emergency Signs

Blank flipchart, Markers , Quick Check wall chart.
Purpose: To teach participants how to identify patients in life

threatening condition and act immediately.
Learning objectives: At the end of this session, participants

will be able to:
1. The approach in assessing a critically sick patient using acute care module 2. How to evaluate a patient using quick checks for emergency signs.
Preparation
None
Content
Why we need the Quick Check? Steps in the Quick Check for Emergency Signs
Methods
Reading and explanation Reading and discussion
Duration
Give a very short explanation, pointing to wall chart of Quick Check. Read quick check section in the module Do a very short demonstration of Quick Check (should take 5-30 seconds when negative) Demonstrate capillary refill. Look at photo of capillary refill1C. Look at photo of central cyanosis1A. Participants practise quick check on each other. Ask: How common is it for patients with stage 3 or 4 to present with emergency signs? Can you give an example of a severely ill HIV patient? Discuss what emergency signs they might have. Look at table of contents and read through the underlined titles. Read pages 6 to 8 of the guideline module. Do the following drill acute vs. chronic problems.
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Chapter 2: Introduction to the IMAI Acute Care Algorithm: Assess Acute Illness/ Classify/ Identify Treatment Duration: 45 minutes Materials:
Blank flipchart, Markers , Assess acute illness/ Classify/Identify Treatments wall chart
1. Understand the main syndromes in adults and adolescents; 2. Develop communication skills for patient evaluation; 3. Distinguish the differences between acute illnesses and chronic illnesses; 4. Practice the self study exercise
Purpose: To introduce the IMAI acute care algorithm to

participants.

will be able to:
Preparation
None
Content
Algorithm & syndromic approach Communication skills
Methods
Volunteer reading and discussion Volunteer reading and discussion
Duration
Difference between Volunteer reading, acute illness, follow up discussion and care for an acute illness case study and follow up of a chronic illness; how to fill the acute care recording form
Explain about the syndromic approach Explain the steps in patient management: Quick Check Assess Classify Identify Treatments Explain how to do the assessment using the IMAI Acute Care guideline modulethis is summarized on page 4 and page 6-7. There are items to assess in all patients, and then items to assess if volunteered by patient. Ask: What is the difference between asking a patient about a symptom and responding to a volunteered symptom? Ask: Why do we check for certain symptoms/conditions in all patients?
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CoughImportant to screen for TB in all patients. This requires asking about cough and listening for cough, not just relying on the patient to report it. Undernutrition and anaemiapatients often do not complain of this; they need to be checked for these conditions. Mouth problemsa rapid check for thrush can help detect patients with possible HIV infection. Learn to use the Acute Care Recording Formmark with an X or checkmark for all relevant main symptoms. The Ask, Look and Feel approach is this same on that they already have learned to use in the clinical review of Chronic HIV Care. Do the following drill to practise the initial use of the Acute Care Recording Form. Each participant should have a recording form for this drill. Tell participants put X for all main problems on their recording form. Case: Tsega is 35 year old woman here for new problem. Weight 54 kg BP 115/90 Quick check is negative Complains of cough No mouth complaint. You see nothing on a quick mouth exam. Pain in back, grade 2 No medications Burning on urination Skin rash Headache Looks depressed Discuss how the Acute Care Recording Form should be filled out.
DRILL: Deciding if your patient has come for an acute problem, follow-up of an acute problem, or follow-up of a chronic problem
QUESTIONS ASK: What type of visit is this if: 1. A man reports that he is taking antibiotics for pneumonia and has come to be checked 2. An old woman with known heart failure says she has caught a cold and is coughing and coughing 3. A 21 year old man is come because he has been coughing for months and is not getting better. This is the first time he has come to the health centre 4. A woman who has HIV comes in to start ART. 5. A woman known to have TB has come for her monthly visit. She has no new problems 6. An asthma patient who comes in with an acute asthma attack 7. An asthma patient who comes in with a fever and cough ANSWERS Follow-up of an acute problem. Acute problem Acute problem
Follow-up of a chronic problem Follow-up of a chronic problem Acute problem Acute problem
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8. A woman who has recently begun TB treatment says she is having nausea and joint pain 9. A woman with TB has come for her monthly follow-up visit. She has no cough or fever or other problems today 10. A woman says she has TB and has come for her monthly follow-up visit. She is coughing and does not feel well 11. An asthma patient who comes in because his medications have run out 12. HIV patient wants refills. He cannot walk without assistance and his breathing looks worse than his usual 13. A 28 year-old man complains of episodes of difficult breathing for last year. No difference in previous week. No problem was diagnosed 14. A woman who has HIV and just started ART comes, because she has developed a rash 15. A diabetic man who comes in to check his blood sugar
Follow-up of a chronic problem (drug side effects) Follow-up of a chronic problem
Acute problem
Follow-up of a chronic problem Acute problem
Acute problem
Follow-up of a chronic problem (drug side effect) Follow-up of a chronic problem
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Chapter 3:Cough or Difficult Breathing

Blank flipchart, markers , Assess acute illness/ Classify/Identify Treatments wall chart
Purpose: To learn how to assess, classify and treat cough and

difficulty of breathing

will be able to: Use the IMAI Acute Care guideline module to assess, classify and identify treatments in patients presenting with cough and difficulty of breathing
1. Develop the knowledge and skill for assessment of a patient with cough or difficulty of breathing 2. Classify the patient with cough and difficulty of breathing by using the acute care IMAI module 3. Understand the treatment decisions using acute care module.
Preparation
None
Content
Assess for cough or difficult breathing Ask questions to ask the patient/ family / caregiver Look and Feel
Methods
Presentation / volunteer reading / discussion
Duration
15 minutes
Classify and treat
Presentation / volunteer reading / discussion Volunteer reading / discussion / presentation / case study
30 minutes
15 minutes
In all patients: Do you have cough or difficult breathing?
1. Read the Acute Care participant manual page 18 till LOOK. Then discuss 2. Do the following drill on chest pain. DRILL: Identifying pleuritic and other chest pains Explain: We want to recognise pleuritic chest pain, which can be managed using the guidelines for acute care of the sick adolescent or adult with cough or difficult breathing.
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Other types of chest pain may indicate angina or a heart attack. That patient needs to see a physician and should be urgently referred to hospital for care following other guidelines.
QUESTIONS ANSWERS ASK: What type of chest pain is this if: 1. A 17 year-old boy says his chest hurts Pleuritic chest pain when he breathes in 2. A 45 year-old man says that his chest hurts Possible ischemic chest painsee it feels like there is a huge weight on his Quick Check for management treat chest then refer this man 3. A woman says that it is very difficult to Pleuritic chest pain breathe in and she has pain on her right side when she does 4. A woman says she has chest pain when Pleuritic chest pain she breathes in. You observe that the left side of her chest seems to move less than the right 5. An old woman says she has constant chest Other chest pain refer this woman pain 6. A man says that he has chest pain when he Possible ischemic chest pain refer this walks up the steep hill to the temple man 7. A woman says her chest hurts when she Pleuritic chest pain. coughs, but not when she lies still Practise counting breathing for one minute with each other (divide into pairs). Do drill on the definition fast breathing. DRILL: Determining if breathing is fast breathing or very fast breathing QUESTIONS ANSWERS ASK: Does this patient have fast breathing or very fast breathing? 1. A woman breathing 32 breaths per Very fast breathing minute 2. A young man who is breathing 19 Normal breaths per minute 3. A man who is breathing 28 breaths Fast breathing per minute 4. A 10 year-old girl who is breathing 30 Fast breathing breaths per minute 5. A 12 year old boy who is breathing 42 Very fast breathing breaths per minute 6. An 8 year old girl who is breathing 28 Normal breaths per minute 7. An old woman who is breathing 33 Very fast breathing breaths per minute 8. A man who is breathing 25 breaths Fast breathing per minute 9. A man who is breathing 24 breaths Fast breathing per minute 10. A teenage girl who is breathing 29 Fast breathing breaths per minute 11. A woman who is breathing 13 Fast breathing breaths in 30 seconds
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12. A man who is breathing 18 breaths in 30 seconds 13. A 6 year-old boy who is breathing 18 breaths in 30 seconds 14. A woman who is breathing 25 breaths per minute 15. A man who is breathing 31 breaths per minute 16. A woman who is breathing 24 breaths per minute
Very fast breathing Fast breathing Fast breathing Very fast breathing Fast breathing
Do drill on recurrent episodes. DRILL: Identifying recurrent episodes of cough or difficult breathing QUESTIONS ASK: Does this patient have recurrent episodes of cough or difficult breathing? 1. A woman who has a cough and fever says that she had a cold last year that lasted a long time. 2. You see on his chart that this man who has cough and difficult breathing today has come to the health centre with cough 4 times in 6 months. 3. A man who has cough says that every winter he gets a cough and cannot get rid of it for months. He wakes up coughing almost every night. 4. A woman has a cough. She says she always has a cough. She gets better sometimes for a few weeks, but then she gets the cough back again. 5. For 6 months this 15 year-old has had trouble getting up in the morning and feels tired all day. On questioning, he says he sleeps poorly and wakes up with cough and mild difficulty breathing. It gets better after he sits by the window for a while.
ANSWERS
No Yes Yes Yes Yes
3. Read from Look till Classify and then discuss Practise taking pulse in the classroom (if necessary, review how to measure blood pressure). Look at the Acute Care Recording Form. Point to an enlarged copy of it on wall. Show how it mirrors the assessment steps, the symptoms, and the signs and how to record findings by circling positive signs that are present. 4. Classify cough Explain how to use classification tables, using blow-up of cough classification table Participants read How acute care algorithm works on page 23. Then discuss how to classify cough or difficulty of breathing Practise assessing and classifying cough. Each participant should use the Recording Form.
5. Classification Drill
Explain: In this drill, you will have just the positive findings and any relevant counts. Use this information to make a classification. You should assume everything else for this patient was normal. All the patients will be over 15 years so for all the fast breathing cut-off is .? (answer: 20) and very fast breathing (answer: 30).
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QUESTIONS Present patient or make up few word description of an adult patient then list signs. Tell participants that all the other signs were checked for and are negative. Cough 30 days, fast breathing, T36, no other positive signs Recurrent episodes cough which wake young man in the early morning over the last 3 years Smokes Coughing for the last 3 weeks during the day also
ANSWERS
COUGH or DIFFICULT BREATHING: Possible chronic lung or heart problem COUGH or DIFFICULT BREATHING: Possible chronic lung or heart problem
Emphasize that all classification tables use the same system, and that classifications selected are recorded on form and treatments are listed for each classification. 6. Identify treatment Explain how to identify treatments using the classification table, pointing to enlarged copy. Expalin how to get specific treatments(dosages,how to give) in the acute care guideline Ask: on what page are the: Dosages for IV/IM antibiotics? Dosages of oral antibiotics? Ask: Why is it important to counsel patients with possible pneumonia and TB to stop smoking? Read through Treatments in the yellow PNEUMONIA column. Ask: Why upgrade to the treatment column suggesting referral and IM antibiotics if: HIV clinical stage 4? Low CD4 count? Pregnancy? Ask: Why send sputums for TB if this is possible pneumonia? TB can present acutely and mimic pneumonia. You can also have bacterial pneumonia on top of pulmonary TB. You do not want to miss TB. If you just treat with antibiotics and plan to get sputums when patient comes for follow-up, you may not see patient again. TB sometimes improves somewhat on antibiotic treatment.
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7. Consider HIV-Related illness, Tb, drug reaction

Assign various parts of the Acute Care algorithm to groups of 3ask them to list those classifications where it is important to consider HIV-related illness. Have them write then call out while Recorder A writes them on a flipchart. Also have them look for classifications that may be TB. Have recorder B write them on a flipchart. Have them look for classifications that include patients who may be having an ARV side effect or serious drug reaction. Recorder C writes these on a flipchart. Discuss in group which classifications may include HIV-related illness. Emphasize: Long list Not all patients in these classifications will have a positive HIV test Important to test With high prevalence, many illnesses become HIV-related Most adults are still HIV negative and still get sick HIV patients dont just have OIs; also get other problems that are not HIV-related Explain that the outpatient medical clinic is an important entry point to identify patients with HIV infection who need ART and other HIV care.
Ask: What are 5 classifications that include patients who may have TB? Answer: POSSIBLE CHRONIC LUNG DISEASE PNEUMONIA PERSISTENT FEVER SUSPICIOUS LYMPH NODE SEVERE UNDERNUTRITION SIGNIFICANT WEIGHT LOSS Ask: (while looking at the flipcharts) Why is it important to always ask about what medications the patient is taking?
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Chapter 4:Check all patients for undernutrition and anaemia

Blank flipchart/ markers
Purpose: To learn how to assess, classify and treat under

nutrition and anemia

will be able to:
Use the IMAI Acute Care guideline module to assess, classify and identify treatments in patients presenting with under nutrition and
anaemia
Preparation
None
1. Evaluate all patients for under nutrition and/or anemia 2. Classify patients with under nutrition and/ anemia using standard definitions and accordingly make treatment decisions.
Content
Assess under nutrition and anemia Ask Look and Feel Classify and treat
Methods
Presentation / volunteer reading / discussion
Duration
15 minutes
Volunteer reading / discussion / presentation / case study
15 minutes
1. Go over assessment read text about how to assess signs of undernutrition and anaemia). Demonstrate MUAC. Use line drawing and practise of MUAC (need adult MUAC tapes). Look at photo of measuring MUAC3A. 2. Do EXERCISE on how to calculate % weight loss (participants may need calculator). Put the following examples on flipchart and ask participants to calculate the percent weight gain or loss. old weight 60kg 60kg 60kg 60kg new weight 58kg 55kg 50kg 70kg absolute gain or loss 2kg loss 5kg loss 10kg loss 10kg gain %gain or loss 3% loss 6% loss 17% loss 17% gain
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Look at photos of loose clothing that used to fit, visible wasting 1B, pitting oedema to the knees 3B, sunken eyes 3C, pallor 3D-G, bleeding gums 3H, petechiae 3I 3. Review classification tables for undernutrition and pallor. Practise classifying cases using these tables.
Classification Drill
QUESTIONS Present patient or make up few word description of an adult patient then list signs. Tell participants that all the other signs were checked for and are negative. Some pallor and fast breathing (not cough or difficult breathing) ANSWERS
UNDERNUTRITION or ANAEMIA: Some anaemia
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Chapter 5: Look in the mouth of all patients and respond to any complaint of mouth or throat problems Duration: 60 minutes Materials:
Purpose: To learn how to assess, classify and treat mouth and

throat problems

will be able to:
Use the IMAI Acute Care guideline module to assess, classify and identify treatments in patients presenting with mouth and throat
problems
Preparation
None
1. Examine patients with mouth and throat problems 2. Understand the types of lesions expected in the mouth and throat by looking at photo booklet 3. Classify the patient and recommend appropriate treatment decisions 4. Practice the self study exercise.
Content
Assess for mouth and throat problems Ask Look and Feel Classify and treat
Methods
Duration
30 minutes
30 minutes
1) Participants read Acute Care participants manual on how to assess mouth/throat problems. Go over assessment on Recording FormLook at photos of white patches (thrush) 4A, red patches (thrush) 4B, oral (hairy) leukoplakia 4C, white exudate on throat 4D, throat abscess 4E, swelling over jaw 4G, ulcers not deep 4H and ulcers deep 4I, gum bubble 4K, purple lumps. Demonstrate how to choose and use the 4 classification tables. Review only first classification table in detail for white or red patches and, mouth ulcer or gum problem (skip classification tables for sore throat without mouth problem, tooth problem or jaw pain or swelling, enlarged neck node). Review the following cases and refer them to photos in photo booklet (use pictures and text description of cases). Practise going to correct classification table, classifying, and listing treatments on recording form.
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QUESTIONS Present patient or make up few word description of an adult patient then list signs. Tell participants that all the other signs were checked for and are negative. Mouth or throatWhite patches in mouth Pain when swallowing Problem swallowing Mouth problemPain in mouth Pain when hot food Problem chewing Loss of tooth substance and tooth cavities Mouth pain Difficulty swallowing Dental caries White patches Swollen and bleeding gums Fever for 3 days and now cannot swallow Sore throat Abscess in pharynx White exudate on tonsils 2 large lymph nodes in neck Visible cavities Loss of tooth substance ANSWERS
MOUTH OR THROAT: Severe oesophageal thrush
MOUTH or THROAT PROBLEM: Tooth decay
MOUTH or THROAT PROBLEM: Oesophageal thrush, gum disease
MOUTH or THROAT PROBLEM: Tonsillitis, also has tooth decay
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Routine screening and follow-up care
Check status of routine screening, prophylaxis and treatment (p 58-60) Special prevention for adolescents (p 59)
Participants read pages 58-59 in Acute Care guideline module. Discuss: How is this different from our current clinical practise?
Follow-up care for acute illness (p 62-66)

SKIP DURING SHORT OI COURSE except for the pneumonia follow-up box on page 62. Ask: what are common problems in an HIV patient that can result in failure to respond to oral antibiotic treatment for PNEUMONIA? Answer: bacterial pneumonia, pneumocystis pneumonia (needs a different treatment-refer), tuberculosis, etc. Ask: What has been forgotten in this follow-up table that you learned to do in Chronic HIV Care? Answer: Check register for sputum resultsshould have already been obtained.
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Respond to volunteered problems or observed signs (SKIP DURING SHORT OI COURSE)

Participants read page 23 in Acute Care guideline module. Explain page 23: The previous signs you check in every patient; from here on, you check only if patient complained or you observed the sign. Participants read again pages 6-7 to be reminded of where they are in the process of acute care. Drill: Give participants 5 recording forms eachread out the name and age and chief complaints of 5 patients. They should check all the symptoms where further assessment is needed.
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Chapter 6: Does the patient have fever? Duration: 30 minutes Materials:

Purpose: To learn how to assess, classify and treat Fever Learning objectives: At the end of this session, participants
will be able to: Use the IMAI Acute Care guideline module to assess, classify and identify treatments in patients presenting with Fever
Preparation
None
1. Comprehend the steps in evaluating a patient with fever using acute care module 2. Classify the patient with fever for appropriate treatment decisions 3. Understand the national recommendation for treatment of malaria .
Content
Assess for fever Ask Look and Feel Classify and treat
Methods
Duration
15 minutes
15 minutes
1. Participants read text on assessing these signs. Explain why we consider TB if fever lasts more than 7 days. 2. Drill on malaria risk (see Review Drill on page 188 of this guide) 3. Written exercise on deciding malaria risk 4. Written exercise on assessment, classification with fever, and identifying treatment (cases have multiple problems).
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Chapter 7: Does the patient have diarrhoea? Duration: 30 minutes Materials:

Use the IMAI Acute Care guideline module to assess, classify and identify treatments in patients presenting with diarrhoea
Purpose: To learn how to assess, classify and treat diarrhoea Learning objectives: At the end of this session, participants
will be able to:
Preparation
None
1. Examine a patient with diarrhoea using acute care module 2. Classify the patient for appropriate treatment.
Content
Assess diarrhoea Ask Look and Feel Classify and treat
Methods
Duration
30 minutes
30 minutes
Go over Recording Form. Participants read explanation of how to assess signs related to diarrhoea in participant materials. Show and discuss drawings and photos of signs of dehydration such as sunken eyes 3C; demonstrate skin pinch of forearm 5A (video of drinking eagerly). Written cases to practise assessment and classification of diarrhoea, identifying treatment, and writing findings on recording form. Read how to treat dehydration pages 88-91 of the acute care module. Written cases about treatment of diarrhoeaCases for which participants calculate the amount of fluid to give. Persistent diarrhoeabefore the HIV epidemic, this was uncommon in adults. In adults documented HIV-negative, read follow-up box on page 64; for HIV+, use Chronic HIV Care section 9.1. Stress importance of symptomatic management for this, use Palliative Care guideline module. Discuss whether this differs from their current management.
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Chapter 8: IMAI Approach to Sexually Transmitted Infections (STI)STI Syndromic Case Management (Short Course)
This 2 days short course is based on:
A.
IMAI Acute Care guideline module, Revision 2, August, 2007 (MoH) IMAI Acute Care Participant Training Manual IMAI Photo booklet STI hand out if available Introduction for facilitators
This short course teaches the WHO IMAI sexually transmitted infection (STI) Module, which is integrated within the IMAI Acute Care guideline module, Revision 2. The STI Module address genitourinary (GU) problems, lower abdominal pain, including STI GU problems, menstrual problems, other abnormal bleeding in women, and urinary tract infections (UTIs). In addition it covers men with special GU problems that are not STIs, such as torsion of the testis. Also covered in this section are other causes of lower abdominal pain that may require urgent referral (e.g., appendicitis), syphilis, which can present in many ways or be asymptomatic, and sexually transmitted skin problems, such as scabies and molluscum contagiosum. Other skin problems are not covered in this course. This course emphasizes the importance of screening all adults and adolescents for STIs as part of basic prevention of HIV transmission. Health care workers will learn to ask all patients about a genital or anal sore, ulcer, or wart, and all male patients about a discharge. Course participants have already learned how to use certain sections of the IMAI Acute Care guideline module during the Acute Care/OI course, and to do provider-initiated classification and routine testing and counselling. This course will provide brief opportunities for them to review those skills during the Expert Patient-Trainer role-plays. Education and counselling will focus on STIs, with only a brief HIV/AIDS review exercise. The general approach of this short course is to re-enforce the format of the IMAI Acute Care guideline modules and continue to teach participants how to use the Assess, Classify, and Treat approach, concentrating on only a few main symptoms. The goal of this course is to integrate STI control, prevention, and treatment into primary care.
Course Objective:

Screen all adolescents and adults for an STI Learn to assess, classify and treat common STIs Learn to assess, classify and treat other GU problems including UTI and menstrual problems Learn to assess, classify and refer adolescents and adults with lower abdominal pain that may be severe or require surgical intervention Integrate STI prevention and control into primary care To review provider-initiated testing and counselling as it applies to STI patients
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B.
Suggested Course Schedule

Day 1
Morning: (3 hours)
STI 2-Day Short Course Schedule

Preparation (before class): 1. Meet with co-facilitator to go over division of tasks in facilitating course 2. Meet with expert patienttrainer (EPT) to discuss role plays* 3. Give EPTs copies of case and ask EPTs to bring copy of STI generic checklist (without case specific questions)
Day 2
Morning: (3 hours)
Pre-Test Introduction to the Short

IMAI STI Course & Training manual IMAI & successful STI control IMAI STI Patient Management: Assess, Classify, & Treat Using the Acute Care guideline module Screening for STIs; Genital/anal sores, ulcers and warts Male GU/abdominal pain
Review Day 1 Female GU/abdominal

pain (continued)
Syphilis/RPR Molluscum Contagiosum Values Clarification

The expert patient-trainer (EPT) He or she is a PLHA who has been trained to role-play specific HIV clinical cases in class and in the skill stations (see Facilitator's Guide to the WHO Basic ART Expert Patient -Trainer Course)
Afternoon: (4 hours)
Afternoon: (4 hours) Putting it all together: Elements of Education & Counselling Educate & Counsel on STIs Rapid Review (Optional) Skill Stations: Expert Patients Wrap Up Post-Test
Female GU/abdominal
pain
Card Sorts Skill Stations: Expert

Patient-Trainers
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Day 1Morning Session
Duration: 9.1. Introduction to the IMAI approach to STI 3 hours total Purpose: Pretest as baseline assessment of knowledge of STIs Materials:
Course materials: 1) IMAI Acute Care Participant Training Manual and Photo booklet, 2) IMAI Participant Handout for Acute Care/STI Short Course, 3) IMAI Acute Care guideline module, Revision 2. Supplies should be handed out prior to introduction to course (in registration). Wall charts: 1) Acute Care Algorithm, 2) 5 As, Blank flipchart, markers Pretest Clinical review form Many copies of Acute Care Recording Form Link between STI & HIV/AIDS STI Syndromic Approach Tea Break IMAI Acute Care
Overview of local context of STI control and guidelines Overview of IMAI Acute Care guideline module and course materials
By the end of this session the health provider should be able to: Understand the importance of STI control in their country Understand the importance of STI control in reducing HIV transmission Understand how to use IMAI Acute Care guideline module in STI control and patient management Content Pre-Test Introduction to STI IMAI Course, Agenda & Handouts IMAI & Successful STI Control Integration of STI services & primary care STI related complications Methods Written Review 2-day agenda & how to use materials & IMAI participant training manual Group discussion & Q&A Group discussion Review chart & Group discussion Group Discussion Review philosophy, science & Group Discussion Group discussion of Acute Care & STIs; Self-study Exercise; Drills; Q&A Assess, Classify, Treat Discussion, group reading, questions Drills, Case Studies Timing 30 min. 10 min.
5 min. 5 min. 5 min. 10 min. 10 min. 30 min. 45 min.
Screening for STIs: Genital or anal sore, ulcer or warts (all patients)
30 min.
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Pre-Test Before giving the pretest, let participants know that they are not expected to know all of the answers, as the test covers much of what they will be learning in the course itself. The purpose of the test is to give facilitators a clear idea of what participants already know, and what they need to learn. Introduction to the IMAI STI Short Course
Review the 2-day course agenda, then review the agenda for this mornings activities. Briefly introduce the course by providing an overview of how this training fits into the IMAI Acute Care guideline module by explaining the following:
"In the Acute Care/OI short course you learned how to use the IMAI Acute Care guideline module to manage adolescent and adult patients, both those with unknown HIV status, those who are HIV negative and patients who are HIV positive. The IMAI Acute Care/OI course emphasized when to suspect TB and HIV infection, how to recommend (as a provider) an HIV test and provide pre-test information, and how to care for common opportunistic infections. Once a patient is known to be HIV-positive, his/her chronic care is guided by the IMAI Chronic HIV Care with ART and Prevention guideline module. You will use Acute Care with all patients when they have an acute problem, both those already in chronic HIV care and those who come for care with unknown or negative status. This course teaches the STI guidelines, which are integrated within the IMAI Acute Care guideline module. These emphasize screening and treatment for STIs and also addresses other genitourinary (GU) problems including urinary tract infections (UTIs) and menstrual disorders in women. Skin problems caused by STIs, such as molluscum contagiosum are also included, as is syphilis (which can present in many ways or be asymptomatic). We will be talking about an integrated process of STI care by building on what we have learned in the IMAI Acute and Chronic Care courses, and learning more about how to use STI care to screen for HIV." Post the course objectives on the wall and ask for a volunteer to read them aloud to participants.
Screen all adolescents and adults for an STI Learn to assess, classify and treat common STIs Learn to assess, classify and treat other GU problems including UTIs and menstrual problems Learn to assess, classify and refer adolescents and adults with lower abdominal pain that may be severe or require surgical intervention Integrate STI prevention and control into primary care by asking all adults and adolescents about genital or anal sore, ulcer, or warts and routinely offering HIV counselling and testing to all sexually active patients To review provider-initiated testing and counselling as it applies to STI patients.
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Introduction to STI Refer participants to the first part of Chapter 9 in the Participant Training Manual. Conduct a brief review of the following topics as listed in the handout. If time allows, ask for a volunteer to read a section of the handout aloud. If time does not allow, ask participants to read the handout during lunch. A. IMAI & Successful STI Control Stress the importance of implementing the IMAI Acute Care guidelines because they will contribute to successful STI control. STI control has important aims: 1. Interrupt the transmission of sexually transmitted infections. 2. Prevent development of diseases, complications and sequelae. 3. Reduce the risk of HIV infection. B. Integration of STI services & primary care Explain that in order to improve access, people with STIs should not need to attend a centre devoted to STI treatment. STI treatment should be available at all health facilities throughout the country including health centres and outpatient clinics.
Patients do not come in labelled as having an STI. Patients with an STI can present with a genital sore or ulcer; with other genitourinary complaints (GU); with a skin problem; with adenopathy; etc. IMAI presents an integrated approach to acute care and is based on symptoms. In this integrated approach, you learn to identify STIs in several sections within the acute care algorithm. This means that service providers are trained to recognise STIs and other problems syndromically and then to offer their patients comprehensive care. Explain that an STI is a strong indicator of possible HIV infection and that when a patient attends the clinic for any reason, it is an important opportunity to screen for STIs, to routinely offer HIV testing and counselling, and to begin care. Stress that all sexually active adults and adolescents are counselled on safer sex.
C. STI related complications Refer participants to diagram in Acute Care Participant Training Manual: Complications that may result from STI or conduct a brainstorm and ask participants to list complications. Record on flipchart. D. Link between STI & HIV/AIDS Ask for a volunteer explain the link between STI and HIV/AIDS (see Participant Training Manual). E. STI Syndromic Approach Definition of syndrome: "Syndrome": A syndrome is simply a group of the symptoms a patient complains about and the clinical signs you observe during the exam.
Ask the participants if they have heard of the "syndromic approach" of if anyone has used it before in their practise. If they know what it is, ask them name some benefits of this approach, and include the following.
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The syndromic approach as used in the IMAI course offers many benefits in this struggle. It enables all trained first-line service providers to: screen for STI during all contacts with adolescents and adults--both when they come for any acute problem and during the periodic clinical review for those in chronic HIV care. assess and classify for STI and treat patients on the spot, without waiting for the results of time-consuming and costly laboratory tests. By offering complete STI treatment on the patients first visit, it helps to prevent the further spread of STI.
IMAI also includes patient education (about the infection, how STIs are transmitted, risky sexual behaviour and how to reduce risk), partner management and the provision of condoms. Discuss the following examples of syndromic diagnosis and treatment in practise.
Ask for volunteer to read the following case A patient complains of a discharge from the penis. Upon examination, you notice a discharge from the urethra. The sign and symptom indicate urethral discharge syndrome. Demonstrate how the sign and symptom taken together suggest the syndrome which then identifies the treatment needed. Explain that urethral discharge syndrome is commonly caused by gonorrhoea and/or Chlamydial infection. Not only can these cause serious complications, but also they can facilitate the transmission and acquisition of HIV. It is therefore essential that we treat the patient for both. Ask for a volunteer to read the next example and explain how they would use the sign and symptom to suggest the syndrome and to identify the treatment: A young woman complains of a sore. Upon examination you notice an ulcer on the outer labia. This indicates the syndrome of genital ulcer. There are two main bacterial causes of genital ulcer: chancroid and syphilis.
Explain that clinically, it is not possible to distinguish the cause of a genital ulcer with any accuracy, so the safest option is prompt treatment for both causative agents, leaving the patient no longer infectious. Provide a summary of the syndromic approach and lead a discussion by asking participants if they are already using the syndromic approach in their clinics.
Additional points for discussion (if the participants feel that the STI syndromic approach is controversial): Stress that STI treatment (antimicrobial regimens) are chosen to cover the major pathogens responsible for the syndromes in the specific geographic area. In order to make this determination, a laboratory analysis of the syndromes is made and the pathogens for each syndrome are identified. This means that, afterwards, the management of individual patients will not depend on laboratory investigation.
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Periodically, the syndromes are reviewed. This is for two reasons: to ensure that the antimicrobial choices are still valid and to monitor any antimicrobial resistance, which may necessitate a change of therapeutic choices. Because of this, the syndromic approach has a scientific foundation and should not be considered second-rate medicine. The syndromic approach is based on a wide range of epidemiological studies in both the industrialized and developing world. This approach has been used and adapted in more than 20 countries throughout the world. Validation studies have compared syndromic and laboratory diagnosis to assess the accuracy of syndromic diagnosis and found their results to be similar, so syndromic diagnosis is accurate. Other studies have thrown light on the possible impact of syndromic case management on the incidence of STI and HIV in a given population. In 1995 in the Mwanza region of Tanzania there was a trial to learn what impact STI case management and treatment-seeking behaviour would have on HIV transmission and STI in a population. After two years, findings in the trial areas compared with control areas included the following:
50% reduction in the prevalence of symptomatic urethritis in men Significant reduction in the prevalence of serological syphilis 38% reduction in HIV incidence
While a clinical or laboratory diagnosis tries to identify just one causative agent, syndromic diagnosis leads to immediate treatment for all the most important causative agents. This is important because mixed infections occur frequently. This means that, if the necessary drugs are available and affordable, syndromic treatment can quickly render the patient non-infectious.
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Review of IMAI Acute Care Management Remind them that they already learned how to use certain sections of the Acute Care guideline module during the Acute Care/OI course. This course is about STIs and other GU problems. Stress the importance of screening all adults and adolescents for STIs as part of basic prevention, and that they will be supported in their efforts by their district medical officer. Consequently all patients will be asked about a genital ulcer or sore and all male patients will be asked about drip.
Tell them to turn to page 6 (Steps to use the IMAI Acute Care Guideline Module) and quickly review the steps.
Review the Quick Check, and emphasize that it can be done very quickly if the patient is walking and talking.
In all patients, the following should be checked. Remind them that later we will go through the individual steps for the STI assessment.
Ask: Do you have cough or difficult breathing? Check for under nutrition and anaemia. Look in the mouth (and respond to volunteered mouth/throat problems) Ask: Do you have a genital ulcer, sore or warts? (This should be phrased in a culturally appropriate manner) Ask men: do you have a discharge from your penis? Ask about pain Ask: Are you taking any medications?
Stress that two of the questions are part of screening all patients for an STI.
Ask the group for examples of other ways to phrase these questions so that they are culturally appropriate. For example, in some cultures, it might be phrased as "Do you have a sore or ulcer down there, in your private parts?" While it is important to be culturally sensitive, it is also necessary to be more medically specific and accurate than local idiom (e.g. Ethiopia: Do you have a "female illness"?). Ask: Why do we ask all adults and adolescents about genital or anal ulcer, sore or warts? Answer: It is very important for prevention of HIV transmission to screen all adult and adolescent patients for STIs using culturally adapted questions. We do this by asking both men and women about genital or anal ulcers or sore and by asking men about a discharge from the penis. These are routine questions, not based on volunteered symptoms, whereas the use of the GU pages for women are based on a volunteered complaint. Remind them to look at page 6 in the Acute Care guideline module. IMAI Acute Care Screening DRILL: Explain that the purpose of this drill is to make participants comfortable screening all adults and adolescents. Write one of the following cases on the flipchart, and explain that you will play the role of this patient.
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Ask for a volunteer (health workers) to demonstrate how he/she would screen such a patient, starting with "What is your problem?" Respond to the questions according to the italics print. If you respond positively to a screening question, the "health worker" should follow-up with other ASK questions in that section on the Acute Care Recording Form. In this case, make sure that the "health worker" does not forget to return to the other screening questions (cough/breathing, genital sore, drip, pain, and meds). Add more types of patients as appropriate and time allows until you are confident that participants are comfortable beginning the exam and asking the questions. 18 year old-female Say you have come because of a swelling in the neck Say no to other screening questions. Syndromes: Skin problem or lump. 40 year-old female in Chronic HIV Care clinic Say you have come because of abdominal pain. Say no to other screening questions. Syndromes: Female GU symptoms/lower abdominal pain. 60 year-old male Say you have come because of a cough. Say yes to screening question about genital ulcer, sore or warts. Syndromes: Cough/difficult breathing, genital ulcer, sore or warts. 16 year-old male who looks obviously depressed and anxious Say you are here because of pain in your groin. Say no to other screening questions. Syndromes: Male GU symptoms/lower abdominal pain and mental problem.
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DAY 1Afternoon Session
Duration: 4 hours total Materials:

Course materials: 1) IMAI Acute Care Participant Training Manual and Photobooklet, 2) IMAI Participant Handout for Acute Care/STI Short Course, 3) IMAI Acute Care guideline module, Revision 2. Wallcharts: Acute Care Algorithm, 5 As Blank flipchart, markers Many copies of Acute Care Recording Form
Purpose:
To learn how to use the assess, classify, and treat IMAI Acute Care guideline module
By the end of this session the health worker should be able to:
Explain why doing the complete assessment is crucial in STI control and prevention Complete an assessment Know where to refer to in Acute Care guideline module as indicated in assessment. Understand meaning of clinical signs and symptoms in patients with STIs Determine patients clinical care needs, based on assessment Learn to assess problems that require urgent referral Assess, classify, and treat most common STIs, GU problems, menstrual or abnormal bleeding problems in women, non-STI GU problems in men, STI-related skin problems, and syphilis Methods Assess, Classify, Treat Discussion, group reading, questions Drills, Case Studies Same Same Timing 30 min.
Content Screening for STIs (continued): Genital or anal sore, ulcer or warts (all patients) Male GU or lower abdominal pain Female GU or lower abdominal pain (continued) Tea Break Skill Stations Card Sort Day 1 Wrap Up
60 min. 30 min.
30 min. Expert Patients Photo Cards Review Learning Objectives Q&A 80 min. 10 min.
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Signs and symptoms: Genital or anal sore, ulcer or wart
ASK
Do you have a genital or anal sore, ulcer or wart? If the patient says yes to this question, then ask: "Are they new? If not, how often have you had them?"
LOOK and FEEL

Discuss the proper preparation for an ano-genital exam:
Remember: behave professionally with the patient before and during the exam Reassure the patient who is reluctant to be examined and gain his/her confidence and cooperationmost patients feel shy about showing their genitals to another person Ensure privacy and adequate light Explain what you are going to do and why an exam is important Ask the patient for his or her permission to make an exam Even though you may have little time to examine the patient, never suggest impatience with him or her Even though syndromic management does not require an internal exam, WHO recommends the use of gloves when examining patients Approach the exam in a confident way yet sensitive to the patients needs Ask only one question at a time Reassure patients about privacy and confidentiality Explain that the exam will be brief and painless as possible
Explain that it is best if a woman can be on an exam table or a couch, and covered with a sheet or her clothing to maintain dignity and respect. In women, ask the patient to bend her knees and separate her legs, then examine the vulva, anus and perineum. It is best if you have clean gloves so you can separate the labia to look for ulcers yourself. If you do not have clean gloves, ask the patient to separate the labia so that you can examine the mucous surfaces for ulcers. Be sure to examine the skin of the external genitalia and to look between the inner and outer labia, the skin covering the clitoris and the urethra. Note vaginal discharge (type, colour and amount) at the same time, and whether generalized inflammation or excoriation is present on the vulva or inner thighs. Using photo 8C in the photobooklet, explain how to examine the vulva, how to look between the inner and outer labia, and the skin covering the clitoris and the urethra. It is important that they understand what these scientific names refer to, otherwise they will be confused by the Participant Training Manual. A man can be examined standing up if there is no exam table or couch or other appropriate alternative. Ask patients to expose the area from the chest to knees for the exam.
Using photo 8E, explain how to examine the penis, point out the foreskin and the glans, and how to retract the foreskin from the glans.
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Ask if they usually wear gloves when they do an examination. Ask: what should you do if you do not have gloves? Answer: They should ask the patient (being very sensitive to cultural taboos and considerations) to expose those areas. Read the Look and Feel instructions out loud. After each physical finding, ask a participant to describe what it looks like.
Look for ano-genital sores or ulcers

Ulcers may be large and wet, or single rather than grouped, and painful (chancroid, herpes) or painless (syphilis). The cause of genital ulcers cannot be distinguished except by laboratory testing. Tell the class to look at photos 8B, 8C.
Look for vesicles

Vesicles are small blisters, which eventually break open to form small painful ulcers. Grouped vesicles or small ulcers are usually caused by Herpes Simplex Virus type 2 (HSV2). Tell the class to look at photo 8A.
Look for warts

Warts are rough, light-coloured raised bumps that are often found in groups anywhere in the ano-genital area. They are usually grouped together and can be quite small or large, up to several centimeters in diameter. Tell the class to look at photo 8E, 8F.
Look/feel for enlarged lymph nodes in inguinal area.

If present, is it painful? Inguinal nodes: a single enlarged and painful inguinal lymph node is a bubo. Multiple smaller non-tender nodes are normal, but if tender may be due to genital ulcers. Tell the class to look at photo 8D.
CLASSIFY AND TREAT

Review how to classify using the Acute Care algorithm:
The tables correspond to the arrows on the previous page. Use the first table for patients with ano-genital ulcers, the second table for painful inguinal nodes, and the third table for warts. Use all classification tables where the patient fits the description in the arrow. Some patients may fit the classification for more than one table. For example, a patient may present with both ano-genital ulcers and genital warts. Start with the left-hand column of the classification table marked Signs: and read the first row. Decide if the patients signs and symptoms match that row. If yes, stop. If no, go to the next row. Use only one row in a classification tablethe first row that applies. The middle column on the row where you stopped tells you the classification of the problem and the corresponding right-hand column tells you the suggested treatment.
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Use all the classification tables that apply. Emphasize this point repeatedly, that only one row in each classification table can be used, but all classification tables that apply to the patient should be used. Explain that STI symptoms and classification are recorded on the Acute Care Recording form for all adults and adolescent patients and should be checked at all visits. Show them where to mark the X or checkmark for all relevant symptoms on the Acute Care Recording Form. Explain the classifications in the following way or have the class read from the Participant Training Manual.
CLASSIFY as GENITAL HERPES if only vesicles are present. Aciclovir can be given if
available, with follow-up in 7 days if no better, and sooner if worse. Pain control may be necessary with analgesics or frequent soaks with plain water. Keeping lesions dry and exposed to air promotes healing. On the management of herpes, reassure the patient that, although the herpes virus infection cannot be cured, the lesions will go away of their own. They may recur. Explain the importance of keeping the area clean and dry, and advise the patient not to have sexual contact until the area has healed and to use condoms. Herpes can be spread to sexual partners both when the lesions are present and at other times. Specific treatment for herpes, acyclovir, can be used to both clear the lesions faster and to prevent their recurrence if taken on a regular basishowever, this is expensive. Explain to patients that this treatment only controls the vesicles and ulcers, but does not cure herpes.
CLASSIFY as GENITAL ULCER if one or more sores are present depending on local
epidemiology. It is key that health workers have access to the most current STI prevalence and treatment protocols. Genital herpes is the most frequent cause of genital ulcer in many parts of the world. But in some areas syphilis or chancroid have a higher prevalence. Treat for both syphilis and chancroid since they are difficult to tell apart, and results of RPR test for syphilis may not be immediately available or syphilis may be misdiagnosed. Note that asymptomatic patients identified through RPR screening will have an unknown duration of infection and should be treated for late syphilis. Ask: why do we treat for both syphilis and chancroid? Answer: Since they are difficult to tell apart, and results of RPR test for syphilis may not be immediately available or syphilis may be misdiagnosed. Note that patients identified through screening will have an unknown duration of infection and should be treated for late syphilis. Ask: what should be considered if ulcers have been present for more than one month? Answer: Consider HIV-related illness (p. 54).
CLASSIFY as INGUINAL BUBO if there is an enlarged and painful node.

When examining the patient, try and determine whether the swelling is really a bubo or simply enlarged lymph nodes or any other pathology that has enlarged nodes in other sites. A bubo is usually painful, warm, tender when palpated and fluctuant. There may be one large mass or a collection of smaller painful swellings. Occasionally the bubo might have ruptured and a sinus, discharging pus, will be present. 116
If a bubo is present, make sure to look for genital ulcers. Whether an ulcer is present or not determines the treatment. In men, remember to examine the underside of the foreskin and the parts normally covered by the foreskin. If the patient cannot retract the foreskin because of swelling, assume there is a genital ulcer and classify accordingly. Buboes are usually caused by either chancroid or lymphogranuloma venereum (LGV). If an ulcer is present, treat for chancroid and syphilis; if no ulcer, treat for LGV. If an ulcer is also present, treat with ciprofloxacin, as you would for chancroid. In many, but not all, cases of chancroid, a genital ulcer may be visible. Also give benzathine penicillin for possible syphilis. If there is NO ulcer, then treat with doxycycline for lymphogranuloma venereum. Infections of the lower limb and other non-STIs can also cause swelling of the inguinal lymph nodes. Ask: How do you drain a bubo? Answer: Drain a bubo if fluctuant, through normal (not affected) skin. It should not be incised, drained or excised through the nodes because they may delay healing. If the bubo is fluctuant, aspirate it through the healthy skin outside of any erythematous area.
CLASSIFY as GENITAL WARTS if warts are present. Podophyllin can be applied to warts
by the health worker, or by the patient if the right compound (Podofilox or Imiquimod) is available. Patients should not apply podophyllin on their own. Podophyllin should not be used in pregnant women or children. Small warts, which do not bother the patient, do not require treatment as they eventually go away on their own (unless the immune system is very weak). Patients with ano-genital warts should be made aware that they are contagious to sexual partners. The use of condoms is recommended to help reduce transmission. Sexual partner(s) should be examined for evidence of warts. Ask what they should tell a patient with an ano-genital wart? Answer: Patients with ano-genital warts should be made aware that they are contagious to sexual partners. The use of condoms is recommended to help reduce transmission. Sexual partner(s) should be examined for evidence of warts. Ask participants what should be provided along with treatment for any classification on this page of the Acute Care guideline module? Answer: Treatment should be provided along with:
Education on STI/HIV Risk reduction counselling Condom promotion and provision Consideration of HIV-related illness (p. 54). RPR testing for syphilis, and encouragement for HIV testing
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Ask what symptoms, natural history, or other indicators might make you suspect that the patient has HIV? Answer: In HIV infected persons, the natural history of genital ulcers and their signs may differ:
Chancroid: ulcers may be larger, more painful, multiple and may be accompanied by fever and chills. Genital herpes (HSV2) is more common where HIV prevalence is high and it may infect other ulcers as well. In HIV infected persons it can be more extensive, painful, last longer and recur more frequently. Genital warts do not usually go away on their own in severely immune compromised patients.
Explain that tomorrow we will cover patient education and counselling.
CASE STUDIES (end of Chapter 9 in the Participant Training Manual) Explain that you will now have an opportunity to practise using the ano-genital flowcharts and filling out the Acute Care Recording Form. Ask the participants to turn to the case studies at the end of Chapter 9 of the Participant Training Manual. Ask the participants to use the flowchart and classification tables for genital and anal sores, ulcers and warts to determine the correct classification and treatment for the four case studies. Read the first case study aloud. Allow a couple of minutes for the participants to think about the case individually and then ask one of them to lead the group through the flowchart and classification table for the case study step by step with the whole group. You may also have the participants discuss the case in pairs or threes. Assume all signs not mentioned are negative. Afterwards, continue the discussion with the points at the end of the case study. Repeat for each of the case studies. 1. Mrs. Bogatsu complains of a painful vulva for 2 days. This is the first episode and she never had vesicles or ulcers before. She also complains of fever. On examination, she has many small sores filled with a clear liquid on both labia majora and minora, and no visible ulcer. Ask: How should this case be classified? Answer: Classify as GENITAL HERPES. Ask what is the follow up care for ano-genital ulcers?
Answer: Explain where this can be found in Acute Care. If ulcer is healed: no further treatment. If ulcer is improving: Continue treatment for 7 more days. Follow up in 7 days. If no improvement: refer.
Explain to participants that in the management of herpes, it is important to reassure the patient. Tell the patient that the lesions will go away of their own accord. However,
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herpes infection cannot be cured completely and the lesions might recur. Even if acyclovir treatment is available, it only lessens the severity of the ulcers, but does not cure the herpes infection. Explain the importance of keeping the area clean and dry, and advise the patient not to have sexual contact until the area has healed. 2. Mr. Thomas complains of a painful sore on his penis for the past week. This is the first time he has ever had such a sore and never had vesicles before. On examination, you find three shallow ulcers on the penile shaft. Ask: How should this case be classified? Answer: Classify as GENITAL ULCER. Ask the participants to turn to "Give appropriate oral antibiotic" in the Acute Care guideline module and review the treatment for chancroid according to national guidelines. Ask the participants to turn to "Give benzathine penicillin" in the Acute Care guideline module and review the dosage for benzathine penicillin treatment for primary syphilis. Ask: How would you treat Mr. Thomas if he had a history of penicillin allergy? Answer: Doxycycline or tetracycline as described in this section of the Acute Care guideline module. 3. Mr. Ahmed complains of a painful sore on his penis for the past week. There is no past history of ulcers or vesicles. He also has pain in the groin. On examination, one ulcer is found on the penile shaft and there is an enlarged painful inguinal lymph node on the right side. Ask: How should this case be classified? Answer: Classify as GENITAL ULCER and INGUINAL BUBO. More than one table should be used in this case. Review the treatment for genital ulcers. In this case, since there are no vesicles, the recommendation would be to treat for syphilis (benzathine penicillin) and chancroid (ciprofloxacin). Explain that when examining the patient, you should try and determine whether the swelling is really a bubo or simply enlarged lymph nodes or any other pathology, which has enlarged nodes in other sites. Infections of the lower limb and other non-STI can also cause swelling of the inguinal lymph nodes. Explain that a bubo is usually painful, warm, and tender when palpated and may be fluctuant. There may be one large mass or a collection of smaller painful swellings. Occasionally the bubo might have ruptured and a sinus, discharging pus, will be present. Explain that when a bubo is present, it is important to look carefully for genital ulcers. This is important in determining the correct treatment.
Remind participants that in men they need to remember to examine the underside of the foreskin and the parts normally covered by the foreskin. If the patient cannot retract the foreskin because of swelling, assume there is a genital ulcer and use the appropriate table.
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In women, they should examine the skin of the external genitalia and then separate the labia and look at the mucous surface for ulcers.
Review the treatment for inguinal bubo. Explain that in this case, the recommendations are to treat for chancroid. If no ulcer was visible, you would treat for both chancroid and lymphogranuloma venereum (LGV). Emphasise that if the bubo is fluctuant, it should be aspirated through healthy skin. Avoid incision and drainage or excision of nodes because these may delay healing. 4. Sindu complains of lumps down there for the past 2 weeks. She never had this before and does not have a history of ulcers or vesicles. On examination, you find 3 vulvar warts the size of a pea. Ask: How should this case be classified? Answer: Classify as GENITAL WARTS. Ask the participants to review the instructions for podophyllin treatment in the Acute Care guideline module. Explain that the removal of the lesion does not mean that the infection has been cured. No treatment is completely satisfactory. Sexual partner(s) should be examined for evidence of warts. Patients with ano-genital warts should be made aware that they are contagious to sexual partners. The use of condoms is recommended to help reduce transmission.
Before going on to the next syndrome (Male GU symptoms and lower abdominal pain), be sure that all the participants have a clear understanding of how to fill out the Acute Care Recording Form, how to assess, classify, and identify treatments.
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Signs and symptoms: Male GU symptoms or lower abdominal pain
ASK
Ask: In your initial assessment, you asked each man whether he has a discharge from their penis. Why do we ask all men about a discharge? Answer: It is the most common symptom of an STI in adult and adolescent males. Explain: If he said "yes" or "maybe" or if he complains of other genito-urinary symptoms or lower abdominal pain, you should do the full assessment that appears as follows:
What is your problem? Do you have discharge from your penis? o If yes, for how long? o If this is a persistent or recurrent problem, see follow-up box Do you have burning or pain on urination? Do you have pain in your scrotum? If yes, have you had any injury there? Do you have sore(s) on your genitals or anus?
LOOK AND FEEL

Discuss how to assess these signs. You may ask for a volunteer to read this section in chapter 8 of the Participant Training Manual. Perform genital exam: Put on gloves and feel for inguinal lymph nodes to see if they are enlarged, tender, inflamed.
Look for scrotal swelling Feel for tenderness o Palpate the scrotal sac gently, comparing the two sides. Is there swelling of the testis (inside the scrotal sac)? o Feel for tenderness of the scrotum. Determine if palpation of the scrotal sac causes pain. o Feel for tenderness or swelling of the epididymisthis is a coiled tube lying on top and in back of each testis. It can also be infected with GC/CT.
Infection can cause swelling, tenderness or both, even in the absence of a urethral discharge.
Look for ulcer. If present, also use the sore/ulcer/wart page (see previous section)
Examine all surfaces of the external genitals for ulcersthe scrotum, around the anus and penis for ulcers (also note any warts or vesicles). Pull back the foreskin and
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examine the undersidethis is a common place for the sores of chancroid and other ulcers. Look at the opening of the urethra as warts and ulcers can be found just inside.
Look for urethral discharge

Look. If the patient reports a discharge but you do not see it, ask him to milk the urethra. Ask him to squeeze the shaft of the penis gently from the base to the tip where the urethral opening is. Have him do this several times to milk out any discharge, which may be present. Show drawing of milking of urethra, photo 7A. (photobooklet)
Look and feel for rotated or elevated testis

Look for bruising or evidence of trauma to the scrotal sac. Determine the position of the testis in the scrotal sacdetermine if it is elevated or rotated. Sudden onset of pain and/or swelling of the scrotum may be due to acute epididymo-orchitis, torsion of the testis, injury to the testis, or a strangulated inguinal hernia. Torsion of the testis is very painful. Several of these conditions may require surgical interventions. Show them the drawings of elevated or rotated testis (Photo 7B, 7C). Scrotal or inguinal swelling which increases when the patient bears down (as if having a bowel movement) may be due to a hernia. This requires non-urgent referral if it is painless.
If abdominal pain (if patient complained of pain), feel for tenderness.
Feel for abdominal tenderness. Tenderness means the patient experiences pain when you touch or press in. Abdominal palpation should first be superficial to detect tenderness (pain) on light palpation. Then make a careful and deep palpation to identify any masses, enlarged organs, and the location of pain.
Lower abdominal tenderness is in the lower half of the abdomen on both sides below the umbilicus. If tenderness:
o Is there rebound? Check for rebound in the area where you found pain on light palpation. Press down slowly and very gently then release the pressure suddenly. Any severe pain that results is known as rebound tenderness. o Is there guarding? On palpating the abdomen, the abdominal muscles become stiff and board-like when even slight pressure is applied. They resist your pressing in.
Guarding and rebound occur when the lining of the abdominal cavity is irritated (peritonitis) by severe infection. Refer the participants to the photobooklet (photo 6A) and explain how to palpate the abdomen and test for rebound and guarding.
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Can you feel a mass? Swelling or lump in the patients abdomen on light abdominal palpation (this could be an abscess, cancer, hard stool or enlarged liver or spleen). Are bowel sounds present? Use a stethoscope or put your head on the stomach, after asking patient's permission. If you hear no bowel sounds at all, listen again for two minutes or more at a spot just under and to the right of the umbilicus. Absent bowel sounds is a serious sign that the bowels have stopped moving. Measure temperature if it has not already been done. Measure pulse if it has not already been done.
CLASSIFY AND TREAT

Emphasize again that they should use all the classification tables that apply. Only one row in each classification table can be used, but all classification tables that apply to the patient should be used. Discuss the classifications.
CLASSIFY as SEVERE SURGICAL OR ABDOMINAL PROBLEM if the patient has

abdominal tenderness with one or more of the following signs:
Fever >38oC in a patient with abdominal tenderness indicates possible serious abdominal infection such as appendicitis or perforation. Rebound tenderness or guarding may be present because of pain and pressure of an appendix or inflammation of the lining of the abdominal cavity (peritonitis). Bowel sounds may be absent because severe infection in the abdomen causes intestinal movement to stop, an ominous signthis may also cause vomiting of fluids. High pulse rate > 110 results from fever, infection and possible sepsis (which can cause shock).
CLASSIFY as PROSTATIC OBSTRUCTION if the patient is unable to urinate and the

bladder is distended. Ask: What can cause a painful bladder? Answer: A prostatic obstruction can cause a very painful distended bladder. It is important to relieve this by passing a urinary catheter if you have been trained. Refer this patient to hospital.
CLASSIFY as POSSIBLE GC/CHLAMYDIA INFECTION if the man has either a visible

urethral discharge or burning on urination. If the man just has burning on urination, he should still be treated for possible GC/chlamydia infection. This is one of the differences between the male and female GU/lower abdominal pain pages. In a woman, burning on urination is
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usually a urinary tract infection that is not related to STI. In men, burning on urination is usually an STI: GC/chlamydia infection. (If the participants are using a previous version of the Acute Care guideline module, have them write in "or burning on urination" after "Urethral discharge" in the Signs: column of the second row of this table). Ask: How do you classify a man that has burning on urination without urethral discharge? Answer: Classify as POSSIBLE GC/CHLAMYDIA INFECTION. Possible GC/Chlamydia infection also appears in the scrotal swelling and tenderness table at the bottom of the page. Ask: What are some serious complications of gonococcal urethritis and chlamydial urethritis? Answer: Infection of the testis or epididymis is a serious complication of gonococcal urethritis and chlamydial urethritis. When infected, the testis becomes swollen, hot and very painful. If early and effective therapy is not given, the inflammation will heal with fibrous scarring and destruction of testicular tissue. This may lead to infertility.
CLASSIFY as POSSIBLE TORSION if the patient has a rotated or raised testis and a history
of trauma. This is an emergency. Ask: What are other non-sexually transmitted causes of scrotal swelling or trauma? Answer: It is important to consider possible non-infectious causes of scrotal swelling and pain, as well as non-sexually transmitted infections. Non-infectious causes include trauma, tumour and testicular torsion and all require referral. In men over 35 years with no risk of STI, and among pre-pubertal boys, other general infections may be responsible.
CASE STUDIES (end of Chapter 8 in the Participant Training Manual) Ask participants to determine the correct management for the case studies using the flowchart and classification tables for male patients who complain of genitourinary symptoms or lower abdominal pain. Read the first case study aloud. Allow a couple of minutes for the participants to think about the case individually and then ask one of them to lead the group through the flowchart and classification table for the case study step by step with the whole group. You may also have the participants discuss the case in pairs or threes. Assume all signs not mentioned are negative. 1. Roba, a young businessman, complains of pain when he passes urine for the past 4 days. He denies urethral discharge, pain in the scrotum or sores. Robas wife is in their village 150 kilometres away: he has not seen her for three months. On examination, you note a slight watery discharge from the tip of his penis. Ask: How should this case be classified? Answer: Classify as POSSIBLE GONORRHOEA/CHLAMYDIA INFECTION.
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Remind the participants that if you cannot see any discharge when examining a male patient, ask the patient to squeeze the penis gently and milk the urethra from its base to the meatus. Ask the participants to turn to page 78 in the Acute Care guideline module and write in the antibiotic treatments for possible GC/Chlamydia infection according to national guidelines. Follow up Care: Ask the participants to review the follow up care for urethritis. Explain that if the patient returns with the same symptoms after seven days, you should check for poor compliance and reinfection and treat the patient as before if either of these proves to be the case. If compliance seems good, the persistent syndrome may be due to either:
drug resistance: if so, offer an alternative drug therapy suggested by your manager. a different causal agent. If your setting has a high prevalence of Trichomonas vaginalis, treat the patient with metronidazole. Ask the participants to review the dosage.
Remind them that if symptoms continue to persist, refer the patient. 2. Chane is an adolescent boy of 15 years who lives in the slum area of a large town. He has been brought to the district hospital because his scrotum is swollen and he is vomiting. On examination, the scrotum is swollen and painful; the testes elevated and rotated. How do you manage this patient? Ask: How should this case be classified? a Answer: Classify as POSSIBLE TORSION. Explain that it is important to consider possible non-infectious causes of scrotal swelling and pain, as well as non-sexually transmitted infections. Non-infectious causes include trauma, tumour and testicular torsion and all require referral. In men over 35 years with no risk of STI, and among pre-pubertal boys, other general infections may be responsible. 3. A young man called Temam comes into the health centre complaining of a painful groin. The testes are swollen and painful, with no history or evidence of trauma or torsion. Ask: How should this case be classified? Am comes Answer: Classify as POSSIBLE GONORRHOEA/CHLAMYDIA INFECTION. Explain that infection of the testis or epididymis is a serious complication of gonococcal and/or chlamydial urethritis. When infected, the testis becomes swollen, hot and very painful. If early and effective therapy is not given, the inflammation will heal with fibrous scarring and destruction of testicular tissue. This may lead to infertility. Review the treatment for gonorrhoea and chlamydia in the Acute Care guideline module.
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Signs and Symptoms: Female GU symptoms or lower abdominal pain
ASK
Remind participants that GU symptoms in women have more possible causes than in men. Highlight that this section presents the current WHO STI guidelines plus the management of urinary tract infections (UTIs) and menstrual problems. It is an opportunity to identify pregnant women who need antenatal care or might have been pregnant and had an incomplete abortion. This is an important assessment because it gives the health worker an opportunity to refer women into early antenatal care, and to ask about contraception and to refer or provide family planning advice. Continue to review the questions, stopping as time allows and probing for participants understanding of why it is important to ask these questions and to explain the reasons. If time allows, lead a discussion about the participants clinical experiences with these symptoms. Remind participants to be sensitive when asking these questions.
What is the problem? What medications are you taking?

Ask participants why is it important to ask this question? Explain that some reproductive health problems may be related to medicines that affect hormonal contraception. Antibiotics can cause overgrowth of yeast and result in vaginal candidiasis. Continue probing by asking anything else until you are sure she has mentioned all drugs she is taking or has taken recently.
Ask if she has:
Burning or pain on urination?

This can mean there is an infection of the urine or STIs. Make sure this is a new complaint. Urine infections are often accompanied by more frequent urination so you now ask about that:
Increased frequency of urination?

There may be the urge to urinate very often, but very little urine is produced. Again reassure her that it is very important that she answer these personal questions to help you know what the problem is and how to treat her.
Ulcers or sore in your genital area?

Ask if any sores or genital ulcers are present, and whether the sore is painful or not and when she first noticed it. Passing urine over the sore might be the cause of pain on urination. Has she had similar sores in the same place before?
An abnormal vaginal discharge? If yes, does it itch?

A small amount of vaginal discharge is normal and healthy. Discharge is increased during the fertile period (mid-cycle), during and after sexual activity, and during pregnancy and lactation. Women complain of vaginal discharge when they think it is unusual for them or if it causes itching or discomfort. In general, they will not seek medication for a discharge they consider normal. An adolescent may not understand
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her normal body functions and needs to have more discussion about this to determine whether discharge is new but normal, or new and abnormal. A change in vaginal discharge such as a large increase in amount of discharge with a new bad smell or itching is abnormal. Most vaginal discharge is due to non-sexually transmitted infections. Women develop the symptom of vaginal discharge if they have either vaginitis (infection of the vagina) or cervicitis (infection of the cervix) or both.
o If yes, does it itch?

Vulval itching can be a sign of vaginal infection that is not sexually transmitted. It can also be a sign of irritation from using products to clean or dry the vagina, or from douching, or using certain harsh soaps. If she says she has itching, ask if she uses any of these products or practises.
Any bleeding on sexual contact?

This could result from irritation of the vagina or lesions on the vagina or cervix such as warts, cancer or precancerous lesions, ulcers or sores. Be sure she understands the question before going on to the next question, that is, that the blood is not related to her menstruation.
A partner who has had a problem with his genitals?

Determine whether he has a urethral discharge or any sores, or has recently been diagnosed or treated for a sexually transmitted infection. This can be a sensitive question. Explain that this information will help determine the cause of her problem and the treatment needed.
o If partner is present, ask him about urethral discharge or sore.

If it is acceptable, ask him directly in confidence. Explain that it is important for his wife or partner and any future children to treat any existing problems of the genitals. Arrange for partner assessment, treatment and education that day before couple leaves the clinic.
When was your last menstrual period? o If missed period: Do you think you might be pregnant?
Determine the number of weeks since last menstrual period. Determine if a period has been missed. This would mean possible pregnancy, if she has been sexually active, especially without adequate protection. Women usually know whether they are or could be pregnant. An adolescent girl will need more help if she doesnt know the signs or understand how she could become pregnant. If pregnancy is unplanned or unwanted she may need counselling and accurate information on legal abortion and the danger of unsafe abortion. If a woman has had an illegal abortion or tried to terminate a pregnancy herself, she may be reluctant to share this information. Be sensitive to this possibility if she has abnormal vaginal bleeding with missed period and abdominal pain.
Do you have very painful menstrual cramps?

This can be a problem that causes many days of disability and pain for women. Most women have some menstrual cramps. Determine if they are so painful that she cannot work or enjoy time with her family.
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Have you had very heavy or irregular periods? Determine if her bleeding is irregular, frequent, prolonged or altogether absent (amenorrhoea). o If yes, is the problem new? o How many days does your bleeding last? o How often do you change pads or tampons? (You need to modify this question to fit the local practises for menstruation. This question may not be applicable in rural areas).
Are you using contraception? If yes, which one?

Hormonal contraceptive methods may cause some changes in menstrual bleeding patterns; intrauterine devices may cause heavy bleeding or pain with menses. Be sure to use words that ensure she understands what you are asking, that is, pills, something the nurse or doctor inserted in your vagina or arm to prevent pregnancy, etc., condoms."
Are you interested in contraception?

If yes, use the Family Planning guidelines. Ask participants why is it important to ask about family planning? Explain to participants that hormonal contraceptive methods may cause some changes in menstrual bleeding patterns; intrauterine devices may cause heavy bleeding or pain with menses. It is important not to miss opportunities to offer family planning. Family planning services and information is recognized not only as a key intervention for improving the health of women and families, but also a human right. Ensure that all patients have access, choice, and the benefits of family planning. Medical, social, behavioural, and other non-medical criteria, particularly client preference, must be considered when contraceptive use is recommended. Follow the guidelines carefully. It is important not to miss opportunities to offer condoms to all sexually active women for prevention of STI including HIV as well as pregnancy (this is dual protection). Adolescents (girls particularly) need access to condoms, accurate information on their use and how to negotiate their use. Condoms help people to have safer sex by preventing direct contact of the genitals with either vaginal or seminal fluids. Using condoms is especially important if your patient has sex with more than one partner or with one partner who has other sexual partners or with a new partner. However it is not enough to know that condoms are important. Patients must also know how to use them properly. Many people resist the idea of using condoms, not because of the embarrassment or cost of buying them, but due to misconceptions and myths about them. For instance, they think that condoms spoil sex or that they are too big or too small. There are often myths about themsuch as the condom itself is infected with STI. People may also associate them with illicit sexrather than for use with a regular partner. It is important to be aware of negative ideas about condoms because, clearly, they would form a barrier to the patients willingness to comply with condom use as a safer sexual behaviour. You also need to explain that condoms work well if used properly and consistently. Describe the benefits of using condoms most relevant to the individual patient. Additional safer sex training and counselling skills will be discussed in the Patient Education Module.
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Remind participants if they are not trained to provide Family Planning counselling as per their national guidelines that they must refer patients and to check that on the Recording Form. They should follow-up with the patient at the next visit to assess whether or not the patient followed through with the family planning referral.
LOOK AND FEEL

Review the steps for completing a genital exam and the considerations for privacy and respect as previously discussed in the section on genital sores, ulcers and warts. Discuss how to assess the signs in this section:
First, check for bowel sounds. Use a stethoscope or put your head on the stomach, after asking her permission. If you hear no bowel sounds at all, listen again for two minutes or more at a spot just under and to the right of her umbilicus. Absent bowel sounds is a serious sign that the bowels have stopped moving. Feel for abdominal tenderness. Tenderness means the patient experiences pain when you touch or press in. Abdominal palpation should first be superficial to detect tenderness (pain) on light palpation. Then make a careful and deep palpation to identify any masses, enlarged organs, and the location of pain.
Lower abdominal tenderness is in the lower half of the abdomen on both sides below the umbilicus. If tenderness:
o Is there rebound? Check for rebound in the area where you found pain on light palpation. Press down slowly and very gently then release the pressure suddenly. Any severe pain that results is known as rebound tenderness. o Is there guarding? On palpating the abdomen, the abdominal muscles become stiff and board-like when even slight pressure is applied. They resist your pressing in.
Guarding and rebound occur when the lining of the abdominal cavity is irritated (peritonitis) by severe infection. Refer the participants to the photobooklet (6A) and explain how to palpate the abdomen and how to test for rebound and guarding.
Can you feel a mass? Swelling or lump in the patients abdomen on light abdominal palpation (this could be an abscess, ovarian cyst, fibroid, cancer, hard stool or enlarged liver or spleen). Measure temperature if it has not already been done. Measure pulse if it has not already been done.
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Perform external genital exam following the steps outlined previously. Be sure to have the door closed or curtain drawn and that no one will enter during the exam. Explain to the patient what you will do before and as you are doing it. Look for ano-genital ulcer or sores. There can be a single ulcer or sore, or groups of sores. Feel for enlarged inguinal lymph node or nodes. Look at the vulva to see if there is redness, sores, ulcers, blisters, swelling, signs of scratching. Look any vaginal discharge coming from the vagina.
A small amount of whitish discharge is usually normal. Yellow or green or foul or fishy smelling discharge may be a sign of infection.
If you are able to do bimanual exam, feel for cervical motion tenderness.
This is the best test for PID (pelvic inflammatory disease) and involves moving the cervix left and right using the index finger of the gloved hand within the vagina. If the woman says cervical motion is painful, or winces when you move the cervix, the test is positive.
If you are able to do a speculum exam, look for discharge, inflammation, ulcers, warts and abnormal lesions on the vaginal walls, and the cervix. Ask participants if they do speculum exams. If none of the participants do speculum exams, skip to the next question. If she said she had bleeding with intercourse, look for inflammation of the cervix that bleeds easily on contact. If she said she had burning or pain on urination especially with fever: o Percuss flank for tenderness: gently first tap, then lightly pound with your fist on flanks for tenderness where the ribs touch the vertebral column (costovertebral angle) while she is sitting. The kidney lies beneath this spot and jarring it when infected will elicit tenderness (pain) if there is infection. Use photobooklet 6B while explaining how to do this.
CLASSIFY AND TREAT
Explain how they can now use the signs and symptoms they have found on the assessment to classify the womans problems. Show them how to go down all the arrows that she fits into. Remind them that they may need to use several classification tables.
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Refer participants to the top classification table on page 37 in the Acute Care guideline module on all women with lower abdominal pain, other than menstrual cramps. Ask: What are the possible classifications for a woman with lower abdominal pain other than menstrual cramps? Answer: In addition to menstrual cramps, there are several possible classifications for a woman with lower abdominal pain: severe surgical or abdominal problem, pelvic inflammatory disease (PID), or gastro-enteritis or other GI or GYN problem.
CLASSIFY as SEVERE SURGICAL OR ABDOMINAL PROBLEM if the patient has
abdominal tenderness with the following signs:
Fever >38o C in a patient with abdominal tenderness indicates possible serious abdominal infection that could be due to pelvic inflammatory disease (PID), appendicitis or septic abortion. PID is usually caused by gonorrhoea or Chlamydia which travels up from the cervix into the uterus and sometimes fallopian tube and ovaryinfection can be extensive and life-threatening causing an abscess in the tube, ovary or both (tubo-ovarian abscess) requiring surgery and/or antibiotic therapy in hospital. Septic abortion with products of conception still in the uterus is also life threatening and requires manual vacuum aspiration of the uterus (MVA) and IV antibiotics. Rebound tenderness or guarding may be present because of pain and pressure of an abscess of the tube, ovary, or appendix or inflammation of the lining of the abdominal cavity (peritonitis). Bowel sounds may be absent because severe infection in the abdomen causes intestinal movement to stop, an ominous signthis may also cause vomiting of fluids. High pulse rate >110 results from fever, infection and possible sepsis (which can cause shock). Recent missed period and abnormal bleeding could signal ruptured ectopic (tubal) pregnancy, especially with severe pain, history of fainting and high pulse rate due to internal blood loss. These signs with fever can also be due to septic abortion.
Ask: What do you need to do if a woman is classified as severe surgical or abdominal problem? Answer: Patient requires URGENT referral to hospital for possible surgical intervention. IV or IM antibiotics and IV fluids should be started before transfer.
CLASSIFY as PID (pelvic inflammatory disease) if there is either lower abdominal

tenderness or cervical motion tenderness. The term pelvic inflammatory disease (PID) refers to infections of the female upper genital tract: the uterus, fallopian tubes, ovaries or pelvic cavity. It occurs as a result of infection going through the cervix. It can be caused by gonorrhoea, chlamydia and some anaerobic bacteria. PID includes endometritis, salpingitis, tubo-ovarian
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abscess and pelvic peritonitis. It can also lead to generalized peritonitis, a potentially fatal condition. Salpingitis may lead to a blocked fallopian tube, resulting in decreased fertility or total infertility, if both tubes become infected. It may also lead to partial tubal obstruction, allowing spermatozoa to pass through, but not the relatively larger fertilized ovum. The result can be a tubal or ectopic pregnancy, which will eventually rupture, causing massive intra-abdominal haemorrhage and, possibly, death. Women with PID usually have a history of lower abdominal pain and vaginal discharge. However, in addition, some women with PID or endometritis will not complain of lower abdominal pain. Other suggestive symptoms include pain during intercourse, vaginal discharge, abnormal bleeding from the womb at any time including during a period, painful urination, pain during menstruation, fever and sometimes nausea and vomiting. Although difficult to diagnose, PID becomes more probable when one or more of the symptoms above combine with lower abdominal tenderness, vaginal discharge and cervical motion tenderness. PID can usually be treated with appropriate antibiotics by mouth, but follow-up within two days is necessary to avoid missing a more serious diagnosis above. PID is usually a complication of GC/Chlamydia infection so counselling on HIV/STI, partner treatment and condoms are needed. PID can also be the result of medical procedures (such as IUD insertion or termination of pregnancy).
CLASSIFY as POSSIBLE GONORRHOEA/CHLAMYDIA INFECTION if:
she is a sex worker, because she is at very high risk of infection from multiple partners who do not use condoms. Offer HIV/STI counselling and encourage condom use. there is bleeding with or after sexual intercoursethis can be a sign of cervical infection but also of pre-cancerous or cancerous lesion of the cervix. Therefore if bleeding does not resolve after STI treatment, follow-up and referral for cervical cancer screening is needed. she knows her partner has a urethral discharge or burning on urination because this is evidence of male infection with GC/CT. she thinks she has an STI for any reason as she may have risks she prefers not to discuss.
Vaginal discharge that is due to cervical infection (cervicitis) with gonorrhea (GC) or Chlamydia Trachomatis (CT), are sexually transmitted. In this module if the woman has a discharge and you suspect GC or CT, use this table POSSIBLE GONORRHOEA/CHLAMYDIA INFECTION. (In areas of higher prevalence of gonorrhoea and chlamydia, more specific questions have been developed to evaluate the risk of GC/CT. If this is true in your area, ask those questions here). Explain that a small amount of vaginal discharge is normal and healthy. For women with abnormal discharge and no other signs (fever, abdominal pain or bleeding, partner with symptoms) use the abnormal vaginal discharge table on the following page.
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If itching or curd-like white discharge, CLASSIFY as CANDIDA VAGINITIS. Candida vaginitis is not sexually transmitted. Often there is also erythema, which are red areas of skin on the vulva (vulvo-vaginal redness), or excoriations, which are abraded parts of the skin. If candida vaginitis is recurrent (occurs frequently) or is very resistant to treatment, consider HIV related illness. Look at photobooklet 6C for characteristic curd-like vaginal discharge. If none of the above, CLASSIFY as BACTERIAL VAGINOSIS (BV) OR TRICHOMONIASIS. BV may have a characteristic fishy odour. She should return for follow up after treatment if the discharge persists since other more serious problems could be the cause of discharge. Treat her partner if possible since Trichomonas is sexually transmitted (unlike Candida or BV).
Vaginal problems such as discharge, itching or dryness can also be due to douching or the use of other local products to clean or dry the vagina these practises are harmful and should be discouraged. Ask if patient uses such products. Ask: Under what circumstances does vaginal discharge change? Answer: During a womans fertile period and during pregnancy. Ask: what are the causes of vaginal discharge? Answer:
Most vaginal discharge is due to non-sexually transmitted infections. Women develop the symptom of vaginal discharge if they have either vaginitis (infection of the vagina) or cervicitis (infection of the cervis) or both. It is important to distinguish between these conditions because one of them, cervicitis, leads to serious complications, so the patients sexual partner(s) must also be treated to avoid reinfection. Vaginal discharge that is due to cervical infection (cervicitis) with gonorrhea (GC) or chlamydia trachomatis (CT), are sexually transmitted.
In areas of higher prevalence of gonorrhoea and chlamydia, more specific questions have been developed to evaluate the risk of GC/CT (if they have country-specific questions, ask them to list them and write them on a flipchart to ensure that the participants are including these questions in their assessments). We can summarize the differences between vaginitis and cervicitis with this table. Vaginitis Caused by trichomoniasis, candidiasis and bacterial vaginosis Most common cause of vaginal discharge Easy to diagnose No complications Treatment of partner unnecessary except for TV Cervicitis Caused by gonorrhoea and chlamydia Less common cause of vaginal discharge Difficult to diagnose Major complications Need to treat partner
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It is important to distinguish between these conditions because one of them, cervicitis, leads to serious complications, so the patients sexual partner(s) must also be treated to avoid reinfection. Without a speculum exam, we decide which patients to treat for possible GC/chlamydia infection based on factors that make cervicitis more likelysex worker, bleeding on sexual contact, partner with urethral discharge or burning on urination, and any woman who thinks she may have an STI.
There are several possible classifications for women who complain of burning or pain on urination (dysuria) or flank pain.
CLASSIFY as KIDNEY INFECTION if a patient has flank pain or fever.

Ask participants what they need to do if a patient has a kidney infection? Answer: Patients need urgent referral to hospital if "systemically ill" which means lethargy, dehydration, high fever, or shaking chills. This could indicate she has sepsis and needs parenteral antibiotics. Otherwise treat with oral antibiotics as at the bottom of the "Give appropriate oral antibiotics" page ("For bladder infection") and have her return the following day. She may require a change of antibiotics or referral to hospital if there is no improvement. Ask: why do you need to know if the patient is taking indinavir? Answer: Indinavir can cause kidney stones.
CLASSIFY as BLADDER INFECTION if a patient has burning, pain on urination or

frequency without fever, and without abnormal vaginal discharge or vulvo-vaginal sores. Treat with appropriate oral antibiotics and encourage increased fluid intake that helps to flush bacteria from the bladder. If no improvement in 2 days, have patient return for follow-up, as the infection may be resistant to the antibiotic used. Ask: how would you Classify and Treat if none of the above symptoms are present? Answer: Bladder infection unlikely if none of the above symptoms are present. Treat abnormal discharge if present, and perform dipstick test on the urine if possible to see if there is evidence of infection. Ask: how is this different from burning/pain on urination for men? Answer: Dysuria in men is usually because of GC/Chlamydia, an STI.
Discuss in detail the possible classification for women who complain of menstrual pain or missed period or irregular bleeding or very heavy period.
CLASSIFY as PREGNANCY-RELATED BLEEDING OR ABORTION if she has irregular

bleeding and is sexually active, or has any bleeding and knows she is pregnant.
CLASSIFY as IRREGULAR MENSES OR VERY HEAVY PERIODS (MENORRHAGIA) if

she is not pregnant and has:
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new irregular menstrual bleeding, or soaks more than 6 pads each of 3 days with or without pain.
Ask participants to define menorrhagia. Answer: Menorrhagia is new irregular menstrual bleeding that soaks more than 6 pads each of 3 days with or without pain. Ask: what are the causes of new irregular or heavy bleeding if she is not pregnant? Answer: Irregular and heavy bleeding can be due to:
Use of some IUDs; combined oral contraceptive pills or the progestin-only pill can cause spotting between periods. Changes in female hormone levels, especially in the years leading up to menopause. Cervical cancer Uterine fibroma (benign tumours of the uterus) cause heavy bleeding and can be removed surgically if necessary. Cancer of the endometrium (uterine lining) is also a cause of heavy, irregular bleeding in women 35 and older; women should be referred for gynecological evaluation if bleeding has no other obvious cause.
Ask: What are the treatments for vaginal bleeding? Answer: Refer any vaginal bleeding after menopause for evaluation for endometrial cancer. Refer any persistent vaginal bleeding, which does not respond to treatment before or after menopause, for cervical cancer screening. Hormonal contraceptive pills, injections or implants can be given to decrease bleeding if contraception is acceptable, provided a serious cause of bleeding has been ruled out. Refer to someone trained in family planning.
CLASSIFY as DYSMENORRHOEA (painful menstruation) if the only symptom is painful menstrual cramps. Oral contraceptives can decrease cramping, and ibuprofen or other nonsteroidal anti-inflammatory (NSAID) given just before the start of menses is effective.
Ask participants what is the follow-up for bladder infection or menstrual problems? Answer: Review this box in the Follow-up Care section. Consider STIs if symptoms persist treat patient and partner for GC/chlamydia. If polyuria continues or is associated with increased thirst or weight loss, check for diabetes mellitus by dipstick of urine. If positive for sugar, refer for fasting blood sugar and further assessment. Check adherence to treatment.
Show them where to mark the X or checkmark for all relevant symptoms on the Acute Care Recording Form.
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CASE STUDIES Ask participants to determine the correct management for the case studies using the flowchart and classification tables for women who complain of genitourinary symptoms or lower abdominal pain. Read the first case study aloud. Allow a couple of minutes for the participants to think about the case individually and then ask one of them to lead the group through the flowchart and classification table for the case study step by step with the whole group. You may also have the participants discuss the case in pairs or threes. Assume all signs not mentioned are negative. 1. Aisha is a 30 year-old woman complaining of abdominal pain for 3 days and chills and fever last night. Her last menstruation was 3 weeks ago and she uses oral contraceptive pills to prevent pregnancy. She has no burning on urination or genital sores or discharge. Her husband came back from the city two weeks ago and she has had sexual intercourse with him every night since then. You find that she has fever of 38oC and general tenderness over the lower abdomen. Ask: How should this case be classified? Answer: Classify as PID. Explain that the term pelvic inflammatory disease (PID) refers to infections of the female upper genital tract: the uterus, fallopian tubes, ovaries or pelvic cavity. It occurs as a result of infection going through the cervix. It can be caused by gonorrhoea, chlamydia and some anaerobic bacteria. Severe untreated PID can lead to generalized peritonitis, a potentially fatal condition. Explain that women with PID usually have a history of lower abdominal pain and vaginal discharge. However, in addition, some women with PID will not complain of lower abdominal pain. Other suggestive symptoms include pain during intercourse, vaginal discharge, abnormal bleeding from the womb at any time including during a period, painful urination, pain during menstruation, fever and sometimes nausea and vomiting. Ask: if a bimanual examination were done, what findings would be likely in this case? Answer: cervical motion tenderness. Review the oral antibiotic treatment for PID in the Acute Care guideline module. Ask: which organism(s) each of the three antibiotics is treating. Answer: ciprofloxacin for gonorrhoea, doxycycline for chlamydia, and metronidazole for anaerobes. [Adaptation: Is ciprofloxacin the drug of choice for gonorrhoea in your national guidelines? If not, how would you modify this regimen?] Review the follow up care box for PID in Acute Care. Ask what symptoms or signs would make you refer her for inpatient treatment? 2. Abeba , aged 22, attended the family planning clinic for her usual check-up while on the contraceptive pill. She tells the nurse about a yellow, itchy vaginal discharge that she has
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had for the past four days. She has no abdominal pain or urination pain. She had her period two weeks ago and it was normal. Shyly, she discloses that she sometimes does free-lance sex work. She last had sex with her regular boyfriend a month ago, as he is out of town. Ask: How should this case be classified?
Answer: Classify as POSSIBLE GONORRHOEA/CHLAMYDIA INFECTION and CANDIDA VAGINITIS.

Explain that women develop the symptom of vaginal discharge if they have either vaginitis (infection of the vagina) or cervicitis (infection of the cervix), or both. It is important to distinguish between these conditions because one of them, cervicitis, leads to serious complications. Unfortunately, it is not easy to distinguish between cervicitis and vaginitis, especially when it is not possible to do an internal examination. Cervicitis is more likely in areas where the prevalence of gonorrhoea and/or chlamydia is high. The higher the prevalence, the stronger the justification for treatment. Explain that because Abeba engages in sex work, she has a higher risk of cervical infection caused by gonorrhoea and/or chlamydia. Other possible risk factors for possible gonorrhoea and/or chlamydia in women listed in the flowchart include bleeding on sexual contact, having a partner with urethral discharge or burning on urination, or being worried that she might have an STI. Review the treatment for gonorrhoea and chlamydia and the follow-up care in the Acute Care guideline module. Explain that the most common cause of vaginal discharge is vaginitis due to candida, trichomonas or bacterial vaginosis. According to the classification table, Abeba should be treated for candida with nystatin. Have the participants review nystatin treatment and the follow-up treatment for candida vaginitis. Ask what is the follow up treatment for candida vaginitis?
Answer: Some improvement usually seen in a few days with no symptoms after 7 days of treatment. If symptoms persist: Re-treat patient. Ask about oral contraceptive or antibiotic usethese can contribute to repeated candida infections. Consider HIV infection or diabetes, particularly if symptoms of polyuria or increased thirst or weight loss. Check urine glucoseif present, refer for fasting blood sugar, repeat candida infections are common. Consider prophylaxis (Chronic HIV Care, H16). Consider treating for cervicitis if not treated on the first visit. 3. Aminat is 17 years old, living in an urban area. She reports a slight yellow discharge but no other symptoms. She has lived with her current boyfriend for nine months and has had no other partners. Her boyfriend has no symptoms.
Ask: How should this case be classified? Answer: Classify as BACTERIAL VAGINOSIS OR TRICHOMONIASIS.
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Review the risk factors for possible gonorrhoea/chlamydia infection. Ask: Does Aminat meet any of the criteria? Answer: No. Ask the participants turn review the recommended dosage for metronidazole. Ask if it is better to use the 2 gm single dose regimen or give 2 tables twice daily for 7 days? Answer: In general, it is better to give single dose regimens when possible to increase patient compliance. Ask the participants to turn to the Follow-up Care section of the Acute Care guideline module and review the follow up care box for BV or Trichomonas vaginitis. This is a complex case because she is an unmarried adolescent. These two factors, namely age below 21 years and single, have been identified in certain settings as positive risk factors for cervical infection. In the Acute Care guideline module, she does not fit any of the risk factors for possible GC/chlamydia. However you need to carefully ask questions about her sexual history and that of her boyfriend. It is important that she feel comfortable enough with you that she will be honest; it may be helpful to refer her to a counsellor or ART Aid. 4. Sara moved in with her present partner four months ago. She is 22 years old. In addition to reporting a non-itchy discharge, she says has pain in her lower abdomen. Her partner has no symptoms. On examination, she has no fever and general lower abdominal tenderness. Ask: How should this case be classified? Answer: Classify as PID and BACTERIAL VAGINOSIS. If this is confirmed on examination and pregnancy is excluded, she should be treated for both a cervical infection (PID) and a vaginal infection (BV). 5. Jemila complains of a slight vaginal discharge. She is 25 years old and has been married for eight years. Her third child was born four months ago, so shes been busy caring for him at home. Apart from this discharge, she feels well and has no other symptoms. Her husband has GU symptoms that she knows of. They do not use condoms. Ask: How should this case be classified? Answer: Normal vaginal discharge. Reassure her. The discharge is slight and may not be abnormal in a woman who is still breast-feeding. The nature of the discharge needs to be verified by examination. If abnormal, she should be treated for vaginal infections only. However, you should carefully ask more questions about her husband before making a final decision about treatment.
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Skill Stations and Card Sort Explain the purpose of the skill stations and the role of the expert patient-trainers. The skill stations will be run similiarly to those in the Basic ART Clinical Course, with the following differences:
In the Basic ART Clinical Course, all the EPTs were playing the role of HIVpositive patients. In these skill stations, they are generally playing the role of patients coming to the OPD who do not know their serostatus. If indicated, the participants should offer an HIV test (and any other tests) as in the STI script of the PITC course. The pre-test session should discuss the link between HIV and STIs, and confidentiality. When the participant asks for permission to do an external genital examination, the EPT is instructed to hand the participant a slip of paper with the relevant physical findings. The participants should use the Acute Care Recording Form and give it to the EPT after the evaluation. The EPT will use this to make sure the correct classification was made. The checklist is similar to the one used by the EPTs in the Basic ART Clinical Course. The participants still need to use the 5 A's, but do not need to refer to a support group, for example. They need to do assess all major syndromes and ask all screening questions.
The card sort station is for participants who are waiting to work with an EPT. After the skill stations, reconvene the large group. Ask participants for feedback from skill stations. Answer questions.
Wrap Up Day 1
Let participants know that this is a lot of information but that they are doing a good job. Remind them to review the STI Handout and the relevant sections of Acute Care guideline module. Thank them for coming on time today and tomorrow.
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DAY 2Morning Session: Chapter 12 of the acute care participant manual

Course materials: 1) IMAI Acute Care Participant Training Manual and Photo booklet, 2) IMAI Participant Handout for Acute Care/STI Short Course, 3) IMAI Acute Care guideline module, Rev.2 Wallcharts: 1) Acute Care Algorithm, 2) 5 As, Blank flipchart, markers
Purpose:
To continue to learn how to use the assess, classify, and treat IMAI Acute Care guideline module To learn to educate and counsel patients on STIs
By the end of this session the health worker should be able to: Identify asymptomatic syphilis and STI-related skin problems or lumps Provide STI education and counselling Provide safer sex counselling to patients Encourage patients to refer their partners for treatment Recommend HIV counselling and testing to all patients Strategize with STI patients to reduce risk of stigma and violence Content: Review Day 1 Methods Rapid Review of Previous Material, Questions & Answers Assess, Classify, Treat Discussion, group reading, questions Drills, Case Studies Timing 15 min.
Female GU or lower abdominal pain (continued) Tea Break Syphilis Molluscum Contagiosum
60 min.
30 min. Assess, Classify, Treat Discussion, group reading, questions, Drills, Case Studies Exercise 60 min.
Many copies of Acute Care Recording Form Blank flipchart, markers Condoms Cucumbers, bananas, penis models, etc.
STIs Values Clarification
15 min.
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Conduct a rapid review of Day 1, including highlights from relevant sections of the STI handout, how to assess, classify, treat and follow up all adults and adolescents presenting at primary care centre. Stress sections that were confusing or participants had questions about. Ask if there are any questions from their reviews last night. Answer questions using wallcharts so that participants become skilled at reading them. HIV-related skin problems Most skin problems and lumps are covered in the Acute Care/OI short course. This course covers STI-related skin problems, such as scabies and molluscum that can also have nonsexual transmission, especially in children. Skin problems commonly found in patients with HIV can be used to screen for HIV. In addition, syphilis can present in many ways (e.g., lymphadenopathy) or be asymptomatic and is also included in this section. Other skin problems occur more commonly in patients with HIV and can be the first symptom of HIV infection since they occur early. Seborrhoea, prurigo and herpes zoster are examples of these kinds of early HIV skin problems and are covered in the Chronic HIV Care with ART and Prevention, section 3. What is syphilis? Explain that syphilis usually starts as a painless genital ulcer that is often ignored by the patient because it is painless. This goes away after 1-2 weeks. This is called "primary syphilis." In the next 1-2 months, the patient may then develop "secondary syphilis", which can be general, non-specific symptoms such as a rash on the palms and soles, generalized lymphadenopathy and fatigue. After this, the patient may be asymptomatic or have minimal symptoms for months or years, then may develop more serious symptoms of "tertiary syphilis", which can involve the brain, eyes or heart. So men or women with syphilis may be asymptomatic or have few symptoms such as enlarged lymph nodes with no local infection to explain them or a painful, burning or numb or cold feeling in their feet or lower legs (painful leg neuropathy). They may not even realize that anything is wrong. If any of your patients present with these symptoms, do a syphilis/RPR test. The RPR or VDRL will turn positive during the "secondary syphilis" phase (about 1-2 months after the ulcer) and this will stay positive for life. During this asymptomatic or "latent" phase, even if you ask the patient carefully, he or she may not remember ever having a genital ulcer. So it is impossible to figure out how long the patient has had syphilis. So any patient who has an RPR should be treated for syphilis (with benzathine penicillin) if he or she cannot remember having a genital sore, and he or she has never been treated for syphilis before. Treatment for primary or secondary syphilis: benzathine penicillin 2.4 M units IM Treatment for late latent or tertiary syphilis: benzathine penicillin 2.4 M units IM weekly for 3 weeks 141
Screening for asymptomatic syphilis Many men and women with an STI, such as syphilis, may not have any symptoms or present with symptoms in other parts of their bodies. Asymptomatic syphilis can present with enlarged lymph nodes (lymphadenopathy page 41) with no local infection to explain them or a painful, burning or numb or cold feeling in their feet or lower legs (painful leg neuropathy page 47). They can also have minimal symptoms and do not realize that anything is wrong. They may visit a clinic for other reasons or not at all. Yet identifying and treating such patients will prevent the development of complications for the individual patient and help reduce transmission in the community. In women, silent asymptomatic infections can be more serious than symptomatic ones. While men are more likely to have symptoms than women, asymptomatic STI is possible. More commonly, men may ignore symptoms if they are not severe. Health care providers can raise awareness about symptoms and encourage men to come for check-ups if they have any. Also note that secondary syphilis can cause a rash on the palms. Refer participants to pages 41 and 47 in Acute Care guideline module for the tables dealing with enlarged lymph nodes or painful leg neuropathy. Point out when one should do an RPR test. In women, silent asymptomatic infections can be more serious than symptomatic ones. Syphilis, gonorrhoea and chlamydia have serious consequences, yet are often asymptomatic. Even PID frequently has mild or no symptoms. Reproductive health services have an important role to play in detecting asymptomatic STI. Since many women attend reproductive health clinics for family planning or antenatal services, every opportunity should be taken to identify women with STI who would benefit from treatment.
Syphilis screening Syphilis remains a leading cause of perinatal mortality and morbidity in many parts of the world despite widely available and affordable technology for diagnosing and treating infection in pregnant women. Among pregnant women in the early stages of syphilis who are not treated, an estimated two-thirds of pregnancies end in abortion, stillbirth, or neonatal infection.
Men and women with STI syndromes other than genital ulcer should be screened for syphilis. Screening is unnecessary for patients with ulcers who should be treated for both syphilis and chancroid without testing. Sex workers should be screened every 6 months. It is imperative that clinic staff not be judgmental when treating sex workers. Encourage them to return every six months by being open and caring. Pregnancy. Screening for syphilis should be done at the first antenatal visit, as early as possible in pregnancy. It can be repeated in the third trimester if resources permit, to detect infection acquired during the pregnancy. Women who do not attend antenatal clinic should be tested at delivery. Although this will not prevent congenital syphilis, it permits early diagnosis and treatment of newborns.
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Women who have had a spontaneous abortion (miscarriage) or stillbirth should also be screened for syphilis; in many areas, identification and treatment of syphilis remove a major cause of adverse pregnancy outcome.
Remind participants that syphilis testing should be done on site wherever possible to maximize the number of patients who receive their results and are treated. If any of the participants have to perform this test themselves, refer them to the procedures for performing it in the "Laboratory Tests" section of the Acute Care guideline module. Review steps as appropriate to local centre protocols and stress the importance of working with their supervisor if they do not understand test procedures if they are responsible for performing the tests. Patients should receive their test results before leaving the clinic. Patients with reactive (positive) results should be treated immediately according to the stage of syphilis. Many patients identified through screening will have an unknown duration of infection and should be treated for late syphilis. Sex partners should also be treated. Ask: what should you do if testing is not available on-site? Ask: what are some other screening tools for syphilis? Answer:
Non-treponemal tests, such as rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL) tests are the preferred tests for syphilis screening. RPR can be performed without a microscope while the VDRL requires microscopic examination. These tests detect almost all cases of early syphilis but false positives are possible. Treponemal tests (e.g. Treponema pallidum haemagglutination assay--TPHA), if available, can be used to confirm non-treponemal test results and rule out false positives. However, they are not useful as a screening test since they stay positive for life, even after a case of syphilis is adequately treated. Quantitative (RPR or VDRL) titres can help evaluate the response to treatment.
Note: where additional confirmatory tests are not available, all patients with reactive RPR or VDRL should be treated.
Molluscum contagiosum This is a pox virus frequently, but not exclusively, transmitted by sexual contact. It manifests as dome-shaped papules, 2-8 mm diameter, with an umbilicated centre. There may be a few lesions or large crop of lesions in the genital area. The most commonly affected sites are the genital areas and inner aspect of the thighs. The lesions may be wide-spread and severe with immunosuppression. Phenol or tincture of iodine is applied to the central core of each lesion with the sharp end of an orange stick or swab stick. If available, cryotheraphy or electrocautery may also be used for refractory lesions. In immunosuppresed patients, the lesions may be widespread and severe. It is best to avoid any treatment. Refer severe cases for cautery or surgery.
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Exercise (HIV-related skin problems) Ask participants to complete the two exercises at the end of chapter 12 of the Participant Training Manual. Allow about five minutes for each exercise. Answers: Skin problems that may indicate HIV Long-lasting ulcers from herpes simplex Herpes zoster Giant or extensive molluscum contagiosum Seborrhoea
List the skin problems that can be sexually transmitted:

Scabies Molluscum contagiosum Herpes simplex Syphilis (can manifest as lymphadenopathy, rash)
DRILL (HIV-related skin problems) Read the cases to the participants and ask them to identify and classify the signs and symptoms
1. Yohannes is 45years old and has been complaining of severe numbness, cold feeling, and pain in his legs. He was widowed last year and no one knows how his wife died.
Answer: Painful leg neuropathy suggestive of asymptomatic syphilis which requires an RPR and consideration of HIV-related illness. 2. Molla has HIV and is covered with widespread, severe pox lesions. Answer: Giant molluscum contagiosum has
3. Hana has several boyfriends and has never had an HIV test despite your encouragement at every visit. She has severe ulcerations for more than 30 days around her mouth and her genitals.
Answer: Severe herpes simplex virus that requires consideration of HIV-related illness.
4. Melat, age 15, has greasy scales and redness on her face, scalp and chest. Her mother died of AIDS.
Answer: Severe seborrhoea which requires consideration of HIV-related illness.
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Values Clarification Exercise While participants are at tea break, post signs for STRONGLY AGREE, AGREE, DISAGREE, and STRONGLY DISAGREE on the four walls of the room. The values clarification exercise Where do you stand? is a good tool for individuals to consider their thoughts and feelings about STIs. Explain to participants that this is the goal of the exercise. Read each question aloud and have participants answer by moving to the sign that most closely echoes their feelings. Emphasize that there are no right or wrong answers. Invite participants to briefly share the reasons for choosing their response. If participants are shy, call on a group standing under one of the signs and specifically ask why they chose this sign. At the end of this activity, ask the group if they think this exercise helped them with their patient care. STIs arouse many feelings and often touch some of our deepest beliefs. Because of this, and our role as health care providers, it is important to know ourselves, and particularly our attitudes and feelings about STIs, how people are exposed to them, and how they affect others. Where do you stand?
Disagree Agree
Question
Once people know they have an STI, they should tell all their sex partners no matter what the consequences. Telling someone that they have an STI is like telling them they are bad. An individual who is single and has an STI should be forced by the health worker to bring all their partners to the clinic for treatment. All parents should be informed when their adolescent has an STI. People with an STI should tell family members. (Add other statements that may reflect local biases)
Strongly Disagree
Strongly Agree
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Educate & Counsel on STIs Explain that they now understand how and why health education and counselling is important. Now we will talk about the elements of good STI education and counselling. For the following, refer participants to the Participant Training Manual and provide brief highlights of each section. Lead a discussion as time allows about their experiences at their health centres.
Speak in private, with enough time, and assure confidentiality. Explain the disease and assess patients understanding of STIs by probing for beliefs/myths.
BRAINSTORM Conduct a group brainstorm about STI beliefs and myths. Ensure that the following are mentioned: Beliefs/myths about STIs: 1. One STI can turn into another one 2. You can only get one STI at a time 3. All STIs, including HIV, are detected using one Classification test 4. Health care personnel can tell if a patient has STI without 5. Examination 6. People with STIs always have symptoms 7. You cant have STI and HIV at the same time 8. You can tell who has an STI by how he or she looks or feels 9. You can tell who has an STI by his/her actions, occupation 10. Social class or number of sex partners 11. One can get STIs through witchcraft Continue to stress that the health worker must be able to explain to the patient what an STI infection is by clarifying the difference between a bacterial and a viral infection using words readily understood by the patient. Since these are difficult concepts for patients to understand, ask how they explain the difference between a virus, a bacteria and a parasite to their patients. Record concepts on flipchart.
How it is acquired Explain that it is important for the patient to understand that an STI is transmitted through sexual intercourse with an infected person. Ask for examples of how they explain penile-vaginal, oral and anal to their patients. What about if a patient has sexually transmitted skin problem? How do they explain that?
How it can be prevented Ask for examples of how health workers assist patients to assess his/her own risk level. Record on flipchart. Refer participants to their manuals for additional information. Ensure that the following is covered:
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Changing sexual behaviour Condoms(more about this later) Sexual practise(s)

Ask if there are particular sexual practices that are higher risk that are practised in their communities.
Other barrier methods

Ask if their patients use other barrier methods.
Personal hygiene and cultural practises

Ask if their female patients practise douching? If so, why? How do they encourage women to wash with soap and water?
Treatment Ask how do they explain treatments to their patients. How do they assist them to follow the treatment regime? Record on flipchart. Ask how do they remind patients that most STIs can be cured, except HIV, herpes and genital warts. Ask how they remind patients of the need to also treat the partners (except for vaginitis), especially since their recent sex partner(s) are likely to be infected but may be unaware.
Listen to the patient Ask how they can tell if the patient is experiencing stress or anxiety related to STIs? Conduct a brainstorm of the possible negative consequences for a patient diagnosed with an STI. Record on flipchart. Stress the need to take time and to use special counselling skills to assess a patients anxiety level about their STI. Refer them to the counselling skills on pages 107 and 108 in the Acute Care guideline module. Ask for examples how they verify that the patient has understood what has been discussed.
Promote safer sexual behaviour to prevent STIs & HIV Provide the definition of safer sex: Safer sex is any sexual practise that reduces the risk of transmitting an STI or HIV from one person to another.
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Ask participants for examples of safer sex and risk reduction strategies. Record on flipchart. Ensure that the list includes: Safer Sex Strategies o Correct and consistent use of condoms. o Abstaining from sexual activity. o Choosing sexual activities that do not allow semen, fluid from the vagina or blood to enter the mouth, anus, or vagina of the partner, and not touching the skin of the partner where there is an open cut or sore. o Limiting the number of sexual partners and careful selection of partners. Ask for examples on how they counsel on limiting partners, abstinence, and careful partner selection. Record on flipchart. Ask if it is difficult for them to discuss these issues with their patients? How do they make it more comfortable for the patient to discuss these issues? Educate on HIV Remind participants of the key points from the HIV Review earlier. Refer them to page 97 of the Acute Care guideline module that covers the key points to be covered when counselling on HIV. Recommend routine HIV testing and counselling
Tell the students to turn to the STI script in the Participant Training Manual in the section on provider-initiated testing and counselling. Review the steps involved in giving pre-test information (provide information on HIV, explain measures to ensure confidentiality, and obtain informed consent (see Provider-Initiated Testing and Counselling: Brief Provider Intervention). Explain that a very effective technique is to emphasize the links between STIs and HIV: How to offer HIV testing People with a sexually transmitted infection are also very likely to have have HIV infection. This is because certain sexually transmitted infections make it easier to become infected with HIV. If you have HIV, it is very important for you to know. Treatment for HIV is becoming more available and can help you feel better and live longer. HIV is a virus or a germ that destroys the part of the body needed to defend a person from illness. The HIV test will determine whether you have been infected with the HIV virus. It is a simple blood test that will allow us to make a clearer diagnosis. Following the test, we will be providing counselling services to talk more in-depth about HIV/AIDS. If your test result is positive, we will provide you with information and services to manage your disease. This may include antiretroviral drugs and other medicines to manage the disease. In addition, we will help you with support for
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prevention and for disclosure. If it is negative, we will focus on ensuring you have access to services and commodities to help you remain negative. For these reasons, we recommend that you be tested for HIV. Unless you object, you will be tested for HIV today. An adult or adolescent with an STI should be offered HIV counselling and testing.
Ask what they should do if patient with an STI reports a recent HIV-negative test result. Remind them that if their patients are HIV negative, but continue to engage in high-risk behaviour and contract STIs, they should be referred for additional counselling. Inform the partner(s) or spouse Remind them that since this is syndromic management, treatment must be given presumptively and the partner treated even if there are no symptoms or signs of STI.
We assume the period of infectiousness to be two months, so all partners within the last two months must be treated. Identifying the source patient has no particular value because the aim is to treat all partners or all those partners that can be reached and their partners in turn.
Stress the importance of developing strategies to help their patients inform their partner(s) so they can be treated. The best time for this to occur is if the patients partner has accompanied them to the centre that day. Ask how they usually handle this problem. Record on flipchart. Remind them that partner management must be confidential and voluntary. Ask what are their patients reactions when they are asked if they can tell their partner(s)? What if their partner is at the clinic? What if they have to convince their partner to get treatment even if they do not have any symptoms? How do they help them bring/send their partner(s) to the health centre? Do they give the patient a prescription for their partner? Patients might approach partners in several ways: 1. By directly explaining about the STI and the need for treatment. 2. By accompanying a partner to the health centre or asking the partner to attend without specifying why. 3. By giving each partner a card asking him or her to attend the centre. Your role as the health worker Explain that their role in partner notification will be determined by their national guidelines.
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Strategies to discuss and introduce condom use Lead a discussion about condoms in their communities. Are they readily available? What do people think of them? How do they get their patients to use them? Have they ever used them? Benefits of Condoms
1. 2. 3. Condoms prevent transmission of STI, including HIV. They help women to avoid pregnancy. Condoms reduce the risk of transmission of an STI if a patient does not wait for the STI to be cured before having sexbut the health care provider should encourage the patient to wait! Women feel dryer inside. The patient will feel safer, with fewer worries. Many men can prolong intercourse if they wear a condom. Bed linen needs washing less often!
4. 5. 6. 7.
Condom Demonstration Have lots of condoms for participants. If you have access to female condoms, use them also. Use bananas, cucumbers, or other appropriate objects if there are no penis models available. Ask for a volunteer to demonstrate how to correctly put the condom on the object/model. Ask for feedback. Encourage everyone to practise. Call time after about 10 minutes. Ask what are the important considerations in condom use, storage, and disposal. List on flipchart.
Risk of violence or stigmatizing reactions from partners and family.

After hearing that his or her partners also need to be treated, many patients might be very uncomfortable with this news. It might cause far-reaching damage to the individuals concerned. Partner management must take account the possible impact on the lives of each individual. News of STI can be especially damaging when a patient or partner hears of their partners infidelity for the first time. Equally someone with mistaken ideas about the cause of STI may respond in ways that are inappropriate or extreme. Patients are sometimes blamed for being the source of infection when it is rarely possible to identify the source of infection.
Remind them that health workers must assess their patients vulnerability to violence or stigma. Ask how they accomplish this. Ask for examples from their centre. Ask what they do if a patient has several sex partners or if male patient is having sex with young girls. Special counselling for adolescents
Refer participants to the Adolescent Job Aid for specific tips for counselling adolescents.
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Referrals o o o o o Concerns about herpes infection (no cure) Possible infertility related to PID Behavioural risk assessment Patient with multiple partners Difficult circumstances or risk
Discuss or read "Three things to remember" in the Participant Training Manual: 1. It is important to keep in mind some issues that may come up when screening or presumptively treating for STI. Women who have come to the clinic for other reasons may not be prepared to hear that they may have an infection, especially one that is sexually transmitted. They may be even more upset if they are told that they have to inform their sexual partner. Such situations must be handled carefully to avoid losing the patients trust and damaging the reputation of the clinic in the community. 2. It is also important to remember that no screening test is 100% accurate, and many are much less so. This should be carefully explained to patients and the possibility of error should be acknowledged. Most importantly, health care providers should avoid labelling problems as sexually transmitted when this is uncertain. A more cautious approachand one often more acceptable to patients and their partnersis to explain that many symptoms are non-specific; treatment can then be offered as a precaution to prevent complications, preserve fertility and protect pregnancy. 3. If there is no evidence of a sore, ulcer or vesicles or other STI, the fact that the patient feels concern about STI makes this an excellent opportunity for education. Educate the patient, counsel him or her if necessary, offer HIV counselling and testing if available, and promote the use of condoms, supplying them if possible. In fact, this is an excellent opportunity for education because the patient has come to you with concerns about STI.
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Day 2Afternoon Session

Course materials: 1) IMAI Acute Care Participant Training Manual and Photo booklet, 2) IMAI Participant Handout for Acute Care/STI Short Course, 3) IMAI Acute Care guideline module, Revision 2. Wallcharts: 1) Acute Care Blank flipchart, markers Many copies of Acute Care Recording Forms Post-Test
Purpose:
To further develop their skills in implementing the IMAI Acute Care guideline module in their health centre.
By the end of this session the health worker should be able to: Understand areas where they need additional training or mentoring. Content Elements of Education & Counselling Educate & Counsel on STIs Wrap Up Rapid Review If time allows Tea Break Skill Stations Card Sorts Methods Discussion, activity, brainstorm Review, discussion, exercises, brainstorms, demonstration Review Learning Objectives Q&A Optional Group Exercise Timing 15 min.
60 min.
15 min. (30 min.) 30 min.
Expert Patients Counsel & Educate Case Studies Photo Card Sort Review (includes all cards used previously) Q&A Written
80 min.
Wrap Up Evaluation Post-Test
20 min. 30 min.
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Rapid Course Review Divide participants up by clinic or teams. Assign each team one of the following topics: Review Sections: 1. STI Screening (all patients) 2. Ano-genital sore or ulcer 3. Discharge (males) 4. Male GU symptoms and lower abdominal pain 5. Female GU symptoms and lower abdominal pain 6. Abnormal bleeding or menstrual problems 7. UTI 8. Asymptomatic syphilis 9. STI-related skin problems 10. Educate and Counsel
Explain that the purpose of the following exercise is to help us review the Acute Care guideline module STI classifications to prepare for the post-test later.
Give each team one page of flipchart paper and a marker. Ask them to prepare a one-page flipchart with the key points from their section. Tell them they will have 10 minutes to prepare their flipchart. They can only use one flipchart page. They need to determine what are the most important key points from their assigned section for their colleagues to know for the post-test. Ask them to write them clearly on their flipchart. When they are finished, they need to hang their flipchart on the wall with the tape provided. Start the exercise. Give a one-minute warning and then call time after 10 minutes. Ask the participants to quickly review the other flipcharts. They will have 10 minutes. Call time after 10 minutes. Ask each team to stand in front of their flipchart. Ask each team to designate a presenter. Explain that they have to present the most important points in 5 minutes. Ask someone to keep time and to say Stop at the appropriate time (3 to 5 minutes depending on time and number of participants).
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Skill Stations and Card Sort See previous section for a description. After the skill stations, reconvene the large group. Ask participants for feedback from skill stations. Answer questions. Wrap Up
Clarify any confusion or misinformation from the review. Ask for and answer questions. EVALUATION Ask participants for some quick evaluation comments about the course, both positive and negative. Record on flipchart. Remind them to use these tools for self-study either on their own or with their colleagues: 1) Acute Care guideline module, 2) participant training manual, 3) STI Handout, 4) National Guidelines, 5) other?
POST-TEST Distribute post-test. Collect at the end of 20 minutes. Congratulate participants on finishing the test and the course. Thank them for their good participation and hard work. Ask if there are remaining questions or concerns from the test. Answer or refer them to their supervisor. Wish them good luck!
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Chapter 9: Skin Problems and Lumps Duration: 45 minutes Materials:

Purpose: To teach participants how to assess, classify and

identify treatment for skin problems and lumps.

will: 1. Evaluate a patient with skin problems and lumps 2. Explain the common dermatological problems 3. Classify patients with dermatologic problems and recommend appropriate treatments 4. Appreciate the clinical findings using photo booklet 5. Practice the self study exercise
Preparation:
None
Content
Assess, classify and identify treatment for skin problems and lumps.
Methods
Reading and discussion
Duration
45 minutes
Do the review drill on page 188 of the Facilitators Guide
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Introduction to the IMAI Neurological and Mental Problems Short Course Duration: 30 minutes Materials:
Content
General introduction to the short course
Methods
Reading and explanation
Duration
30 minutes
Preparation:
Read well before the course starts
1.
Briefly introduce the course by providing an overview of why it is important to understand the links between mental/neurological disorders and HIV/AIDS and know how to treat and manage these disorders. It is highlighted below.
Why include mental health within the IMAI? Health is defined by the WHO as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. When dealing with health interventions, one therefore needs to include the mental as well as the physical aspects. There are close inter-relationships between a persons physical and mental health. A healthy body supports a healthy mind, while a healthy mind supports a healthy body. Treating patients with mental problems differently from patients with other health problems promotes stigma against people with these problems. This is most likely the case with people with severe mental disorders (e.g. psychosis), but some neurological disorders (e.g. convulsions, dementia) are also regarded differently from other health problems. While some people with mental disorders will need referral to more specialized care (as with other health problems), many people with neurological and mental problems can be effectively treated by general health workers at a primary care level. Many people infected with HIV/AIDS experience neurological and mental problems. Reasons for this include:156
Mental conditions may have existed before the person became HIV infected and may have put them at risk for infection in the first place. HIV invades the central nervous system leading to cognitive impairment, dementia and in some cases psychosis. Reactions to being diagnosed positive and living with HIV/AIDS. Reactions to stigma and discrimination. Side effects of some treatments (notably efavirenz)
Why is it important to identify and treat neurological and mental problems within the context of HIV/AIDS treatment programmes? In the same way that treatment of opportunistic infections and other health problems is important in dealing with a person receiving ART, so neurological and mental problems need to be treated, particularly as treatment may contribute to improvement in both HIV/AIDS and mental status. Neurological and mental disorders and substance abuse problems may be obstacles to ART treatment adherence. Treating these problems should increase adherence.
2.
Explain that this short course is comprised of three sections, which correspond to chapters 13, 14 and 15 of their participant manual write them on a flipchart: Ch 10. Headache and neurological problems Ch 11. Mental health problems Ch.12. How to use diazepam, haloperidol and amitryptiline Post the course objectives on the wall and ask for a volunteer to read them aloud to participants. Outline the content of the course (see introduction to Guide above) and stress its introductory nature (can only deal with key points briefly). Outline the training approach - questions, role-plays, case studies; active participation Outline the IMAI Acute Care guideline module general approach: Note to facilitator: adapt this session according to the previous experience of the participant group, as follows: For participant group that has just completed another Acute Care short course Recap with them the steps in the ACUTE CARE GUIDELINE MODULE general approach: Start with Quick check for emergency care Then: assess (ask, look and feel); (review) signs, classify, treat Ask about problems (what brings you here today/how are you feeling?) General checks for all patients (e.g. cough, under-nutrition, pain)
3.
4.
5.
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Respond to volunteered problems (if patient complains of) or observed signs (e.g. feels hot, has temperature, appears depressed) with further questions or examination or investigations Review findings against signs, starting from top of table and working down until row where signs match findings, in order to classify condition Identify treatment linked to classification
For participant group trained some time before this course: Have participants look at the flow chart on page 3 of the Acute Care guideline module and relevant pages to illustrate application to cough, difficulty breathing (p.16-17) For all participant groups: Explain how we will apply the ACUTE CARE GUIDELINE MODULE approach to neurological/mental problems: Have participants look at pages 46-48 of the Acute Care guideline module (neurological problems) and p.50-52 (mental problems) Highlight: relevant headings (e.g. if, IF YES, ASK, LOOK AND FEEL, questions start from volunteered problem or observed signs (see If headings) and then proceed to ask relevant questions (see ASK), other assessment (see LOOK AND FEEL) some questions relevant to more than one condition (e.g. alcohol) - for training purposes repeated where relevant for each topic separately importance of careful assessment neurological and mental problems may present in fairly subtle ways and overlap with symptoms of other conditions including HIV infection (e.g. lethargy, agitation, confusion) consider more than one classification (e.g. lethargy seen in range of conditions, including mental problems) Key distinction: differentiating between conditions that should be referred and those that can be managed at PHC level 6. Explain how the training module will be structured:

The training will be conducted over a period of 2-3 days divided into morning and afternoon sessions There will be short breaks in the morning and afternoon and a lunch break of 1 hour At the beginning and end of each training day, 5-10 minutes will be spent summarising the topics covered and allowing time for questions
7.
Explain your role as a facilitator (along with your co-facilitator, if you have one), your role throughout this course will be to:

guide them through the course activities answer questions as they arise clarify any information that they may find confusing
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give individual feedback on exercises where indicated lead group discussions and drills
8.
Administrative tasks - There may be some administrative tasks or announcements that you should address. For example, you may need to explain the arrangements that have been made for lunches, the daily transportation of participants from their lodging to the course, or payment of per diem. Answer any questions before proceeding to Section A.
9.
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A. Headache and neurological problems (Chapter 10)

Purpose: To learn how to assess, classify and treat headaches

and neurological problems

will be able to: Use the IMAI Acute Care guideline module to assess, classify and identify treatments in patients presenting with headache and neurological problems: o Differentiate between generalized and focal convulsions o Describe how to check for focal neurological signs o Recognise painful foot or leg neuropathy o Describe common cognitive problems o Understand how to differentiate between delirium and dementia o Describe HIV-related dementia Use the IMAI Acute Care guideline module to identify serious neurological problems that require referral
Preparation
Read well before the class begins.
Content
Assess for neurological problems Ask questions to ask the patient/ family / caregiver Look and Feel check for focal neurological signs Classify and treat if headache or neurological problem / if painful leg or foot / if cognitive problem
Methods
Volunteer reading / brief discussion
Duration
20 minutes
Volunteer reading / brief discussion Volunteer reading / brief discussion / case study
15 minutes
25 minutes
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If patient has a headache or neurological problem Assess for neurological problems ASK
1. Ask participants to have pages 46-48 of the Acute Care guideline module and Chapter 13 of their participant manual available for periodic reference. 2. Read the learning objectives aloud 3. Introduce the section, explaining that there are four major symptom groups to be covered: Serious neurological problem (convulsions, dysfunction specific to one part of the body) Headaches (associated with sinusitis, migraine, tension headache) painful feet or legs (may occasionally affect hands) cognitive problems: confusion, disorientation, problems thinking or remembering / delirium / dementia 4. Explain that using the assess, classify and identify treatment approach, we will first learn how to assess for neurological problems. Explain that neurological problems may present with: Convulsions Focal neurological problems (e.g. problem walking or talking) Certain kinds of headaches 5. Remind participants that when assessing for neurological problems they must use the same approach that they have already learned and practiced: ask (listen), look and feel. 6. Ask them to turn to page 46 of the Acute Care guideline module and to look at the list of questions under the column IF YES, ASK. 6. Ask for a volunteer to read through the first question, then ask participants what might be the cause of weakness in any part of the body? Ensure that participants understand that weakness can be caused by a lesion in a particular part of the brain caused by trauma, infection, a stroke or other medical condition 7. Read through the next question (have you had an accident or injury involving your head recently) and ask for a volunteer to read the corresponding text under that question in their participant manual. 8. Read the next question (have you had a convulsion?) and ask what participants understand by the term convulsion? Are there any other terms that can be used to report a convulsion? 9. Ask for volunteers to read through the explanations of generalised convulsion and focal convulsions as outlined in the participant manual. Highlight the fact
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that whilst convulsions may be caused by an underlying medical condition, often no cause can be found. 10. Ask participants, if the patient/family answered YES to the question on convulsions, what questions would you ask to find out what kind of convulsion it was? (e.g. what happened?; then, more specific questions, especially regarding consciousness during episode, to identify type of convulsion; has this happened before? when and how often?) 11. Ask participants whether there are any superstitions around convulsions in their country? Discuss the implications (e.g. stigma, discrimination, hiding people away, not seeking help). 12. Ask how would you explain convulsions to a patient and family? E.g. the brain is the thinking part of the body and controls what rest of body does; like other parts of the body, brain can be hurt; if the brain is hurt e.g. at birth, in an accident, it may not work properly at times so that person becomes blank for a short while or there are unusual movements in parts of body. 13. Ask participants what they should do if the patient is having a convulsion just now? Refer them to the Quick Check on pages 12-13 of the Acute Care guideline module. 14. Ask if there are any questions. 15. Read the next question (Assess alcohol and drug use). Ask participants why is it necessary to assess alcohol and drug use in relation to neurological problems? Ensure that all points in the participant manual under this section have been covered. 16. Explain that the remaining questions relate to cognitive problems problems thinking or remembering or disorientation the classification of which (delirium, dementia, normal ageing) is found in the table on page 48. 17. Read the first question (Are you taking any medications?). Ask participants why do we need to ask this in relation to cognitive problems? Explain that impaired cognitive ability or confusion may be a side-effect of medication. Highlight the fact that ART can contribute to confusion in some patients. 18. Read the next question (Do you feel your brain/mind is working more slowly?) and ask for a volunteer to read through the corresponding text. Repeat this for the subsequent two questions (Do you have trouble keeping your attention on any activity for long/do you forget things that happened recently) and discuss as necessary. 19. Ask participants why it is also important to ask the patients family certain questions? (Many patients are not aware of problems or deny that cognitive changes are a problem, or their mental state may impair or prevent accurate or coherent answers to questions. What sort of questions should they ask? [has patients behaviour changed? In what way? etc.]
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20. Ask participants what could they do if the patient or the family reports a memory problem? Demonstrate the procedure for the memory screening test using a volunteer as the patient. Explain what you are looking for and what it means if the patient can/cant repeat the objects back to you immediately and after 5 minutes If confused (either patient appears confused or family reports confusion) 21. Ask participants to think about specific questions to Ask when the patient is confused and write up their answers on the flipchart. Ensure that the correct questions are covered and run through the explanations as outlined in the participant manual (When did it start? Determine if the patient is oriented to place and time). If patient has a headache 22. Highlight the point that headaches are commonly occurring symptoms but may indicate serious neurological problems. Ask participants to think about possible indications (of headaches) for more serious problems. Use the following box to aid you in the discussion:
Duration and persistence: daily headaches persisting for a number of weeks, or through the night (may indicate cryptococcal meningitis, with or without fever) Onset (acute or gradual): sudden onset, severe headache may indicate subarachnoid haemorrhage, meningitis, malaria Severity: severe headache with limited response to over-counter meds New or unusual headache or persisting for >1 week in known HIV patient (may indicate meningitis or space occupying lesion) Possible indications of space occupying lesion/other cause of increased intracranial pressure: - Increasing severity over time: recent onset of headache, worse over time - Changes in severity over course of day: worse in morning, improving later - Changes accompanying coughing, bending down, lying down - Presence of nausea or vomiting - common with migraine; with worsening daily headache, may indicate space occupying lesion - Presence of visual disturbances - common in migraine, but if new onset, no previous diagnosis of migraine or previous symptoms that resolved, may indicate space occupying lesion 23. Ask participants to think about specific questions to Ask when the patient has a headache and write up their answers on the flipchart. Ensure that the correct questions are covered and run through the explanations as outlined in the participant manual [For how long? Visual defects? Vomiting?].
24. Ask what the considerations are there when assessing headaches in an HIV patient?
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25. Tell participants that we will next run through how to Look and Feel for headache and neurological problems. Ask if there are any questions before continuing. LOOK AND FEEL Check for focal neurological signs 1. Ask participants to continue to refer to page 46 of the Acute Care guideline module and their participant manual. 2. Ask participants what they understand by the term focal neurological problems and discuss, ensuring that you cover what is included in paragraph 1. Probe with questions such as Does a person with a focal neurological problem remain conscious? 3. Run through the first four assessment questions that should be considered (Is the patients face flaccid on one side? Does the patient have a problem walking, down to Does the patient have a problem moving his/her eyes). Discuss the possible indications if the answer is yes for each of these questions. 4. Run through the subsequent questions:
Demonstrate what a flaccid arm or leg looks and feels like. Explain that if the limb is flaccid it is important to test for strength. Discuss what reduced strength may indicate. Demonstrate how to feel for a stiff neck and Discuss the indications Explain the significance of measuring BP. Explain if headache, feel for sinus tenderness. Ask if everyone is familiar with how to do this? Ask what you should do if the patient is confused? (look for physical cause, alcohol and drug intoxication or withdrawal or medication toxicity). Ask for a volunteer to read through the description of confusion.
5. Ask if there are any questions and tell participants that you will now go through how to classify if headache or neurological problem.
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CLASSIFY and TREAT

If headache or neurological problem (loss of body function or convulsion) 1. Have participants read through the SIGNS in the top row of the table on page 47 of the Acute Care guideline module. 2. Explain that if any of listed signs are present (run through the signs), classify as possible serious neurological problem 3. Ask participants what they would do if there was new onset of any of these signs? (new onset requires referral for further assessment to determine the underlying cause and treatment). 4. Explain that in the meantime, there may be treatments that are appropriate before/during referral and run through interim/supplementary management as indicated in the table under treatments (page 47). 5. Ask for a volunteer to read through the paragraphs starting A headache or neurological problem can be serious down to Differentiating between headaches. 6. Explain the importance of differentiating between headaches: note the indications for a serious neurological problem, i.e. prolonged headache (>2 weeks), or recent onset, getting worse, worse in morning, persisting at night, associated with vomiting, worse with coughing, bending, lying down or in known HIV patient, new unusual headache or headache >1 week. 7. Explain that if headache does not fit the criteria for a serious neurological problem, they should consider an alternative less serious classification (sinusitis, migraine, tension headache). Ask for volunteers to read through headache associated with sinusitis, migraine headaches and tension headache. 8. Ask what they should do to treat these conditions? [consider possible link with HIV illness/treatment and provide pain relief (page 47)]. Ask participants to look through the treatments column and highlight the need for referral if a headache is present for more than 2 weeks. 9. Ask participants to look at the photo booklet Group 10 (Bells palsy and test for sinus tenderness). Ask if there are any questions before proceeding with the case study. 10. Hand out copies of the case study on differential classification: serious neurological problem versus other headache. 11. Explain that, working individually, the task is to read the scenario and then use the table on headache/neurological problems (p.47) to: suggest what to investigate/exclude identify signs
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consider what classifications might be most likely
Case study (Case No. 1) Scenario A 45-year-old woman complains of severe and persistent headache, mainly over the right side of the head. It started a month ago and though she sometimes feels a bit better in the morning, by the afternoon its back in full force. Sometimes it has been so bad that she has had to leave work early to go home this makes things worse, because then she has to catch up the next day. Sometimes she wakes up during the night and finds she still has the headache. She sometimes feels nauseous, but there has been no vomiting. She has not experienced any visual disturbances with the headaches. She has tried various medications from the chemist, but they dont seem to help. She has had similar headaches in the past, but not as bad as this. She has never been diagnosed with migraine, but she has an aunt who was. She has never been tested for HIV. In response to questions, she says: How severe is the headache? (3-4 on scale of 1-5) Was the onset sudden or was it gradual? (hard to say, I just noticed that I was having them) Is the headache episodic (does it come and go) or is it sustained? (its there most of the time, but some days it only starts later in the day) What time of the day is the headache worse? (its usually worse in the afternoons and evenings) Is the headache getting worse over time? (no) Is it worse when you are lying down or bend down or cough? (it can be very bad at night, but it can be just at bad in the afternoons)
12. Allow 15 minutes for completion of the exercise, then discuss with particular attention to signs and possible classification. 13. Ask if there are any questions, before telling participants that we will now go on to classifying if there is painful foot or leg neuropathy.
CLASSIFY and TREAT

If painful foot or leg (or hand) neuropathy 1. Ask participants to look at the bottom table on page 47. Explain that if the patient complains of painful burning or numb or cold feeling in the feet or lower legs (and less commonly in the hands) then this should be classified as painful leg neuropathy.
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2. Discuss common causes of peripheral neuropathy and the need for assessment for underlying cause. 3. Run through treatments.
CLASSIFY and TREAT

If cognitive problems problems thinking or remembering or disorientation 1. Ask participants what do we mean when we say that a patient has cognitive problems? List their answers on a flipchart and ensure that all correct answers are covered (difficulties in specific thinking tasks, including memory, attention, speech and language skills, visual-spatial skills, abstract thinking and speed of information processing). 2. Ask participants to have the Acute Care guideline module open at page 48. Explain that in case of confusion or cognitive problems, delirium and dementia are two possible classifications, but they should also be aware that cognitive problems may be part of the normal ageing processes. Highlight the fact that cognitive problems are common in people living with HIV/AIDS and that we will go on to discuss HIV-related dementia. 3. Ask participants to recap the questions to ask the patient that will help to classify cognitive problems and write on flipchart: [To the patient: Are you taking any medication? Do you feel your brain/mind is working more slowly? Do you have trouble keeping your attention on any activity for long? Do you forget things that happened recently? Ask the family: Has the patients behaviour changed? Is there a memory problem? Is the patient confused? When did it start?] 4. Explain that we will look at delirium, dementia and HIV-related dementia in turn.
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Delirium 1. Ask participants to read through the SIGNS for delirium on page 48. 2. Ask for a volunteer to read through the first paragraph under Delirium in the participants manual, writing the key points on a flipchart as they read. Next run through the list of additional signs that a person with delirium may show (and write them on the flipchart). 3. Explain that the change in mental state of the patient with delirium will usually be very obvious and can fluctuate over the course of the day. Highlight the importance of talking to caregivers about the onset and course of the mental stage changes, explaining that onset of confused state is very important and is often the distinguishing feature between delirium and dementia. 4. Ask participants in what groups is delirium most common? (elderly patients and people with major medical illnesses). Ask how would you diagnose delirium? (by clinical evaluation with complete history, including details on any recent changes in medical status, medications, drug and alcohol usage and physical examination). 5. Explain that delirium is due either to a single or multiple underlying medical conditions. Highlight the fact that most causes of delirium are amenable to treatment and therefore it is very important to find the cause. 6. Ask participants to give examples of common causes of delirium and makes sure that all points listed in the participant manual are covered. 7. Explain that patients in advanced stages of HIV/AIDS are at high risk for developing delirium. Evaluation of such patients must consider: all possible usual causes of delirium secondary opportunistic conditions associated with advanced immune suppression (CD4 count < 200) drug interactions related to multiple medications additive layering of side effects leading to acute confusional state 8. Ask participants what they should do if they suspect that the patient has delirium? (ensure that they understand that every effort must be made to find the cause and treat if the cause is not obvious it is always best to REFER the patient to hospital for urgent treatment as the cause may be life threatening if not treated quickly). 9. Ask what they should do if immediate referral is not possible? (give fluids to prevent dehydration, check blood glucose and give glucose and thiamine). 10. Run through the recommended treatments for delerium (correcting the underlying medical disorder and providing supportive care and management of the symptoms), discuss management of delirium due to alcohol withdrawal or other. Explain use of diazepam and haloperidol. Highlight sensitivity of HIV/AIDS patients to haloperidol.
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Dementia 1. Introduce dementia by explaining that dementia is a chronic condition resulting from a gradual decline in cognitive abilities. 2. Ask for volunteers to read through the paragraphs on dementia, down to causes of dementia. As they read, note the key points on a flipchart. Highlight the fact that dementia results in failure to cope with activities of daily live and loss of independence. 3. Ask participants to list possible causes of dementia. Record correct responses on the flipchart and discuss as necessary. 4. Stress the importance of full assessment of every patient with dementia to make sure that there are no reversible causes (discuss and list on the flipchart reversible or treatable causes). 5. Ask if there are any questions. 6. Ask participants if any of them are familiar with HIV-related dementia? Explain that cognitive complaints are common in people living with HIV/AIDS Ask why? (progression of HIV/AIDS and declining immune function) but stress that it is important to note that not all people develop HIV-related cognitive syndromes as part of their illness. 7. Explain HADC and MCMD. 8. Discuss behavioural complications (characterized by fatigue, depression and loss of energy and motivation). 9. Ask how diagnosis is made? Ensure that correct answers are listed on a flipchart, in line with the participant manual. 10. Explain that it is important to exclude other reasons for cognitive complaints in people living with HIV/AIDS, such as major depression, medication side effects, substance related disorders. 11. Explain that cognitive symptoms must be interpreted within the context of the patients overall health status Take participants through the sections what is the patients CD4 count?, writing the categories up on a flipchart for emphasis. 12. Ask for a volunteer to read through is the patient medically unwell? 13. Ask if there are any questions. 14. Run through the additional questions to clarify possible HIV-related dementia. 15. Discuss cognitive problems that may be experienced as part of the normal ageing process.
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16. Ask participants what would they do if the patient is classified as having dementia? Ensure that you cover all points made in the participant manual:

full assessment to exclude reversible cause consult or refer for treatment counsel family or friends regular intake of fluids rehabilitation strategies help family members and friends to access emotional and practical supports
17. Ask participants what is the main treatment for HIV associated dementia complex? (ART). Explain the importance of patients with HIV associated dementia complex being identified and offered ART. Highlight the fact that ART will help prevent further progression of cognitive deficits and may help reverse deficits in some, but not all patients. 18. Ask participants what issues there may be around adherence to ART for patients with HIV associated dementia? What would they do to ensure good adherence? 19. Ask if there are any questions. 20. Summarize: Confusion and/or cognitive problems are found in a number of conditions, but are characteristic of delirium (confusion) and dementia (cognitive problems). delirium where inability to think clearly is due to acute impairment in level of consciousness associated with fluctuating level of arousal and awareness (condition usually reversible) dementia where gradual decline in cognitive abilities interferes with ability to remember and process information clearly and coherently, sometimes resulting in confusion (chronic condition) HIV/AIDS increases the likelihood of these problems because of increased vulnerability to CNS opportunistic infections and effect of disease progression on brain. Important to identify and treat or refer (reversible causes of delirium, treatable causes of cognitive symptoms) ART can substantially alleviate symptoms in HIV-infected individuals Counselling and care for family is critical
35. Tell participants that we will now go on to learn about mental health problems covered in Chapter 14 of their participant manual.
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CONSULTATION AND COUNSELLING SKILLS Effective consultation/interviewing and counselling skills are necessary to deal with any illness. However, they are particularly important in dealing with neurological and mental conditions. Why? - conditions often present in subtle ways, may be difficult to describe - there are few laboratory or other investigations to support diagnosis - clear history necessary to identify critical information e.g. onset - what is said, how it is said, often critical to diagnosis good listening skills essential - careful observation necessary to identify certain signs - counselling may be sufficient or an essential supplementary intervention Highlight need to consider complaints/report of both patient and family Listening and observing - ask open-ended questions, especially initially - clarify responses that you do not understand - allow time some symptoms will only emerge after some time, others may be difficult to pinpoint - allow for pauses dont rush the patient or yourself - listen to what is said and how it is said - note gaps in what is said - use your knowledge to help you explore relevant aspects in more depth - observe non-verbal communication - body posture/gestures/facial expression Counselling Refer participants to Acute Care guideline module p.96-99 Note: brief introduction to some key counselling concepts - lay basis for later references to counselling. Encourage participants to attend 1-2 day courses. All health care providers can (and already do) apply counselling skills together with other interventions in a range of clinical situations. What do we mean by the term, counselling? What does it include? What is it not? Follow-up question: In what ways is counselling different from giving advice? - recognises that feelings/motivation/relationships are as important as facts in determining how people behave, whether they change how they behave - goal: develop clients capacity to cope/make decisions that fit his/her situation best - patient (client) centred - conversation with purpose - process important to achieve sound outcome - relationship is critical (helping relationship, partnership) - supportive (and sometimes, challenging) Not: advising, persuading, warning, judging, blaming, persuading, sympathizing, giving solutions, telling client what to do, doing things for client - Need to assess when to use counselling only, or as first line intervention (e.g. some kinds of anxiety); when in association with medication (e.g. depression); when as support to medication (e.g. psychosis) Highlight particular importance of empathy and confidentiality Draw attention to problem-solving model (can be applied to range of problems) -
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B. Mental health problems (Chapter 11) Duration: 60 minutes Materials:

Blank flipchart/ markers AUDIT interview form
Purpose: To learn how to assess, classify and treat mental

health problems

will be able to: Use the IMAI Acute Care guideline module to assess, classify and identify treatments in patients presenting with mental health problems
Preparation
Prepare copies of AUDIT form
Content
Ask Assess for depression Look and feel Classify and Treat If sad of loss of interest or decreased energy; If bizarre thoughts; If tense, anxious or worrying; If more than 21 drinks/week (men)
Methods
Volunteer reading / brief discussion Volunteer reading / brief discussion
Duration
Volunteer reading / 30 minutes discussion/ role plays and scenarios, review of AUDIT form
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If patient has a mental problem, looks depressed or anxious, sad, fatigued (tired), has an alcohol problem or recurrent multiple problems Introduction
1. Ask participants to have pages 50-52 of the Acute Care guideline module and chapter 14 of their participant manual available for periodic reference. 2. Read the learning objectives aloud. 3. Introduce the section, explaining that we will cover four major conditions: depression psychosis anxiety disorders alcohol related conditions 4. Explain that in a real clinical setting, assessment is made bearing all of these conditions in mind however during training we will initially deal with each in turn. 5. Ask participants why the patient/family do not necessarily report mental problems? [somatisation, failure on part of patient or family to recognise as treatable health problem, stigma]. 6. Highlight that health workers need to: assess whether recurrent or multiple problems without underlying physical cause are masking a mental health problem be alert to culturally specific ways of expressing condition (e.g. depression described as having a sore heart 7. Ask participants what is the first thing that they should do when they see a patient with a possible mental problem? (Assess: ask (listen), look and feel). 8. Ask them to turn to page 50 of the Acute Care guideline module and to look at the list of questions under the column IF YES, ASK. Read the first question How are you feeling? 9. Highlight: the importance of this open-ended question the need to take time to listen without interrupting (where necessary with verbal or non-verbal encouragement to continue) patients response may provide answers to subsequent questions, which need not then be asked, or key symptoms may become evident (e.g. thought disorder, delusions)
10. Explain that, as usual, the subsequent questions will help them to classify patients using the classification tables (pages 51 and 52). Explain that we will run through the assessments relating to each classification table in turn:
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If sad or loss of interest or decreased energy If bizarre thoughts If the person is tense, anxious or worrying excessively If more than 21 drinks per week for men/14 for women or drunk more than twice in last year
ASK If sad or loss of interest or decreased energy Assess for Depression 1. Highlight the fact that depression is the most commonly occurring, but often overlooked condition; and may occur in the presence of physical illness such as HIV. 2. Ask participants what they understand by the term Depression and discuss (ensuring that you make the distinction between depressed feelings and depression as an illness highlight that with mental problems, everyday words are sometimes taken over to describe a symptom or condition. For example, all of us feel anxious or depressed from time to time. But when we talk of depression or anxiety as a mental health problem, we are talking about something more serious, with a specific set of symptoms and a need for professional help in managing the condition). Explain that when assessing mental problems, we need to consider both the patient/or familys complaint (if made) and our own observations (since mental problems not always reported). 3. Ask for a volunteer to read through the first three questions under Assess for Depression. 4. Explain that if the answer is yes to any of these 3 questions, it is important to first consider possible physical or medical causes of fatigue or loss of energy what are some of these? [e.g. anaemia, infection, medications, lack of exercise, sleep problems, HIV disease progression, hypothyroidism] 5. Explain that if they can rule out physical/medical causes then they should assess specific depression symptoms as outlined in their participant manuals. Ask participants to read through the list (disturbed sleep, appetite loss or increase etc.). This will help them to decide whether it is a Major Depression or a Minor Depression (as they will see on the classify table 5 or more depression symptoms are a factor suggesting major depression and less than 5 symptoms suggest minor depression). 6. Ask participants what type of questions they should ask when assessing these symptoms how have you been sleeping?, how has your appetite been lately?, have you been having any difficulties concentrating?, how have you been feeling about yourself? and could you tell me more about that? 7. Refer participants to the next question Have you had bad news for yourself or your family? and discuss why this may have caused depression.
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8. Explain that it is important to assess the level of risk of suicide in someone who expresses thoughts of suicide or a wish to die. Ask for volunteers to read through the list of risk assessment factors to consider. 9. Discuss why it is important to ask questions around alcohol consumption and medications? Ensure that the following points have been covered: - alcohol and drug use can cause or aggravate depression - certain medications can cause depression, hence important to review all medication (both prescribed and other) that patient is taking - depression (including suicidal thoughts) can occur quite suddenly in patients who have recently started ART (especially efavirenz); usually lasts less than 3 weeks; can usually be managed by taking medication at night; refer if depression severe or persists 10. Ask for volunteers to read through Calculate drinks per week over the last 3 months and Have you been drunk more than two times in the past year. 11. Ask if there are any questions before proceeding to look and feel. LOOK AND FEEL 1. Refer participants to the LOOK AND FEEL column on page 50. Read through the first two questions. Ask participants for examples of how agitated and depressed would be assessed in a health care setting [e.g. agitated - anxious, distressed; depressed - withdrawn, tearful]. Note that if the patient is verbally or physically aggressive, this is hard to miss. 2. Ask what other condition(s) could also present with agitation and restlessness? [alcohol or drug withdrawal, anxiety disorder, medical emergencies]. 3. Read the next two questions. Stress that if the answers are yes to the questions is the patient disorientated to time and place? and is the patient confused?, this may be a neurological/ cognitive problem and not a mental problem and it would be more appropriate to follow the assessment for headache or neurological problem that they have already learned in the previous session (p46). 4. Read the next question Does the patient express bizarre thoughts? and Ask for a volunteer to read through the questions to ask If yes. Discuss the need to distinguish between signs that may indicate psychosis and those that are due to alcohol and drugs (including efavirenz) which may disappear when the drug wears off. Ask what signs of alcohol intoxication or withdrawal may be confused with psychosis)? [Tremor].
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CLASSIFY AND TREAT If sad or loss of interest or decreased energy 1. Ask for volunteers to read through the first table on page 51 of the Acute Care guideline module, then summarise key points: Suicide risk: Suicidal thoughts need careful investigation and management; immediate treatment should be to manage suicide risk, if present. Highlight the importance of mobilisation of the family, high risk cases should be referred. Major/minor depression: Highlight the importance of differentiating between major depression and minor and depression/complications following bereavement (five or more depression symptoms for at least two weeks to be major depression). Both major and minor depression requires medication, and psychological counselling. Explain that treatment with amytryptiline is described on page 82 of the Acute Care guideline module and we will also go into how to give treatment with amytryptiline in the next section. Referral: High-risk suicide cases and patients suspected as having bipolar disorder should be referred. Difficult life events/loss: counselling and support for the patient is more important than medication, though, if the patient is very distressed, you may offer diazepam or amytryptiline. 2. Tell participants that there will now be a role-play to practice assessing a patient for depression. Role play (Case No. 3) Scenario (for both role-players and observers) Mulatua, a 43-year old mother of five, who is HIV-positive and who has been attending your clinic for follow-up, is now in Stage 3. Her CD4 count is 300. She complains that she has not been sleeping well for the past month. She looks unhappy and says that she has been having a lot of trouble with her teenage son, who is argumentative and disrespectful. She is a single parent and works as a cleaner and assistant at a local shop. Directions for patient role: If asked for more detail about your sleeping, you will say that you have difficulty falling asleep and sometimes wake during the night and cant get back to sleep. You find it difficult to get yourself up to go to work in the morning. At work, sometimes you lose track of what you are doing and it seems to take longer to finish things. You dont have much of an appetite and have to force yourself to eat properly. If asked, you will agree that you feel depressed, especially because of the battles with your son, which make you feel that you are no good as a mother. Sometimes its hard to keep going, but the younger children need you. As bad as you feel, you have not had thought of harming yourself or any of the children. Note to facilitator: Brief the person playing the patient role, using the directions specific to this role (see below, not included in Training materials). Other participants should read the scenario provided in the Training materials at the start of the exercise.
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Briefing for exercise: The task is firstly to assess patient for depression and, secondly, to suggest appropriate management. Brief a co-facilitator or participant to play the role of patient. Have another participant take the role of health care worker to assess the patient for depression. Other participants should observe how the interview is conducted and identify symptoms, classify, suggest treatment/management (including whether to refer). Invite comment from those in the role-play and observers. What worked well? Where were there difficulties? How else could it have been done? Discuss - depression symptoms and duration: depressed mood, suicidal thoughts, poor sleep and appetite, poor concentration, poor self-esteem for past month - possible alternative causes of fatigue and loss of energy: HIV-related, multiple responsibilities, stress at work, with son - classification of case: they learn major depression: at least 5 symptoms, including depressed mood or loss of interest/pleasure, at least 2 weeks - whether to refer? probably not diagnosis fairly clear cut, no evidence of suicide risk; refer if no response to treatment after 1 month - treatment (management) options: amitryptiline starting with50mg daily at night, increasing by 25mg/week till effective (100-150mg/day); counselling and support CLASSIFY AND TREAT If bizarre thoughts 1. Ask participants to look at the relevant table on page 51 and refer them to the section on psychosis in their participant manual for later reading. Explain that if a patient has bizarre thoughts and delusions or hallucinations, they will be classified as POSSIBLE PSYCHOSIS - a severe mental illness. Ask participants what they understand by the terms delusions and hallucinations and discuss [ delusions: fixed false beliefs that are not culturally acceptable and which are not open to rational discussion, hallucinations: perceptual disturbances - present to see something that others do not]. 2. Ask participants to list some of the causes of psychotic symptoms and discuss. 3. Ask participants, given the severity of the illness what considerations must be made when assessing and treating a patient with possible psychosis? regardless of condition, all patients should be treated with respect and compassion and involved in assessment as far as possible because of patients state, he/she will generally not able to provide important information about his/her condition, history therefore it must be obtained from family/others who know patient well some people with psychosis may appear quite normal until engaged in conversation or by report of family/associates allowing time for symptoms to emerge and careful, systematic observation of patient is critical
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4. Discuss treatment. Ask participants what conditions may present with similar symptoms, and could be confused with psychosis? Highlight the importance of excluding alcohol intoxication or drug toxicity or ARV side effect. Explain that all patients with suspected psychosis should be referred for psychiatric care, but if acutely agitated or dangerous to themselves or others, they should receive haloperidol (to be discussed in the next section). 5. Case scenarios: (see next page). Divide participants into groups of 4-5 people each. Each group should appoint a rapporteur. Provide each group with one of the scenarios. The group should:

read and discuss the scenario identify signs indicate what conditions should be considered or excluded classify the condition indicate treatment
Each group should report back on their case, using the above format Discuss, with particular attention to signs, classification, possible differential diagnosis, treatment Note to facilitator: Possible differential diagnoses stated in brackets following each scenario, but should obviously not be provided to participants until after the discussion. Approximate times: setting up 5 minutes, small group discussion 10 minutes, feedback 20 minutes, discussion 10 minutes.
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Scenarios Set A Scenario 1 [schizophrenia, substance-induced psychosis, HIV or other infection]
An 18 year old woman is brought to the clinic by her sister, who says she has become very withdrawn and uncommunicative. She talks to herself a lot, usually under her breath so its hard to know what she is saying. Sometimes she looks anxiously about, almost as if she is hearing or seeing something that no-one else can see. She dropped out of her first year of a teacher training course a few months ago and stopped seeing her friends. It was difficult to get her to come to the clinic today and while waiting to be seen, she kept trying to leave and had to be restrained. The woman appears agitated and keeps trying to leave the room. She does not make eye contact. She responds to her name, but does not respond to questions. When she does talk, it is difficult to understand what she is saying. Scenario 2 [efavirenz or other ART induced psychosis]
You are asked to see a 33 year old HIV positive man, who is brought to the clinic by his wife. She says he has been behaving strangely for the last few weeks. He has become very withdrawn, but sometimes gets very angry for no reason. In the last few days, he has refused to eat anything, saying that they are trying to poison me. It is not always easy to understand what he is saying. Sometimes he seems to be talking to someone, even though there is nobody there. Sometimes he seems to be hearing voices. He has been sleeping poorly and often wakes up suddenly during the night, sometimes shouting, as if he has had a bad dream. All this started shortly after he was started on ART. The man is agitated and restless. He does not respond to his name or answer questions you ask. At times, he seems fearful. Scenario 3 [substance-induced psychosis]
A 19 year old man is brought to your clinic by his mother. He has been behaving strangely for the last few weeks. He talks to himself and seems to hear voices. He doesnt eat properly and has lost weight. He hasnt been washing himself and refuses to put on clean clothes. If you try to get him to do something, he becomes angry, but if left alone, just sits quietly staring into space. He has stopped going to work, but still sometimes goes out with friends. When he comes home, his clothes smell of marijuana, but when his mother asks him about it, he just shouts at her. He is a thin young man, who is difficult to interview. He takes time to answer questions and often does not answer or answers incompletely. He is able to tell you his name, his home address and where he is, but, although he knows the month and year and that it is morning, he cannot remember the day or date. Scenario 4 [delirium; possibly psychosis]
A 54-year-old woman is brought into the clinic by relatives. She is HIV positive and has been on the ART programme run from the clinic for a number of years. Her response to ART has been good. Her relatives state that, over the past three days, she has become confused and difficult, resisting their efforts to get her to eat or take her medication. She has been restless and agitated and seems to sleep poorly. She talks to herself and sometimes seems to be seeing things that are not there. Today she seems confused, not fully alert and does not make eye contact. She does not respond to questions.
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CLASSIFY AND TREAT If tense, anxious or excess worrying 1. Ask participants to turn to the first table on page 52 of the Acute Care guideline module. Note that if a person is tense, anxious or worrying excessively, s/he may be suffering from an anxiety disorder and this should be explored further. Remind them that the assessment involves ask (listen), look and feel. Ask what sort of questions they could ask to assess for anxiety disorder? Start with open-ended question (tell me more about what has been happening/how you have been feeling?). Probe for specific indications, using additional questions: Do you sometimes suddenly begin to feel extremely anxious? Are you anxious in specific situations? Do you generally worry a lot, feel very tense, unable to relax? Ask participants to read through the section on anxiety disorders (panic disorder/ stress disorder/ generalised anxiety disorder). Once they have read through, ask for volunteers to describe features that differentiate between the different anxiety disorders (and write up their ideas on the flipchart). Ask if there is a possible overlap of symptoms with other conditions? [restless, agitated, sleep and appetite the servants, functional impairment] / possible coexistence with other conditions? [ especially depression, also substance abuse, delirium]. Discuss the possibility of anxiety as a side effect of ART[ especially efavirenz] Discuss treatments, giving a demonstration of how to teach slow breathing and progressive relaxation. Stress the importance of counselling and follow-up and, only if severe anxiety, consider short-term use of anti-anxiety medication such as diazepam.
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CLASSIFY AND TREAT If more than 21 drinks/ week in men and more than 14 drinks/ week in women or drunk more than twice the last year 1. Ask participants to look at the second table on page 52. Ask participants why alcohol use is a concern and why should we investigate alcohol use in all patients? (Ensure that all points in the participant manual are covered e.g. risk of harmful consequences to the drinker or others). Ask participants Some people believe that people with alcohol problems cannot be helped unless they hit rock bottom and seek treatment themselves and that the only answer is total abstinence but that most cant manage this what do you think? [if identified, can be helped at earlier stages; brief interventions at PHC level can be effective].
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Ask participants how we might to categorise different levels of the alcohol use, write up on a flipchart and discuss. low risk: occasional, moderate, controlled drinking - low risk of harm to self/others hazardous: pattern of use carrying high risk of harmful consequences to drinker or others (includes generally moderate, but sometimes drinking to intoxication) harmful use: already causing damage to physical health (e.g. liver damage) or mental health (e.g. depressive episodes), even if no overt signs of impairment (due to tolerance) alcohol dependence: physical addiction (severe withdrawal is a sign of dependence) Explain that patients with hazardous alcohol use may progress to HARMFUL ALCOHOL USE, and it is important to assess carefully using the WHO AUDIT (Alcohol Use Disorders Identification Test) or another tool to try to help a patient before the problem becomes very serious, contributes towards an injury or progresses to alcohol dependence [give out copies of the AUDIT- contained in the
training materials].
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Explain that this is one way of assessing alcohol use and note: need for local adaptation (e.g. re what constitutes a standard drink) and training found useful in general medical and PHC settings, relatively free of gender and cultural bias; picks up risky drinking as well as more serious levels of drinking Qs1-3: quantity and frequency of regular/occasional alcohol use Qs 4-6: occurrence of possible dependence symptoms Qs 7-10: recent and lifetime problems associated with alcohol use
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Suggest participants complete AUDIT for themselves in own time. Outline scoring and interpretation: 8-15: hazardous drinking 16-19: harmful use 20+: possible dependence - needs referral for assessment Highlight: total score, consumption level, signs of dependence and evidence of harm should all be considered in deciding management.
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Ask participants Many people think of and label those who drink excessively in very negative ways e.g. as weak, or stupid, or sinful, an alkie, a soak. What are some of the labels used locally? Highlight - to intervene effectively, health workers need to accept that social and addictive factors are involved, adopt non-judgmental attitudes. Ask what participants understand by alcohol dependence (physical addiction to alcohol). Explain that severe alcohol withdrawal symptoms are a sign of alcohol dependence.
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Ask for a volunteer to read through section on the severe alcohol withdrawal signs and discuss if anything is not clear. Highlight: although hazardous use does not necessarily progress to dependence, noone develops dependence without having engaged at some time in hazardous drinking possible overlap of symptoms (restless, agitated, confusion, hallucinations, appetite disturbance, functional impairment) with other conditions possible co-existence with other conditions (e.g. psychosis, delirium) important to describe patterns of alcohol use and behaviour rather than using personal labels with negative connotations (i.e. hazardous/harmful use rather than binge drinker/alcoholic)
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10. Briefly discuss treatment for severe alcohol withdrawal signs tell participants that using diazepam to treat severe alcohol withdrawal is covered in the next session (Chapter 15 of their participant manual). 11. Run through the following brief intervention guidelines for hazardous / harmful alcohol use: all patients: - feedback from screening (or from findings of history/clinical assessment) - compare with low risk levels (no more than 2 standard drinks/day, no drinking at least 2 days/week) for those with risky levels of drinking - highlight specific risks and discuss existing and potential consequences (e.g. already had one accident, physical symptoms; could affect employment, progress to more serious illness) - motivate (emphasise seriousness, deal with denial), assess willingness to change, obtain commitment - Identify specific reduction goal (reduced drinking or abstinence) - identify strategies (habit breaking plan) to achieve goal (including support) - follow-up regularly possible alcohol dependence - motivate and arrange referral 12. Ask participants, do you see any obstacles in your situation to implementing brief interventions? Discuss. 11. Prepare participants for the role play: Note to facilitator: Brief the person playing the patient role using the directions specific to this role (see below, not included in Training materials). Other participants should read the scenario provided in the Training materials at the start of the exercise.
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Briefing for exercise: The task is, first, to assess patient for alcohol-related conditions and, second, to manage appropriately. Brief a co-facilitator (or participant) to play role of patient. Have a participant take role of health care worker. If the first participant taking the role becomes stuck at any point, s/he (or facilitator) can call on another participant to take over. Pause for discussion after assessment phase (see below). Then continue with a new participant taking the role of health care worker for the second part of the task. Other participants observe. Invite comment from those in role-play and observers. Following first part of task: What does the assessment indicate regarding signs and classification of patients condition? What would be the appropriate management in this case? Following both first part and again following second part of task: What worked well? Where were there difficulties? What could have been done differently? Role-play (Case No. 4) Scenario (for both role-players and observers) A 35-year old man has been attending your clinic for follow-up of his chronic HIV infection. He is now in stage 3 and his CD4 count has dropped to 150. He is due to start ART. You have suspected for a while now, that he abuses alcohol, although he has denied this in the past. He now comes to the clinic and appears to be intoxicated and smells of alcohol. Directions for patient role (for patient only) Without exaggerating too much (!), slur your words and appear a little unsteady on your feet. At first deny that you have been drinking, but then confess that you have had one or two drinks every now and then and that you are drinking more than you used to do. With the help of the health worker, work out that in fact you drink most days, usually 2 or 3 drinks a day during the week and more at weekends. Agree that you have been drunk at least twice in the last year. The drinking leaves you hung over the next day and, recently, you have started to take a drink in the morning to get you going for the day. Say that you really intend to stop, because you know its bad for you 12. Ask participants to summarize key points re assessment, signs, classification and treatment of alcohol-related conditions, using probing questions to produce the following list: not only quantity and frequency but also pattern of drinking important (past year, in the past) necessary to differentiate between low risk, hazardous use, harmful use and dependence possibility of progression to higher levels of risk (brief intervention can be effective for lower levels of risk)
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possible overlap of symptoms (restless, agitated, confusion, hallucinations, appetite disturbance, functional impairment) with other conditions possible co-existence with other conditions (e.g. psychosis, delirium) attitude of health worker critical in patient response to brief intervention/referral
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C. Using medication in neurological and mental disorders: How to use diazepam, haloperidol and amitryptiline (Chapter 12) Duration: 30 minutes Materials:
Purpose: to learn the correct use of diazepam, haloperidol and

amitryptiline in the management of patients with neurological and mental health problems

will be able to: Provide treatment with diazepam, haloperidol and amitryptiline Understand the indications for use of each drug Describe the correct prescription/ dose for each drug Understand the possible side-effects / contraindications Describe how to monitor and manage patients on each drug
Preparation
Prepare copies of medication summary table
Content
Review of medication summary table Practice with use of diazepam, haloperidol and amitryptiline
Methods
Volunteer reading and discussion Short case studies
Duration
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Read the learning objectives aloud. Ask participants to have pages 51-52, 71, and 82-83 of the Acute Care guideline module available for periodic reference and Chapter 12 of their participants manual for later reading. As a revision exercise, ask participants to think back over the previous two sessions (headache and neurological problems and mental health problems). Ask them to name the key medications that have been discussed for use in treating neurological and mental disorders. List Diazepam, Haloperidol and Amitryptiline in 3 columns. Ask participants what conditions each of the drugs should be used for. Have participants look at the Medication Summary Table. Explain that the table may be used for quick reference, highlighting: Table summarizes for each drug: - Indications for use
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- Prescription/dose - Possible side-effects - Monitoring/management 6. Ask for a volunteer to read through the indications for use of Diazepam. Ask for a second volunteer to read through the prescription/dose column. Discuss possible side effects and monitoring and management. Highlight the following:
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Diazepam is an addictive drug and should not be given for more than 2 weeks at a time and preferably not every day (except in the case of treating alcohol dependence) Oral administration should be prescribed and managed at the district hospital/medical officer/auxiliary level ONLY HOWEVER, it can be used in emergencies at the PHC level for: o Emergency treatment of ongoing epileptic fits/seizures o Emergency treatment of severe alcohol withdrawal But in both cases patient must be sent to hospital for further treatment
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Introduce Haloperidol and highlight the following:
Haloperidol acts on the brain and its main use is for treatment of psychotic disorders and also for agitated or uncontrolled behaviour in a patient with delirium Psychotic symptoms can take some weeks to disappear but the person will be calmed after the first dose Can be used IM or IV in an emergency Most important side-effects are on the nervous system and it is very important to know how to managed acute dsytonia
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Run through the table on Haloperidol with volunteers reading as above.
10. Introduce Amitryptiline a drug which acts on the brain and is used to treat serious depressive illness and highlight the following:

Amitryptiline acts on the brain and is useful to treat serious depressive illnesses, sleep problems and pain It usually takes 2 3 weeks for symptoms of depression to be relieved by drugs such as Amitryptiline, but side-effects can be felt immediately so it is very important to clearly explain this otherwise there are likely to be issues with adherence Better to take the medication before going to bed to reduce the experience of side effects Important side effect on the heart should not be given to any patient with history of heart disease The medication should be taken for 6 months up to a year and the patient should not stop taking it if they start to feel better otherwise the depressive illness may return
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11. Run through the table on Amitryptiline with volunteers reading as above. 12. Ask if there are any questions. 13. Ask participants to turn to the case studies on using medication (Worksheet A). Divide the group into pairs and allocate one case per pair. Each pair should discuss and propose appropriate medication (10 minutes). In the large group, ask each pair to report back and discuss (40 minutes). Once the exercise is completed, distribute copies of Worksheet B showing the model answers.
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Review Drills
QUESTIONS Present patient or make up few word description of an adult patient then list signs. Tell participants that all the other signs were checked for and are negative Lymph nodes everywhere, more than 1 cm Firm Weakness of face Flaccid right face Complaining of runny nose, ear pain, fever T 37.8 Cough for 1 week, breathing 15 times/minute Low malaria risk Severe itching. Also itching in other family members. Lesions with burrows on lower arms and hands, abdomen. Lesions on left wrist are warm with crusts and tenderness Very painful blisters on right front chest, in a patch. Red, scarring. Tender to touch Fever Low malaria risk Red rash over upper chest and back Headache Fever in 24 year-old HIV patient in stage 2 Unusual headache off and on for past 2 weeks Sinus tenderness Low malaria risk Agitatedcannot sit still or stop talking about his constant worry about school Agitatedcannot sit still or stop talking about his constant worry about mambas, fever Bereaved over loss of wife. Very sad, no pleasure in life. Difficulty sleeping and poor concentration. Able to go to work ANSWERS
SKIN PROBLEM or LUMP: Persistent generalized lymphadenopathy NEUROLOGICAL: Serious neurological problem FEVER: Fever malaria unlikely (other apparent cause of fever)
SKIN PROBLEM or LUMP: Scabies, left wrist with infected skin lesions
SKIN PROBLEM or LUMP: herpes zoster FEVER: Very severe febrile disease HEADACHE: Serious neurological problem HEADACHE: Serious neurological problem
MENTAL PROBLEM: Anxiety disorder FEVER: Very severe febrile disease MENTAL PROBLEM: Difficult life events/loss
Quick check: family says he has had a convulsion this morning You find only the following: Severe anxiety Tremors Usually drinks large amount each night, drunk at least once per week Painful feetburning feeling. Cannot put shoes on Cough more than 4 weeks
MENTAL PROBLEM: Severe withdrawal signs
HEADACHE or NEUROLOGICAL PROBLEMS: Painful leg neuropathy COUGH: Possible chronic lung or heart problem
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Drill: Case study using recording formfor oral presentation I will read the case while you both fill out a recording form and do the classifications: Ayele a 34 year-old man from a village near Dese, comes to clinic. As he walks into the room, you see that he can walk well and although he looks ill he has no signs of severe breathing problems, serious pain or conditions that would make a fever lifethreatening. You shake his hand and feel that it is warm. You say let me take your pulse while you tell me what your problems are. As you let go, you quickly check his capillary refill time which is very fast. He tells you that he is very sick from a cough, mouth pain, a fever, and diarrhoea. His card shows that he weights 62 kg, BP 120/88, Temperature: 37o C. He is tall. (stopcheck that they have filled the form correctly to this point) You ask him how long he has had cough7 days. And chest pain? Yes, some chest pain but not all the time, only when he breathes in deeply and only on the right. He does not smoke. He is on treatment for TB. He is alert and calm. He speaks in full sentences. Respiratory rate= 26 per minute. He is able to lie flat. You cannot hear any wheezing. (Classify his illness then check these; why didnt I ask questions about whether his cough is recurrent?) He looks wasted. He denies having lost weight. His clothes look loose. Until a week ago he was eating as usual but now he is sick and his mouth is sore, so he can only drink liquids. He used to drink but not since he started TB treatment. The weight on his TB card shows that he was 70 kg when he started TB treatment. His clothes are not loose. You measure MUAC- 205 mm. He has no pallor. (Classify!)
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Adult clinical practiceInpatient and outpatient
Role of Facilitator During Clinical Sessions

The role of the facilitator during clinical sessions is to: 1. Do all necessary preparations for carrying out the clinical sessions 2. Explain the session objectives and make sure the participants know what to do during each session 3. Demonstrate the case management skills described on the charts. Demonstrate the skills exactly as participants should do them when they return to their own clinics 4. Observe the participants' progress throughout the session and provide feedback and guidance as needed 5. Be available to answer questions during the session 6. Lead discussions to summarize and monitor the participants' performance
(There should be 1 to 2 facilitators for every group of 2 to 6 participants.)
How to Prepare for the Inpatient Demonstration of Signs

1. For inpatient demonstration of signs or case presentations, you will need permission from the hospital superintendent or in-charge and nurse in charge of the ward prior to the course (see course director guide). Also ask for permission and help that day from the ward nurse in charge of the ward(s) to identify patients with the desired clinical signs who would be willing to be examined Early in the morning on the day of the clinical session, examine all patients admitted to the inpatient ward to see if their signs are appropriate for the clinical session. This must be done in the morning as the clinical condition of hospitalized patients can change very rapidly, even overnight. Identify patients that have the signs relevant to the objectives of the session for that day. Identify fresh cases, that is, cases that arrived within the previous 1-3 days. Their history should be still valid so that it matches their current classifications. Patients with unambiguous clinical signs should be used for demonstration. Identify patients with infrequently seen signs. Because these signs are infrequently seen, you want to show them to participants whenever there is an opportunity, and not wait until the day they are studied. Though patients with these signs may not be
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assigned to participants, you will show the signs to participants at the end of the session. These signs include: any severe signs/classifications, severe respiratory distress or wheezing, stiff neck/meningismus, jaundice, severe pallor. Ask the permission of the patients to be seen by participants that day. If the patient is very ill, ask the spouse or family. Try to arrange that the patients will be in their beds during the sessions. 4. Select 6 cases who together have an appropriate variety of signs for participants to assess/classify in the sessions that day plus any other which provide good demonstrations of clinical signs (select one case per participant. Select 6 if there will be 6 participants in a group. If the group is smaller, select fewer). It is important to have a separate patient for each participant to assess and classify during the session. Select patients so that there are differing combinations of signs present, resulting in different classifications. Also select any additional patients with infrequently seen signs that you will show to participants, or with the signs you are emphasizing during that day's session. Keep a list with brief notes on each of these cases for your own reference during the session. Note the patient's name, age, (location in the ward if necessary), and positive signs. However, keep in mind that clinical signs can change rapidly in very ill patients from one session to the next. Partially complete an Acute Care Recording Form for each of the selected patients and post it on the patient's bed. Obtaining and recording the history in this way will prevent repetitive questioning of patients and will expedite the assessment and classification. How to Prepare the Acute Care Recording Form: Highlight the top section of the form: patient's name, age, weight, temperature and main problem. Fill in this information. Make sure the patient's weight and age are recorded. If these are not available from the patient chart, weigh the patient and/or take the temperature. Highlight all main symptom questions. Fill in this information based on the patient's responses (though occasionally you may need to make up some information, it is better not to fabricate history to avoid confusing participants if they interview the patient). Do not fill in any information about the patient's additional clinical signs or classifications. These will be determined by the participants when they examine the patient. Draw a line where you want the assessment to stop, or fold under that part of the Acute Care Recording Form.
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Put the form on a clipboard or in a plastic sheet protector and tape or tie it to the foot or head of the bed. Remove or turn over any hospital records that are on or near the bed so that participants cannot see them.
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Mark the beds of any additional patients that you plan to show to participants, for example, by posting a coloured card at the foot of the bed. This will help you locate these patients easily.
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Conducting the Inpatient Demonstration of Signs

Each inpatient session will last about 45 minutes. Allow about 15 minutes for the participants to assess and classify their assigned patients, and about 30 minutes for review of participants' assessments and demonstration of clinical signs. It is necessary to keep up the pace of the review session. 1. Tell participants the objectives of today's inpatient session: to practise assessing patients using the Acute Care Recording Form. Explain that even though they are in a hospital evaluating patients who have already been admitted, they should pretend that they are in a first-line health facility such as a health centre evaluating patients who have presented to the outpatient clinic with signs of acute illness. Give them the following tips: Always communicate with the conscious patient. Never assume the apparently unconscious patient cannot hear you. Be prepared to convey requests from inpatients to the clinical team. Do what you promise. However, you cannot start treating the patients and should consult with the clinical team when answering clinical questions. Talk away from adult patients and family when discussing cases (real or hypothetical). Use the Acute Care Recording Form to do a very focused physical examination. Keep questions to a minimum in order to avoid fatiguing the patient. 2. Demonstrate for the participants any new part of the assessment process. Before participants practise a clinical skill for the first time in the inpatient ward, they should see a demonstration of it done correctly. Explain and demonstrate the clinical skill exactly as you would like participants to do it. Assign each participant a case to assess and classify. Tell them how much of the assessment and classification you expect them to do. Be sure that each participant has a blank Acute Care Recording Form to use. Observe while the participants assess and classify the cases. Be available to assist or answer questions. Make sure they are circling the patient's signs on the Acute Care Recording Form and writing classifications. Encourage them to refer to the Acute Care guideline module when they classify the child. Make sure participant work is not interfering too much with the ward routine, especially provision of treatment. You or your assistant should make sure patients and families understand what is going on. Conduct case discussions with the group of participants: When conducting the discussion of participants' cases, start with the cases whose classifications are simple (such as a patient with cough or difficult breathing for more than 2 weeksclassification POSSIBLE CHRONIC LUNG OR HEART PROBLEM). Cases with more complex classifications can be presented later, for example, a second case could have chest pain and fast breathing (classification PNEUMONIA), or could have pulse > 120 and lethargy (classification SEVERE PNEUMONIA/SEVERE DISEASE). By having participants see patients with increasingly complex classifications, a variety of signs and assessments can be demonstrated to participants.
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Gather the participants start discussing the first case. Ask the assigned participant to present the case, describing the signs found and the classifications (do not comment now on whether the assessment is correct). Ask the participant to refer to the classification box in his Acute Care guideline module to explain how he determined the classification. This is important to do throughout the sessions since errors of classification occur almost as frequently as errors of assessment. Tell the correct assessment of the sign. If all participants did not assess it correctly, demonstrate or let participants assess again. Find out why they decided differently - where they were looking, when they think breathing in or out is occurring, or other relevant factors. Treat their opinions with respect. Convey the fact that you might be wrong. "Let's look again." "Now is it more clear in this position?" "Abdi was correct to doubt pallor if he was not sure. Let's look at the patient again." Ask the participant to tell the patient's classifications again. If your assessment of any sign was different from his initial assessment, allow him a chance to decide how the classification should change. Summarize the case so that participants understand the correct assessment of the patient's signs and classifications. Thank the participant and praise him for any new or difficult tasks that he did correctly. Then review the case in the same way.
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Conduct bedside rounds of cases that were difficult to assess and classify. If in the early morning additional patients were identified with signs that are infrequently seen (meningismus, very fast breathing, severe pallor, etc.), demonstrate these signs to participants at the end of the session. This will ensure that participants will get to see infrequently seen signs, whenever the opportunity arises. At the end of the clinical session, summarize the important signs and tasks covered in the session and refer to common problems that participants encountered (for example, missing severe palmar pallor, or errors of classification). Ask participants to keep their Acute Care Recording Forms so that they can refer to them to complete their Group Checklist of Clinical Signs. Summarize for the participants the important signs and classifications that they saw in the session. Reinforce them for new and difficult steps that they did correctly, and give them suggestions and encouragement to help them improve.
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After the session, record on the Checklist for Monitoring Inpatient Sessions the cases seen by the participants.
10. During the course, participate in the meeting of facilitators at the end of each day. Report to the facilitators and the Course Director on the performance of each group at the inpatient session that day. Discuss whether participants are seeing all the clinical signs and classifications. Determine if there are patients with certain signs that you should try to locate and include in the next day's cases.
How to Prepare for the Acute Care Outpatient Session

1. When you arrive at the outpatient department or health centre, meet with the clinic staff who will intercept patients in the triage area. During your training, you and the Course Director may have already established contact with a nurse or other clinic staff member
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who will help by identifying cases to send to the area where participants are working. Staff responsibilities often change in large clinics so you may need to explain again to clinic staff information such as the purpose of the course, arrangements made, and who gave permission. If there are specific physical signs that you want your participants to see, explain this to the clinic staff so they will refer the patient with these signs to you. Patients with general danger signs should be seen first by the regular clinic staff. 2. You or your co-facilitator should check to see if all the necessary supplies for today's session are available where the participants will be working. You may need to find a tray or table on which to set up any supplies or equipment. Do this before the session begins. When you have finished discussing arrangements with the clinic staff, begin the day's session.
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Conducting the Acute Care Outpatient Session

1. Gather the participants together. Explain what will happen during the session. Describe the skills they will practise and answer any questions they might have. Be sure participants have their Acute Care guideline modules and pencils with them. Distribute sufficient copies of the Acute Care Recording Form and tell participants they will use it to record information about the cases they see. Tell them they should assume all the patients they work with during the outpatient sessions have come for an initial visit. Also explain that they will need to keep their Recording Forms from each session to use later in the classroom. They will use them to complete a Group Checklist of Clinical Signs. Before participants practise a clinical skill for the first time, they should see a demonstration of the skill. To conduct a demonstration: Assign patients to participants. Participants should practise doing the steps relevant to each session's objectives with as many patients as possible. It is best if participants work individually. If necessary, participants can work in pairs. When working in pairs, they can take turns so that one participant assesses a case while the other observes. Or after one participant does the steps, the other participant also does them. When participants work in pairs, you are responsible for making sure that every participant, and not just each pair of participants, practises assessing, classifying, and treating sick children and young infants correctly. Every participant should also practise counselling mothers. 6. Observe each participant working with his assigned patient. Make sure he is doing the clinical skills correctly. Also check the participant's Acute Care Recording Form to see if he is recording information correctly. Provide feedback as needed. Remark on things that are done well in addition to providing guidance about how to make improvements. When you have not been able to observe the participant's work directly, take note of the patient's condition yourself. Then: 194
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Ask the participant to present the case to you. He should refer to his Recording Form and tell you the patient's main symptoms, signs, and classifications. Later in the course, the participant should also summarize his treatment plan.
If time is very limited, look at the participant's Recording Form. Compare your observation of the child's condition with the participant's findings. Ask clarifying questions as needed to be sure the participant understands how to identify particular signs and classify them correctly.
Discuss the case with the participant and verify the assessment and classification of the case. If treatment has been specified, verify that it is correct. In some clinics, the participant will be allowed to treat the patient. 8. Provide specific feedback and guidance as often as necessary. Provide feedback for each case that the participant sees. Mention the steps the participant does well and give additional guidance when improvement is needed. When a participant finishes a case, assign him to another patient. If no new patient is available, ask the participant to observe management of other patients. As soon as another patient is available, assign a participant to that patient. Your emphasis should be on having participants see as many patients as possible during the session. Do not let participants become involved in discussions of cases or wander off after managing just one or two patients. If a patient has symptoms and signs which the participants are not yet prepared to assess and classify, return the patient to regular clinic staff for continuation of assessment and treatment. If the patient is returned to the regular clinic staff for treatment, you may need to write a brief note on the findings and likely diagnosis or briefly discuss the case with the clinician in charge to make sure the patient receives correct and prompt care. It is important that the patient receive appropriate treatment before leaving the clinic. At anytime during any session, if a patient presents with a sign which is seen infrequently, or with a particularly good or interesting example of a sign being emphasized that day, call all the participants together to see the sign in this patient.
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How to Prepare for the Chronic HIV Care Outpatient Session

1. When you arrive at the HIV Care/ART clinic, meet with the clinic staff who will intercept patients in the triage area. During your training, you and the Course Director may have already established contact with a nurse or other clinic staff member who will help by identifying cases to send to the area where participants are working. Staff responsibilities often change in large clinics so you may need to explain again to clinic staff information such as the purpose of the course, arrangements made, and who gave permission. 2. You or your co-facilitator should check to see if all the necessary supplies for today's session are available where the participants will be working. This includes wallcharts and HIV Care/ART Cards, and job aids.
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3. When you have finished discussing arrangements with the clinic staff, begin the day's session.
Conducting the Chronic HIV Care Outpatient Session

1. Gather the participants together. Explain what will happen during the session. Describe the skills they will practise and answer any questions they might have. Be sure participants have their Chronic HIV Care guideline modules and pencils with them. Explain carefully how they should introduce themselves to patients. They should explain that they are not part of the patient's care team and will not be making any recommendations or giving any treatment to the patient. They should explain that they are there to practise their interviewing and counselling skills, and that if the patient has any concerns, they will rely these concerns to the care team. If the participants learn new information that could influence the care of the patient, they should not make any recommendations directly to the patient, but instead talk to Course Director who will relay the information to the treating physician. 2. 3. Distribute sufficient copies of the Clinical Review Form and the HIV Care/ART Card. Assign patients to participants. Participants should practise doing the steps relevant to each session's objectives with as many patients as possible. It is best if participants work individually. If necessary, participants can work in pairs. When working in pairs, they can take turns so that one participant assesses a case while the other observes. Or after one participant does the steps, the other participant also does them. When participants work in pairs, you are responsible for making sure that every participant, and not just each pair of participants, practise assessing patients correctly. Every participant should also practice counselling patients. 4. Observe each participant working with his assigned patient. Make sure he is doing the clinical and counselling skills correctly. Provide feedback as needed. Remark on things that are done well in addition to providing guidance about how to make improvements. When you have not been able to observe the participant's work directly, take note of the patient's condition yourself. Then:
5.
Ask the participant to present the case to you. He should refer to his Clinical Review Form and HIV Care/ART Card and tell you the patient's main symptoms, signs, and treatment plan.
Discuss the case with the participant and verify the assessment and staging of the case. Verify that the correct codes have been entered in the HIV Care/ART Card. If a treatment plan has been specified, verify that it is correct.
6.
Provide specific feedback and guidance as often as necessary. Provide feedback for each case that the participant sees. Mention the steps the participant does well and give additional guidance when improvement is needed.
196
7.
When a participant finishes a case, assign him to another patient. If no new patient is available, ask the participant to observe management of other patients. As soon as another patient is available, assign a participant to that patient. Your emphasis should be on having participants see as many patients as possible during the session. Do not let participants become involved in discussions of cases or wander off after managing just one or two patients. If the patient is returned to the regular clinic staff for treatment, you may need to write a brief note on the findings and likely diagnosis or briefly discuss the case with the clinician in charge to make sure the patient receives correct and prompt care. It is important that the patient receive appropriate treatment before leaving the clinic. At the end of the outpatient session, lead a discussion to summarize the session.
8.
9.
10. Gather participants together and discuss the cases seen and specific skills practised that day. If problems occurred, discuss what happened and how the problem was corrected. Encourage the participants to discuss their observations about the day's cases. Answer any questions and discuss any concerns that participants have about the case management skills or cases seen that day. Reinforce the use of good communication and counselling skills. Discuss words that patients use to understand concepts and issues related to HIV. 11. During the course, participate in the meeting of facilitators at the end of each day. Report to the facilitators and the Course Director on the performance of each group at the inpatient session that day. Discuss whether participants are assessing patients and formulating treatment plans correctly.
197
Expert Patient-Trainer Cases (Compiled after Gondar field-testing) Case 1 You are a 20 year-old man. You are coming to a clinic to consult for an urethral discharge. If asked:
You have had several similar episodes before. You finished your studies 2 years ago, but you have no regular job. You are working time to time, on short contracts. You have no partner, but you have casual partners when you are going out for drinking beers with friends. You admit that you are not using condoms each time.
Physical examination: no ulcer/warts; small amount of yellow discharge seen Case specific questions: Classify as URETHRAL DISCHARGE Treatment given and dose/days explained Offer HIV testing and counselling Discuss link between STI and HIV Partner management Recommend RPR testing Advise to come back after 7 days if no improvement
198
Case 2 You are a 24 year old woman. You are complaining of a painful sore on your private parts. If asked:
You moved in with your boyfriend one month ago You have had sexual relations together for 6 months You are not using condoms You cannot afford acyclovir
Physical examination: Small, fluid-filled vesicles on the right vulva Case specific questions: Classify as GENITAL HERPES Explained that acyclovionly controls the sore and doesn't cure herpes Explained other measures to care for the sores Promote and provide condoms Offer HIV testing and counselling Discuss link between STI and HIV Partner management Recommend RPR testing Advise to come back after 7 days if no improvement
199
Case 3 You are 32 years old and working as a waitress in a night club. You have painful sores on your "private parts", for the past three weeks. If asked:
You have never had these symptoms before You were treated the past years for several episodes of vaginal discharges You are married but you admit that sometimes you accept to go with some clients of the nightclub before your duty time because you need money to send your children to school
Physical examination: ulcer (without vesicles) on left vulva Case specific questions: Classify as GENITAL ULCER Provide treatment Educate and counsel Promote and provide condoms Offer HIV testing and counselling Partner management Recommend RPR testing Advise to come back after 7 days if no improvement
200
Case 4 You are a 35-year old married woman with 3 children. You have come to the clinic because of lower abdominal pain. You have never had this before. If asked:
Your husband is working in factory at the capital, he is working a lot and he is coming back home only once a month. You trust him and think he is faithful You also have a vaginal discharge She is taking contraceptive pills
Physical examination: bilateral lower abdominal tenderness, no guarding, no rebound. Scant vaginal discharge, yellow, "fishy" smell Case specific questions: Classify as PID and BACTERIAL VAGINOSIS Provide treatment Educate and counsel Ask her to use condoms if sexual relation and provide some Partner management Recommend RPR testing Ask her to come back in 3 days
201
Case 5 You are a 19 year-old woman. You have a painful sore on your "private parts". If asked:
You have been working as sex worker for 3 years now in a slum area. Many clients are refusing to use condoms You have a child who is often sick You are afraid of getting AIDS, as your best friend, also sex worker, just died of AIDS one month ago
Physical examination: ulcer (without vesicles) on left vulva Case specific questions: Classify as GENITAL ULCER Provide treatment Educate and counsel Promote and provide condoms Offer HIV testing and counselling Recommend RPR testing Ask her to come back if there is no improvement
202
Case 6 You are 20 years old. You have a painful bump in your groin area for the past week and a sore on your penis. If asked:
You are not married You have a girlfriend for 1 year You occassionally use condoms. You occasionally have other partners
Physical examination: fluctuant inguinal swelling and a painful ulcer (no vesicle) on the penis. Case specific questions: Classification: INGUINAL BUBO and GENITAL ULCER Recommends aspiration of the bubo Provide treatment Educate and counsel Promote and provide condoms Partner management Offer HIV testing and counselling Recommend RPR testing Ask him to come back in 7 days or before if it is worsening
203
Further cases needed: Lymphadenopathy, RPR positive Abnormal vaginal bleeding Testicular pain (males) Itchy vaginal discharge (candidiasis); needs reassurance Woman with non-specific symptoms (not vaginal discharge), with history of multiple sex partners (syndrome: GC/chlamydia)
204
Case #: 1 Observer: Health Worker: GENERAL

Respectful Simple words Listened to patient Made sure patient understood
GOOD
OK
NOT GOOD
NOT DONE
ASSESS
Asked why came to the clinic? Asked all the screening questions for all major syndromes Look: physical exam
ADVISE
On treatment plan (e.g. dosage and days) Educate and counsel about STI's Promote and provide condoms
AGREE
On treatment plan Involved patient
ASSIST
Provided treatment options Helped solve treatment problems Provided psychological support
ARRANGE
Follow-up date(s) Explained when patient should come back earlier
CASE-SPECIFIC QUESTIONS
(ask for the Acute Care Recording Form) For example: Classified as GENITAL ULCER? Recommended treatment with ciprofloxacin and doxycycline? Promoted condoms and provided some? Discussed treating the partner? Recommended RPR testing? Offered HIV testing? Asked the patient to come back in 3 days?
205
Photo booklet Key

Chronic HIV Care with ARV Therapy: P = Participant Manual F = Facilitator Manual
PGL. Angular Cheilitis. Seborrhoea Prurigo Herpes Zoster.. Recurrent Mouth Ulcers. Oral Thrush..... Oral Hairy Leukoplakia.. Vaginal Candidiasis Herpes Simplex... Lymphoma.. Kaposi Sarcoma... Extrapulmonary TB Herpes Simplex.. Herpes Simplex.. Genital Warts.. Genital Warts.. Skin Rash Pallor.. Pallor... Jaundice.. Oral Thrush Oral Thrush
18P 20P 20P 20P 20P 20P 21P 21P 18F 18F 18F 18F 18F 48P 48P 48P 48P 49P 51P 51P 51P 51P 51P
Acute Care Participant Manual: 1A. Central Cyanosis.. 1B. Respiratory Distress 1C. Capillary Refill.. 2A. Recovery Position 3A. Mean Upper Arm Circumf... 3B. Pitting Oedema... 3C. Sunken Eyes 3D. Some Palmar Pallor 3E. Severe Palmar Pallor.. 3F. Moderate Conjunctival Pallor. 3G. Severe Conjunctival Pallor. 3H. Bleeding Gums. 3I. Petechiae 4A. Oral Thrush -- White Patches 4B. Oral Thrush -- Red Patches... 4C. Oral Hairy Leukoplakia 4D. White Exudates 7 7 7 9 28 28 28 28 28 28 28 28 28 31 31 31 31
4E. Tonsil Abscess. 4F. Enlarged Lymph Node. 4G. Jaw Swelling. 4H. Shallow Ulcer 4I. Deep Ulcer.. 4J. Dental Abscess. 4K. Gum Bubble.. 4L. Kaposi Sarcoma. 4M. Loss of Tooth Substance... 4N. Tooth Cavities. 5A. Dehydration.. 6A. Test for Rebound. 6B. Flank Tenderness 6C. Vaginal Candidiasis. 7A. Urethral Discharge... 7B. Scrotal Swelling 7C. Elevated Testis. 8A. Genital Herpes. 8B. Penile Ulcer.. 8C. Vulvar Ulcer...... 8D. Inguinal Bubo 8E. Genital Warts 8F. Genital Warts 9A. Extrapulmonary TB.. 9B. Red Streak 9C. PGL 9D. Pyomyositis.. 9E. Soft Tissue Infection 9F. Cellulitis. 9G. Folliculitis.. 9H. Impetigo. 9I. Scabies 9J. Papular Itching Rash 9K. Eczema.. 9L. Ringworm.. 9M. Varicella Zoster 9N. Contact Dermatitis... 9O. Herpes Simplex -- mild... 9P. Herpes Simplex -- severe... 9Q. Stevens Johnson Reaction 9R. Fixed Drug Reaction 9T. Seborrhoea.. 9U. Psoriasis 10A. Bell's Palsy.. 10B. Elicit Sinus Tenderness
31 31 31 31 31 31 31 31 31 31 44 54 54 54 56 56 56 58 58 58 58 58 58 62 62 62 62 62 62 62 62 62 62 62 62 62 62 62 62 62 62 62 62 68 68
206

April 2008, Last Facilitator Guide - Adult3

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April 2008, Last Facilitator Guide - Adult3

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Course Director/ Facilitator Guide

Federal HIV Prevention and Control Office Ministry of Health, Ethiopia

Expert Patient-Trainer Cases.......... 198 Photo booklet key... 206

Day 3 (Wednesday) Day 4 (Thursday)

Whole day; Do all exercises on M & E

Sunday Day 7 (Monday)

PIHTC Short Course

Day 9 (Wednesday) Day 10 (Thursday)

STI Short Course Day 11 (Friday)

Day 12 (Saturday) Clinical Team (MDT) Building

IMNCI (Paediatric Acute Care)

Paediatric Chronic HIV Care/ART

Instructional Materials, Supplies, Venue, Timetable

B. Checklist of Instructional Materials Needed for Both Courses:

1 for each facilitator

Day 2-3 (Ch. 11)

Acute Care Recording Forms

C. List of Other Supplies and Equipment Needed in the Classroom

E. Timetable for preparation

Estimated Time Needed

Official letters needed? If venue is unknown, visit to ensure suitability

Facilitator techniques common to all courses

B. How to conduct a drill

C. How to provide individual feedback to written exercises

E. Explanations and lecturing

F. How to use the skill stations

Chapter 1: Overview of HIV/AIDS in Ethiopia Duration: 90 minutes

Reassurances about the pre-test

Chapter 2: Integrating Prevention with Treatment

Duration: 60 minutes Materials:

Purpose: Learn how to integrate prevention with treatment Learning objectives:

7 years Acute viral syndrome

Chapter 3: Introduction to Chronic HIV Care with ART

Duration: 90 minutes Materials:

10 minutes 25minutes 35 minutes

Role-play # 1: Good use of the 5 A's

Role Play #2: Poor use of the 5 A's

EPT: Fine. F: Have you had any problems lately?

Chapter 5: Opportunistic Infections (OI) and WHO Clinical Staging

HIV clinical staging

3 (oral hairy leukoplakia) 1 (PGL)

2 (herpes zoster) 3 (oral thrush)

4 (KS) 4 (cervical cancer) 3 (vaginal candidiasis)

Duration: 60 minutes Materials:

Purpose: To learn about prophylaxis Learning objectives:

EXERCISE 1, Reading, Case discussion

Reading and brief discussion

Duration: 2 hours Materials:

How to do clinical review

8. What would you advise to a woman who is breastfeeding?

Provide clinical care:

4. Patient has chronic diarrhoea?

6. Patient has anxiety?

7. Patient has psychosis? 8. Patient has depression?

9. Patient has difficulty in sleeping?

10. Patient has itching?

11. Patient has fever?

15. Patient has hazardous alcohol use?

16. Patient is pregnant?

2. Suspect TB: Sputums

3. No suspicion of TB: No signs

5. No suspicion of TB: No signs