HIV Nurses Manual 2011

NURSES MANUAL
HIV/AIDS AND ART TRAINING FOR NURSES
National AIDS Control Organisation

Indian Nursing Council
HIV/AIDS and ART Training for Nurses
Nurses Manual
Page i
Copyright 2009 by Indian Nursing Council.

All rights reserved. No part of this publication may be reproduced, reviewed,
abstracted, stored in a retrieval system or transmitted in any form or by any means
including photocopying without the prior written permission of the Indian Nursing
Council, New Delhi.
Disclaimer:
The names and situations used in case discussions in this manual are fictitious and
does not bear any resemblance to any person alive or dead. Any resemblance is
purely co-incidental.
First Edition 2009

Second Edition 2011
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Page ii
Table of Contents
Foreword. ......................................................................................................................................................... v
Acknowledgements. ..................................................................................................................................... vii
List of Contributors. .................................................................................................................................... ix
List of Abbreviations. ................................................................................................................................... x
SECTION ONE: About this Course. ........................................................................................................... 3
Background of the Global and Indian HIV Epidemic ................................................................................. 3
Goals of the Training ...................................................................................................................................... 3
Training Schedule Page ................................................................................................................................. 4
Organization of the HIV/AIDS and ART Training for Nurses Course ...................................................... 6
How to Use this Manual ................................................................................................................................. 6
SECTION TWO: Course Units. .................................................................................................................... 7
Unit 1 HIV/AIDS & Nurses Role ................................................................................................................ 9
Unit 2 Stigma & Discrimination: Legal & Ethical Issues HIV/AIDS ....................................................15
Unit 3 HIV Epidemiology ...........................................................................................................................23
Unit 4 Counselling for PLHIV ................................................................................................................... 34
Unit 5 Prevention of HIV Transmission ...................................................................................................44
Unit 6 Prevention of Parent to Child Transmission (PPTCT) of HIV .................................................52
Unit 7 Infection Control and Post Exposure Prophylaxis (PEP) .........................................................58
Unit 8 Sexually Transmitted Infections (STIs) ........................................................................................72
Unit 9 Symptom Management & Opportunistic Infections (OIs) .........................................................78
Unit 10 Introduction to Antiretroviral Therapy (ART) .............................................................................. 94
Unit 11 Paediatric HIV Infection .............................................................................................................. 108
Unit 12 Complementary Therapies in HIV/AIDS .................................................................................... 114
Unit 13 Palliative Care for People Living with HIV/AIDS (PLHIV) ...................................................... 118
Unit 14 Positive Living for PLHIV ........................................................................................................... 126
Unit 15 Challenges Faced by Nurses in HIV/AIDS Care .................................................................... 132
SECTION THREE: Exercises. ................................................................................................................. 135
SECTION FOUR: Annexures. .................................................................................................................. 159
Annexure
Annexure
Annexure
Annexure
Annexure
Annexure
Annexure
1
2
3
4
5
6
7
Baseline Assessment .......................................................................................................... 162

Quick Reference Steps in using a Male and a Female Condom ............................... 165
Disinfection of Needles and Syringes with Bleach ........................................................... 167
Hand Hygiene Checklist ..................................................................................................... 168
Guidelines for Disposal of Used Disposable Needles and Syringes .............................. 169
Guidelines for Disinfection and Sterilization ...................................................................... 170
Situational Guide Cleaning up a Blood Spill on the Floor ........................................... 171
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Annexure 8
Annexure 9
Annexure
Annexure
Annexure
Annexure
Annexure
Annexure
Annexure
Annexure
Annexure
Annexure
Annexure
Annexure
10
11
12
13
14
15
16
17
18
19
20
21
Annexure 22
Annexure 23
Annexure 24
Annexure 25
Annexure 26
Annexure
Annexure
Annexure
Annexure
Annexure
Annexure
Annexure
Annexure
Annexure
27
28
29
30
31
32
33
34
35
Situational Guide Care of the Body after Death of a PLHIV ...................................... 173
NACO PEP Policy: Procedure to be followed after an Accidental
Exposure to HIV Infectious Fluid ....................................................................................... 174
STI Syndrome Flowchart Lower Abdominal Pain ......................................................... 185
STI Syndrome Flowchart Inguinal Bubo ........................................................................ 186
STI Syndrome Flowchart Painful Scrotal Swelling ........................................................ 187
STI Syndrome Flowchart Ophthalmic Neonatorum ....................................................... 188
STI Syndrome Flowchart Genital Ulcers ....................................................................... 189
STI Syndrome Flowchart Urethral Discharge ................................................................ 190
STI Syndrome Flowchart Vaginal Discharge (1) ........................................................... 191
STI Syndrome Flowchart Vaginal Discharge (2) ........................................................... 192
Guide to Common Symptoms and Possible Aetiologies ................................................. 193
What a Nurse needs to know about Dementia and Delirium ......................................... 195
Comprehensive laboratory evaluation in HIV/AIDS .......................................................... 197
Specimen Collection (by heel prick) and handling procedure for
HIV DNA PCR testing by Dried Blood Spot (DBS) sample collection ............................ 198
Monitoring and follow up patients on ART: Recommendations in
the National Programme .................................................................................................... 203
PPTCT True or False Statements and Answers .............................................................. 205
PPTCT: Three Safe Infant Feeding Options Some Important Points
You Could Keep In Mind When Counselling Mothers On Feeding Options .................. 206
Replacement Feeding Checklist ........................................................................................ 208
Questions and Issues that must be assessed by the Nurse to Aid
In Preparing the Child And Family For ARV .................................................................... 209
Ways to Promote ART Adherence in Children ................................................................. 210
Assuming the quality /amount of PTH .............................................................................. 211
Music Therapy ..................................................................................................................... 212
National AIDS Control Organization (Phase III) ............................................................... 214
List of State AIDS Control Societies (SACs) .................................................................... 215
List of ART Centres ............................................................................................................ 218
List of Community Care Centres (CCCs) ......................................................................... 225
Ice Breakers & Energizers ................................................................................................. 247
Role of Nurse at ART & CCCs ......................................................................................... 250
SECTION FIVE: Glossary of Terms and References. ...................................................................... 251

GLOSSARY OF TERMS ............................................................................................................................ 253
REFERENCES ............................................................................................................................................ 260
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Foreword
The free Antiretroviral Therapy (ART) Initiative was launched by the Government of India on the
1st April 2004 in the six high prevalent states (Andhra Pradesh, Tamil Nadu, Karnataka, Maharashtra,
Nagaland and Manipur) in eight Government hospitals. As in November 2008, there are now 191 ART
centres in the country providing comprehensive ART services to the eligible people. In a country with
2.3 million infected with HIV, currently about 1,80,000 people have been enrolled for ART.
The nurses are the first point of contact of the HIV infected in a hospital setting or any setting
with in-patient facility. The nurses need to be equipped with adequate knowledge on HIV/AIDS and
all the aspects including prevention, treatment, care and support. This will not only enable them to
protect themselves from getting infected with HIV but also help in reducing stigma and discrimination
against people infected with HIV and encourage nurses to provide quality care and support services
to the PLHAs. In a resource limited setting where there is a dearth of qualified professionals to
conduct quality counseling it has become increasingly important to train the nurses in the art of quality
counseling for long term sustainability.
The Indian Nursing Council in coordination with the National AIDS Control Organization (NACO)
has put in unprecedented efforts in bringing up these two modules for training of nurses in HIV/AIDS.
These two modules Facilitators Guide and the Nurses Manual have been prepared including all
the aspects of the HIV/AIDS prevention (Primary and secondary), treatment, care and support of the
PLHAs. All relevant guidelines from the National AIDS Control Organization (NACO) have been
incorporated in these modules.
The modules will equip the nurses to provide standardized and quality counseling, care and
support services to the people infected with HIV. The nurses form the backbone of our health system
and empowering them with knowledge on HIV/AIDS will also help in reducing the stigma and
discrimination and help in improving the quality of the PLHAs.
(K. Sujatha Rao)

Secretary & DG
AIDS Division
Ministry of H. & F.W.
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Acknowledgement
The Nurses Training program on HIV/AIDS prevention care and treatment under the Global Fund
Round 7 has completed its first phase of the project in September 2010 and around 45,000 staff
nurses from different hospitals and other health facilities across the country have successfully
participated in the 5 day training programs. The feedback from the participants has been very good
and most trainees have expresses satisfaction on the quality and content of the training courses. The
training course has reemphasized the adoption of strict Standard safety precautions in the hospitals
while delivering good quality care.
Regional Cross learning workshops organized during the course of the project brought together select
trainers from across the states. These workshops provided a wonderful opportunity to share experiences
and lessons learnt and provided the necessary feedback on the training content and the curriculum.
Additional inputs were provided by the experts in the Project Steering Committee meetings chaired by
the DG, NACO.
Based on the feedback and in view of the changing scenario of the HIV/AIDS epidemic, the training
curriculum was revised by the core Committee of INC, which included experts from NACO. The
training units have been strengthened with the updated technical information and the incorporation of
video clips in some areas to make the training more interesting and engaging. With the nurses
envisaged to take on more responsibilities on counselling, the Counselling unit has been made more
comprehensive with additional role plays and discussions. The training course has been extended to
six days from the previous five days to accommodate these additions into the various units.
I would like to thank Mr. K. Chandramouli, Secretary, Ministry of Health and family Welfare and Ex
DG NACO for his valuable inputs in planning for the next phase of the project. I would also like to
thank Mr. Sayan Chatterjee, Secretary and DG, NACO for the leadership and guidance in taking
forward this program to all nurses. I would like to express my gratitude to Dr. Mohd. Shaukat, ADG,
NACO for his guidance and support. I would like to express my sincere thanks to all Core Committee
members, Experts from NACO, Nursing Experts and trainers who have put in great efforts in the
updating and revision of the facilitators guide and Nurses Manual. I would also like to acknowledge
the regular feedback from all trainees which have been critical in revising the course content. I would
like to thank Mrs. K. Bharati, Asst Secretary, INC and the Project Director of this project for her
leadership in putting this manual together while taking in all inputs. Lastly, I would like to thank all
my colleagues in the Indian Nursing Council, Futures Group and other project staff who have worked
tirelessly in completing the manuals in the shortest possible time.
I hope the revised manuals will be equally appreciated by the trainers and participants and would help
better equipping nurses in provided quality care for people with HIV/AIDS.
Mr. T. Dileep Kumar

President, Indian Nursing Council
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List of Abbreviations
AIDS
Acquired Immune Deficiency Syndrome
ANC
Ante Natal Care
ART
Anti Retroviral Therapy
BCC
Behaviour Change Communication
CBO
Community Based Organisation
CCC
Community care centres
CMV
Cytomegalo Virus
CSW
Commercial Sex Worker
DNA-pcr
Deoxy ribo Nucleic Acid Polymerase Chain Reaction
DOTS
Directly Observed Therapy Short Term
ELISA
Enzyme-Linked Immunoflourescent Assay
HIV
Human Immunodeficiency Virus
HCP
Health Care Professionals
ICTC
Integrated Counselling and Testing Centre
IDU
Injecting Drug User
IEC
Information Education Communication
KS
Kaposis Sarcoma
MSM
Men who have Sex with Men
NACO
National AIDS Control Organization
NGO
Non-Government Organization
OI
Opportunistic Infection
OPD
Out Patient Department
PCP
PneumoCystis Pneumonia
PEP
Post Exposure Prophylaxis
PLHA
People Living with HIV/AIDS
PML
Progressive Multifocal Leukoencephalopathy
PPE
Personal Protective equipment
PPTCT
Prevention of Parent To Child Transmission
RNTCP
Revised National Tuberculosis Control Programme
SACS
State AIDS Control Societies
SCM
Syndromic case management
STI
Sexually Transmitted Infection
TB
Tuberculosis
TIP
Targeted intervention programme
WBC
White Blood Cell
WHO
World Health Organization
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List of Contributors
1.
Mr. T. Dileep Kumar

President, INC,
Nursing Advisor,
DGHS (Nursing Section),
Nirman Bhawan, New Delhi
2.
Dr. Asha Sharma

Retd.Principal
RAK College of Nursing, Lajpat Nagar,
New Delhi
3.
Dr. Manju Vatsa

Principal,
College of Nursing, AIIMS,
Ansari Nagar, New Delhi
4.
Ms. Harinder Jeet Goyal,

Senior Lecturer,
R.A.K. College of Nursing,
Lajpat Nagar, New Delhi.
5.
Dr. Sandhya Gupta,

Lecturer,
College of Nursing, AIIMS
Ansari Nagar, New Delhi.
6.
Dr. Juliana Linnette DSa

Dean
Manipal College of Nursing,
Centre for Basic Sciences Complex,
Bejai, Mangalore
8.
Mrs. Sunita Miglani,

AIDS Nurses Educator,
College of Nursing, AIIMS,
9.
Mrs. K.S. Bharati

Asstt. Secretary
Indian Nursing Council
New Delhi
10. Dr. S.N. Misra

Senior Technical Advisor
Futures Group International
Gurgaon
11.
7.
Ms. Deepika C Khakha,

Lecturer,
College of Nursing, AIIMS
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Dr. Dilip Vaswani

Regional Manager
Gurgaon
12. Ms. Poornima Sharma

Training Coordinator
Gurgaon
13. Ms. Shanta Misra
Communication Expert
Consultant, Futures Group International
Gurgaon
14. Dr. Daisy Lekharu
Public health Specialist
Ex-Project Manager,
Gurgaon
SECTION ONE
About this Course
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Section One: About this Course

Background of the Global and Indian HIV Epidemic
Globally there were estimated 33million people infected with HIV in 2007 with 2.7 million new
infections and 2 million HIV related deaths. Nearly an estimated 5 million people infected with HIV
lived in Asia in 2007 and about 380 000 people were newly infected [2008 UNAIDS Global Epidemic
Update].
In India, the estimated number of HIV infections as of 2008 is 2.47 million. The distribution of HIV
infection and mode of transmission varies by state. Most HIV infections in India (86% of reported AIDS
cases) are due to unprotected heterosexual transmission (UNAIDS, 2008 Report on Global AIDS
Epidemic). HIV prevalence tends to be higher in the industrialized, peninsular states. The six states
with the highest HIV prevalence are: Maharashtra, Andhra Pradesh, Tamil Nadu, Karnataka, Manipur,
and Nagaland.
In India, more than 1,88,000 people living with HIV/AIDS are accessing ART from public sector
hospitals/clinics as of November 2008. NACO proposes to deliver ARV therapy through effectively
functioning health infrastructure and properly trained and motivated staff. Building capacity to train all
cadres of health professionals in HIV/AIDS care and simplified, standardised ARV therapy is urgent
in the Indian context. This training programme was developed to address the need for training hospital
and ART centre nurses in HIV/AIDS and ART care and treatment as part of the overall NACO training
agenda.
Goals of the Training

The objective of the training is to provide basic information on HIV, AIDS, and antiretroviral
therapy (ART) to nurses in India so that they can care for and treat their patients who are HIV positive.
At the end of the course, it is expected that participants will be able to:
Demonstrate knowledge of HIV prevention, comprehensive care, and antiretroviral treatment

for adults, pregnant women and children
Express confidence in their ability to care for HIV+ patients
Utilize clinical decision making skills using a case-based approach to planning and providing
care to HIV+ patients
Apply the counselling skills acquired during the course to provide support for HIV+ patients
Recognize the KEY role of the nurse in the multidisciplinary team approach to HIV care
Recognize the symptoms and signs suggestive of HIV infection, arrange for HIV testing and
counseling, and refer to ART Centers as required.
Recognize and treat opportunistic infections under the supervision of the medical officer.
Ensure implementation of universal precautions in the various wards of the hospital.

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GFATM Round 7 Training of Nurses on HIV/AIDS & ART

TRAINING SCHEDULE
Time
Topics
Duration
(in minutes)
DAY 1
8.30 9.30 AM
Registration
60 min
9.30 10.30 AM
Unit-0 Introduction & Pre Test
60 min
10.30 11.00 AM
Tea
30 min
11.00 1.00 PM
Unit 3 HIV/AIDS Epidemiology,

Diagnosis & Disease Progression
120 min
1.00 2.00 PM
Lunch
60 min
2.00 3.30 PM
Unit 2 Stigma & Discrimination
90 min
3.30 4.00 PM
Tea
30 min
4.00 5.00 PM
Unit 1 HIV/AIDS & Nurses Role
60 min
DAY 2
9.00 11. 00 AM
Unit 5 Prevention Of HIV
120 min
11.00 11.30 AM
Tea
30 min
11.30 1.00 PM
Unit 6 Prevention Of Parent To Child

Transmission (PPTCT)
90 min
1.00 2.00 PM
Lunch
60 min
2.00 4.00 PM
Unit 7 Infection Control & Post

Exposure Prophylaxis (PEP)
120 min
4.00 4.30 PM
Tea
30 min
4.30 6.00 PM
Unit 7 Infection Control & Post

Exposure Prophylaxis (PEP) Contd.
90 min
DAY 3
9.00 11.00 AM
Unit 8 Sexually Transmitted

Infections (STIs)
120 min
11.00 11.30 AM
Tea
30 min
11.30 1.00 PM
Unit 9 Symptomatic Management of

Opportunistic Infections (OIs)
90 min
1.00 2.00 PM
Lunch
60 min
2.00 3.00 PM
Unit 9 Symptomatic Management of

Opportunistic Infections (OIs) contd
60 min
3.00 3.30 PM
Tea
30 min
3.30 5.30 PM
Unit 10 Introduction To Antiretroviral

Therapy (ART)
120 min
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GFATM Round 7 Training of Nurses on HIV/AIDS & ART

TRAINING SCHEDULE
Time
Topics
Duration
(in minutes)
DAY 4
9.00 AM Onwards
Visit to ART Center & ICTC
1.00 2.00 PM
LUNCH
2.00 PM Onwards
Group work Case based Assessment &

Presentation
60 min
(Tea to be Served during the session)

DAY 5
9.00 10.30 AM
Unit 11 Pediatric HIV
90 min
10.30 11.00 AM
Tea
30 Min
11.00 AM 1.00 PM
Unit 4 Counselling For PLHIV-Ist Session

(Theory)
120 Min
1.00 2.00 PM
Lunch
60 min
2.00 3.30 PM
Unit 4 Counselling For

(Role Plays)
3.30 4.00 PM
Tea
4.00 5.30 PM
PLHIV-2nd
session
90 min
30 min
Unit 4 Counselling For PLHIV(Role Plays)
3rd
Session
90 min
9.00 10.00 AM
Unit 12 Complementary therapies For PLHIV
60 min
10.00 11.00 AM
Unit 13 Palliative Care For PLHIV
60 min
11.00 11.30 AM
Tea
30 min
11.30 1.00 PM
Unit 14 Positive Living For PLHIV
90 min
1.00 2.00 PM
Lunch
60 min
2.00 3.30 PM
Unit 15 Challenges Faced By Nurses
90 min
3.30 4.30 PM
Post Test & Issue of Certificates
60 min
DAY 6

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Organization of the HIV/AIDS and ART Training for Nurses Course

This course has been designed for hospital and ART centre nurses. This is a facilitator-led program
and consists of 15 units focusing on HIV prevention, treatment, care and support with an emphasis
of the role of the nurse in each of these areas. Each unit has clearly stated unit objectives and session
plans which include the following teaching/learning methods:
Lecture
Case studies
Role plays
Large and small group discussions
Worksheets
Individual work and discussions
Brainstorming sessions
Videos
Clinical Site Visit
How to Use this Manual

This manual was developed to assist you as you participate in the training. The manual contains
the following information to support your success in the training:
Unit wise summary of content covered during the five day training
Annexure
Worksheets to facilitate individual and group work during the training
Guidelines, checklists and other referral information which could aid your day to day work
after the training
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SECTION TWO
Course Units
UNIT 1 HIV/AIDS & NURSES ROLE

Unit Objectives
Explain role of the nurse in providing comprehensive and holistic care to the patient
utilizing family- centred and multidisciplinary team approach
Conduct a systematic clinical nursing assessment
Discuss role of the nurse in patient education and accessing social support
1. HIV/AIDS and Nurses Role

HIV - THE GLOBAL SCENARIO
33.3 million people living with HIV

worldwide in 2009)
2.6 million people became infected

with the virus in 2009
1.8 million people died of HIV

related causes in 2009
For every two new persons put on

ART, there are five persons who
are getting newly infected
The annual number of AIDS deaths

has declined in the past five years
from 2.1 million [1.9 million2.3
million] in 2004 to 1.8 million [1.6
million2.4 million] in 2009, in part
as a result of the substantial
increase in access to HIV treatment
in recent years.
Source: UNAIDS: 2010 Report on Global AIDS Eepidemic
EVOLUTION OF HIV IN INDIA
First HIV case in India was reported from Chennai in 1986

First case of AIDS was reported from Mumbai in 1987
HIV cases are now in all states of India approximately 2.27 million PLHIV in India (NACO 2008-09)
All districts across the country are classified into categories A, B, C and D based on prevalence in
antenatal women and high-risk groups.

Section Two: Course Unit-1
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PREVALENCE & VULNERABILITY

High Prevalence
(>5% in high risk
groups and >1% in
antenatal women)
Moderate Prevalence Low Prevalence

(>5% in high risk
(<5% in high risk groups and <1% in antenatal women)
groups and <1% in
antenatal women)
Highly Vulnerable
Vulnerable

Gujarat
Goa
Pondicherry
Tamil Nadu
Andhra Pradesh
Maharashtra
Karnataka
Manipur
Nagaland

Assam
Bihar
Delhi
Himachal Pradesh
Kerala
Madhya Pradesh
Punjab
Rajasthan
Uttar Pradesh
West Bengal
Chhattisgarh
Jharkhand
Orissa
Uttarakhand

Andaman & Nicobar Islands

Arunachal Pradesh
Andhra Pradesh
Chandigarh
D&N Haveli
Daman & Diu
Haryana
Jammu & Kashmir
Lakshadweep
Meghalaya
Mizoram
Sikkim
Tripura
Source: National AIDS Control Programme, Phase III (2006-2011); November 30, 2006
NURSES AND HIV/AIDS CARE: GLOBAL SCENARIO:

The HIV/AIDS epidemic has decimated populations widely all over the globe. In resource limited settings,
where there is lack of skilled man power like doctors and pharmacists to take care of the infected people,
the nurses have been increasingly involved in providing care and treatment to HIV/AIDS infected persons
and have contributed towards the improvement of the health status of the PLHIV. Studies have shown that
the quality of care provided by the Nurse Practitioners (NPs) and Physician Assistants (PAs) to persons
infected with HIV is comparable to the care provided by the trained physicians and doctors.
KEY APPROACHES TO NURSING CARE of PLHIV:

A. Family- centered approach
B. Multidisciplinary approach
In order to provide holistic and comprehensive care to PLHIV, a family centered and multidisciplinary
team approach needs to be utilized, in which nurses play a key role.
A. FAMILY - CENTRED APPROACH

What is meant by Family - Centered approach?
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It means engaging the family members in providing support to the PLHIV in various ways like :
1. Assisting them in managing their own care
2. Helping them in adhering to lifelong antiretroviral treatment (ART )
3. Increasing their capacity for home based care of the PLHIV
Why is family centered care important in the care of PLHIV?
The family plays an important role in an individuals life in terms of providing care, support, etc. It is
important that we as health care providers recognize this and draw on the family in order to provide the
best environment for the PLHIV. If the family learns the best way to be involved with care, the patient
will:
be more confident and increase ability to manage his/her health needs

Will more likely adhere to treatment and access care and support
Have increased capacity for home-based care
B. MULTIDISCIPLINARY TEAM APPROACH

What is meant by multidisciplinary team approach?
Multidisciplinary Team Approach
The nurse is a multidisciplinary team member and coordinates the plan of care. She:
Assesses the physical, social, and psychological and spiritual needs of the patient
Provides care and support
Reports to doctors and other members of the multidisciplinary team
Monitors, evaluates, and follows up
Links the patient and family to community-based support programmes
Maintains documentations
Why is the multidisciplinary approach important in the care of PLHIV?

A multidisciplinary team approach to care puts clinical issues into the context of psychosocial needs,
acknowledging the multiple needs of PLHIV.
It links family and community to medical care thus ensuring that care is coordinated and collaboratively
decided.
It recognizes that all members of the healthcare team make important contributions which may not be
possible when working alone.
Members of the team respect the patients right to privacy and confidentiality. There are times when
we need to be sensitive to the fact that staff and patients could live near the health care facility and
patients may not want others to know of his/her HIV status

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2. AREAS OF NURSING CARE IN HIV/AIDS

The nurses have a key role to play in the following aspects of HIV/AIDS care :
Basic care: physical, psychosocial & spiritual care

Psycho-social: Stigma & discrimination
Education & Counselling
Prevention: Primary & Secondary
Palliative Care
Referral & Linkages
Treatment, Care & Support (ART Adherence)
Management of symptoms; OIs, respiratory infections, skin infections, STIs etc
Patient literacy and adherence to treatment
Management of drug side effects
Infection Control
Diet and Nutrition
Psychological problems
Issues related to children, women, pregnancy
WHAT NURSES NEED TO DO WHILE CARING FOR PLHIV?

1.
2.
3.
4.
Perform baseline assessment

Plan care utilizing the various approaches to care
Implement care utilizing the various approaches to care
Ongoing assessment & follow up
1. PERFORM BASELINE ASSESSMENT
Baseline assessment needs to be performed before designing a plan of care.

This is to determine
Clinical staging of patient
Physical, psychosocial and spiritual needs
Counseling and information needs
Treatment, Care and Support
Baseline assessment helps to get a complete picture of current status of the patient, eliminate irrelevant
possibilities, and begin to think about appropriate treatment and nursing interventions
The areas of baseline assessment are
Medical history
Social History
Sexual history
Patients self evaluation of how s/he is doing
Physical exam
Lab findings
(Refer Annexure-1)
2. PLAN CARE UTILIZING THE VARIOUS APPROACHES TO CARE
IDENTIFY NURSING PROBLEMS: Analyze the information you have collected and identify which areas you
(as a nurse) can assist in.
NURSING PLAN OF CARE: Develop a comprehensive plan of care including all relevant medical and
nursing issues for the particular case study. Be specific about what needs to be done. Use the areas listed
below as a guideline. Remember that ALL of them may or may not apply depending on each case:
Management of symptoms
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ART adherence
Management of drug side effects
Nutrition and Diet
Palliative care
Infection Control
Psychological problems
Social and family problems
Counselling and education
Stigma and discrimination
Referral and linkage
Issues related to children, women, pregnancy
Patient advocacy/patient privacy
Healthy Life Style Practices
Implement care utilizing the various approaches to care

Nurses Role in Prevention, Treatment, Care and Support and in collaboration with partners of multidisciplinary team
3. NURSES ROLE IN PREVENTION
Primary Prevention
-
To prevent acquiring infection

To prevent transmitting infection to others
Rational and safe use of Blood
Offering pre and post test counseling to the people at risk
ANC Women, Patients attending STI Clinics or Received treatment for T.B.
Harm reduction strategies for IDUs
Secondary Prevention
Educate and counsel PLHIV on
Safe sex practices including Condom use
Facilitate positive living (see details in positive living in unit 14)
Nurses role in patient education and counselling

A nurse plays an important role when it comes to educating PLHIV and their families about HIV care. Topics
include:
HIV/AIDS Counseling (Pre-test and Post-test counseling)

HIV testing, transmission, and disease progression
Diet and Nutrition
Hygiene
Treatment management - medication side effects
Adherence support
Safe sex practices
Emotional issues
Recognizing Psycho Social issues and symptoms of the PLHIV which need to be reported immediately
Simple symptom management for the PLHIV e.g. Management of Diarrhea etc.
Family Planning
Nurses role in addressing social issues

Some social issues that may have to be addressed include
Low socioeconomic status

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Lack of disclosure
Lack of positive social support
Barriers to medical care
Exposure to violence at home and in the community
Gender differences
Stigma & Discrimination
The main role nurses can play concerning the above issues is recognizing them and preparing PLHIV to
deal with them by linking to support groups for further assistance.
4. FOLLOW UP & LINKAGES

Nurses role in referral, linkages and networking
To improve patient care and to delegate care, nurses should refer patients to:
Other health care centers such as PHCs, ART centers, STI clinics, PPTCT, ICTC, higher level hospitals
etc.
Other sources of support for patients:
- NGOs & CBOs
- Networks For PLHIV
- Financial resources
- DOTS programmes
- Religious groups
Fulfilling nursing roles
The ability to fulfill all the nursing roles would depend upon our
Knowledge: Know about disease progression, OIs, drugs for prophylaxis and ART, side effects, doses
& dietary requirements, life style Management etc
Understanding: Be aware of the challenges and psycho-social needs of:
- YOUR patient
- YOURSELF
Confidence: Your patient will look to you for advice, information, and support.
Be CONFIDENT!
Key Messages :
Approaches to nursing care of PLHIV:
Family centered approach
Multi disciplinary approach
The Nurse plays a vital and diverse role in the care and treatment of the patient with the aim to
Provide comprehensive HIV care
Support patients and families in HIV treatment
Provide many opportunities for teaching and counseling
Link patients to appropriate medical and social services
Nurses should understand their importance and believe in their ability to be leaders in HIV care and
treatment
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UNIT 2 STIGMA AND DISCRIMINATION : LEGAL &

ETHICAL ISSUES HIV/AIDS
Unit Objectives
Define HIV/AIDS-related stigma and discrimination
Discuss the causes and consequences of HIV-related Stigma & discrimination.
Identify ways to address stigma and discrimination in the context of providing HIV
service.
Handle dilemma causing situations appropriately.
Clarify personal values and attitudes with regard to HIV/AIDS prevention and care.
Understand the legal and ethical issues that relate to PLHIV.
Discuss these issues openly with their colleagues or with other persons in their day
to day practice
Identify nurses role in reducing stigma and discrimination
1. INTRODUCTION
If we do not appreciate the nature and impact of stigma, none of our interventions can begin
to be successful. AIDS is probably the most stigmatized disease in history Justice Edwin Cameron
( South Africa).
HIV-related stigma and discrimination are critical barriers to effectively address HIV. These operate throughout
society: within individuals, families and communities. Stigma and discrimination are major road blocks to
universal access to HIV prevention, treatment care and support. Nurses play a key role in reducing stigma
and discrimination.
Defining HIV- related stigma and discrimination
Stigma refers to unfavorable attitudes and beliefs directed toward someone or something.
Discrimination refers to an act or behaviour, the treatment of an individual or group with partiality or
prejudice.
HIV-related stigma and discrimination is defined as . a process of devaluation of people either living or
associated with HIV and AIDS. Discrimination follows stigma and is the unfair and unjust treatment of an
individual based on his or her real or perceived HIV status (UNAIDS)
What are the Different Types of Stigma?
Types of Stigma
Description
Self or internal stigma
Hatred, shame, blame towards self

It could cause depression and self isolation
This could lead to poor access to care

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Types of Stigma
Wrong
Right
Pre-existing stigma Stigma already exists with regards to

class, gender, sexual orientation, and
poverty, mode of transmission
Do not assume route of

transmission or that Men who have
sex with men are dysfunctional
HIV related stigma
PLHIV are seen as people coming

from underprivileged social or
economic backgrounds
HIV is found in all strata of society,

irrespective of background
Enacted stigma/
discrimination
Could occur due to visible symptoms

of HIV e.g. skin diseases
Symptoms are not always visible
Stigma by
association
Isolation, identify with a mark/name,

neglect, violence, Label on the bed,
patients records at bedtime,
color code on file.
Health care providers should not

use separate marking system to
identify PLHIV
Isolation, different treatment towards

those associated with HIV such as family
of PLHIV or HIV health care providers
Family and friends of PLHIV

should not be isolated
Discrimination
An act or behaviour
Enacted stigma i.e. stigma put into action
The treatment of an individual or group with partiality or prejudice in terms of human rights and
entitlements in various spheres, including healthcare, employment, legal system, social welfare,
reproductive and family life
Examples of discrimination
A person with HIV is denied services by a healthcare worker.

The wife and children of a man who recently died of AIDS are ostracised from the husbands familial
home or village after his death.
An individual loses his job because it becomes known that he/she is HIV-infected.
A person finds it difficult to get a job once it is revealed that he/she is HIV-infected.
A woman who decides not to breastfeed is assumed to be HIV-infected and is ostracised by her
community.
Rejection by the society
2. WHAT ARE THE CAUSES OF STIGMA & DISCRIMINATION?
Lack of information regarding HIV/AIDS

Lack of or limited understanding about HIV/AIDS
(This includes myths of HIV/AIDS)
Fear of the unknown (Fear of contracting the virus & fear of dying).
3. WHAT IS THE IMPACT OF STIGMA & DISCRIMINATION ON PLHIV AND THEIR

FAMILIES?
Stigma and discrimination can be perceived as seriously as the illness itself.

If PLHIV disclose their HIV status or seek treatment, they are likely to face stigma and discrimination,
like
- Abandonment by their spouses and or family members.
- Denial of treatment by health-care services,
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Difficulty in getting, or loss of jobs,

Denial of admissions to schools/colleges or expulsion from schools/ colleges,
Violence,
Rejection, isolation and depression.
Stigma and discrimination can affect the prevention and control of HIV:
Reduced uptake of HIV preventive services,

Testing and Counseling
Refusal of ART treatment and Prophylaxis
Discourages:
Access/Adherence to
Treatment, care and
support
Social interaction
Impact of
Stigma and
Discrimination
Non disclosure to
Partners, Family
members and health
care providers
In Prevention of Parent To Child Transmission programmes (PPTCT) it discourages women :
From accessing antenatal care services and accept PPTCT interventions

Use of recommended PPTCT safer infant-feeding practices (Replacement feeding or early cessation of
breastfeeding)
Follow up of mother- baby pair for testing & treatment
HIV IMPACTS THE WOMEN, MORE THAN MEN

4. HOW CAN WE REDUCE STIGMA AND DISCRIMINATION IN THE HEALTH CARE
SET UP?
Identify and recognize stigma
We must look at how our own attitudes and beliefs that lead to stigmatizing certain individuals based
on their HIV-status or their perceived HIV status.
Use scales that measure stigma and identify its occurrence in the health setting.
Utilize strategies to stop stigma and discrimination

In a health care setting:
Accept responsibility for challenging stigma & discrimination.

Avoid separating clients with HIV from the general client population, unless there is an indication to do
so( E.g., in Wards, in Outpatient departments(OPDs), in Iabour rooms etc}
Avoid non- verbal communication that shows disrespect and disgust. (E.g. Inappropriate facial
expressions).
Educate the community regarding HIV/AIDS; its transmission, prevention, and ART, regarding the
impact of stigma & discrimination on PLHIV and their families.
Teach PLHIV regarding positive living and support groups & encourage them and their families to fight
stigma & discrimination.

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Build safe and confidential spaces for PLHIV to discuss their issues
Provide psychosocial support to PLHIV and their families
Involve PLHIV and their families in plan of care and support services
5. INTRODUCTION TO LEGAL & ETHICAL ASPECTS

Every person has the right to live with dignity, so also a person affected with HIV/AIDS. But there have been
instances where PLHIV and/or their children were denied schooling, medical care and treatment, employment
etc.
Awareness on legal and ethical issues that relate to PLHIV could help you take care of such persons more
effectively.
Protect, respect, and fulfill human rights in relation to HIV
All women and men, irrespective of their HIV status, have a right to determine the course of their sexual
and reproductive lives and to have access to information and services that allow them to protect their
own and their familys health.
Children have a right to survival, development, and health.
Women and girls have a right to information about HIV/AIDS and access to the means of protecting
themselves against HIV infection.
Women have the right to access to HIV/AIDS counselling and testing to know their HIV status.
Women have a right to choose not to be tested or to choose not to be told the result of an HIV
test.???
Women have a right to make decisions about infant feeding, on the basis of full information, and to
receive support for the course of action they choose.
Every individual has certain rights such as the right to a name, a nationality, a religion, an education, basic
amenities such as food, water, shelter, clothing, health, freedom etc. This means that persons with any
illness would be entitled to these rights.
Examples of Legal issues
Denial of property rights

Custody of children
Termination of job
6. LEGAL ISSUES RELATED TO HIV
Mandatory testing of blood and blood products for transfusion (Drugs and Cosmetic Rules-1993 Blood
safety)
Artificial Insemination Human Act 1995
Right to privacy of a person- Article 21 of the Constitution of India stresses on fundamental right for
treatment
Testing only for
- High risk groups with consent &
- People who volunteer to be tested after pre-test counseling
- For Surveillance, testing is done anonymously
- For research purposes, it must be unlinked or anonymous but with consent
Legal and ethical issues in the event of refusal of treatment by health personnel
- Medical practitioners have the responsibility to diagnose, treat, counsel the patients
- Litigation in the case of negligence could lead to accountability of the practice
7. ETHICAL ISSUES
Ethical principles
Beneficence (do good)
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Nonmaleficence (above all do no harm)

Justice (treat everyone fairly, without discrimination, without taking undue advantage of the person)
Veracity (to be truthful)
Self determination (to be fully informed so that a rational decision can be made by the person)
Respect for human dignity
Maintain the confidentiality (not to disclose the information received from person to another person)
Maintain anonymity (not to be able to link to information about one person to the same person.)
Issue in relation to testing for HIV

Information to be given to Mr. X
Testing of HIV infection involves a simple test but the results have a lot of importance for the person
concerned and the community
ETHICAL ASPECTS
Mandatory testing should not be done

Voluntary testing can be done after
informed consent
Pre and post test counseling must be
done to ensure that the person being
tested has the knowledge of HIV,
understands test results and consents
to test.
Reduce risk behavior
SOLUTION
Counsel the person on the benefits of testing

Counsel the person on the benefits of knowing
ones status early i.e. initiation of therapy
Counsel the person on the available options for
treatment
Counsel the person on all aspects of ICTC
Remember that more than one session of counseling
may be required Details on both pre and post test
counseling refer to Counselling unit
Details on Therapy for options on care
Screening for safety purpose

Screening is allowed for
Safe blood supply

Sero Prevalence study: This is unlinked anonymous screening that helps to collect quantitative data to
understand whether the epidemic is worsening or under control
Refer laws in relation to HIV given earlier in the Chapter
Possible advice a nurse could give a couple that is HIV positive

If the husband and wife are both positive
All couples by duty of health care personnel must be counseled in order to reduce transmission.
Discuss family planning options
The option of adoption should be made known to them. However the ultimate decision must be that
of the couple
The couple needs to be explained about the consequences of having their own child
They must be explained about the need to practice safe sex i.e. the use of condoms in order to prevent
re-infection with HIV
Ethical issues in relation to privacy & confidentiality
Healthcare Providers should protect patient confidentiality

Unwanted disclosure should be prohibited
Treating health care team should have access to his HIV status
Counsel the concerned person on the need for disclosure to significant others, identified by PLHIV.
PLHIV must be counselled on the need for disclosure to the partners/Spouse

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After repeated counselling, if a PLHIV still does not agree to disclose HIV status to the sexual partners/
spouse the primary HCP could take on the responsibility of disclosing the information to them following
assessment of risk to the partner
The PLHIV should be informed to whom HCP will reveal their HIV status and what the benefits of doing
so will be. This holds true even if disclosure is to other health care providers.
The PLHIV should also be encouraged to disclose information with the family as it may facilitate homebased care and support.
Allow disclosure to sexual or needles sharing partner only person concerned has to give consent for
the same
Identification of HIV status should not be marked on the persons medical record
Reporting to health authorities as per prescribed government format
Discuss options with PLHIV on whom to disclose status.
No mandatory testing
Results to be kept strictly confidential
Shared Confidentiality (Sharing of HIV status with significant others of PLHIV and the health care team
with consent of PLHIV)
Offer Provider Initiated Counseling and Testing (PICT)
Informed consent from Clients
Motivate for Partner notification and testing.
8. CODE OF ETHICS & PROFESSIONAL CONDUCT-INC

The code of professional conduct for nurses is critical for building professionalism and accountability. Ethical
considerations are vital in any area dealing with human beings because they represent values, rights and
relationships. The nurse must have professional competence, responsibility and accountability with moral
obligations. Nurse is obliged to provide services even if it is in conflict with her/his personal beliefs and
values.
Purpose
The purpose of professional conduct is to inform both the nurse and the society of the minimum standard
for professional conduct. It provides regulatory bodies a basis for decisions regarding standards of professional
conduct.
The code of ethics helps to protect the rights of individuals, families and community and also the rights of
the Nurse.
The use of the code
Acknowledges the rightful place of Individuals in health care delivery system

Contributes towards empowerment of individuals to become responsible for their health and well-being
Contributes to quality care
Identifies obligations in practice, research and relationships
Informs the individuals, families, community and other professionals about expectations of a nurse
9. HIV/AIDS AND THE LAW

Rights are justified claims that individuals or groups can make upon other individuals or upon the society.
PLHIV have the same rights as HIV negative people - right to education, employment, health, travel,
marriage, procreation, privacy, social security, scientific benefits, asylum, etc.
LEGAL & ETHICAL ISSUES AROUND HIV AND SHARED CONFIDENTIALITY AND PARTNER
DISCLOSURE
Some existing Indian laws related to HIV/AIDS:
Malignant act likely to spread infection of disease dangerous to life
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Drug and Cosmetic Rule: screening of donated blood and organs for HIV
Artificial Insemination Act: appropriate HIV testing to be done before insemination
Bio-medical waste management regulations
Requirements of notification to public health officials of infectious diseases
Legal & ethical issues around HIV testing and screening
Counselling and informed consent are essential requirements of HIV testing

No individual should be made to undergo mandatory testing for HIV
No mandatory HIV testing should be imposed as a precondition for employment or for providing health
care facilities during employment.
In India it is aimed to get ALL antenatal mothers are provided for counselling tested for HIV. The
procedure is as follows in the PPTCT centre
Mothers are counselled in a group
They are given information on HIV infection and the advantages of testing
They are told that they will be tested
If they choose not to undergo the test, they cannot be forced to do so. They can only be tested
after they have given voluntary informed consent
Results should be kept strictly confidential
Provider Initiated Counselling & Testing
Identify prospective client(s) at DOTS centers, STI clinics, Medicine OPD, ANC clinic, Skin OPD,
General Clinics in PHCs and CHCs
Motivate the client s having following conditions for testing
- STI
- TB
- Chronic diarrhea
- Weight loss
- Chronic fever
- Chronic cough
- Herpes Zoster
- Oral Candidasis
- Recurrent oral ulcers and
- Lymphadenopathy
- Pregnant women
Legal & Ethical issues around HIV and pregnancy
HIV-positive women and couples should have complete choice in making decisions regarding pregnancy
and childbirth
The risk involved of getting re-infected and also with a different strain of HIV during sexual contact is
high and this must be mentioned to the couple when they plan to have a child
Couples should be counselled for prevention of parent to child HIV transmission
Educate on the following aspects:
Risks of HIV transmission to the baby
Preventive services available to reduce risk of transmission under the PPTCT programme
Legal & ethical issues around PLHIV access to health care
No patient can be denied care and treatment on the basis of their HIV Sero-status.
Intensive advocacy and sensitization among doctors, nurses and other paramedical workers is needed
to prevent discrimination against PLHIV
Biomedical waste management- legal aspect-detail-act
All HCP must be trained on Infection Control and Medical Waste Management
Strict enforcement of bio-safety and infection control measures in the hospitals is needed
Treatment of AIDS cases do not require any specialized equipment other than what is necessary for
treatment of opportunistic infections arising out of HIV/AIDS

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10. RESPONSIBILITIES OF PLHIV

Educate the PLHIV: Just as health care practitioners have responsibilities towards PLHIV and others, PLHIV also have
responsibilities towards society as a whole:
To preserve human life

Not to infect others deliberately - Indian Penal Code: 270. Malignant act likely to spread infection of
disease dangerous to life - whoever malignantly does any act which is, and which he knows or has
reason to believe to be, likely to spread the infection of any disease dangerous to life, shall be punished
with imprisonment of either description for a term which may extend to two years, or with fine, or with
both.
To inform their sexual partners about their HIV Status.
To take steps, while they are able, to contribute to family and community.
Key Messages :
Stigma and discrimination are evident by the following
Treating people differently
Naming/labeling a person as HIV positive
Placing a sticker on the bed to show that the person is HIV seropositive
Stigma and discrimination discourages
People coming forward for HIV testing
People from disclosing their HIV status to their partners, leading to spread of HIV
PLHIV from accessing services treatment for OIs or ART
People from caring for PLHIV
Stigma and discrimination are linked. Stigmatised individuals may suffer discrimination and human
rights violations. Stigmatising thoughts can lead a person to act or behave in a way that denies
services or entitlements to another person.
Nurses can reduce stigma in the health care setting by:
Recognizing stigma and discrimination when it occurs
Speaking up on the rights of PLHIV
Educating all health care personnel on HIV causes, transmission, prevention and management
Training all health care personnel on infection control measures
Educating the public about HIV, causes, transmission, prevention and its management
Taking measures to ensure confidentiality of the PLHIV
The fundamental rights of PLHIV need to be respected by
Providing counselling and obtaining informed consent for HIV testing
Protecting patient confidentiality
Encouraging disclosure of HIV status to partner/ family
Counselling couples for prevention of parent to child HIV transmission
Providing quality care and treatment
HIV positive persons have a right to live with the same dignity as others
Nurses could play a vital role in handling networking with other groups to meet the legal and ethical
issues that relate to persons with HIV/AIDS
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UNIT 3 HIV EPIDEMIOLOGY

Unit Objectives
Define HIV and AIDS
Describe how HIV works in the body
Explain HIV transmission and factors that increase the risk
Explain different types of HIV tests, understand NACO Testing strategies
Define window period and Seroconversion
Describe progression and staging of HIV
Nurses Role in Disease Progression
1. HIV EPIDEMIOLOGY AND DISEASE PROGRESSION
What is the immune system?
We need to know what the immune system is and how it works in order to fully understand how HIV affects
the body
Immune system protects and defends the body from infections

White blood cells (WBCs) are the most important part of the immune system
WBCs fight and destroy bacteria, fungi, and viruses that enter the body
CD4 cells: It is also known as helper T cell or CD4 lymphocyte. It is a type of white blood cell (WBC)
that carries the CD4 receptor on its surface and fights infections. It signals other cells in the bodys
immune system to perform their special functions and coordinates immune response. The number of
CD4 cells in a sample of blood is an indicator of the health of the immune system. HIV infects and kills
CD4 cells, leading to a weakened immune system
What are HIV and AIDS?

HIV
H
I
V
Human
Immunodeficiency
Virus
HIV is the acronym for human immunodeficiency virus.
A person infected with HIV is known as an HIV positive person.
HIV is a retrovirus. The genetic material of retroviruses is carried in the form of RNA rather than DNA.
HIV cannot be destroyed by the body. An infected person carries HIV for life.
AIDS
A
I
D
S
Acquired (not inherited - contracted by direct contact with body fluids that have high concentrations
of HIV, either from high risk behaviour or exposure)
Immune (weakens the immune system)
Deficiency (of certain white blood cells -T4 lymphocytes in the immune system)
Syndrome (a group of symptoms or illnesses as a result of HIV infection)

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HIV and AIDS are different!

HIV is the virus that weakens the immune system.
The collective presence of different opportunistic infections, as a result of immune deficiency, is
known as Acquired Immune Deficiency Syndrome (AIDS).
AIDS is defined by:
A loss of CD4 T lymphocytes such that CD4 count is in an HIV infected individual < 200. (However
some patients with CD4 < 200 continue to display reasonably good health).
The appearance of opportunistic infections and/or cancers
PLHIV may be infected with HIV for many years before their immune system is damaged sufficiently
(CD4<200) to cause opportunistic infections and hence AIDS.
How HIV works in the body?

HIV uses the CD4 cell like a factory to reproduce more of itself. The figure below shows the steps in HIV
cell replication.
3. Integration into host cells

nucleus
HIV
4. Reproduction of
viral components
1. Attachment
to host CD4
cell
2. Reverse
transcriptase
makes DNA
from the
viruss RNA
5. Assembly of
new HIV
viruses
6. Release
How HIV causes AIDS?
Viral replication leads to decrease in CD4 cells

As viral replication continues there is further impairment of the immune system reducing the bodys
capacity to fight infections
The individual becomes more susceptible to opportunistic infections
AIDS is characterised by the presence of opportunistic infections
What is the difference between HIV and AIDS?
HIV is a virus and AIDS is a disease

AIDS is deficiency in the bodys defence mechanism or immune system
AIDS is acquired, not hereditary
HIV infection leads to AIDS, depending on the bodys defence mechanism
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2. HIV TRANSMISSION
How is HIV Transmitted?
Body fluid considered at risk for HIV,
contaminated exposure
Contaminated Blood
Semen, Breast milk.
Vaginal secretions
Cerebrospinal Fluid
Synovial, pleural, peritoneal, pericardial fluids
Amniotic fluids
Other fluids contaminated with visible blood
How HIV is not transmitted!

Body fluid considered not at risk
exposure (Unless contaminated with
visible blood)
Tears
Sweat
Urine and faeces
Saliva
HIV cannot be transmitted by:

Kissing
Hugging
Swimming in the same pool/pond
Sharing cooking utensils, same toilet,
clothing and bed linen
Cooking/Eating food cooked by a PLHIV
Having daily contact with
PLHIV
Insect bites
Biological factors that increase risk of HIV transmission from host

Host
Recipient
High viral load

Primary HIV infection
Advanced disease
Presence of blood, semen or genital
secretions during contact
Female/Infants
Poor health
Presence of STI (if route is sexual)
Exposure to blood, semen or genital secretions
Trauma during sexual activity
Agent: HIV
Why are women at higher risk for infection?
Large amount of mucosal surface area in the vagina

There is pooling of semen during intercourse
Women are especially vulnerable to HIV through sexual contact:
When they are young because of an immature genital tract
When they have STIs
When they undergo menopause leading to fragile vaginal tract

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Understand biological and social factors affecting HIV transmission effecting patients attitudes to HIV/
AIDS and ability to access health care.
Work with patients to find positive solutions to problems and refer to organizations for Further Support.
Socioeconomic factors that affect HIV transmission
Initially, HIV infection in India was restricted to high-risk populations: sex workers, trafficked women, or men
having sex with men (MSM) and injection drug users.(IDUs)
HIV today is no longer restricted to any particular group. It has reached the general population - which
includes married women, babies and children, youth, and men who have never had any high-risk behaviour.
Infected individuals can transmit HIV infection through unsafe contact (e.g. unprotected sex, needle sharing)
to individuals who belong to the bridge population. Once a member of the bridge population (e.g. truck
drivers, clients of sex workers, migrants, etc.) gets back to their home, they can infect their wives/partners,
who in turn can infection to pass on their babies.
High-risk
Populations
Sex Workers
Trafficked women
Men who have sex
with men
Needle sharing
drug users
Bridge Populations
Clients of sex workers
Partners of IDUs
Migrant / mobile
populations
Truck drivers
Populations in conflict
situation
General Population
Married women
Infant, Children and
Youth
Men & woman
Social Mobility: HIV/AIDS follows routes of commerce, and with globalisation, it has now spread all over
the world and into the general population.
Gender: Cultural practices that support multi-partner relationships for men and lack of negotiating power
of women enable transmission of HIV. Unequal distribution of power between men and women creates
barriers for women to negotiate precaution for HIV and other STIs.
Poverty: Results in lack of access to information, care, and treatment, thus enabling spread of HIV.
Cultural: Traditions, beliefs, and practices affect understanding of health and disease and acceptance of
conventional medical treatment.
Stigma and Denial: Denial and silence about HIV is the norm. Stigma prevents people form getting tested
and seeking care which enables the spread of HIV.
Drug Use and Alcohol Consumption: Leads to impaired judgement and encourages high risk behaviour
such as sharing needles and unsafe sex, which contributes to the rapid spread of HIV not only in high risk
groups, but also to the general population.
People in Conflict: People who live in areas of conflict and war are often subject to violence or may get
involved in unsafe practices that could result in increased spread of HIV.
3. HOW IS HIV DIAGNOSED

There are two types of tests which are used to diagnose HIV infection.They are :
HIV Antibody Tests
HIV Antigen Tests
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Antibody: A substance that is produced by the immune system in response to specific antigens,
thereby helping the body fight infection and foreign substances.
HIV Antibody Tests are:
Most commonly used tests for diagnosis (age > 18 months)

Economical
Rapid
Can be performed easily in most laboratories
They are:
HIV Rapid test
ELISA
Western Blot Test (Confirmatory Test)
3 tests are done before declaring whether a person is HIV positive or negative. In case of indeterminate
results or if the person is in the window period the person is advised to return for HIV testing again and
is counseled to stay HIV negative .
Antigen: Any substance that antagonizes or stimulates the immune system to produce antibodies (i.e.
proteins that fight antigens). Antigens are often foreign substances such as bacteria or viruses.
HIV Antigen Tests
Detect HIV sooner than antibody test

Usually used for
Diagnosis: age < 18 months
Monitoring HIV disease progression
Monitoring response to ARV therapy
Expensive
Require expertise to perform and interpret
They are:
DNA PCR
P24 Antigen
NACO Testing Strategies

Strategy I
For Transfusion/transplantation safety, One test kit required

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Under NACO Testing Strategy I, for Transfusion or Transplant safety purposes, only one test kit is
required.
If the test result is positive, the sample is considered positive for HIV infection.
If the test result is negative, the sample is considered negative for HIV infection.
As per the guidelines to ICTCs, the unit of blood is destroyed.
Note :
1. All HIV tests are to be administered with Pre test Counselling.
2. All HIV test reports ( whether negative or Positive) are to be handed over to the client with Post
Test Counselling.
NACO Testing Strategy (II A)
For Surveillance-2 test kits required
NACO strategy II A is employed for surveillance purposes. For this, two (2) testing kits are required.
If the first blood test shows negative result , the sample is considered negative for HIV infection.
But if it shows positive result, blood sample is retested with a second test kit. If the second test result is
positive, the sample is considered positive for HIV infection.
If the second sample is negative, it is considered negative for HIV infection.
Note :
Test Counselling.
NACO Testing Strategy (II B)
Diagnosis of an Individual with AIDS indicator disease symptoms (3 Test Kits Required)
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NACO Testing strategy II B is used for diagnosis of an individual with AIDS indicator disease symptoms.
To conduct the blood test,3 Test kits are required.
If the first blood test result is negative, the sample is considered negative for HIV infection.
If the test result is positive, the sample is retested with the second kit.
If the result is positive, the sample is considered positive for HIV infection.
If the results are negative, the sample is tested with the third kit.
In this case, if the result with this kit, is positive, the sample is considered positive for HIV infection.
But if the results are negative, the sample is considered negative for HIV infection.
Note :
Test Counselling.
NACO Testing Strategy (III)
Detect HIV infection in asymptomatic persons (3 Test Kits Required)

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NACO Testing Strategy III is used to detect HIV infection in asymptomatic persons and 3 Test kits are
required.
If the first test result is negative, the sample is considered negative for HIV infection.
If the result is positive, the sample is retested with second kit.
If second test results is also positive, the sample is tested again with the third test kit.
If the third test result is positive, the sample is considered positive for HIV infection.
If the third test result is negative, the sample is considered equivocal and is subjected to a Confirmation
Test with Western Blot/ DNA PCR.
If second test result is negative, the sample is tested again with the third test kit.
If the third test result is positive, the sample is considered equivocal and is subjected to a Confirmation Test
with Western Blot/ DNA PCR.
If the third Test result is negative, the sample is considered for HIV infection.
Note :
2. All HIV test reports (whether negative or Positive) are to be handed over to the client with Post
Test Counselling.
Interpretation of Antibody Test Results: Special Cases
HIV positive individuals recently infected in the window period could get negative test results
Usually 2-6 weeks
Can be 2-12 weeks
Rarely up to 6 months after exposure
HIV negative children <18 months born to HIV positive women can get positive test results
The Window Period for a test designed to detect a specific disease (particularly infectious disease) is the
time between first infection and when the test can reliably detect that infection.
In Antibody-based testing, the window period is dependent on the time taken for sero conversion.
The window period is important to Epidemiology and safe sex strategies, and in blood and organ donation,
because during this time, an infected person or animal cannot be detected as infected but may still be able
to infect others. For this reason, the most effective disease-prevention strategies combine testing with a
waiting period longer than the tests window period.
Therefore, the nurse must stress upon the need for repeated antibody testing and safe sex and risk
reduction counseling for people who test negative.
For Children born to HIV-positive mothers, false positive test results may occur up to 18 months of age
because mothers pass HIV antibodies to their newborn children during antenatal period.
3. HIV DISEASE PROGRESSION

Progression to AIDS among individuals is variable, with some individuals progressing as rapidly as within
1 to 2 years, while others remain healthy for many years.
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Source: Fauci et al. Ann Intern Med. 1996: 124: 654-663.
Clinical Staging System for HIV Disease Progression

Primary HIV Infection
or Acute Retroviral
Syndrome (ARS)
When HIV first enters the body, the immune system recognises the
antigen and causes flu-like symptoms. During this time, HIV viral load
is high and therefore infected person is highly infectious and can easily
transmit virus to others during this time. ARS is symptomatic in 53% to
90% of people. Occurs 2 4 weeks after exposure and lasts 12 weeks
Common Symptoms: Fever, Rash, Lymphadenopathy, Pharyngitis,
Erythematous maculopapular with lesions on face/trunk and
sometimes palms or soles, Myalgia or Arthralgia, Lethargy/Malaise
Window period
Once body is infected it usually takes 2 to 12 weeks for it to develop

HIV antibodies. During this window period the person although
infected, tests negative for HIV antibodies.
Asymptomatic
Chronic Infection
Early immune depletion - CD4>500. Level of virus is low. HIV replication

takes place mostly within lymph nodes. Generally lasts 5 years or more.
May be less for patients with malnutrition or co-infection. Generalised
persistent lymphadenopathy. Usually no other symptoms
Symptomatic
HIV Infection
Intermediate immune depletion CD4 between 200-500 Infections start

and persist as CD4 count decreases. ART and OI prophylaxis
considered.
Advanced HIV
Infection/AIDS
Advanced immune depletion CD4<200. Case definition of AIDS is

having a CD4 count of <200. OIs develop.
OIs are the leading cause of morbidity and mortality in HIV-infected individuals. The most common
OIs are preventable and treatable.
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4. WHO CLINICAL STAGING OF HIV/AIDS FOR HIV-INFECTED ADULTS &

ADOLESCENTS 2006
WHO has developed a staging system in which four clinical stages of disease are identified based on
certain signs and symptoms. These stages give us an idea of the severity of disease and prognosis and
facilitate planning for appropriate treatment and care.
CLINICAL STAGE 1
Asymptomatic
Persistent generalized lymphadenopathy
CLINICAL STAGE 2
Unexplained moderate weight loss (<10% of presumed or measured body weight)

Recurrent respiratory tract infections (sinusitis, tonsillitis, otitis media, pharyngitis)
Herpes zoster
Angular cheilitis
Recurrent oral ulceration
Papular pruritic eruptions
Seborrhoeic dermatitis
Fungal nail infections
CLINICAL STAGE 3
Unexplained severe weight loss (>10% of presumed or measured body weight)

Unexplained chronic diarrhoea for longer than one month
Unexplained persistent fever (above 37.5oC intermittent or constant for longer than one month)
Persistent oral candidiasis
Oral hairy leukoplakia
Pulmonary tuberculosis
Severe bacterial infections (e.g. pneumonia, empyema, pyomyositis, bone or joint infection, meningitis,
bacteraemia)
Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis
Unexplained anaemia (<8 g/dl ), neutropenia (<0.5 x 109 /L) and or chronic thrombocytopenia (<50 X
109 /L3)
CLINICAL STAGE 4
HIV wasting syndrome

Pneumocystis pneumonia (PCP)
Recurrent severe bacterial pneumonia
Chronic herpes simplex infection (orolabial, genital or anorectal of more than one months duration or
visceral at any site)
Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs)
Extrapulmonary tuberculosis
Kaposis sarcoma
Cytomegalovirus infection (retinitis or infection of other organs)
Central nervous system toxoplasmosis
HIV encephalopathy
Extrapulmonary cryptococcosis including meningitis
Disseminated non-tuberculous mycobacteria infection
Progressive multifocal leukoencephalopathy
Chronic cryptosporidiosis
Chronic isosporiasis
Disseminated mycosis (extrapulmonary histoplasmosis, coccidiomycosis)
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Recurrent septicaemia (including non-typhoidal salmonella)

Lymphoma (cerebral or B cell non-Hodgkin)
Invasive cervical carcinoma
A typical disseminated leishmaniasis
Symptomatic HIV associated nephropathy or Symptomatic HIV associated cardiomyopathy
NURSES ROLE IN CLINICAL STAGING

Nurses play an important role in:
Identifying and referring patients who may need

HIV testing
HIV treatment and care
Educating patients about

What to expect (e.g. OIs)
Healthy life style practices
Adherence to treatment
Counselling patients about

Risk reduction strategies
Palliative care
Key Messages :
HIV is a virus that destroys the immune system
It uses the CD4 cells for its replication
AIDS is the end-stage of HIV infection
HIV is transmitted through
Unprotected sexual contact with a HIV+ person.
Transfusion of infected blood/blood products
Sharing needles
Infected mother to child during pregnancy, child birth and breast feeding
Women are at greater risk of acquiring HIV through sex
HIV progression to AIDS can be controlled by
Taking good nutrition
Practicing safe sex
Getting support for emotional problems
Treating any infection correctly
Taking ART when prescribed
Accurate knowledge of HIV disease progression will enable the nurse to:
Recognise a person with a possible HIV infection
Refer people at risk for HIV infection for HIV testing
Educate and counsel patients and families on:
The importance of early testing and diagnosis
What the patient can expect
A healthy lifestyle
The importance of ART
Prevention of transmission
Palliative Care
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UNIT 4 COUNSELLING FOR PLHIV

Unit Objectives
Describe the key elements of counselling
Describe the various types of counselling for PLHIV
Identify the important issues in ongoing counselling for PLHIV during each stage of
disease
Demonstrate counselling skills through role play practice
1. HIV AND COUNSELLING

Counselling services are the backbone of the HIV program. Counselling is offered through the ICTC
program for people at risk, pregnant women and their spouse, Infant feeding for HIV positive mothers,
importance of institutional delivery and treatment for positive women. At the ART centre counselling is
offered for treatment adherence, home based care, diet and nutrition etc. The CCC counsellor supports the
care and support program by offering counselling for treatment adherence, creating social and familial
support, positive living and end of life care. Counsellors at the Blood banks offer pre-donation counselling
including HIV counselling. Under the Targeted Intervention program (TI) the role of the counsellor is to
counsel people at risk for HIV to motivate them to test for HIV and reduce risk.
2. WHAT IS COUNSELLING?
Counselling is a dialogue between the client and Care provider aimed at enabling him/her to cope with
stress and make personal decisions e.g. decisions relating to HIV/AIDS. The process involves identification
of the Problem, gaining insight , knowledge and skills to cope with the problem and ultimately, behavior
change leading to positive living.
Specific goals of counseling are based on the presenting problem or the need of the client.
Different Counselling Settings their Target Group and Main Counseling Goal:
Counselling Setting
ICTC
(Voluntary
Clients)
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Target Group
Main Counselling Goal
Pre test
General population,
voluntary & referred
Decision re. HIV testing

Risk reduction
Post
test negative
HIV negative
clients
Risk Reduction & prevention,

Partner testing
Post test
positive
HIV positive
clients
Psychological support
Risk Reduction
Disclosure & partner testing
Positive Prevention
Referral to care, support &
treatment

Counselling Setting
PICT
(Provider
Initiative
Counseling
and Testing)
(eg: Pregnant
women)
Target Group
Main Counselling Goal
Pre test
Pregnant women
(ANC attendees
TB/STI)
Decision re. HIV testing

Spouse Involvement
Risk reduction
Post test
negative
HIV negative
mothers
Prevention
Safe motherhood
Post test
positive
HIV positive
mothers
PLHIV on ART
Treatment preparedness
Treatment adherence
Treatment support
ART
Psychological support
Safe motherhood
Nevirapine prophylaxis
Delivery options
Infant feeding practices
Referral to care & treatment
3. HOW IS COUNSELLING DIFFERENT FROM PATIENT EDUCATION?

Patient education
Counselling
Assesses understanding of health related

information
Includes patient education
Gives valuable information about disease

and treatment
Helps PLHIV identify feelings, risk behaviours,

readiness to change behaviour etc.
Facilitates confidence in self care
Guides PLHIV to establish a plan

Facilitates clear thinking and decision making
4. KEY ELEMENTS OF EFFECTIVE COUNSELLING

In order to be effective counsellors, we need to put into practice effective communication. As HIV infection
has many implications on the physical, emotional, social, and spiritual well being of a person, this
communication needs to occur within a supportive environment. The components of effective communication
and a supportive environment are listed below in the table.
EFFECTIVE COMMUNICATION
SUPPORTIVE ENVIRONMENT
Message
Be positive, focused
Make the listener comfortable
Ask for a feedback
Emphasise important points
Timing
Be sure patient is ready for the information
and counselling
Schedule at a convenient time for the patient
Listening/Non verbal communication

Maintain eye contact and smile
Lean toward the person, say
yes hmm and OK
Do not hesitate to touch the person
when needed
Place: Ensure privacy and comfort

Acknowledge the feelings of the patient.
Assess the main concerns of the patient
Address concerns based on the patients
priorities
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EFFECTIVE COMMUNICATION
SUPPORTIVE ENVIRONMENT
Tone
Use a tone of voice that encourages
communication
Utilize praise and encouragement more
Begin with less intimidating/less sensitive issues

start with topics that the patient is
comfortable discussing, e.g. his/her work
rather than the sexual history
Questioning technique
Use open ended questions and state
them clearly
Wait for answers rather than speaking
immediately
Repeat questions when not understood
Using positive messages while communicating with PLHIV is more effective than using negative messages.
When giving messages, always try and frame them so that they are positive rather than negative.
5. COUNSELLING IN HIV CARE
STIGMA &
DISCRIMINATION
IS RELATED TO
HIV
DECISION TO
UNDERGO HIV
TEST CAN BE
FACILITATED
ENSURE
ADHERENCE TO
TREATMENT
TO IMPROVE THE
QUALITY OF
LIFE/POSITIVE
LIVING
IMPORTANCE
OF
COUNSELLING
PREVENTION OF
TRANSMISSION
OF HIV/AIDS
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HIV IS A LIFETHREATENING,
LIFE-LONG
DISEASE
PHYSICAL
PSYCHOLOGICAL
AND SOCIAL
IMPLICATIONS
OF HIV

Counselling aims at:

AIMS
PROVIDING PSYCHOLOGICAL,
SOCIAL AND EMOTIONAL
SUPPORT FOR
PEOPLE
WHO HAVE
CONTRACTED
THE VIRUS
OTHERS
AFFECTED
BY THE
VIRUS
PREVENTING TRANSMISSION OF HIV BY
PROVIDING IN
INFORMATION
ABOUT RISK
BEHAVIOURS
(SUCH AS
UNSAFE SEX
OR NEEDLE
SHARING)
MOTIVATING
PEOPLE TO
TAKE GOOD
CARE OF THEIR
HEALTH
ASSISTING
PEOPLE TO
DEVELOP
PERSONAL
SKILLS
NECESSARY
FOR
BEHAVIOUR
CHANGE
ADOPTING
AND
NEGOTIATING
SAFE SEXUAL
PRACTICES
I.
Principles to be kept in mind while counselling clients with HIV/AIDS
Respect the patient.

Build a non-judgmental & non-threatening relationship
Have high level of acceptance
Use simple language & Short sentences
Avoid using jargons
Listen actively
Be sensitive to the needs of the client.
Provide individual- based counseling.
Provide privacy
Provide a comfortable environment
Provide realistic options
Watch for non-verbal messages & facial expression
ENSURING
EFFECTIVE USE
OF TREATMENT
PROGRAMMES
BY
ESTABLISHING
TREATMENT
GOALS AND
ENSURING
REGULAR
FOLLOW-UP
Counselling within the context of HIV care includes:
Pretest and post test counselling;

Follow up and long term counselling (ongoing counselling).
Each stage of counselling involves multiple sessions. These sessions may be of different lengths and
intensity, but they are all equally important and contribute to the overall counselling success.
6. PRE-TEST COUNSELLING
(i) Goals:
Prevent transmission
Prepare the person emotionally for a positive or negative result
Identify strengths and weaknesses of person
(ii) Steps in pre-test counselling

(a) ASSESS need for HIV test: it is important that you are able to identify who needs to be referred for
an HIV test. Assess the persons risk status: by obtaining a reliable personal history of the patient
concerned. You do not need to go into detail, but use the examples of risk assessment questions
provided below as a guide.

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(b) Ask the Client
Do you have sex with more than one person?

Do you have sex with men or women or both?
Do you have oral, anal or vaginal sex without using a condom?
Do you have sex with someone with known or suspected history of
Multiple sex partners
Bisexuality
Intravenous drug use
Taking other drugs
Receiving blood transfusion
Have you ever had
Genital ulcers
Warts
STDs such as Syphilis, Gonorrhea, crabs, Scabies, Herpes, Hepatitis B
Have you ever self injected any drugs intravenously and if so, do you share needles?
WHO SHOULD UNDERGO HIV TESTING?

Any person who wants to be tested (voluntary)
All pregnant women and women considering pregnancy

Those with high risk behaviours (e.g. Mutiple partners, drug abuse)
Men who have Sex with Men - MSMs
Persons with multiple sexual partners or who trade sex for money, pleasure or drugs
Sexual partners of people who have high risk behaviours.
Injecting drug users (IDUs) and their partners.
Recipients and donors of blood, organs and sperm
Persons with sexually transmitted infections (STIs)
Hepatitis B, Hepatitis C (non A / B Hepatitis)
Tuberculosis infected persons
Persons with AIDS like illness or illness consistent with AIDS
Infants born to HIV infected or high risk mothers
(c) Provide Information

Be
sure patient understands:

HIV disease and transmission
The purpose and limitations of HIV testing
Meaning of test results
Availability and importance of treatment and counselling
(d) Describe testing procedure
In ICTCs, the cost of testing and counselling services is free

Rapid test for detecting antibodies to HIV is done
Results could be obtained the same day,by the client himself/herself., only.
Three positive tests on the same blood sample are needed to confirm diagnosis
(e) Obtain Informed consent and reassure Confidentiality
Informed consent:
It is a written consent obtained from clients for HIV testing after providing them the following information
The reasons why HIV counselling and testing is being recommended
The clinical and prevention benefits of HIV testing and the potential risks, such as discrimination,
abandonment or violence
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The services that are available in the case of either an HIV-negative or an HIV-positive test result,
including whether antiretroviral treatment is available
The fact that the test result will be treated confidentially and will not be shared with anyone other
than heath care providers directly involved in providing services to the patient
The fact that the patient has the right to decline the test and that testing will be performed unless
the patient exercises that right
The fact that declining an HIV test will not affect the patients access to services that do not depend
upon knowledge of HIV status
In the event of an HIV-positive test result, encouragement of disclosure to other persons who may
be at risk of exposure to HIV
An opportunity to ask the health care provider questions
Confidentiality: This is a very important component of counselling .the client has to ensured that the
information shared by him and his HIV status will not be known to any other person except himself and
the counselor.
Shared confidentiality : Under special circumstances the HIV status of the person can be shared with
the health care worker ( doctor/nurse ) and this is called Shared confidentiality.
7. POST-TEST COUNSELLING
Post-test counselling should follow HIV testing once the results are known
(i) Goals:
Inform the patient of his/her status

Provide accurate information regarding care and treatment
Get the partner tested.
Link to services NGO/CBO etc.
Provide emotional support
Prevent HIV transmission
Link to ART centres if positive for treatment, care and support.
(ii) When delivering a HIV negative result, remember:
Check if the person is ready for the result

If not, suggest a later date and ask him/her to bring a support person if needed
Give results with an explanation of the window period and on-going risk of infection
Reinforce HIV prevention and risk reduction information
(iii) When delivering an indeterminate result, remember:

Give results with an explanation of the window period and on-going risk of infection
Inform on need for further testing
Inform to avoid donating blood, semen, breast milk or organs till confirmed negative.
(iv) When delivering a Positive result remember:

Give results clearly and sensitively and deal with immediate reactions
Allow time for result to sink
Give information according to the needs of the person, using a positive approach
Give information about availability of care and treatment including referral to ART centres

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(v) When delivering positive result to pregnant mother?

In addition to the above
Moderate institutional delivery

Discuss infant feeding option
Focus on further family planning
Mother baby follow up
Provide treatment options
(vi) Possible Responses of PLHIV and Family to HIV Positive Result:

People have different responses to crises. The time of diagnosis of HIV could be a crisis for any person.
Some possible reactions to an HIV positive result are listed in the box below. However, remember that
people may not go through all of the reactions listed before they reach acceptance (if at all), and that PLHIV
and their families can feel these emotions during any time of the disease progression - not only at the time
of diagnosis.
8. PSYCHOLOGICAL IMPLICATIONS OF THE DIAGNOSIS:

PLHIV/Family immediate reaction to diagnosis:
Shock
Anger
Denial and disbelief
Guilt or shame
Blaming
PLHIV/Familys late reaction to diagnosis:
Depression
Suicidal tendencies
Crisis points for Patient and Family
First hospitalization, first OI or new symptoms

Recurrences or relapses
Terminal stage of illness
What should the nurse do?
Recognise the crisis

Provide emotional support
Educate and counsel
Identify community resources
Facilitate homebased care
9. ONGOING COUNSELLING
Goals:
To provide support for the PLHIV with regards to
Enhanced coping skills

Reduction of risk for re-infection
Reduction of risk for transmission to others
Prevention or treatment of OIs
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Improve nutrition( Nutrition Counseling )

Adherence to ART( Adherence counseling )
Positive living
Depression is commonly seen any time during the course of the disease progression but is usually identified
and dealt with during ongoing counselling.
10. IMPACT OF DEPRESSION ON HIV DISEASE ROGRESSION

Depression is a significant problem in HIV, since it
increases the risk for HIV transmission

may have a negative impact on adherence
may affect quality of life
is a predictor of poor treatment outcome
The Role of the Nurse in Care of a Patient with Depression

We have seen above that depression can have a negative impact on HIV disease progression and the
PLHIV quality of life. Thus, it is essential that nurses be able to identify depression as early as possible
in PLHIV, so that the necessary care and treatment can be provided.
Signs and Symptoms of Depression
Feelings of guilt
Sleep disturbance
Appetite/weight changes
Attention/concentration changes
Psychomotor disturbance/slowing
Depressed mood
Loss of interest or pleasure
Fatigue/Loss of energy
Suicidal thoughts
Nursing Interventions
Assess for level of depression

Supervise client closely.
Never allow the client to be alone
Provide therapeutically safe environment.
Refer for appropriate treatment
Get the family or support person to get involved in care of the PLHIV
Encourage the use of coping skills- spiritual help, relaxation techniques
Show the person with depression other PLHIV who are coping well, to restore hope
Encourage PLHIV to join positive network groups for support and help
11. SUICIDAL TENDENCIES

Degree of depression: Suicide usually occurs in the middle range of depression when the patient still feels
hopeless but can mobilize energy to act on it. The risk is highest during transitional periods (diagnosis of
HIV or AIDS, first hospitalisation, first OI or new symptoms, recurrences or relapses, terminal stage of
illness).
Again, as in depression, nurses can play a vital role by recognizing suicidal intentions and acting appropriately
to safeguard the patient.

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Assessment
Look for
What you could do
Past history of suicide attempt
Feelings of sadness
Refer for immediate psychiatric

intervention
Sample questions:
Have you ever thought
life is not worth living?
Do you often think of
death?
Do you think about
hurting yourself?
How might you do that?
Is this something you
feel you might do?
Reports of feeling empty

or hopeless
Ensure patient safety
Sleep or appetite disturbance
Administer medications to
manage the depression
Inability to experience pleasure

in activities that person earlier
found pleasurable
Fatigue and lack of energy
Encourage family member or

support person to remain close
to the PLHIV and to get
involved in care
Passive withdrawal from

treatment
Verbalising suicide plan
Examples of positive and negative messages
POSITIVE MESSAGES
NEGATIVE MESSAGES
Using condoms will help you be free of STIs
Not using condoms could put you at risk of

getting STIs
Safe sex practices will help protect yourself

as well as protect others
If you do not practice safe sex, you could get an

STI and you could transmit HIV to others.
Taking your ART exactly as prescribed every

day will prevent you from developing
resistance to the medications and keep you
healthy for a longer period of time.
If you do not take your ART exactly as prescribed

every day, you will get resistance to HIV, and
the medications will not work for you.
Avoiding counselling mistakes

Counselling is not an easy task, and skills will improve with practice. Use the tips below to help avoid simple
counselling mistakes.
DO
DO NOT
Encourage spontaneous expression of feelings and needs
Control
Be neutral to allow patients to express concerns
Judge
Ask patients what they think they can change/do better next time
Moralize
Find out the persons fears, anxieties
Label
Tell the facts gently to the patient
Give false reassurance
Help patient identify options

Guide patients in making decisions
Advise
Ask open ended, non-accusatory questions
Interrogate
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DO
DO NOT
Help patients identify their own strengths

Acknowledge resources of the patient
Encourage dependence
Encourage patient to list concerns

Guide patient to prioritize concerns
Provide factual information to the patient
Help patient identify steps of action for identified concerns
Cajole (trying to
persuade the patient to
accept new behaviour
by flattery or lies)
Checklist for the Nurse, at the end of counselling session with the client.
Action Plan
Prepare an action plan along with the client.

Inform importance of follow-up, fix the next follow-up date.
Emphasize partner treatment.
Encourage to come again.
Assure your availability whenever the client needs you.
Refer if needed.
Key Messages :
Maintain confidentiality
Develop a relationship of trust
Be sensitive to patient & family needs
Make a plan for counselling from admission onwards
Prioritize needs as per the PLHIV perception and the situation
Counsel on one aspect at a time
Never miss an opportunity to counsel a patient
Be thoroughly informed about HIV, disease progression, treatment options
Learn about new trends to counsel patients appropriately
Apply counselling skills to reduce stigma, and disease transmission
Be able to refer clients to local services like NGOs, ART Centres , DOTS, STI Clinics etc.

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UNIT 5 PREVENTION OF HIV TRANSMISSION

Unit Objectives
Describe primary and secondary HIV prevention
Explain HIV prevention programmes under NACP
Discuss various HIV prevention interventions with regards to:
ABC Approach
Drug use
Awareness Campaigns
Blood management
Prevention for Positives
Traditional practices
1. PREVENTION OF HIV
Prevention is the only way to stop HIV transmission. Looking at the magnitude of the problem, 33.3 million
people living with HIV worldwide and approximately 2.2 million PLHIV are in India. (NACO 2007) and about
one in six people (16%) are in need for ART.
Nurses are in an ideal position to educate patients, families and communities about HIV and how to prevent
it.
THERE IS NO CURE
PRIMARY AND SECONDARY PREVENTION

PRIMARY PREVENTION: targets people at risk for HIV to prevent acquiring the infection
Examples : Safe Sex, Use of safe blood free from HIV, not sharing needles )
SECONDARY PREVENTION: targets people known to be HIV infected to prevent spread of the infection
to others
Examples : Prevention of transmission of HIV from HIV infected mother to the child ; prevention of
HIV transmission from HIV positive drug user to his partner)
HIV PREVENTION PROGRAMMES UNDER NATIONAL AIDS CONTROL PROGRAMME

(NACP)
The NACP III (2007 2011) programmes overall objective is to reduce the spread of HIV infection, and
to strengthen the capacity of central and state governments, civil society and private sector to respond to
AIDS on a long term basis. The activities for prevention under NACP include:
Integrated Counselling and Testing (ICT)

Targeted Interventions with CSWs, MSMs, IDUs and Transgenders
Condom promotion
Harm reduction
Promoting access to safe blood
Creating awareness about symptoms, spread, prevention, and treatment
Positive prevention ie.
Promotion of safe sexual practices and Infection control
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Screening and treatment of STIs and RTIs

Prevention of Parent to Child Transmission (PPTCT)
Issues of sexuality and HIV
1. Main functions of Integrated Counselling and Testing Centres (ICTCs):
Pre-test counselling
Risk reduction
Rapid testing
Post-test counselling
Referrals
2. Targeted Interventions with CSWs, MSMs and IDUs:

HIV Prevention Programs
Safe Sex Is:
Safe sex refers to the precautions to be taken so as not to transmit or

acquire sexually transmitted infections including HIV.
Safe sex practices prevent bodily fluids, which can carry viruses or
bacteria, from being transmitted between partners.
Counsel on safer sex and reducing risk of transmission
Counsel on partner reduction while emphasizing consistent condom usage during all sexual encounters
including anal intercourse.
Counsel on less risky sexchoose sexual activities that do not allow semen, fluid from the vagina, or
blood to enter the mouth, anus or vagina of the partner.
Emphasize that even if a client is on ART, HIV transmission can still occur.
Educate on symptoms of STIs and counsel to receive prompt treatment if they suspect a STI.
Dispel any prevailing myths on cleansing of HIV infection through sexual intercourse with minors or
others. Discuss any other local myths that may impact on positive prevention, for example, belief that
condoms transmit HIV (refer to patient flipchart).
Respond to concerns about sexual function. Encourage questions from clients. Emphasize that normal
sexual activity can continue, with above stated precautions.
Help patient assess current risk of transmission and make an individual risk reduction plan.
Counsel on consistent and correct use of condoms during every sexual encounter
Educate that it is essential to consistently use condoms even if already infected with HIV or if both
partners are HIV positive.
Use condoms for vaginal, anal and oral intercourse.
Demonstrate how to use both male and female condoms.
Use model to demonstrate correct use
Educate to put condom on before penetrative sex, not just before ejaculation
Request client to demonstrate correct use of condoms
Educate on advantages/disadvantages of both male and female condoms.
Advise to use water-based lubricants.
Provide condoms and discuss how client will assure a regular supply of condoms
ABC Approach:
A
B
C
Abstinence
Be Faithful
Condom Use

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Some examples of safe sex practices are:
Avoiding penetrative sex

Being faithful to one partner/reducing partners
Regularly being tested and treated for STIs
Using condoms
Masturbation
Mutual masturbation
Who should use condoms?

Anyone (even if both partners are HIV+) who wants
to protect themselves from
HIV infection
Re infection of HIV
STIs
Pregnancy
CONDOM PROMOTION
What is condom?
A condom is sheath made of latex and is available in a rolled form, packed in a sterile aluminium foil.
Condoms act as a wall and prevent the sperms and ST/HIV causing organisms from entering the
vaginal Cavity/penis.
The closed lower end of the condom has t teat which collects the seminal fluid
Special Varieties of condoms

Plain, dotted, ribbed ultra thin, plain contoured condoms are available in many colors with different flavors
Brands available in the market
Kohinoor
Kamasutra
Moods
Durex
Nirodh
Nirodh Delux
Fiesta
Ustad
Sajan
Midnight Cowboy
Spiral
Uses of Condoms
Prevents unwanted pregnancies and

Protects from diseases such as STIs and HIV
When one should use condoms?
When partners feel that one of them may have ST/HIV infections
When one partner has more one sexual partner
When having casual intercourse
When partner is a commercial sex worker
The partner could either be a male or a female
Availability
Free condoms
Free condoms are available at Primary Health Centers (PHCs), Government Hospitals and NGOs.
Priced condoms
Priced condoms are available at Medical shops, Provision shops, Grocery, Fancy stores, Supermarkets and
even in petty shops
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Benefits of condom use:
Reduces
Reduces
Reduces
Prevents
transmission risk
re-infection risk
risk of getting other sexually transmitted infections (STIs)
unwanted pregnancies.
Steps in male condom use
1.
Check expiry date and

open the packet carefully
2.
4.
Remove the penis from

the vagina while still erect
holding on to the condom
at the base of the penis
Roll the condom over the

erect penis by pinching the
tip of the condom to remove
any air
5.
Remove the condom from the

penis while it is still hard.
Take measures to see that
semen does not spill
3.
Note how the rim of the

condom is turned out so
that it could be rolled
downwards
6.
Tie a knot and discard

the condom in the bin
or wrap in paper and
dispose
Check the expiry date and make sure condom is not damaged by
Reading the date

If the individual is illiterate check by moving the condom from side to side and bending it before
opening the packet.
Checking if the packet is damaged
Tear the packet carefully without damaging the condom and remove the condom
Hold the space at the end of the condom to squeeze out air, and then gently roll it onto the penis model
Check to make sure there is space at the tip and that the condom is not broken
Hold the condom at the base of the penis model (This presumed to be during penetration to ensure that
the condom does not slip out)
The condom, should be removed carefully, without spilling the semen, BEFORE the penis gets soft.
A knot should be tied in the used condom, and it needs to be wrapped in a tissue or newspaper and
thrown in a covered dustbin or pit
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Female condom use
It is used for vaginal sex

It is advisable to decide on the use of a condom with your partner beforehand as you may forget in
the heat of the moment.
Always check the expiry or manufacture date on the condom package to make sure it has not expired.
Make sure it is not more than 4 years old.
Using your fingers, carefully open the condom at the indicated place. Make sure your fingernails do not
damage the condom. DO NOT use sharp objects, such a scissors or a razor as they may cut the
condom.
Inspect the condom to make sure it is intact.
Rub the outside of the condom to evenly spread the lubricant inside the condom. Add the lubricant as
desired.
Find a comfortable position for inserting the condom.
Hold the condom at its closed end. Squeeze the inner ring (the ring at the closed end of the condom)
between the thumb and the middle finger with the forefinger between the two.
Spread the vaginal lips with the other hand, and insert the condom in the vagina.
Use your forefinger to push the inner ring all the way up in the vagina until you feel the pubic bone
with your finger.
Make sure the outer ring (at the open side of the condom) lies against the outer lips.
Guide and insert the penis inside the condom. Make sure the penis does not go underneath or beside
the condom.
If during intercourse the penis does not move freely, there is a sound, or the condom is moving in and
out with the penis, add lubricant (to the penis or inside the condom).
If the outer ring is pushed in the vagina or the penis goes beneath or to the side of the condom, stop
and put on a new condom.
Keep the condom on during intercourse. After ejaculation and after the penis is pulled out, squeeze and
twist the outer ring to avoid spilling semen and pulling the condom out of the vagina.
Wrap the condom in toilet paper and, as soon as possible, throw it away out of reach of others. Do
NOT flush the condom down the toilet.
NEVER reuse the condom.
Module 2 Submodule 5
Behaviour change communication: HIV transmission
1.
OPEN END (Outer ring): Covers the
area around the opening of the vagina.
INNER RING used for insertion. Helps
hold the pouch in place.
3.
HOW TO INSERT IT: Squeeze the
inner ring. Insert the pouch as far as
possible into the vagina. Make sure
the inner ring is past the public bone.
2.
HOW TO HOLD THE POUCH: Hold
inner ring between thumb and middle
finger. Put index finger on pouch
between other two fingers.
4.
MAKE SURE PLACEMENT IS
CORRECT: The pouch should not be
twisted. Outer ring should be outside
the vagina.
Fig. 2.7 How to use a female condom for vaginal sex

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Nurses role
Counsel on safe sex practices

Motivate on condom use
Demonstrate condom use
Provide condoms to clients
Clarify doubts and misconception of sexual practices
To Counteract Myths Related to Condom Use
Myth
What nurses could do
Condoms fail to protect us from HIV
Teach that condoms are 95% effective if used consistently

and correctly.
Demonstrate correct condom use Reinforce the Dos and Donts
of condom use
Inform that most condoms come with some lubricant base
Discuss use of additional water based lubricant if necessary
Reinforce that a condom can be used only once, and needs to
be discarded correctly when the sexual act is over
Not knowing how to use condom.
Condoms are soft and lubricated.
Proper use of condom will not cause irritation.
Sexual intercourse also is sticky due to the vaginal and
seminal fluids.
Women may not be aware of benefits of condom usage.
They will accept the condom usage once they are convinced
about its benefits
Educate by demonstrating practical tips.
Condoms break during intercourse

Use of condoms decreases pleasure
Condoms are reusable
Using condom during sex
is irritating
Condom is sticky and oily
Women do not like it
The gained erection may be lost
during condom manoeuvre
Harm Reduction (Injecting Drug Users & HIV)

What nurses can do in Harm Reduction Strategies
Abscess Management
Teach patients NOT to share their needles and syringes
Inform and encourage participation of needle and syringe exchange programmes if available
Refer for rehabilitation Detoxification Centres
Remember that non-injecting drug use can be just as dangerous in the context of HIV transmission as drugs
could alter states of consciousness leading to impaired judgment and high risk behaviour.
Promoting Access to Safe blood

Blood units found to be HIV+ve needs to be destroyed.
All blood banks follow national guidelines on screening donor blood for transmissible diseases. This includes
HIV, Syphilis, Hepatitis B, Hepatitis C, and Malarial parasite.
If screening at a blood bank reveals HIV positive blood the blood bank must refer the donor to an ICTC
for counselling and testing. The blood banks are not allowed to reveal the status to the donor.
What nurses can do :
Counsel the donors
Refer them to ICTC for counselling and testing
Check the label for HIV testing on the blood bottle before transfusion
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Creating Awareness about symptoms, spread, prevention and treatment Campaigns:

NACO and State AIDS Control Societies (SACS) run regular campaigns to create awareness not only
amongst target populations such as commercial sex workers, men who have sex with men, and Injecting
Drug Users, but also amongst those who are vulnerable to HIV infection, and the general population.
What nurses can do in Awareness campaigns
Participate in awareness campaigns

Create HIV awareness in high risk groups
Motivate for HIV testing
Explain available treatment options of HIV i.e, ART therapy
Educate the general population with HIV awareness
Creating awareness around traditional practices

Nurses can advise patients and communities to practice traditional customs safely by educating them about
the need for
Safe sex and condoms with regards to:

Wife sharing/wife inheritance/multiple sex partners/Devdasi
Use of disposable/sterilized instruments with regards to:
Circumcision ensure that equipment used is sterile
Scarification (tattooing): ensure needles are disposable/properly disinfected
Skin piercing practices (ears, nose, cheek etc) ensure needles are disposable/properly disinfected.
Creating Awareness under NACP III

Five Key Areas of Focus under NACP III
Modes of Communication
Risk reduction
Mass media
Vulnerability reduction
Outdoor hoardings
Stigma reduction
Local events
Impact mitigation
Interpersonal communication
Demand generation for services
Mobile vans/community radioInnovative

methods art, mime, SMS
WHAT NURSES CAN DO
Participate in creating awareness under NACP III

Counsel the clients on risk reduction- eg. Safe sex practices, Needle Exchange Programme
Reduce stigma by educating regarding HIV transmission, care and treatment
Discuss fears and concerns regarding HIV transmission
Positive Prevention
Most prevention strategies to date have been targeted at uninfected people to prevent them from becoming
infected with HIV. A change in the risk behaviour of an HIV positive person will, on average and in almost
all affected populations, have a much bigger effect on the spread of the virus than an equivalent change
in the behaviour of a negative person.
Strategies for positive prevention should aim to support people with HIV to protect their sexual health, to
avoid new STIs, to delay HIV/AIDS disease progression and to avoid passing their infection on to others.
Strategies for positive prevention are not stand alone, but work in combination with one another.
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WHAT NURSES CAN DO
Counsel on safe sex practices

Healthy life style practices Food and nutrition
Oral hygiene
Personal hygiene - external genital hygiene
Food hygiene
Exercise
Establish a positive outlook
Educate on HIV disease progression
Explain OI management and treatment options
Stress on importance of adherence
Family planning options
Regular follow up
Key Messages :
Provide primary and secondary prevention messages to stop the spread of HIV/AIDS
Educate and counsel PLHIV on
Safer sex practices
Condom use
Healthy lifestyle practices
Family planning options
Harm reduction if they are IDUs
Blood safety
Practice of traditions safely
Support prevention for positives and facilitate positive living by educating and counselling them on
the following issues
Protection of their sexual health
Prevention and early treatment of STIs,
Delay of HIV disease progression
Prevention of passing their infection onto others
In health care settings, follow standard safety precautions while providing care to clients.

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UNIT 6 PREVENTION OF PARENT TO CHILD

TRANSMISSION (PPTCT) OF HIV
Unit Objectives
Explain the Prevention of Parent To Child Transmission (PPTCT) Programme

List risk factors and appropriate interventions for:
HIV transmission during pregnancy
HIV transmission during labour and delivery
HIV transmission postpartum and during infancy
Describe the nurses role in PPTCT
1. PREVENTION OF PARENT TO CHILD TRANSMISSION (PPTCT) OF HIV

In India mother to child transmission is by far the most significant route of transmission of HIV infection in
children below 15 years. Without interventions the risk of transmission from infected mother to her child
ranges from 15-25% in developed countries 25-45% in developing countries
It is estimated that nearly 5 % of HIV infections are attributable to parent to child transmission.
Approximately 30% of HIV infected pregnant women will transmit HIV to their babies
Approximately 2.1 million children under 15, were living with HIV (2007)
An estimated 290,000 children under 15, died of AIDS-related causes (2007)
The epidemic is more pronounced in urban areas than rural ones, decreases with increasing education
levels and is found to be the highest among women whose spouses work in the transport industry.
What is PPTCT or Prevention of Parent to Child Transmission?
Mothers may transmit HIV to infants during
Pregnancy
Labour and delivery
Breast feeding
For the well being of the mother and child, it is beneficial for both parents to participate in PPTCT
programme.
Risk of Parent to Child HIV Transmission
The highest risk is during birth, then during breast feeding and then during pregnancy
Of 100 Babies born to

HIV Infected Mothers
33 may get HIV either
during pregnancy,
birth or by breast feeding
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Factors That Increase Risk for Transmission of HIV

During Pregnancy
During Labour and Delivery

Maternal Factors
Newborn Factors
During Infant Feeding
High viral load

Recent infection of
HIV
Infected with HIV
during pregnancy
Advanced HIV
disease
Viral, bacterial, and
parasitic (esp.
malaria) placental
infection
Concurrent STI
Malnourishment
IDU-Substance use
leading to risky
behaviors
Alterations in the
integrity of placenta,
chorion
Chorioamnionitis
Invasive procedures
on the uterus
High viral load

Rupture of
membranes > 4
hours
Intrapartum
haemorrhage
Invasive
procedures
Invasive foetal
monitoring
ARM (artificial
rupture of
membranes)
Episiotomy
Vacuum cups
Forceps deliveries
Preterm birth
Low birth weight
First infant of
multiple birth
Altered skin
integrity
High viral load

Reinfection
Primary infection
Advanced disease
Breast pathologies
Engorgement
Cracked
nipples
Mastitis/ abscess
Poor maternal
nutrition
Mixed feeding (breast
milk along with other
foods)
Feeding beyond 4
months
Mouth sores in infant
2. WAYS TO PREVENT PARENT TO CHILD TRANSMISSION OF HIV

A. What can be done before pregnancy?
Primary Prevention:
Education on STIs and pregnancy prevention (usage of Condoms and Oral contraceptives to prevent
pregnancy especially for women who already have STIs or who have partners with STIs)
Counselling pregnant or lactating HIV negative women on HIV & early testing
HIV prevention during pregnancy and lactation due to high viral load during primary infection and
increased chances of parent to child transmission.
Referrals to STI clinic, ICTC, or PPTCT during pregnancy or lactation
B. What can be done during and after pregnancy?

Secondary Prevention: Nurses and patients can take many steps during pregnancy, labour, delivery, and
postnatal period to prevent an HIV positive mother from passing on the virus to her child.
NURSES ROLE IN PPTCT AFTER PREGNANCY

Pregnancy in HIV positive women
Educate the woman on the importance of:
Testing for HIV

Antenatal visits
Diet + Vitamin & Iron supplements
Avoiding invasive procedures

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Practicing safe sex

Treating ANY infection/STI/RTI
Importance of hospital delivery: indications for vaginal versus caesarean section
Continuing to monitor the progress of her HIV infection: CD4 counts/presence of OIs
What is the role of ARVS in PPTCT?

ARVs reduce risk of PPTCT by
Improving the overall health of the mother through a reduction of viral replication and viral load
Treating maternal infection
Protecting the HIV-exposed infant
WHO
stage
CD4 testing not available

(or pending results)
CD4 testing available*
Do not treat
Treat if CD4 < 250 cells/ mm3
Do not treat
Treat
Consider treatment if CD4 < 350 cells/mm3 and

initiate ART before CD4 drops below 200.
Treat
Treat irrespective of CD4 count
* Consider initiation of ART in asymptomatic HIV-infected pregnant women with CD4 < 250 cells/mm3 and
initiate before CD4 drops below 200 cells/ mm3
I.
Motivate the mother for breast feeding after explaining the feeding options ( Refer Annexure 24)
Intervention
Risk of Mother-to-ChildHIV Transmission
No ARV, breastfeeding
30-45%
No ARV, No breastfeeding
20-25%
Short course with 1 ARV, Breastfeeding
15-25%
Short course with 1 ARV, No breastfeeding
5-15%
Short course with 2 ARVs, no breastfeeding
5%
3 ARVs (ART), no breastfeeding
1%
2 ARVs, breastfeeding
unknown
3 ARVs (ART), breastfeeding
unknown
A single dose of Nevrapine, under the GOI PPTCT intervention programmes, reduced the risk of
MTCT with and without breastfeeding reduced to 5-25%.
C. Labour and Delivery in HIV Positive Women
Nurses should assess whether mothers have already:
Had regular Antenatal checkups

Had HIV Testing done
If not, offer pre-test counselling for emergency testing (Single Rapid Test) during labour
If + ve, administer single dose of NVP (Nevprarine) to mother and baby
Next working date: Counsel by ICTC counsellor and send fresh samples for conformation test
If mother does not receive NVP, it should be still administer to the baby
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If the mother is known HIV+ ve , administer single dose of Nevrapine during labour and within 72
hours of birth to the child.
Other Critical Issues in Labour Include:
Disclosure & shared confidentiality

To women, if HIV + status just diagnosed
To delivery team
To spouse and other family members
Emotional support
Administer Nevirapine to mother (PPTCT programme)
Mode of delivery
Vaginal delivery in the hospital
Caesarean section indicated electively only after 38 weeks of gestation,when viral load is high or
as an emergency for obstetrical causes/foetal distress
Dos
1. Do Nots
For nurse
Use appropriate Personal Protective Equipment
(PPE)
Minimize splash of blood and fluids by using
clamps and gauze when cutting the cord
If assisting to express breast feeds, stand on the
same side as mother
Soak all used linen in bleach solution for 2 hours
For mother during labour

Isolate
Shave pubic area
Give an enema
Perform frequent PV exams
Rupture membranes
Use instrumental deliveries unless
absolutely necessary
For mother during labour

Give NVP 200 mg 4 hours before onset of
labour (observe untoward reaction-e.g.skin rash)
Perform vaginal cleansing with 0.25% Chlorhexidine/
Povidine Iodine
Take measures to prevent episiotomy
For newborn care

Use mouth-operated suction
Suction newborn with Nasogastric
tube unless Meconium-stained
For newborn care

Cut cord under cover of light gauze with a
fresh blade
Clean baby thoroughly of secretions
Determine mothers feeding choice before latching
to breast
Give single dose NVP 2mg/kg for the baby
within 72 hours of birth (observe untoward
reaction-e.g. skin rash)
If these precautions are taken, there is no need to be fearful of conducting or assisting in a
normal delivery for HIV positive women!
What are the options for feeding infants of HIV+ mothers after delivery?
Exclusive Breast feeding

Avoid mixed feeding at all costs!

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OPTION 1: Breast Feeding
Good hygiene
Good position
Give Colostrum
Duration-shorter the better(NOT BEYOND 4 months)
Never to mix feeds (never give breast milk along with other feeds such as cows milk or formula)
Option of expressing breast feed compared to direct feed
OPTION 2: Replacement Feeding
If Acceptable Feasible Affordable Sustainable Safe (AFASS criteria)
Please see Annexure 24 for more on PPTCT: Three Safe Infant Feeding Options Some Important Points
You Could Keep In Mind When Counselling Mothers On Feeding Options
Please see Annexure 25 for more on Replacement Feeding Checklist
D. Follow up care
Follow up care of mother should include:
Routine postnatal care

Evaluation to decide eligibility for ART and continuing ART>
Need to report any signs of infections
- chest, urinary, puerperal, episiotomy or breast infections, and OIs
- Reinforcement of safer sex
Discussion of family planning BEFORE discharge
Review birth control and infection control
- Dual protection to prevent and reduce further HIV infection, STIs, and pregnancy
- Data suggests hormonal contraception is less effective with ARVs
- Access to emergency contraception
Follow up care of baby born to HIV positive women:
DNA PCR HIV testing for infants (where available)

- 6 weeks
- 6 months
- 12 months
- 18 months
- 24 month
Routine well baby visits
Follow standard immunisation schedule
Need for immediate medical attention if signs and symptoms of any Opportunistic Infection(OI) present.
Cotrimoxazole ( CPT/CTX) prophylaxis dose per kg body weight
- All HIV exposed infants start at 4-6 weeks of age till detected as HIV negative
HIV antibody testing at 12 months & 18 month visits
Role of the Nurse In PPTCT

It is important for the nurses to
Disseminate correct, non-judgmental information on PPTCT to

- Patients
- Families
- Communities
- Colleagues
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Educate on risk factors and ways to reduce risk of PPTCT during antenatal, intranatal and postnatal
periods
Administer ARVs to lower mothers viral load and act as prophylaxis for the baby
Modify obstetric practices to minimize babys exposure to HIV
Support safe infant feeding practices
Develop links for follow up of mother and baby
Key Messages :
In the absence of any intervention, there is a significant risk of PPTCT in peri partum periodespecially during labour and delivery
Appropriate nursing interventions and ART can reduce PTCT risk
A discordant or positive couple should practice safe sex throughout pregnancy and breastfeeding.

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UNIT 7 INFECTION CONTROL AND POST

EXPOSURE PROPHYLAXIS (PEP)
Unit Objectives
Describe the basic principles of Infection Control and Standard Precautions
Demonstrate how to prevent infections
List measures to safeguard against TB and blood-borne pathogens
Manage post exposure prophylaxis
Discuss Nurses role In Infection Control
INFECTION CONTROL AND POST EXPOSURE PROPHYLAXIS (PEP)
Basic Principles of Infection Control
Patients blood and other body fluids can pass on infections such as HIV, Hep B, and Hep C, with those
who come into contact with those fluids. In order to avoid such spread of infections, precautions must be
taken
1
2
All patients are potentially infectious. Precautions must be taken at all times with all patients
Follow Standard Precautions for all patients
Standard work precautions

Universal Precautions as defined by CDC, are a set of
precautions designed to prevent transmission of Human
Immunodeficiency Virus (HIV), Hepatitis B virus (HBV), and other
blood borne pathogens when providing first aid or health care
Standard safety precautions, if carefully followed, will prevent spread
of HIV, Hep B, and Hep C infections in the health setting.
The routes of HIV infection in the hospital setting are from patient
to health care personnel,
Patient to patient,
Through hospital wastes,
From health care personnel to patients.
All blood and body fluids, substances, secretions and excretions must be considered to be
potentially infectious regardless of the perceived risk of the source!
Precautions to be taken to control infection
1
2
3
4
5
Hand Hygiene
Disinfection and Sterilization of equipments
Use of Personal Protective Equipment(PPE)based on the risk of the procedure
Standard precautions against air borne pathogens
Standard precautions against blood borne pathogens
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1. Hand hygiene
Hand washing is one of the simplest, but often overlooked procedures that can be followed to prevent
infection from spreading.
Hand washing could help in reducing risk of transmission of pathogens within the healthcare setting among
patients, among patients and health care workers, and to caregivers and family members of the patient.
Ensure patients and caregivers to follow the simple Hand washing practice. (Transpose)
When to use
Effect on
germs
How to use
Soap and water
Use this technique

when hands have
visible dirt and
whenever you come in
contact with a patient.
Removes
germs
Wet hands to wrist

1. Apply soap on the palms, back
of the hands, between fingers,
around the thumb
2. Clean the nails
3. Rub for at least 15 seconds
4. Rinse with running water
5. Dry by air or single use towel
Alcohol rub
(if available)
If no visible dirt on
hands and before
procedures needing
aseptic technique
Kills
germs
1. Place 3-5 ml on dry hands

2. Rub until dry No water or
towels needed
Surgical scrub
Done before surgery

or procedures needing
sterile technique.
Kills
germs
1. Clean under nails with stick

2. Wet up to elbow;
3. Use antiseptic, long acting and
rub all surfaces for 2-6 minutes.
4. Rinse with running water
5. Dry with sterile towel
1. Palm to palm
4. Backs of fingers to
opposing palms with fingers
interlocked

2. Right palm over left

dorsum and left palm over
right dorsum
5. Rotational rubbing of
right thumb clasped in left
palm and vice versa
3. Palm to palm fingers

interlaced
6. Rotational rubbing, backwards and

forwards with clasped fingers of right
hand in left palm and vice versa
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1. DISINFECTING AND STERILIZING

Definitions
Cleaning
Disinfection
Sterilization
Decontamination
Cleaning is a
process that
removes foreign
material (e.g. soil,
organic material,
micro-organisms)
from an object.
Disinfection is a
process that reduces
the number of
pathogenic
microorganisms, but
not necessarily
bacterial spores,
from inanimate
objects or skin, to
a level which is not
harmful to health.
Sterilization is a
process that destroys
all microorganisms
including bacterial
spores. Sterilization
cannot be proved
except by culturing,
so normally an object
is said to have been
sterilized if it has
gone through a
controlled process
of sterilization.
Use of physical or chemical

means to remove, inactivate, or
destroy blood borne or other
pathogens on a surface or item,
to the point where they are no
longer capable of transmitting
infectious particles, and the
surface or item is rendered safe
for handling, use, or disposal.
The level of decontamination should be such that there is no risk for infection when using the equipment.
The choice of the method depends of a number of factors, including type of material of object, number and
type of organisms involved and risk of infection to patients or staff
DISINFECTANTS IN USE:
Name of
Disinfectant
Method of
Dilution
Glutaraldehyde
2% e.g. Cidex
Add activator
powder/liquid to the
liquid in the 5 L jar
& use undiluted
Disinfection: 20
14 to 28 days
to 30 minutes
(see manufacturers
Sterilization: 10 hrs instructions)
Span will be reduced if
solution is diluted so
utilize in-use test for
confirming efficacy
Combination of
Gluta aldehyde &
chemically bound
Formaldehyde
e.g. Korsolex,
Bacilloid
Korsolex : water
1 part : 9 parts
Disinfection
15 minutes.
14 days
Bacillocid : water
1 part : 49 parts
(20 ml : 980 ml)
Sterilisation 5 hrs
30 minutes
24 hrs
Phenol 5%
(Carbolic acid
100%)
Phenol : water
5 ml : 95 ml
10 15 minutes
in 5% solution
24 hrs
24 hrs
Ethanol
Isopropyl alcohol
70% eg.
Bacillol 25
Do not dilute
2 10 minutes
24 hrs
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Purpose
Contact Time
Effective
time Span

Name of
Disinfectant
Method of
Dilution
Hydrogen Peroxide
6% (available as
30% stabilized
solution)
Contact Time
Effective
time Span
20ml H2O2
with 80ml
Normal saline = 6%
H2O2 (use
freshly prepared)
6 8 minutes
Use immediately
after preparation
Sodium
Hypochlorite
solution 1% e.g.
Polar bleach
available in
5% & 10%
concentrations
5% : 80ml water
+20ml bleach
solution
10% : 90ml water
+ 10ml bleach
solution
20 30 minutes
8 hrs
Calcium
Hypochlorite eg.
Bleaching Powder
(70% available Cl2)
14 gm / L dissolved
properly for visibly
contaminated
articles.
1.4 gm per L for
clean objects.
20 30 minutes
24 hrs
30 minutes
then open the
area after 6 hrs
15 30 days
Formaldehyde
40%
Purpose
Source: Infection control manual- AIIMS

Ensure all the above disinfectants are available
Antiseptics (iodine, etc) are ineffective against HIV
Please see Annexure 3 on Disinfection of Needles and Syringes with Bleach Solution
These steps are for the Patients who are Substance Users (IDUs).
Please see Annexure 5 on Hospital Disposal of used disposable Needles
Please see Annexure 6 for more on Guidelines for Disinfection and Sterilization

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A)
HOUSEHOLD WASTE (NONINFECTIOUS).
VIII. USE BLACK DRUM /
BAG
LEFT OVER FOOD, FRUIT PEELS,

VEGETABLES, WASTE PAPER,
PACKING MATERIAL, EMPTY BOX &
BAGS ETC.
I.
V.
B) INFECTED WASTE
i)
HUMAN ANATOMICAL
WASTE, ORGAN, TISSUE,
BODY PARTS, BLOOD,
BODY FLUID, PLACENTA
ETC.
ii)
SOLID WASTE: USED
COTTON, GAUZE,
DRESSINGS, PLASTER,
POP CAST ETC.
iii) ANIMALS USES IN
RESEARCH DEAD
ANIMALS, THEIR BODY
PART OR TISSUES.
VII.
THIS WASTE TO BE SENT

FOR INCINERATION
USE YELLOW
DRUM / BAG
XI.
USE BLUE DRUM / BAG
II.
VI.
C) INFECTED PLASTIC
WASTE
i)
USED DISPOSABLE
SYRINGE & NEEDLE
ii) USED SHARPS: BLADE
& BROKEN GLASS
ETC.
iii) PLASTIC ITEMS USED
ON PATIENTS: IV. SET,
B.T. SET, E.T. TUBE,
RYLES TUBE,
CATHETER, URINE BAG
ETC.
III.
IV.
PUT IN TRANSLUCENT CONTAINER WITH

1% BLEACH
THIS WASTE WILL

BE AUTO CLAVED
TO MAKE IT NON
INFECTIOUS.
THIS WILL THEN BE

SHREDDED
BEFORE FINAL
DISPOSAL.
DOCTOR, NURSE
& TECHNICAL
STAFF
Nurses role in waste management
Be up-to-date on infection control practices

Segregate hospital wastes appropriately
Teach/train other staff in the ward with regards to waste segregation and disposal
Teach, train and supervise junior staff/students and cleaning staff
Educate patients with regards to waste management
Guidelines in Special Units

Endoscopy
All scopes to be disinfected with 2% Cidex for 30 minutes, followed by 3 to 4 rinses with sterile water
after each use.
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Dentistry
Use disposable mask for each patient

Dental handles to be autoclaved
Tubings cleaned with flush down tablets
Labour Wards
Stainless steel table to be used

Disinfect surfaces with Lysol or bleach
Proper disposal of placental waste (bagging in black/Yellow bags)
Manage blood spills as per previous guidelines
Neonatal Units
Incubators, Nebulisers and Ventilators to be disinfected and cleaned regularly
Critical Care
Ventilators, Suction bottles to be disinfected and cleaned regularly

Tubings to be cleaned with flush down tablets
Patients with burn injuries and those with bed sores to be handled with gloves
In such patients, plastic sheets on mattresses help avoid soiling of linen with body fluids
Others
OPD
Injection Room
Dressing room
SURGICAL UNITS
Trauma Center / Casualty

Operation Theatre(O.T)
[The precautions to be taken for these two are discussed under Personal Protective Equipment
(PPE)]
Hospital Waste Management
Classify and segregate waste

Use colour-coded bags for segregation of waste
Disinfect waste before disposal
Incinerate when appropriate
Deep burial of the waste, as needed
Disinfect & destroy disposables before discarding
Personnel handling the wastes, to be provided with appropriate protective cover and these staff are to
be adequately trained in handling the wastes.
Disposal of dead body of AIDS Patients
Plug all orifices well

Cover open wounds with water proof dressing
Place body in double plastic sheets and with bleaching powder
Tie the body bag well
Label the body; label the sheet covering the dead body; label the bag in which the body is kept.
Suggest the relatives of the dead not to open the body bag, once it is closed

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Cremation is the best procedure for disposal of the dead. However, with due respect to religion and
tradition, when cremation is not practiced, suggest deep burial.
Post Exposure Prophylaxis (PEP)
The term Post Exposure Prophylaxis refers to treatment of occupational exposures using Antiretroviral
Therapy. Post-exposure prophylaxis, if initiated immediately after exposure to HIV, may contain HIV
infection.
Health care providers can be faced with occupational exposures with the infected fluids, while handling
the patients.
To tackle such situations, Post Exposure Prophylaxis is practiced.
Use Personal Protective Equipment (PPE)

PPE is designed to protect employees from workplace injuries or serious illnesses resulting from contact
with chemical, radiological, physical or mechanical or other workplace hazards,
PPE
When to wear
Points to keep in mind
Gloves
Wear sterile gloves when

Handling sterile supplies
Doing invasive procedures
Wearing clean or sterile gloves

Wash hands.
Slip each hand into glove, pulling it snugly over
the fingers to ensure a good fit.
Pull glove over the wrist as far as it will go to
maximize coverage.
Grasp the glove by the other gloved hand and
remove first glove by turning the glove inside
out as it is pulled over the hand. (This will
keep the contaminated areas away from
your skin).
During removal of the second glove, avoid
touching the outer surface by slipping the
fingers of the ungloved hand under the glove
and pulling it inside out as it is pulled over the
hand, effectively sealing the first glove inside.
Dispose of the used gloves in a lined waste
container or disinfect as per standard protocol
Sterilize gloves before re-use for invasive
procedures.
Wear utility gloves when

Cleaning or managing waste.
Utility gloves
Do not use them to touch patients, patient care
items, or anything near patients.
Use the same utility gloves for the same tasks
Use separate gloves for dirty and clean tasks.
Wash with detergent and bleach and leave to
dry at the end of the shift.
Eye Wear
(goggles,
visor, face
shield)
Protect eye when

anticipating splash of
infectious body fluids
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The eyewear surrounds the rim of the whole

eyes without any gap.
Disinfect if there is a splash of potentially
infectious fluid on it.
Wash thoroughly before reuse.
If eyewear is not available make use of the
face shield /visor. It costs approximately
Rs. 100-150 and can be easily disinfected.
PPE
When to wear
Points to keep in mind
Gowns and
Aprons
Protect skin when risk of

splashing or spraying of blood
or body fluid contact is
expected using impervious/
plastic gowns.
Prevent soiling of clothing

during procedures that may
involve contact with blood
or body fluids.
Masks
(cloth and
paper)
Protect mouth and nose

from potential splashes
of infectious fluid
Use when handling patients

with respiratory infections
Doing any invasive
procedures
Conducting delivery
Gowns need to be thick enough so that blood

will not soak through easily
Cotton gowns are inappropriate as the cloth
absorbs dirt very easily and needs to be
disinfected and cleaned daily
Aprons need to be water resistant preferably
made of plastic.
Wash hands after removal of gowns/aprons
Disinfect the cotton cloth gowns as per
standard protocol
Soak in bleaching solution (1%) for
20 minutes, then wash and sun dry
OT and labour room gowns would need
to be sterilized
Disposable gowns need not be sterilized.
Cover both the nose and the mouth during
procedures and patient-care activities
While wearing a mask, make sure it is:
Fitting properly over the nose, mouth, lower
face, and below the jaw line in a tight
enough fit (face seal) to prevent air
leakage around the edges.
Changed for each procedure.
Replaced if wet or contaminated.
Not worn under the chin or dangling around
the neck after use.
When removing, hold masks by the strings/ties
as the centre of the mask is most contaminated
Dispose immediately after use.
Wash hands after disposing the mask
Caps
Used to keep the hair and

scalp covered so that flakes
of skin and hair are not shed
into the wound during surgery
Should be large enough to cover all hair
Footwear
Worn during procedures and

patient-care activities when
large-particle droplet spatter
or sprays of blood or body
fluids is anticipated
Slippers are not sufficient protection

If foot wear does not completely cover the foot
then put a plastic cover over it and secure
this with a rubber band
Footwear should be fluid proof
They should be washable and easily disinfected
(Plastic or sandak)
Using Appropriate PPE during Common Nursing Procedures

Protection required
Common nursing procedures
Type of exposure
Gloves helpful but

not necessary
Bed making, Back care, Sponge

bath, Mouth care, Minor wound
dressing, Perineal care,
Taking temperature, BP
Low risk (Chances of direct

contact with infectious body
fluids is minimal)

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Protection required
Common nursing procedures
Type of exposure
Use gloves with

waterproof aprons,
For intubation, wear
gloves, mask, goggles
and apron
Injections, Lumbar puncture,

Insertion and removal of IV
needles, PV examination,
Dressing large wounds,
Handling blood spills or
specimens, Intubations,
Suctioning, Collecting blood
Medium risk (Chance of direct

contact with infectious body fluid
is moderate i.e. probable contact
with blood, splash unlikely)
ALL PPE (Surgical

gloves, Apron, Masks,
Protective eyewear,
Foot wear)
Vaginal delivery,
Uncontrolled bleeding,
Surgery, Endoscopy,
Dental procedures
High risk (Chance of direct

contact as well as splash of
infectious body fluid is high,
uncontrolled bleeding)
Dos and Donts for Use of PPE

Do
Do Not
Use PPE based on risk of procedure
Share PPE
Change PPE completely after each procedure
Use same gloves between patients
Discard the used PPE in appropriate

disposal bags
Reuse disposable gloves, eyewear, masks
Dispose PPE as per the policy of the hospital
Use eye wear that restricts your vision
Always wash hands after removing PPE
Use masks when wet
Educate and train all junior and auxiliary

staff in the use of PPE
Standard Precautions against Airborne Pathogens
In addition to the standard work precautions detailed above, there are also specific infection control measures
that can be taken against air borne pathogens.
Nurses need to know what these measures are and practice them routinely, especially when caring for
patients with Tuberculosis which is a highly infectious airborne pathogen.
Mix of Patients
Level of Risk for TB Transmission
HIV - and HIV +
Low risk
Smear + TB and HIV +
High risk
MDRTB smear + and HIV +
Greatest risk
MDRTB smear + and HIV
High risk
Role of the nurse while caring a patient with air borne disease like tuberculosis
Educate about early detection and treatment of TB
Encourage persons with chronic coughs (>2 wks) to get evaluated at a TB centre whether it is
- you
- another staff member
- a visitor
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- a volunteer
- a family member
- a patient
Start and complete treatment (DOTS) without delay
Instruct coughing/sneezing patients to
Turn their heads opposite to you

Cover the mouth with a cloth or rag
- Wash hands regularly
- Wash/burn the cloth used
i)
Separation of Smear TB+ and HIV+ patients
ii) Identify procedures that may put a health care provider at risk for TB
Suctioning
Nebuliser
Inter costal drainage insertion and dressing
Bronchoscopy
Sputum collection in poorly ventilated areas
Surgery
Handling mycobacterium cultures
Cleaning suction cups
Post-mortem care
iii) Use mask appropriately
When caring for patients with TB/other airborne diseases

While transporting or doing procedures on patients with TB
When suffering from a respiratory infection yourself
Remember the precautions related to use of mask
- A paper or cloth mask gets wet in <10 minutes, allowing bacteria to pass
- Change when wet, as wet surfaces attract dirt and pathogens
iv) Ensure good ventilation
Open windows
Ensure proper airflow direction in wards with TB patients
Supervise proper patient placement & Spatial separation
Spatial separation, ideally
3 feet, of persons with respiratory infections in OPD and between beds in infectious wards to
reduce risk of transmission of droplet infection.
v) Educate patients and families to
Report signs and symptoms of TB and seek treatment

Take the complete course of treatment as prescribed
Observe cough hygiene
Ensure good ventilation around them
Standard Work Precautions against Blood borne Pathogens

Blood borne pathogens are microorganisms such as viruses or bacteria that are carried in blood
and can cause disease in people.
HEPATITIS B-Stable virus, can survive outside the body after the body fluid dries.
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HEPATITIS C-Stable virus, can survive outside the body after the body fluid dries
HIVFragile virus, usually dies outside the body after the body fluid dries
In addition to the standard work precautions detailed above, there are also specific infection control
measures that can be taken against blood borne pathogens.
Disinfect surfaces contaminated with body fluid or blood.

Follow the hospital policy for waste management.(See picture on Safe Disposal Of Hospital Waste)
Get vaccinated against Hepatitis B (No other vaccine is available)
Please see Annexure 7 for more on Situational Guide - Cleaning up a Blood Spill on the Floor
Reducing Risks of Sharp Injuries
Sharps refer to instruments such as needles, knives, and scissors etc which have sharp edges with
potential for puncturing or tearing skin. Naturally, as risk of acquiring blood borne pathogens increases with
severity of exposure, it is best to avoid sharps injuries by taking simple steps as listed below.
Dos
Donts
Use needle cutter/destroyer

immediately after use.
Do not recap needles before disposal
Separate sharps from other waste
Do not collect the used needles.
Use rigid, puncture proof disposal bins
Burn immediately- to reduce chances of

getting the needle stick injury
Empty sharps containers when they

are full
Handle, empty, or transfer used sharps

between containers
Protect yourself
Be aware of the policy of PEP in your institution

Take three doses of hepatitis B vaccine. It gives you life long protection
Take measures to prevent accidental needle stick and other sharps injuries
Talk to designated physician about taking Post Exposure Prophylaxis (PEP) in the event of any
occupational exposure
Follow standard precautions at all times
Carry out all the procedures meticulously.
Occupational Exposure and Post Exposure Prophylaxis (PEP)

Occupational exposure refers to exposure to harmful substances/material that occurs during the course of
ones work.
Occupational exposure can place healthcare workers at risk for contracting HIV, Hepatitis, and other
pathogens.
The term Post Exposure Prophylaxis or PEP refers to the comprehensive management given to
minimize the risk of infection following potential exposure to blood-borne pathogens (HIV, HBV, and
HCV).
Risk of infection after needle stick from a patient with the infection:
HBV: 30% (30 in 100)

HCV: 3% (3 in 100)
HIV: 0.3% (3 in 1000)
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Which Body Fluids Have Risk for HIV Transmission?

Body fluids* considered at risk
exposure
Body fluid considered not at risk exposure

(Unless contaminated with visible blood)
Blood
Tears
Semen
Sweat
Breast milk
Urine and faeces
Body fluids with blood
Saliva
Vaginal secretions
Cerebrospinal Fluid
Synovial, pleural, peritoneal, pericardial fluids
Amniotic fluids
Other fluids contaminated with visible blood
How does a person becomes infected
Source body fluids* if infected

Port of exit from infected person (injury, needle stick etc.)
Port of entry into susceptible person (break in the skin, mucus membrane-nose, mouth, eyes)
Factors that Influence Risk for Acquiring HIV
Type and extent of exposure

- Size and type of needle
- Depth of injury
- Amount of blood
Types of procedures that carry a higher risk of transmission:
- Procedures involving a needle placed in artery or vein
- Use of invasive devices visibly contaminated with blood
Amount of virus present in the contaminated fluid
Whether PEP is taken or not within the specified time
Occupational Exposure Protocol

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Do not put injured part in mouth or squeeze

Remain CALM
First aid Wash and irrigate the site
Dispose the sharp appropriately
Report to the appropriate authority
Get evaluated for PEP and baseline testing for HIV
PEP should be started within 2 hours of exposure, and not later than 72 hours
PEP must be taken for 4 weeks (28 days)
Follow-up HIV testing (6weeks, 3 months, 6 months)
Follow-up counseling and care
It is absolutely essential that nurses are aware of the occupational exposure protocol followed
by their institution and follow them routinely. Below are the basic steps which need to be observed
following occupational exposure to HIV

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Crisis management
Remain CALM
Dispose the sharp
Appropriately
First aid
For skin if skin is broken after a needle-stick or sharp instrument:

1. Immediately wash the wound and surrounding skin with water
and soap. Do not scrub.
2. Do not use antiseptics or skin washes (Bleach/Chlorine/Alcohol/
Povidone Iodine)
After a splash of blood or body fluids
1. To unbroken skin:
Wash the area immediately
Do not use antiseptics
2. For the eye:
Irrigate exposed eye immediately with water or normal saline
Sit in a chair, tilt head back and ask a colleague to gently
pour water or normal saline over the eye
If wearing contact lenses, leave them in place while irrigating,
as they form a barrier over the eye and will help protect it.
Once the eye is cleaned, remove the contact lenses and clean
them in the normal manner. This will make them safe to
wear again
Do not use soap or disinfectant on the eye
3. For mouth:
Spit fluid out immediately
Rinse the mouth thoroughly, using water or saline and spit
again. Repeat this process several times
Do not use soap or disinfectant in the mouth
Report
To the appropriate authority as soon as possible
Get evaluated for

PEP and baseline
testing for HIV
PEP should be started within 2 hours of exposure, and not later than
72 hours. PEP must be taken for 4 weeks (28 days)
Basic Regimen: Zidovudine/Stavudine (AZT or d4T)
300mg BD + Lamivudine (3TC) - 150mg BD
Expanded Regimen: Above +
1st choice: Lopinavir/ritonavir (LPV/r) 400/100 mg twice a day or
800/200 mg once daily
2nd choice: Nelfinavir (NLF) 1250 mg twice a day or 750 mg thrice a day
3rd choice: Indinavir (IND) 800 mg every 8 hours
A. Side effects
Nausea, vomiting, anorexia,, fatigue, abdominal pain,
weakness, diarrohea
Counsel on side effects
MOTIVATE TO COMPLY WITH TREATMENT REGIMEN
Follow-up
HIV testing (0, 6 weeks, 3 months, 6 months)

Support for PEP adherence and management of side effects
Counselling and care
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Please see Annexure 9 for more on NACO PEP Policy: Procedure to be followed after an Accidental
Exposure to HIV Infectious Fluid
Key Messages :
Standard precautions are
for ALL patients and health workers
to reduce the risk of blood borne and airborne infections
Standard precautions against blood borne infections include
Practice of hand hygiene
Use of personal protective equipment based on risk of exposure
disinfection and sterilization techniques
Appropriate separation and disposal of waste
Proper sharps disposal
Standard precautions against airborne infections include
Identification of smear positive patients and appropriate isolation
Maintain good ventilation
Educate and counsel on
recognition of signs and symptoms of TB
need for seeking and taking complete treatment (DOTS)
cough hygiene
Nurses must educate all other health care team members on standard precaution protocols and
ensure that these protocols are followed
Occupational exposure
Report the exposure to the concerned committee in your workplace
Wash the area with soap and water, or irrigate mucous membranes with clean water Seek
counselling and advice on the need for PEP
Take PEP for 28 days as prescribed
Report any side effects that are not manageable
Repeat HIV test at 6weeks, 3 months, 6 months and then 1 year

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UNIT 8 SEXUALLY TRANSMITTED INFECTIONS

(STIs)
Unit Objectives
List the common STIs seen with HIV

Recognize the factors affecting STI transmission
Explain the link between HIV and STIs
Describe common signs and symptoms of STIs
Discuss Syndromic Case Management (SCM) of STIs
Nurses Role in SCM of STIs
1. SEXUALLY TRANSMITTED INFECTIONS (STI)

Sexually transmitted infections (STIs)
Infections that spread from person to person during sexual contact

More than 50% of people with an STI do not present with any major sign or symptom that could make
them suspect they have an infection.
Referred to as STDs previously.
Reproductive tract infections (RTIs)
Infections of the reproductive tract that occur due to:

Poor personal hygiene
Poor Asepsis
Global Statistics
According to the World Health Organisation (WHO) more than 340 million new cases of sexually transmitted
bacterial and protozoal infections occur throughout the world every year.
In pregnancy, untreated early syphilis will result in:
A stillbirth rate of 25%

Neonatal deaths of 14%
Overall perinatal mortality of about 40%
2. FACTORS AFFECTING STI TRANSMISSION

It is important for nurses to understand the factors affecting STI transmission so that they can provide
appropriate support/make referrals and linkages to other organizations.
Biological
Behavioural
Social
Age - younger
more vulnerable
Gender - women
more prone to
infection than men
Immune status
Personal sexual behaviors

unprotected sex with multiple partners
Other behaviors associated with
risk- alcohol and/or substance use
predisposing to high risk behaviour
Partners behaviour multiple
partners, injecting drug user
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Lower status of women in

most societies
Mens reluctance to use
condoms
Sexual violence
Limited access to health
care facilities
Lack of knowledge of STIs

Women are more prone to getting STIs compared to men because:
Women are the receptive partners during sexual encounters which makes it easier for organisms to
enter their bodies
Women may have STIs and not even know it because:
They have internal reproductive organs, which makes it difficult for them to inspect themselves and
detect if they have a problem. Moreover, a woman may not have the privacy required to examine her
self (such as a toilet or bathroom).
More than 50% of STIs in women are asymptomatic
Symptoms, e.g. white discharge, may be considered natural and therefore ignored (see table below for
more information on vaginal discharge)
3. WHAT IS THE LINK BETWEEN STIS AND HIV?
A person with a STI has a higher risk of getting HIV through sex than a person without an STI
Treatment of STI could reduce risk of sexual transmission of HIV
Prevention strategies for HIV and STIs are the same
Treatment of STIs is fairly simple and could reduce risk of sexual transmission of HIV. So it is extremely
important that nurses recognize them early and refer patients to STI clinics for diagnosis and treatment.
Also, prevention strategies for HIV and STIs are the same Nurses Should Take The Time To Educate
Patients About These Strategies (e.g. condom use).
STIs in PLHIV: The Need for Early Treatment
PLHIV have decreased immune system

STIs are thus more severe in PLHIV, so there is a great need for early detection and treatment
Causes of STIs
Cause
Bacterial
Protozoal
Viral
Not always
sexually transmitted
Type
of STI
Syphilis
Gonorrhoea
Chancroid
Nongonococcal
Urethritis
Chlamydial
Infection
Lymphogranuloma
Venereum
Trichomoniasis
Herpes
HIV
Genital
Warts
Anal
Warts
Hepatitis
Pubic Lice
infestation
Vaginitis
Scabies
Molluscum
Contagiosum
4. COMMON SIGNS & SYMPTOMS OF STIS

Nurses should recognize and observe patients for common signs and symptoms of STIs to facilitate early
treatment.
MALES
FEMALES
Ulcers / sores
Discharges (urethral)
Swellings/growths warts (groin / scrotum)
Pain / burning when voiding
Ulcers/sores
Vaginal discharge
Swellings/ growths-warts (groin/labia)
Burning when voiding
Pain (low abdominal/back ache)

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5. SYNDROMIC CASE MANAGEMENT (SCM)

A syndrome is a set of signs and symptoms that tend to occur together and which reflect the presence of
a particular disease or an increased chance of developing a particular disease.
The SCM approach to STIs: It Includes
Education, condom promotion

Partner treatment
Referral to Integrated Counselling and Testing Centre (ICTC)
It is all-rounded and also guides in partner management and education on prevention. Syndromic case
management is based on the assumptions that:
Symptoms of STI may be simple, and easily recognizable

These symptoms may be the result of one or more infections
Based on the chief complaint of the patient, a thorough history, and relevant clinical examination, an
appropriate flow chart is determined
Using the flow chart ensures accurate and complete treatment and management of the patient.
Ensures compliance
Steps of Syndromic Case Management

There are four steps in SCM clinical history and examination, use of the flowchart, partner management,
and education and counselling on prevention.
(i) Clinical history and examination:
Assure privacy, confidentiality, be non-judgmental

ASK about duration of presenting complaints
Sexual history
Clinical history
Partner history
Examine genitalia, perianal region, mouth for ulcers, swelling or inflammation
Checklist How and What : History Taking of Patients with STIs

How to take a history?
Done
Be polite
Greet Patient
Provide Privacy
Face and look at patient
Explain why & what
Reassure confidentiality
Listen carefully and show sensitivity
Take consent before any examination
What information?
Collect chief presenting complaints

Get details of presenting complaints (how long/features/ associated problems)
Obtain sexual history
Past history
Partner history
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What do you ask a woman with vaginal discharge?
Done
When did the discharge start?

What is the nature of the discharge? (colour/ smell / etc)
Whether the woman is pregnant / has recently delivered?
Whether the woman is using Loop/IUD?
Whether she has burning urination or itching in the vulva?
Does she have any pain in the lower abdomen?
Does she have any ulcer in the genital region?
Whether the sexual partner has any sore on the genital
organ or urethral discharge?
Causes & Characteristics of Vaginal Discharge:

It is normal for women to have some amount of vaginal discharge. The vagina is a self-cleaning organ. It
produces mucus and other secretions. The vagina normally contains bacteria. Bacterial growth is controlled
and affected by many different factors, such as acid level (pH) and hormones.
Anything that upsets this balance may increase the risk of infection or overgrowth of any of the normal
bacteria or by yeast.
Possible causes include:
Antibiotic use
Birth control pills
Douching (Rinsing of Vagina)
Diabetes
Pregnancy
Stress
Tight or synthetic undergarments
Vaginal discharge may result from infection with:
Yeast, also called Candida, a type of fungi that is part of the normal flora of human skin but can also
cause infections
Gardnerella, a type of bacteria found normally in the female genital tract that is the cause of bacterial
vaginosis
Trichomonas, a type of protozoa, an organism made up of one cell
Sexually transmitted diseases such as gonorrhea or chlamydia also can cause vaginal discharge
Some symptoms of an abnormal vaginal discharge and infection include:
Changes in color, consistency of discharge

Increased vaginal discharge
Presence of itching, discomfort, or any rash
Vaginal burning during urination
Presence of blood when the woman is NOT menstruating
Cottage cheese-like vaginal discharge
Foul odor accompanied by yellowish, greenish, or grayish white vaginal discharge
(ii) Use the appropriate flow chart: Syndromic diagnosis & treatment:
The correct flow chart is identified based on the clinical history and examination findings and is used
to facilitate further action.

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Treatment is based on the guidance from the flow chart and is usually for mixed infections.
7 syndromes have been established through Epidemiological Studies (Refer Annexure- 9 to 16).
Please
Please
Please
Please
Please
Please
Please
see
see
see
see
see
see
see
Annexure for more on STI Syndrome Flowchart Lower Abdominal Pain

Annexure 10 for more on STI Syndrome Flowchart Inguinal Bubo
Annexure 11 for more on STI Syndrome Flowchart Painful Scrotal Swelling
Annexure 12 for more on STI Syndrome Flowchart Ophthalmic Neonatorum
Annexure 13 for more on STI Syndrome Flowchart Genital Ulcers
Annexure 14 for more on STI Syndrome Flowchart Urethral Discharge
Annexures 15 and 16 for more on STI Syndrome Flowchart Vaginal Discharge
Symptom: Patient comes in with

STI symptom
History and exam: Provider performs
history and physical exam
Decision: Provider must answer a question
(e.g. is discharge confirmed; do exam
findings support symptoms?).
Exit: Provider chooses a path depending
on whether the answer to the question is
YES or NO (e.g. treatment for discharge
or if no discharge, further investigation)
Syndrome
Most Common Causes
Genital Ulcer
Syphilis, Chancroid, Herpes
Urethral Discharge
Gonorrhoea, Chlamydia
Vaginal Discharge
Gonorrhoea, Chlamydia, Trichomoniasis,

Candidiasis, Bacterial Vaginosis
Lower Abdominal Pain
Gonorrhoea, Chlamydia, Anaerobic organisms
Inguinal Swelling
LGV, Chancroid, Syphilis
Painful scrotal swelling
Neonatal Conjunctivitis
(iii) Partner management:
ALL sexual partners exposed in past 2 months to be treated

for the same STI
even if asymptomatic
When patients feel they cannot refer partners:
Give patient a duplicate course of treatment to give to partner
Proceed with provider referral
If partner does not come for treatment:
Use outreach services
Check if partner has used other services
(iv) Education & Counselling on Prevention:
Practice abstinence
Treat partner
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If possible have fewer partners

Use condoms when on
treatment for STI
there are more than one sexual partner
one/both partners have STI or HIV
Refer to ICTC for counselling on HIV testing
6. NURSES ROLE IN STI MANAGEMENT
Use Syndromic Case Management (SCM) approach to STIs

Discuss sexual issues
With confidence
Have a non-judgmental attitude
Be open, accept the patient as she/he is
Do not discriminate on the sexual behaviour and sexual orientation
With sensitivity to needs of patient confidentiality
Assess the clinical syndrome through relevant history collection
Identify the suspect of HIV infection and motivate for testing
Identify case of re infection- carry out aggressive counseling
Educate and counsel on
Prevention of STIs -Safe sex practices
STIs treatment as well as use of condom for every sexual contact
Link between STIs and HIV
Need to take full course of treatment
Need for partner/s to be treated
Need for HIV testing and the benefits of it
Dietary care
Make efforts to refer patients and their partners for treatment of STIs and for HIV testing
Develop a referral directory that could be used
Check whether referral has been made to an STI specialist if the patient does not have any
improvement or there is development of complications such as super added infections
Key Messages :
Identify and refer any person with the following symptoms for treatment of STIs
Ulcers in the genitalia
Excessive urethral discharge
Abnormal vaginal discharge
Swelling in the groin or genitalia
Pain in the lower abdomen in women
Baby with discharge in the eyes
Educate people to get treated for STIs since it
Increases the risk of getting HIV through sexual route
Increases the chance of HIV transmission
Increases HIV progression to AIDS
Follow the steps of Syndromic Case Management (SCM) as is recommended in India for STI
management
Take a thorough history of a person presenting with suspecting signs of STI and carry out
relevant physical examination
Refer them for treatment
Educate on its prevention, practice of safe sex, on the need to treat the partners simultaneously
and follow up
Refer any one with STI for HIV testing if not yet teste
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UNIT 9 SYMPTOM MANAGEMENT AND

OPPORTUNISTIC INFECTIONS (OIs)
Unit Objectives
Review clinical staging for HIV Infection
Explain symptom management in HIVDefine Opportunistic infections
Describe common opportunistic infections (OIs)
Etiology
Diagnosis
Treatment
Identify the role of the nurse in managing opportunistic infection
1. SYMPTOM MANAGEMENT IN HIV DISEASE

Symptom management is an important component of the continuum of care whether in the hospital, clinic,
community or home. It is a CORE domain of nursing. Symptoms are usually indications of underlying
etiology, which are rarely singular, and are usually more than
Symptoms can be caused by:
1. HIV
2. Associated diseases
3. ARV treatment
4. Overlapping causes
2. OPPORTUNISTIC INFECTIONS (OIs)

AIDS (Acquired Immune Deficiency Syndrome) is a condition caused by a virus called HIV.
This virus attacks the immune system, the bodys security force that fights off infections. When
the immune system breaks down, patient looses this protection and can develop many serious,
often deadly infections and cancers. These are called Opportunistic Infections (OIs) because they
take advantage of the bodys weakened defenses. You have heard it said that someone died of AIDS.
This is not entirely accurate, since it is the opportunistic infections that cause death.
Opportunistic infections are infections caused by pathogens that usually do not cause disease in a
healthy immune system. A compromised immune system, presents an opportunity for the pathogen to
infect.
Many people with HIV/AIDS first learn they are HIV infected when they are diagnosed with an OI.
Antiretroviral drugs can help ameliorate opportunistic infections. It is important to know strategies:
To
To
To
To
To
To
identify clinical manifestation of OIs,

initiate ART in the presence of an OI,
manage OIs developing during ART,
make Recommendations during pregnancy,
identify geographically distinctive OIs (Penicilliosis and leishmaniasis)
manage drug interactions during concomitant OI and ART.
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3. HIV RELATED INFECTIONS MOST FREQUENTLY ENCOUNTERED IN INDIA

BACTERIAL
FUNGAL
VIRAL
PARASITIC
OTHER ILLNESSES
Tuberculosis
Candidiasis
Herpes simplex
virus diseases
Cryptosporidiosis
AIDS Dementia
Complex
Bacterial
respiratory
infections
Cryptococcosis
Oral hairy
leukoplakia
Microsporidiosis
Invasive cervical
cancer
Pneumocystis
Carinii
Pneumonia
Varicella Zoster
virus disease
Isosporiasis
Non Hodgkins
Lymphoma
Bacterial
enteric
Penicilliosis
Giardiasis
Cytomegalovirus
disease
Human papilloma
virus infections
Stongyloides
Toxoplasmosis
4. EDUCATE ON SIMPLE PREVENTIVE MEASURES TO AVOID OIs
Eating well cooked and balanced diet

Drink boiled water,
Hand washing before food and after toilet use,
Avoid situations that lead to infections,
Be vigilant for any untoward symptoms
Do not neglect any discomfort / symptom
Appropriate and timely immunizations all go a long way towards decreasing disease burden.
Suitable precautions should be taken to prevent the spouse of the infected partner from acquiring the
same OI.
Maintain oral, personal, food and environmental hygiene.
Regular health check-up
Stress management
5. RESPIRATORY OIs
Preventable and treatable respiratory infections are present in up to 2/3rd of all HIV infected individuals.
Although HIV-associated respiratory disease includes upper respiratory infections, sinusitis, and bronchitis,
pneumonias are the most commonly diagnosed bacterial respiratory infection.
Respiratory OI
CD4 Count
Mycobacterium tuberculosis (TB)
<400
Pneumocystis jirovecii Pneumonia (PCP)
<200
Other Bacterial Respiratory Infections
Any CD4
5.1. TB and HIV Co-infection (TB-HIV)

Mycobacterium tuberculosis is the most common cause of death in people with HIV worldwide.
i)
ii)
iii)
iv)
About one third of the worlds population is infected with Mycobacterium tuberculosis (TB)
India accounts for nearly one third of this global TB burden
In India, TB accounts for nearly 50% of OIs in HIV infected individuals
TB can be treated easily, but untreated, it is the leading killer of patients with HIV/AIDS in developing
countries, accounting for one-third of all AIDS deaths

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v) Pulmonary TB is the most common form of TB

vi) In PLHIV:
TB progresses faster, is more severe and life threatening
It increases HIV viral load, decreases CD4 count, and may lead to faster progression to AIDS
Latent TB is 30 times more likely to be reactivated in people with HIV
Extra-pulmonary TB - spreads beyond the lungs in advanced HIV and can spread to:
Lymph nodes, causing swelling and fever
Intestines, causing diarrhoea and fever
Liver, causing jaundice and fever
Brain, causing meningitis with symptoms of confusion
Around the heart
Bones most seriously in the spine
a. Symptoms:
Cough with expectoration > 2 weeks not responding to usual antibiotic treatment
Production of purulent, sometimes blood-stained sputum
Evening fevers
Night sweats
Weight loss
Loss of appetite
Anaemia
Anybody who presents with these symptoms should be referred for TB testing and treatment if necessary.
b. Treatment:
TB is treatable. Standard DOTS regimens are to be followed using RNTCP program in India. The patient
should be referred to a DOTS centre for ATT. The same regimens are used for the treatment of pulmonary
and extra-pulmonary tuberculosis. Around 6 to 8 months of treatment appears to be sufficient to many sites
of extra-pulmonary disease. Twelve months therapy is recommended for miliary TB, bone or joint disease
and tubercular meningitis. Persistently positive sputum culture after 2-3 months of therapy suggests the
possibility of drug resistant tuberculosis or non-compliance with therapy.
ATT is started before the initiation of ART. ART is started after completion of the intensive phase of ATT
(two months duration). During this period, the patient needs to be counseled to adhere to treatment protocol
for his long term benefit.
Revised National Tuberculosis Control Programme (RNTCP):
Treatment regimen followed vary according to the type of patient, a new case of tuberculosis or one who
has been treated for tuberculosis previously, severity of the illness and response to treatment
Table: Tuberculosis treatment categories
Treatment
Category
Type of TB
Regimen IP
Regimen CP
New smear +ve pulmonary TBNew smear

ve; pulmonary TB; seriously ill
New extra pulmonary TB
All HIV + individuals
2(EHRZ)3
4(HR)3
II
Sputum smear positive relapses

Sputum smear +ve; treatment
failure cases/after default
2(SEHRZ)3
+
1(EHRZ)3
5(EHR)3
III
New smear ve; pulmonary TB; not seriously ill 2(HRZ)3

New smear ve; extra pulmonary TB; not seriously ill
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4(HR)3

In addition
If a patient needs ART, then the doctor has to consider:
i) When to start ART
ii) Which regimen to use in order to avoid drug interaction and added risk of liver toxicity
iii) NACO recommends category I or II in HIV infected, irrespective of site or sputum results
c. Monitoring of pulmonary TB:
Sputum smear examination:

- At the time of diagnosis and initiation of DOTS
- At the end of initial phase (2/3 months)
- During the continuation phase (end of 5 months)
- On completion of treatment (6/8 months)
d. Precautions:
In HIV infected TB patients, combining Rifampicin with protease inhibitors or Nevirapine has been found
to decrease the level of these ARVs
This decreases the effectiveness of the ARVs and increases the Rifampicin levels, leading to Rifampicin
toxicity
In case ATT and ART are used together, an Efavirenz based ART regimen should be followed
If Oral Candidiasis is also present, administration of anti-TB drugs together with Fluconazole can result
in hepatotoxicity
Nurses must ensure proper infection control practices to prevent the spread of TB and other air borne
pathogens, e.g. cough hygiene, cross ventilation, masks, isolating smear positive patients, disposal of
sputum properly, nutritional counseling and identification of side effects & toxicity
5.2. Pneumocystis Pneumonia (PCP)

a. Etiology:
Pneumocystis jirovecii (previously Pneumocystis carinii) is classified as a fungus on the basis of DNA
sequence analysis. However, P jiroveci retains several morphologic and biologic similarities to protozoa,
including being susceptible to a number of antiprotozoal agents but resistant to most antifungal agents.
PCP is one of the most common OIs worldwide. The diagnosis of PCP is usually made clinically supported
by x-rays. Symptoms are dangerous and progress slowly over the course of a few weeks. Patients initially
present with:
Dry cough
Progressive shortness of breath
Fever
If untreated it can lead to:
Persistent fever
Tachypnoea and hypoxia
Cyanosis
Tachycardia
Sweating and confusion
PCP can lead to death if not treated early (30% mortality per year)
b. Treatment:
Trimethoprim (15 20 mg/kg daily) + Sulfamethoxazole (75-100 mg/kg/day in 3 or 4 divided doses) for
21 days. In an adult, this is usually equivalent to Cotrimoxazole double strength (160/800) 2 tablets
thrice daily. Clinical worsening during the first 3-5 days should be anticipated and should not lead to
early change in treatment. Improvement usually occurs in 7-10 days.

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If allergic to sulfamethoxazole, rapid desensitization should be carried out. Alternative regimens include:
- TMP 15 mg/kg/day/orally + Dapsone 100 mg/day orally for 21 days
- Clindamycin 600-900 mg IV q6-8h or 300-450 mg q6h orally + primaquine base 15-30 mg/day orally
for 21 days
Moderately severe to severe disease in adults: PO2 <70 mmHg or A-a gradient >35 mmHg prednisolone
(40 mg orally twice daily for 5 days, then 40 mg once daily for 5 days, and then 20 mg per day to
complete 21 days of treatment)
- Steroids should be started within 72 hours of initiation of specific treatment to decrease alveolar
edema and improve oxygen perfusion across alveoli
- Oxygen is administered during the acute phase of infection
If there is no improvement within 10 days of treatment, PCP diagnosis should be reviewed.
After successfully treating the acute episode of PCP, it is necessary to continue secondary prophylaxis with
Trimethoprim 160 mg/Sulphamethoazole 800 mg 1 tab per day on a long-term basis, and refer the patient
for ART as PCP is an AIDS defining illness.
5.3. Other bacterial respiratory infections
Bacterial lower respiratory tract infections are more frequent and severe in immuno-suppressed persons
with HIV
Bacterial pneumonias may be the cause of death in persons with advanced immuno suppression and
AIDS
Clinical manifestations of pneumonia:
Fever, Chills
Productive cough
Dyspnoea, Orthopnea
Pleuritic chest pain
Fatigue and malaise
Investigations:
Abnormal Chest x-ray

Radiological changes on chest x-ray vary and the diagnosis is often based on clinical findings as well
as X-ray rather than sputum and blood culture. These are done where feasible and affordable.
Sputum exam and blood culture
Role of the Nurse in Care of the Patient with Respiratory Infections

Diagnosis
Detect infectious patients early and refer for diagnosis and treatment
Treatment and
Monitoring
Administer ATT and ART if appropriate

Potential for liver toxicity identify symptoms of drug toxicity
Identify if there is worsening of TB symptoms as the immune system
responds to treatment
Symptom
Management
Respiratory support
Treat fever
Provide oral and/or IV hydration
Provide nutritional support
Care/prevention of bed sores
Provide adequate rest
Reassure the patient
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Diagnosis
Detect infectious patients early and refer for diagnosis and treatment
Patient
Education
Adequate nutrition, fluids and rest

Adherence to medications DOTS/ART and regular follow up
Prevention of HIV reinfection
Available community resources
Prevention of TB transmission
Secondary prophylaxis for PCP
Follow up care and treatment
Breathing exercises as prophylactic measures
6. ORAL/DERMATOLOGICAL/EYE OIS
Oral/Dermatological/Eye OIs
CD4 Count
Candidiasis (Thrush) Oro-Pharyngeal
CD4 < 300
Oesophageal Candidiasis
CD4 < 100
Vaginal Candidiasis
Any CD4
Herpes Simplex I & II (HSV) infection
Any CD4 chronic HSV < 100
Herpes Zoster (VZV) infection
Any CD4
Molluscum Contagiosum infection
Any CD4
Human Papillomavirus Infection (HPV)
Any CD4
Cytomegalovirus (CMV) infection
CD4 < 50
6.1. ORO-PHARYNGEAL CANDIDIASIS
Fig. Oropharyngeal candidiasis

Oro-pharyngeal candidiasis is distinguished by white or yellow plaques on the oropharyngeal mucosa and
on the tongue. Candida organisms are everywhere in the environment. Candida infection in HIV individuals
is mostly mucosal.
a. Symptoms:
Burning pain
Altered taste sensation
Oral ulcers

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Diagnosis: Oral candida (otherwise known as thrush) is diagnosed by appearance alone, and diagnosis of
Oesophageal Candida is based on presentation and response to empiric treatment.
b. Treatment:
Treat oral candidiasis with Fluconazole 100 to 200 mg po for 7 to 14 days

Clotrimazole troche 10 mg five times/day until lesions resolve (usually 7-14 days) or Nystatin oral
suspension 500,000 units gargled 4-5 times/day may be used topically
6.2. OESOPHAGEAL CANDIDIASIS

a. Symptoms:
Difficulty swallowing
Pain in chest
Feelings of obstruction
Heartburn
Patient may be asymptomatic
b. Treatment:
Treat with Fluconazole 200 to 400 mg per day po times 14 to 21 days or itraconazole 200 mg/day PO x
14-21 days may be used.
Diagnosis
Conduct oral exam and refer for treatment
Treatment and monitoring
Dispense medication and ART
Symptom Management
Apply topical analgesics Oral hygiene
Patient Education
Frequent oral hygiene measures Importance of adequate food and fluids
6.3. HERPES SIMPLEX VIRUS (HSV) INFECTION
Fig. Herpes Simplex Virus Infection
HSV I is usually oral and where initial infection is often during childhood
HSV II is usually acquired through sexual transmission and is a significant risk factor for acquisition and
transmission of HIV
HSV I & II lesions can occur on mouth, penis, vulva, vagina, and anorectal area. Lesions may present
as small localized red, painful, burning ulcerations or can spread to cover large areas
Dissemination may lead to infection of the lungs, the Oesophagus, and the brain, and may also cause
Meningoencephalitis
Frequent recurrence can occur in immune suppressed patients with the degree of immunosuppression
influencing the rate and severity of the reactivated disease
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Treatment:
Acyclovir 200 400 mg 5 times per day for 7 -10 days (14 days in case of recurrences) OR
Acyclovir 5 mg/kg IV q8h for 10 days for severe cases (including encephalitis).
Role of the Nurse in care of the Patient with HSV Infection

Diagnosis
Assess for lesions and refer
Dispense anti-viral medications and ART if appropriate
Symptom Management
Administer oral and/or topical medication

Provide stool softeners for ano-rectal lesions
Keep lips lubricated
Give bland and soft food,
Increase fluid intake
Patient Education
Oral hygiene
Condom use
Do Not use tobacco and alcohol use
Home remedies
6.4. VARICELLA ZOSTER (VZV) INFECTION
Varicella Zoster Virus (VZV) is also known as Herpes Zoster

Varicella Zoster is a virus that causes chickenpox and shingles in children and adults
It is spread by aerosolized viral particles
Contagious period is 24 to 48 hours before rash is observed and lasts until all lesions are crusted over
Patients present with painful burning sores on a red patch of skin in a localised Neuro-dermatomal
distribution
a. In immune suppressed persons, Zoster is often:
Multi dermatomal and multi-segmental in distribution

Persistent and extensive
Associated with severe pain and debility
b. Treatment:
To be effective medication needs to be started within 3 days of the symptoms.

Typically, treatment is used only during a flare-up.
Oral Acyclovir is the recommended treatment (20 mg/kg body weight up to a maximum dose of 800
mg four to five times daily).
If cutaneous lesions are extensive or if clinical evidence of visceral involvement is observed, intravenous
Acyclovir 10 mg/kg IV q8h is given for 7-10 days and continued until lesions are clearly resolving.
Switching to oral therapy with Valacyclovir or Famciclovir after the patient has defervesced might be
permissible, if no evidence of visceral involvement exists.
Analgesics can be used to manage the discomfort of Zoster.
Adjuctive Corticosteroid therapy to prevent post Herpetic Neuralgia is not recommended.
c. Role of the nurse in care of the patient with Varicella Zoster Infection
Diagnosis
Symptom Management
Assess symptoms, lesions, and refer

Dispense anti-virals and ART if appropriate
(Refer to ART centre if not already on ART)
Provide analgesia as needed
Keep lesions clean and dry
Apply topical agents

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Patient Education
Family to avoid direct contact with lesions

Keep lesions clean and dry
Use gloves when there is contact with lesions
Personal hygiene-cleanliness, short nails, avoid scratching lesions
Encourage use of cotton clothing
Pain management is a big part of nursing care for HSV. Analgesics should be provided as required.
Nurse must ensure proper infection control practices (especially with people who have not had chicken pox)
as Varicella virus is highly contagious until all lesions are crusted over. Practice standard infection control
precautions with wound contact.
6.5. MOLLUSCUM CONTAGIOSUM INFECTION
Fig.(i) Molluscum contagiosum on the face (ii) Enlarged image of umbilicated papules
Caused by the poxvirus

Spread by direct contact
It is typically more widespread and chronic in HIV-infected individuals
Characteristic lesions appear as flesh-coloured, dome shaped, 2 to 5 mm papules with central umbilication.
They typically first develop on the face and genitals, but may become widespread over time( See fig.)
Diagnosis is based on clinical findings
a. Treatment:
Cryotherapy using liquid nitrogen to freeze lesions, laser treatment, curettage, scraping of MC lesions,
and electrocautery can be used to remove lesions.
Incision and drainage can be done using tincture of iodine.
Topical gels and creams like Podophyllum, Trichloroacetic acid, Cantharidin, and Tretinoin, Tincture of
Iodine, Silver Nitrate, or Phenol can be applied directly to the MC lesions. Repeated application may
be required until the lesions clear.
The normal skin around may need to be protected with paraffin wax.
Griseofulvin and Cimetidine is effective in MC lesions.
Cimetidine can be used if the area becomes inflamed or itchy.
If the lesions are extensive, HAART needs to be initiated.
b. Patient education:
Lesions are benign but may cause anxiety in the patient provide reassurance
May be the first presenting symptom of HIV infection refer to an ICTC for testing
Avoid touching the lesion and then other part of body or another person
6.6. HUMAN PAPILLOMAVIRUS (HPV) INFECTION

HPV causes genital warts, flat warts and skin warts and is associated with Cervical cancer and Intraepithelial
Neoplasia of the Cervix, Vagina, Vulva, Penis, and Anus. HPV can occur anytime during HIV disease.
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a. Treatment:
Treatment depends on the location and severity of disease.

Patient-applied methods are generally recommended for uncomplicated external lesions, and consist of
topical gels and creams are 30% 80% effective in reducing wart size.
- Podofilox applied topically to lesions as a 0.5% solution or a 0.5% gel twice daily for 3 consecutive
days. Treatment is repeated weekly for up to 4 weeks. The efficacy is 40% - 60% in immunecompetent subjects. Skin irritation may occur.
- Imiquimod topical cytokine inducer
- Trichloroacetic or Bichloroacetic acids made in an 80-95% aqueous solution; application repeated
weekly for 3-6 weeks.
- Podophyllin Resin prepared as a 10-25% suspension in tincture of Benzoin, applied and removed
by washing a few hours later.
- Cryotherapy with liquid nitrogen may be used until each lesion is thoroughly frozen.
Surgical treatments are excision with scissors, shaving or curetting or electro surgery.
b. Patient education:
PAP smear every 6 months for 1 year after diagnosis

Educate patients about safe sex practices
6.7. CYTOMEGALOVIRUS (CMV) INFECTION
Usually appears as a late stage AIDS illness (CD4 <100)

CMV may affect multiple systems and organs in immuno-suppressed individuals, especially the eyes
(CMV retinitis)
A fetus exposed to CMV can suffer severe consequences such as mental retardation or even death
a. Symptoms:
Many patients are completely asymptomatic

Fever
Diarrhoea
Dyspnoea
Early signs of CMV retinitis include:
- Decreased vision
- Floaters
- Unilateral visual field loss that can lead to blindness
- Without antiviral treatment or immune reconstitution following ART, the retina may be destroyed
resulting in permanent blindness
Because treatment for CMV may not be accessible to most patients, it is imperative that ART is started to
strengthen the immune system
Patient education:
Encourage patients with HIV to seek eye exams and report vision changes
Provide appropriate psychosocial support to help patients combat fear and other issues related with
loss of vision
Inform patients that CMV can be spread through:
- Perinatal transmission
- Contact with urine and saliva
- Kissing
- Sexual intercourse
- Blood transfusion/organ transplantation

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7. GASTROINTESTINAL OIs : MANAGEMENT OF DIARROHEA

Gastrointestinal OIs
CD4 Count
a. Cryptosporidiosis: Cryptosporidium Parvum

b. Microsporidiosis: Microsporidia
Bacterial enteric infections
CD4 < 100

CD4 < 100
Any CD4
a. Cryptosporidiosis
Cryptosporidiosis is caused by Cryptosporidium Parvum which lives in the intestine of humans and
animals
It is transmitted through water, food, and animal-to-human and human-to-human contact
The parasites form cysts that survive outside the body for long periods of time and are resistant to
chlorine disinfection
Common symptoms:
Watery diarrhoea
Abdominal pain
Nausea
Vomiting
Weight loss
Loss of appetite
Dehydration
Treatment:
No anti microbial agent found to be completely effective against
Cryptosporidium. However, some drugs have shown significant responses
Nitazoxanide at 500 mg or Azithromycin at 750 mg daily.
Paromomycin at 1500-2000 mg daily can cure the infection and reduce diarrhoea. Dapsone is helpful
at 750 mg daily.
Nitozoxanide have been FDA approved for treatment of Cryptosporidiosis in children.
Anti-motility drugs such as Octreotide, Loperamide and Paregoric to control diarrhoea
b. Microsporidiosis
Microsporidia are intracellular protozoan parasites found in domestic animals. The domestic animal produces
resistant spores that commonly cause intestinal infection in humans
Common symptom:
Diarrhoea
Can also cause
- Encephalitis
- Ocular infection
- Sinusitis
- Myositis
- Disseminated infection
Treatment:
All patients should be offered ART as part of the initial management of their infection.
Nitazoxanide is approved for use in children.
Fluid support should be offered if diarrhoea has resulted in dehydration.
Malnutrition and wasting should be treated with nutritional supplementation
Albendazole is recommended for initial therapy of intestinal and disseminated (not ocular) Microsporidiosis
caused by Microsporidia other than E. bieneusi.
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Itraconazole combined with Albendazole also might be useful, especially in disseminated infections
caused by Trachipleistophora or Brachiola.
Patient education for Cryptosporidiosis and Microsporidiosis:
Teach good personal hygiene measures

Educate patient on water and food safety
Use only boiled water for drinking (boiled for at least 20 minutes)
Do not eat hotel foods or eat outside the home unless assured of the food hygiene
Avoid spicy food
Eat only well-cooked food
Do not eat leftovers from the day before unless adequately refrigerated
Avoid raw eggs, fruits, and vegetables
Role of the Nurse for Cryptosporidiosis and Microsporidiosis:
Nurses must ensure proper infection control practices by wearing gloves and washing hands when
required, especially after handling faeces.
8. BACTERIAL ENTERIC INFECTIONS
Diarrhoea is among the most common symptoms of HIV infection and is experienced by over 90%
patients with AIDS
It becomes more frequent as immune deficiency progresses
Likely to be severe, recurrent, and persistent
Diarrhoea and weight loss are independent predictors of mortality
Role of the Nurse in Care of the Patient with Gastrointestinal Infections

Diagnosis
Collection of stool samples for analysis should be done if available

Monitor symptoms and refer for treatment
Treatment and
Monitoring
Supportive therapy with fluids and electrolytes

Dispense antibiotics
ART if appropriate
Symptom
Management
Administer anti-diarrhoeal/anti-emetics
Provide bland food
Maintain hydration
Patient
Education
Continue to take food and fluids as tolerated

Teach good personal hygiene and simple infection control measures
(e.g. how to handle soiled linen)
Teach food hygiene measures
Counsel on dietary measures
Advise on local remedies
Nurse must ensure proper infection control practices to prevent the spread of diarrhoea in the health care
facility, e.g. Gloves, Hand washing, and proper disposal of waste.
Refer to Infection Control and PEP Unit 5 for additional information.
9. CENTRAL NERVOUS SYSTEM (CNS) OIs

CNS OIs
CD4 Count
Cryptococcal disease
CD4 < 50
Toxoplasmosis: Toxoplasma gondii
CD4 < 50
Progressive Multifocal Leukoencephalopathy (PML)
CD4 < 50

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9.1 Cryptococcal Disease
Cryptococcal Meningitis is the most frequent systemic fungal infection in PLHIV. It occasionally appears
as pulmonary or disseminated disease
Cryptococcal disease is diagnosed by microscopic examination of Cerebrospinal fluid to detect the
yeast organisms
If untreated, it is slowly progressive and ultimately fatal
Symptoms:
Headaches
Stiff neck (+/-)
Double vision
Indolent fever
In the terminal stage symptoms include
Vomiting
Altered mental status
Treatment:
Induction: Amphotericin B (0.7 mg/kg/d) 5-Flucocytosine 25 mg/kg QID x 14 days

Consolidation: Fluconazole 400 mg/d for 8-10 weeks or until the CSF is sterile.
Maintenance: Fluconazole 200 mg/d lifelong (stop when CD 4 count is more than 200 for 3 months)
Role of the Nurse in Care of the Patient with Cryptococcal Meningitis

Diagnosis
Assess neurological symptoms and refer for treatment
Treatment and
monitoring
Administer medications and ART if appropriate

Keep patient hydrated with Amphotericin B (to minimise renal toxicity)
Symptom
Management
Relieve pain
Anti-emetics
Avoid over stimulation
Reduce fever
Reassure the patient
Provide routine care for the unconscious patient
Patient Education
Possibility of relapse
Need for maintenance therapy/ secondary prophylaxis
Support the family in ensuring patients safety measures
(patient may have seizures, or change in mental status)
9.2. Toxoplasmosis
Toxoplasmosis is the most common HIV-related neurological complication

Usually occurs from ingestion of food /water contaminated with oocysts from the faeces of infected cats
or from undercooked/raw meat which contain the oocysts
Toxoplasmosis infection most commonly involves the central nervous system and usually invades the
brain, lymph nodes, and spleen. Less commonly, it affects the lungs, liver, and myocardium.
Toxoplasmosis can also cause chorioretinitis and uveitis
Toxoplasmosis infection is reactivated from latent infection when CD4 cells < 50
Symptoms:
Flu-like symptoms
Fever and headache
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Confusion
Myalgia
Arthralgia
Often lymphadenopathy
In patients with AIDS, focal seizures, altered sensorium or encephalitis and necrosis of the brain leading
to paralysis & coma
Diagnosis:
Serology for Toxoplasma antibodies

CT scan or MRI
Treatment:
Combination of Pyrimethamine, Sulfadiazine, and Leucovorin is the recommended initial regimen.

- Pyrimethamine started orally at 100-200 mg daily, followed by a lower dose.
- Leucovorin decreases the haematological side-effects of Pyrimethamine.
- Sulfadiazine 4-8gm/day. orally four times a day
- Clindamycin or TMX/SMZ can be used in case Sulphadiazine is not available.
- Other combinations used include: Atovaquone + Sulfadiazine; Atovaquone + Pyrimethamine +
Leucovorin; Azithromycin + Pyrimethamine + Leucovorin. Dapsone, 5 Fluorouracil, Clarithromycin,
and Minocycline has all been used with the above in various permutations and combinations.
Initially high doses of these medications are given for 4-6 weeks followed by lower doses as maintenance
therapy to prevent recurrence.
Maintenance therapy can be discontinued in an asymptomatic patient on HAART with CD4 count >200
for at least six months. It has to be restarted if CD4 count falls or MRI/CT shows persistent cerebral
mass lesions.
Corticosteroids such as Dexamethasone may help control inflammation of the brain in those with focal
neurological symptoms. However they need to be used carefully, given that corticosteroids may precipitate
other OIs.
Anticonvulsants should be administered only if there is history of seizures. They should not be given
prophylactically.
Patient education:
Wash hands and kitchen surfaces after handling raw meat/handling pets/gardening, etc.
Avoid handling cat faeces or gardening without gloves
Eat only completely cooked meats
Create quiet setting when experiencing severe headache
Support and educate family on safety measures as patient may experience loss of balance, change in
mental status, and seizures
Need for maintenance therapy/secondary prophylaxis
10. OPPORTUNISTIC MALIGNANCIES

Lymphoma
CD4 <200
Cervical Cancer
any CD4
Kaposis Sarcoma (KS), (uncommon in India)
CD4 < 200
10.1 Lymphoma
Lymphoma is a disease in which cancer cells are found in the lymph system
It can spread to almost any of the bodys organs or tissues including the liver, bone marrow, spleen,
or brain

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Two general types: Hodgkins lymphomas and Non-Hodgkins lymphomas (more commonly found in
HIV patients)
Treatment:
Chemotherapy (using drugs to kill cancer cells and shrink tumours)

Radiation therapy (using high-dose x-rays or other high-energy rays to kill cancer cells and shrink
tumours)
10.2. Cervical Cancer
Cervical Cancer is a common cancer of women throughout the world, accounting for about 30% of all
cancers and 80% of all Gynaecological cancers
The incidence of Cervical Dysplasia and risk of Cervical cancer is increased in HIV infected women.
Human Papilloma Virus (HPV) infection is associated with cervical cancer
Cervical cancer is detectable with use of routine Pap smear screening
With early detection, cervical cancer is highly curable
Treatment:
Surgery
Radiation therapy
Chemotherapy
Patient education:
Pap screening recommendations:

- Every 6 months x 2 and if both are negative, go to yearly
- All abnormal Pap smear results should be followed up with a Colposcopy procedure
OPPORTUNISTIC INFECTION PROPHYLAXIS

Prevention of AIDS-related opportunistic infections (OIs) by primary prophylaxis (PRO) is a major focus of
treatment. Initiation of Opportunistic Infection Prophylaxis is largely based on CD4 count
A) Primary Prophylaxis
Prophylaxis is treatment to prevent development of infection

Prophylaxis is usually recommended for people with symptomatic HIV infections, and/or CD4 counts <
200/mm3
Cotrimoxazole(CTX) prophylaxis prevents a variety of infections for a very low cost including:
Diarrhoea due to Isospora

PCP
Toxoplasmosis
Dosage:
Cotrimoxazole (Sulphamethoxazole 800 mg and Trimethoprim 160 mg) once daily orally. Treatment is
continued indefinitely or if started on ART, may discontinue after CD4 count is > 200 for at least 6 months.
Side effects:
The most common reactions are rash, fever, nausea, low white blood count (Leucopoenia), and Hepatitis
Rash could lead to a fatal allergy called Stevens-Johnson syndrome
- Stop drug or reduce dose; reinitiate and desensitize by gradually, escalating dose
- Monitor closely
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CTZ Alternatives:
Dapsone (100 mg per day) or Atovaquone (with or without Pyrimethamine and Leucovorin) for PCP
prophylaxis
For children, Dapsone 2mg/kg once daily or 4mg/kg once weekly
Do not provide the same protection against other organisms
Mycobacterium
avium complex
CD4+ count
<50/L
Azithromycin** 1200 mg po qw (AI), or

Clarithromycin 500 mg po bid (AI)
check the dosage
B) Secondary Prophylaxis
Prophylaxis for other OIs usually follows initial treatment of infection (secondary prophylaxis). The same
drugs used for treatment but in lower doses.
Remember that maintenance therapy may be required for life.
Key Messages :
Symptoms in a patient infected with HIV may be due to
HIV
Associated diseases
ARV treatment
Overlapping causes.
Opportunistic Infections (OIs) in a person infected with HIV are preventable.
Common Opportunistic Infections (OIs) are:
Respiratory OIs
TB-HIV coinfection
PCP
Other bacterial respiratory infections
Oral/Dermatological/Ophthalmic OIs
Candidiasis
- oropharyngeal
- esophageal
Herpes Simplex Virus (HSV) infection,
Herpes Zoster Virus (HZV) infection ,
HPV infection,
CMV infection
Gastrointestinal OIs
Cryptococcosis
Microsporidiosis
Central Nervous System OIs
Cryptococcosis ,
Toxoplasmosis,
Progressive Multifocal Leukoencephalopathy(PML)
Opportunistic Malignancies
Lymphoma
Cervical Cancer

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UNIT 10 INTRODUCTION TO ANTIRETROVIRAL

THERAPY (ART)
Unit Objectives
Describe the benefits and general principles regarding use of antiretroviral (ARV)
therapy
Identify possible adverse effects and drug interactions with ARV use
Explain why ARV resistance occurs in some patients
List factors affecting adherence to ARV therapy
Describe nurses role in care of patients on ARV treatment (ART)
1. INTRODUCTION
HIV antiretroviral treatment is the main type of treatment for HIV or AIDS. It is not a cure, but it can
stop people from becoming ill for many years. The treatment consists of drugs that have to be taken
every day for the rest of someones life.
Antiretroviral treatment for HIV infection consists of drugs which work against HIV infection itself by slowing
down the replication of HIV in the body. ANTIRETROVIRAL THERAPY (ART) increases the bodys ability
to fight disease.
The drugs are often referred to as:
ART Anti Retroviral Therapy
ARVs Anti Retro Virals
HAART Highly Active Anti Retroviral Therapy
These terms are all

used interchangeably!
2. ANTIRETROVIRAL THERAPY
a) Goals of Antiretroviral Therapy ( ART )
Goals of ARV Therapy
Clinical Goals: Prolongation of life and improvement in quality of life.
Virologic Goals: Greatest possible reduction in viral load for as long as possible.
Immunologic Goals: Immune reconstitution that is both quantitative and qualitative.
Therapeutic Goals: Rational sequencing of drugs in a fashion that achieves Clinical, Virologic and
Immunologic goals while maintaining treatment options, limit drug toxicity and facilitate adherence.
Decreases hospitalization.
Reduction of HIV transmission: Reduction of HIV transmission from one individual to another when
the viral load is suppressed.
ARVs transform HIV infection from a terminal (fatal) disease to a chronic disease
The availability of treatment may be an incentive for Voluntary HIV counselling and testing
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For antiretroviral treatment to be effective for a long time, it has been found that you need to take more
than one antiretroviral drug at a time. This is what is known as Combination Therapy.
The term Highly Active Antiretroviral Therapy (HAART) is used to describe a combination of three
or more anti-HIV drugs.
b) Benefits of ART
1.
2.
3.
4.
5.
6.
7.
Alters/reverses course of existing Opportunistic Infections(OIs)

Decreases hospitalizations
Increases survival
Restores hope
Improves quality of life
Reduces HIV transmission
Benefits both adults and children
c) Limitations of ART
Although ART dramatically improves the health and life expectancy for PLHIV
I. ART is not a cure for AIDS
II. HIV is never entirely eliminated from the body
III. HIV can still be transmitted to others, even when the PLHIV is healthy and taking his/her medication
regularly
IV. ART is to be taken lifelong
d) Antiretroviral Agents (listed by class):
Nucleoside reverse transcriptase inhibitors (NRTIs) :
HIV infects a cell, Reverse Transcriptase copies the viral single stranded RNA genome into a doublestranded viral DNA.
The viral DNA is then integrated into the host chromosomal DNA, which then allows host cellular processes,
such as transcription and translation to reproduce the virus.
NRTIs block Reverse Transcriptases enzymatic function and prevent completion of synthesis of the doublestranded viral DNA, thus preventing HIV from multiplying.
Non Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) :
NNRTIs are not incorporated into the viral DNA but instead inhibit the movement of protein domains of
Reverse Transcriptase that are needed to carry out the process of DNA synthesis.
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Protease inhibitors (PIs)

Protease inhibitors (PIs) block the protease enzyme. When protease is blocked, HIV makes copies of itself
that cant infect new cells.
Studies have shown that protease inhibitors can reduce the of virus in the blood and increase CD4 cell
counts
Nucleoside Reverse
Transcriptase Inhibitors
Non-nucleoside Reverse
Transcriptase Inhibitors
Protease Inhibitors
Zidovudine (AZT, ZDV)

Lamivudine (3TC)
Stavudine (d4T)
Didanosine (ddI)
Abacavir (ABC)
Tenofovir (TDF)
Emtricitibine (FTC)
Efavirenz (EFZ)
Nevirapine (NVP)
Nelfinavir (NFV)
Lopinavir/ritonavir (LPV/RTV)
Saquinavir (SQV)
Amprenavir (APV)
Fosamprenavir (FPV)
Indinavir (IDV)
Atazanavir (ATV)
Ritonavir (RTV)*
*Recommended as a booster only
e) Drug regimens under the National AIDS Control Programme

Government has provision for first line regimens consisting of fixed dose combinations of the
following ARV drugs for adults and adolescents:
Stavudine (30mg) + Lamivudine (150mg) + Nevirapine (200 mg)
Zidovudine (300mg) + Lamivudine (150mg) + Nevirapine (200 mg)
Stavudine (30 mg) + Lamivudine (150mg)
Zidovudine (300mg) + Lamivudine (150mg)
Nevirapine (200mg) for lead in dosage
Efavirenz (600mg) for single dose
Considering current operational constraints, within the 1st line ART regimen, priority of usage
should be in the following order:
AZT + 3TC + NVP (for patients with Hb > 8 g/dl)

D4T + 3TC + NVP (for patients with Hb > 8 g/dl)
ARVs must be given in a 3-drug combination.
This combination is referred to as the ARV regimen also known as a drug cocktail
Giving only 1 or 2 ARVs to treat HIV disease is incorrect & leads to resistance of drugs.
Starting antiretroviral medication is not an emergency!!
3. INITIATION OF ART :
a) Factors to consider when starting ART
There are many factors that affect how a person will do on ART, and all of these need to be considered
carefully before ART initiation.
National guidelines on ART eligibility
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PLHIV stage of disease progression and concurrent health conditions

Potential side effects and drug interactions
PLHIVs readiness for ART and opportunity for follow up
Please see Annexure 26 for more on Questions and Issues that must be assessed by the Nurse to Aid
in Preparing the Child And Family For ARV
b) Initiation of ART based on CD4 and WHO Clinical Staging
Classification of HIVassociated clinical disease
WHO
clinical stage
CD4 test available
Asymptomatic
Treat if CD4 < 250
Mild symptoms
Advanced symptoms
Consider treatment ifCD4 < 350
Severe/advanced symptoms
Treat irrespective of CD4
Notes:
Clinical staging is part of the baseline assessment (first visit) on entry into the care and treatment
programme and is used to guide decision on when to start Cotrimoxazole prophylaxis and when to start
ART in situations where CD4 testing in not immediately available (or pending result).
Offer ART for symptomatic patients (Stage 3 and 4) if CD4 between 200 350 cells/mm3
If CD4 is between 200- 250 cells/mm3, physicians can consider repeating the CD4 test in 4 weeks in
asymptomatic patients. This is to rule out the 20% laboratory error.
c) Patient Evaluation Prior to Initiating ART

In order to be able to stage the patient correctly and find out about concurrent health conditions, a
systematic patient evaluation needs to be conducted.
Clinical
Evaluation
Recommended Medical
History
Recommended
Physical Examination
Clinical stage of
HIV infection
Past HIV-related
illnesses
Current HIV-related
illnesses that require
treatment
Co-existing medical
conditions and
treatments
Date and place of HIV diagnosis

What are the current symptoms?
Past symptoms, known diagnoses,
treatments given
Symptoms of TB or previous
treatment
History of sexually transmitted
infections
Pregnancy history
Current and previous ART
Readiness to commence ART
Current medications
Body weight (BW)

Skin
Lymph nodes
Mouth
Examination of heart and lungs:
active tuberculosis (TB).
Abdomen
CNS -mental state, motor
and sensory deficit
Vision
Genital/urinary tract
d) Concurrent Health Conditions/Potential for Drug Interactions:

Concurrent health condition
Drugs that are avoided
TB
Anemia
Hepatitis/Chronic liver disease
Pregnancy

NVP during first 2 months of Rifampicin ATT

AZT/ZDV
NVP
EFV IN first trimester
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If patient has concurrent infection-treat infection BEFORE starting ART (i.e. Stabilize the patient
first)
4. ARV DRUG INTERACTIONS

First-line ARV Drug Interactions
If patient is
taking
Remember NOT to
co-administer with these drugs
Other cautions
Nevirapine (NVP)
Rifampin
Ketoconazole
Do not rely on Estrogen based oral

contraceptives. Switch or use
additional protection.
Lamivudine (3TC)
No major drug interactions
Stavudine (d4T)
Do not give with ZDV

(Zidovudine, AZT)
Higher risk of d4T neuropathy when

also taking Isoniazid
Zidovudine
(ZDV, AZT)
Do not give with d4T or

Ganciclovir
Higher risk of anemia when also

taking Acyclovir or sulpha drugs
Efavirenz (EFV)
Diazepam (OK for

convulsions in emergency)
Other benzodiazepines
other than lorazepam
Phenobarbital
Phenytoin
Do not take with high fat meal

If on Methadone, will need to
increase dose.
Monitor for withdrawal signs
5. ADVERSE EFFECTS OF ART :

a. Major Toxicities of First line ARV Regimens
Regimen
Toxicity
D4T/3TC/NVP
d4T related Neuropathy or Pancreatitis

d4T related Lipoatrophy
NVP related severe Hepatotoxicity
NVP related severe rash (but not life threatening)
NVP related life threatening rash (Stevens Johnson syndrome)
AZT/3TC/NVP
AZT related persistent GI intolerance or severe Haematological toxicity

NVP related severe Hepatoxicity
NVP related severe rash (but not life threatening)
NVP related life threatening rash (Stevens - Johnson syndrome)
D4T/3TC/EFV
d4T related Neuropathy or Pancreatitis

d4T related Lipoatrophy
EFV related persistent CNS toxicity
AZT/3TC/EFV
AZT related persistent GI intolerance or severe H Haematological toxicity

EFV related persistent CNS toxicity
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b. Clinical Signs, Symptoms, Monitoring and Management of Symptoms of Serious Adverse Effects
of Antiretroviral Drugs That Require Drug Discontinuation
Adverse
Effect
Clinical signs
Possible
offending drug/s
Management
Acute
hepatitis
Jaundice, liver enlargement,

Gastrointestinal symptoms,
fatigue, anorexia;
NVP-associated hepatitis may have
hypersensitivity component
(drug rash, systemic symptoms,
Eosinophilia).
NVP;
Less common
with EFV, ZDV,
ddI, d4T (<1%);
and PIs,
Most frequent
with RTV.
Close clinical monitoring

Serum
Transaminases, bilirubin.
All ARV should be stopped
until symptoms resolve.
NVP should be permanently
discontinued.
ddI, d4T;
Less common
with 3TC
All ART should be stopped

until symptoms resolve.
ART restarted with change
to different NRTI, preferably
one without Pancreatic
toxicity (e.g., ZDV, ABC).
Acute
Nausea, vomiting, and
pancreatitis abdominal pain.
Close clinical monitoring
If possible, monitor serum
pancreatic amylase, lipase.
Lactic
acidosis
Initial symptoms are variable:

All NRTIs (d4T
A clinical Prodromal Syndrome
more common)
may include generalized fatigue and
weakness, gastrointestinal symptoms
(nausea, vomiting, diarrhoea,
abdominal pain, Hepatomegaly,
Anorexia; and/or sudden unexplained
weight loss), respiratory symptoms
(tachypnea and dyspnea); or
neurologic symptoms (including
motor weakness).
All ARV discontinued

Symptoms may continue or
worsen after discontinuation
of ART Provide supportive
therapy. Regimens that
Can be considered for
restarting ART include a
PI combined with an
NNRTI and possibly either
ABC or TDF.
Hypersensitivity
reaction
ABC: Constellation of acute onset

of symptoms including: fever,
fatigue, Myalgia, nausea/vomiting,
diarrhoea, abdominal pain,
Pharyngitis, cough, dyspneoa
(with or without rash).
The combination of acute onset of
respiratory and gastrointestinal
symptoms after starting ABC is
typical of a hypersensitivity reaction.
NVP: Systemic symptoms of fever,
myalgia, arthralgia, hepatitis,
eosinophilia with or without rash.
ABC
All ARVs discontinued until

symptoms resolve
The reaction progressively
worsens with drug
administration and can be
fatal. Supportive therapy
initiated. ABC (or NVP)
should never be re-used,
as anaphylactic reactions
and death have been
reported. Once symptoms
resolve, ARVs restarted
with different NRTI
Rash usually occurs during the

first 2-4 weeks of treatment.
The rash is usually Erythematous,
Maculopapular, confluent, most
prominent on the body and arms,
may be pruritic and can occur
with or without fever.
NVP
Less common
with EVZ
Severe
rash/
Stevens
Johnsons
Syndrome

NVP
All ARVs discontinued until

symptoms resolve. NVP
permanently discontinued
Once resolved, switch ART
regimen to different ARV
class (e.g., 3 NRTIs or
2 NRTIs and PI). If rash is
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Adverse
Effect
Clinical signs
Possible
offending drug/s
Life-threatening Stevens-Johnson
Syndrome or toxic Epidermal
Necrolysis (SJS/TEN) has been
reported in ~0.3% of infected
individuals receiving NVP
Severe
peripheral
neuropathy
Pain, tingling, numbness of

hands or feet; distal sensory loss,
mild muscle weakness, and
Areflexia can occur.
Management
moderate but not severe and
without mucosal or systemic
symptoms, change in
NNRTI (e.g., NVP to EFV)
is considered after rash
resolves.
ddI, d4T, 3TC
Suspect NRTI stopped and

switched to different NRTI
that is not Neuro toxic
(e.g., ZDV, ABC).
Symptoms usually resolve
in 2-3 weeks.
Please see Annexure 22 for more on Monitoring and follow up patients on ART: Recommendations in the
National Programme.
c. Nurses Role in Educating Patients about Management of Common Side Effects of ARV Therapy
Common
side effects
Advise the patient to:
Headache
For on-the-spot relief, try resting in a quiet, dark room with eyes closed; place cold
washcloths over eyes; massage the base of skull with thumbs and massage both
temples gently; take hot baths or showers.
To prevent headaches from recurring, try to anticipate when the pain will strike. Avoid
or limit those foods known to trigger headaches, especially caffeine (in coffee, tea,
and soft drinks), chocolate, alcohol, citrus fruit (if more than half a cup a day), food
additives (Monosodium Glutamate), nuts, onions, and vinegar.
Nausea and
vomiting
Eat a diet of bananas, rice, stewed apple sauce, toast and tea, if possible (known
as the BRAT diet).
Eat small amounts of bland, odorless foods such as toast, clear soup or kanji, which
are easier to keep down.
Eat simple boiled foods such as porridge, potatoes and beans.
Avoid hot, spicy, strong-smelling and greasy food.
Keep some dry biscuits at your bedside. Before getting out of bed in the morning, eat
a few dry biscuits and sit in bed for a few moments.
Eat small snacks throughout the day, and avoid large meals.
Try ginger tea.
Rash
Consult physician.
Use creams, moisturizers, or a topical ointment such a Calamine to soothe and
comfort the skin.
Use unscented soaps, or non-soap based cleansers.
Avoid taking very hot showers or baths; they tend to irritate the skin.
Wear cotton clothes
Protect skin from sun exposure; the ultraviolet (UV) rays of the sun may worsen a
rash.
Diarrhoea
Eat a diet high in soluble fibre (which slows the diarrhoea by absorbing liquid). These
include the BRAT diet (see above) and soft white rice, oatmeal, cream of wheat or
other locally available porridge and soft bread (not whole grain).
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Common
side effects
Advise the patient to:

Avoid foods high in insoluble Fiber, such as corn, popcorn, fruits (dried and raw),
vegetables, nuts, seeds and most grains. These can make diarrhoea worse.
Decrease high fat foods.
Avoid milk products and greasy, high Fiber or very sweet foods. These tend to aggravate
diarrhoea.
Prevent dehydration by drinking lots of fluids. If dehydrated, drink rehydration solution.
Drink rice or barley water made by boiling a half cup of rice or barley in one liter of
water. Once the rice or barley is cooked, pour off the water and drink it in small sips.
Fatigue
Try to follow the same sleeping pattern everyday. Changes in sleep patterns can
make a person feel more tired.
Avoid caffeine, alcohol, or nicotine for 4-6 hours before going to bed.
A light snack, warm milk, and relaxation techniques before bedtime are often helpful.
Try to get a little exercise during the day. Exercise eases stress and makes a person
feel stronger and more alive.
Anaemia
Return to the clinic to check Hemoglobin count regularly.

Eat a diet of locally available foods that are high in folic acid, including spinach and
other green leafy vegetables, and high in iron and vitamin B12, such as fish, meat and
poultry, if available. Also eat fruits and vegetable rich in Vitamin C such as oranges
and tomatoes to increase absorption of iron into the system.
Take Multivitamins and/or supplements of Folic acid or Iron.
Peripheral
Neuropathy
Wear loose-fitting shoes, roomy cotton socks and padded slippers around the house.
Good air circulation around the feet helps.
Keep feet uncovered in bed. Bedding that presses down on the toes can add to the
problem.
Walk around, but not too much. Walking helps blood to circulate in the feet, but too
much walking or standing can make the problem worse.
Massage the feet gently; vigorous massage will deteriorate the problem.
d. Immune Reconstitution Inflammatory Syndrome (IRIS)

IRIS is a spectrum of clinical signs and symptoms resulting from the bodys ability to mount and inflammatory
response associated with immune recovery.
Antiretroviral therapy partially restores immune defects caused by chronic HIV infection including restoration
of protective pathogen-specific immune responses.
The protective response sometimes causes (atypical) inflammatory manifestations to concurrent infective
or non-infective conditions e.g. TB, MAC or CMV.
Clinically, IRIS presents as occurrence or worsening of clinical and/ or laboratory parameters despite a
favorable outcome in CD4 counts (and viral load).
The temporal association between commencement of HAART (or change from a previously failing regimen)
and the development of an unusual clinical phenomenon often provides a strong clue to the diagnosis of
IRIS.
IRIS occurs in one of two scenarios:
A patient receiving treatment for a known OI, initiates combination ART

Manifestations of a previously unrecognized OI appear or are unmasked with the initiation of ART
It usually occurs in patients with advanced HIV disease and sub clinical opportunistic infections
(OIs), e.g., TB, CMV. These OIs should be treated appropriately while maintaining the antiretroviral regimen.
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In some cases Corticosteroids are given. Rarely, in the most severe cases, there may be a need to
discontinue ART.
Nurses Role in the Management of IRIS:
Observe patients who start ART for new or worsening signs and symptoms of HIV and OIs.
Reassure the PLHIV that this is not unexpected, and is a sign that the immune system is recovering
Treat OI symptoms with medications and other supportive interventions
Check the rise in the value of CD4 cells.
6. TREATMENT FAILURE :
a. Indications :
Antiretroviral therapy does not always work. It may be successful at controlling HIV infection for a period
of time, but may eventually fail, allowing the disease to progress and worsen the patients condition.
Indications of failure can be:
Clinical Failure
(i)
Immunological Failure
Virological Failure
New or recurrent WHO Stage 4 condition,

after at least 6 months of ART (ii, iii)
(iv)
Fall of CD4 count to pre-therapy baseline (or below); or

50% fall from the on-treatment peak value (if known); or
Persistent CD4 levels below 100 cells/mm3 (v)
Plasma viral load > 10,000 copies/ml
(vi)
Notes:
i.
Current event must be differentiated from IRIS( N.B. In patients, with treatment failure, the CD4 count
is either normal or decreased whereas in patients with IRIS, the CD4 counts are found to rise.
ii. Certain WHO clinical stage 3 conditions (e.g. Pulmonary TB, Severe bacterial infections), may be an
indication of treatment failure and thus require consideration of second-line therapy.
iii. Some WHO clinical stage 4 conditions (lymph node TB, uncomplicated TB Pleural disease, Oesophageal
Candidiasis, recurrent bacterial Pneumonia) may not be indicators of treatment failure and thus do not
require consideration of second-line therapy
iv. Without concomitant infection to cause transient CD4 cell decrease
v. Some experts consider that patients with persistent CD4 cell counts below 50/mm3 after 12 months on
ART may be more appropriate
vi. The optimal viral load value at which ART should be switched has not been defined. However, values
of more than 10,000 copies/ml have been associated with subsequent clinical progression and appreciable
CD4 cell count decline
b. Factors Contributing to Treatment Failure
Suboptimal ARV regimen

Suboptimal drug level
Side effects and drug toxicity
Lack of proper adherence to therapy
High cost
Drug stock outs
c. Reasons for ARV drug substitution/ARV regimen switch

Reasons to consider ARV drug substitution:
Intolerance
Drug toxicity
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Occurrence of active TB
Pregnancy
Side effects
Reasons to consider ARV regimen switch:
ARV treatment failure
Notes:
The general principle is that single-drug substitution for toxicity should be made within the same ARV
class. [e.g., substitution of AZT or TDF for d4T (for Neuropathy), TDF or d4T for AZT (for anaemia) or
NVP for EFV (for CNS toxicity or in pregnancy)]
Substituting d4T may not reverse Lipodystrophy but may slow its progression. Besides AZT, TDF, ABC
or ddI are acceptable alternatives but are not available in the national programme.
d. If a life-threatening toxicity occurs, all ART should be stopped until the toxicity has resolved and a
revised regimen commenced when the patient has recovered.
7. DRUG RESISTANCE
Resistance
Resistance is the ability of an organism (such as HIV) to overcome the inhibitory effects of drug/s.
Development of Drug Resistance
HIV reproduces very rapidly

The virus often makes errors while copying itself
Each new generation of viruses differs slightly from the one before
This is called mutation. Mutant viruses take advantage of gaps in ARV circulation in the blood and
start replicating.
These mutant forms of HIV are not sensitive to ARVs. In other words, the ARVs are no longer able to
control HIV.

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If resistance develops:
Drugs start failing and the virus is able to replicate

As virus replicates, immune system is damaged
OIs occur, progressing to AIDS
New drugs can be tried however; there are only limited drug options available
Role of the Nurse in Reducing Resistance:
Be sure to provide adherence support

Work with patients and their families to minimize barriers to medication adherence
Ensure that patients are on triple therapy
Instruct patients that if ARV medications are to be discontinued, to stop all drugs at the same time
Nurses can use the checklist given below to monitor medication adherence in patients.
8. ADHERENCE
What is adherence?
Adherence is the patients willingness and ability to stick to his/her medication regimen and follow-up care.
The patient takes their medications exactly as prescribed:

Right drug
Right dose
Healthcare providers are often unable to
Right way
predict who will adhere correctly
Every time
Must be taken more than 95% of the time
(i.e Not missing more than 3 doses a month)
ARVs must never be shared
Before starting ART, it is essential to assess the

patients readiness to start therapy and his/her
commitment to taking these medications correctly
and consistently, (probably) for the rest of their
life to ensure successful treatment. It is at this
stage that nurses should also ensure the PLHIV
has the opportunity to return for regular, reliable
follow up visits, which are crucial to the success
of long term ART.
Remember
Initiating ART is NOT an emergency!
Medication Adherence Checklist

Patient Name:
Date:
Review Treatment History
Current regimen
Previous medications
Side effects
Other treatments
Discuss Current Health Status
Overall health and current problems

Latest laboratory tests (including CD4 count)
Goals for health
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Medication Adherence Checklist

Assess Medication Knowledge, Behaviors and Attitudes
Knowledge of HIV medications

Understanding of drug resistance and implications
Criteria for evaluating medications
Attitude about talking medications
Review Patient/Family Living Situation
Daily activities: work, school and travel schedule

Eating patterns
Access to health centre
Special factors: disclosure of HIV diagnosis, medication storage issues
Describe Proposed Medication Regimen
Drug names
Dosing
Food requirements
Special instructions/how to give
Side effects
Storage
Assess Patient Readiness for Regimen
Review possible drug interactions

Review barriers to adherence (support system, work, living situation)
Document the Treatment Plan
Give information on drug names, dosing, frequency, food and storage requirements
Discuss potential side effects and a plan for response, including prescriptions
Review logistics of filling and refilling prescriptions
Plan to Follow-up
Schedule next appointment; discuss what should prompt an earlier visit

Schedule support by other members of the health care team as appropriate (home visit,
follow-up calls)
Closure
Ask the following questions:
Do you know how and when to get your prescriptions filled?
Do you know when, and how, to get more pills when you need them?
When is your next appointment with the doctor?
Are their other things you need to do to make it easier to follow your treatment plan?
Review each medication and ask the following:
How many times each day?

How many pills each time?
With food or empty stomach?
What side effects will you watch out for, and what will you do if you get them?
Additional Comments
Name of Health Care provider :
Signature of health care provider:
Please see Annexure 27 for more on Ways to Promote ART Adherence in Children
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Nurses Role:
Patient education about ART

Counselling
Assessing ART readiness
Monitoring ART
- Performing patient self appraisal
- Clinical Examination: e.g. weight gain, rash,
- Laboratory Testing: e.g. CD4 count monitoring, HB,LFTs, Creatinine
- Observe and manage the side effects
Assess adherence to ART and motivate
Helping in resuming the normal life pattern
Helping to improve the quality of life
Watch for any new symptoms or worsening of the previous symptoms
Look for treatment failure and intervene accordingly
Refer the patients to PLHIV Networks/ self-Help groups/ NGOs working in the field of HIV/AIDS
Co-coordinating and communicating with the Multidisciplinary Team
Barriers to Adherence
Nurses need to recognize potential barriers to adherence and support patients to overcome them through
education, counselling, linkages and referrals etc.
Personal
Factors
Socioeconomic
Factors
Medication
Factors
Institutional
Factors
Feeling well
PLHIV doesnt
think he/she
needs the
medication
anymore
Too ill to take
medications
Taking other
medications
Forgetting to
take pills
Does not
understand
purpose of
therapy
No belief in
treatment
efficacy
Debilitating
symptoms
Poor selfesteem,
depression,
and mental
illness
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Expenses
related to care
Competing
prioritieswork,
family, food access
Lack of social
support
Stigma &
disclosure issues
Cultural or religious
beliefs (fasting,
mourning,
traditions)
Substance abuse
Drug interactions
Complex regimen
Difficult to swallow
Side effect/s
Interference
with daily life
Pill fatigue/tired
of taking
medicines for
months/years
Location of centre is
inconvenient, difficult or
expensive to get to
Inadequate staffing,
insufficient time
No appropriate
education provided
Language &
communication barriers
Attitude of Clinician
& Care team

Key Messages :
ART is not a cure for HIV/AIDS
HIV can still be transmitted, even when an individual is on ART or when HIV viral loads are below
the limits of detection
ART can significantly reduce HIV-related mortality and morbidity
For therapy to be effective, patient readiness must be assessed and triple ARV medications must
be used
Patients on ART require close monitoring and frequent evaluation
Nurses can identify PLHIV who would require ART and refer them for Assessment and Counseling
Educate and counsel on how ART can help
Reduce the viral load
Improve the immune status
Decrease chance of developing OIs
Educate and counsel on how to take ART
Always take the medication as prescribed
Not to miss doses (even 3 doses in a month) as it can cause resistance.
If a dose is missed NEVER take a DOUBLE dose
The drug should never be shared with anyone
Risk of transmission of HIV is reduced but could still occur. So practice safe sex
ART is life long. If the medicine is stopped the PLHIV, will become ill in few months
Report any of the following symptoms
Tingling, numb or painful feet or legs and hands
Arms, legs, buttocks, cheeks become thin & breasts, belly, back of neck become fat
Persistant Diarrhea
Worsening Skin rash
Yellow discoloration of the skin and sclera
Severe abdominal pain
Fatigue and shortness of breath
Assist in managing side effects of ART

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UNIT 11 PAEDIATRIC HIV INFECTION

Unit Objectives
Describe the magnitude of paediatric HIV infection

Discuss differences between paediatric HIV and adult HIV
Describe the use of ART in children
Discuss important psychosocial issues concerning Paediatric HIV
Explain the role of the nurse in Paediatric HIV management
1. PAEDIATRIC HIV
Magnitude of Paediatric HIV
Global
Globally, no. of children below 15 years, who died due to AIDS related illnesses, dropped to 260,000
in 2009 from 320,000 in 2004*
More than 90 % were from Sub-Saharan Africa
Without antiretroviral treatment, the progression of HIV infection in children is particularly aggressive,
and many children die at a young age (Taha et al.,2000; Newell et al., 2004; Brahmbhatt et al.,
2006).Increase in acess to pediatric antiretroviral treatment, the number of new infections in children
has reduced
India
Approximately 30% of HIV infected pregnant women will transmit HIV to their babies*
Estimated number of HIV infected children under 15 years is 4%
80% children born with HIV infection, die before the age of 5 years
Appoximaetly,20,000 eligible HIV infected children are on ART (NACO, 2010)
*Source: Global Report On AIDS Epidemic 2010, UNAIDS

Estimated Risk and Timing of MTCT in the Absence of Interventions
How do Children get HIV?
Mother to Child Transmission (MTCT) is by far the most significant route of transmission of HIV infection
in children below 15 years
Without interventions the risk of transmission from an infected mother to her child ranges from
- 15-25% in developed countries
- 25-45% in developing countries
This difference is attributed to breast feeding and delivery practices
What are the Indicators of HIV Infection in a Child?
Infant symptomatic with 2 or more signs
Oral thrush
Severe pneumonia
Severe sepsis
History of Mother:
Recent HIV related maternal death,
Advanced HIV disease in mother, CD4 < 200
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Child: Any AIDS indicator signs

PCP
Cryptococcal Meningitis
HIV Wasting Syndrome
Extra pulmonary TB
Kaposis Sarcoma
Stunted Growth/Failure to thrive

HIV Diagnosis in children <18 months:
HIV DNA PCR at 6 weeks and 6 months (where available)

HIV antibody testing at 12 and 18 months
Diagnosis of Paediatric HIV Infection
Confirmatory Diagnosis of HIV infection in children<18 months
For children <18 months old, both breastfed and non breastfed, born to a HIV positive mother the
following testing strategy applies according to the NACO programme.
* If child >12 months old, can use adult testing strategies such as rapid test or ELISA however, definitive
and confirmatory testing is only possible after 18 months of age
Please see Annexure 20 for more on Specimen Collection (by heel prick) and handling
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WHO Clinical Staging of HIV in Children

Just as in adults staging in children with HIV is done based on clinical signs and symptoms.
Clinical stage 1
Asymptomatic
Persistent Generalised Lymphadenopathy (PGL)
Clinical stage 2
Unexplained persistent Hepatosplenomegaly
Papular Pruritic eruptions
Extensive wart virus infections
Extensive Molluscum Contagiosum
Recurrent oral ulcerations.
Fungal nail infections
Lineal Gingival Erythema (LGE)
Unexplained persistent Parotid enlargement
Herpes Zoster
Recurrent or chronic upper Respiratory Tract Infections (Otitis media, Otorhoea, Sinusitis, Tonsillitis)
Clinical stage 3
Unexplainedi moderate malnutrition not adequately responding to standard therapy
Unexplained persistent Diarrhoea (>14 days)
Unexplained persistent fever (>37.5*C intermittent or constant, for longer than 1 month)
Persistent Oral Candidiasis (after first 6-8 weeks of life)
Oral Hairy Leukoplakia
Pulmonary TB
Lymph Node TB
Severe recurrent bacterial Pneumonia
Acute necrotizing Ulcerative Gingivitis/Periodontitis
Symptomatic Lymphoid Interstitial Pneumonitis (LIP)
Chronic HIV-associated lung disease, including Bronchiectasis
Unexplained Anaemia (<8gm/dl), neutropenia (<1,000/mm3) or chronic thrombocytopenia
(<50,000/ mm3) for > 1 month
Clinical stage 4
Conditions where clinical diagnosis is accepted
Unexplained severe wasting, stunting or severe malnutrition not responding to standard therapy.
Pneumocystis pneumonia
Recurrent severe bacterial infections (e.g. Empyema, Pyomyositis, bone or joint infection,
Meningitis, but excluding Pneumonia)
Chronic Herpes Simplex Infection; (Orlabial or Cutaneous of > 1 month duration or visceral at
any site)
Extra pulmonary Tuberculosis
Kaposis sarcoma
Oesophageal Candidiasis (or Candidiasis of Trachea, Bronchi or Lungs)
CNS Toxoplasmosis (after 1 month of life)
HIV Encephalopathy
Cytomegalovirus infection: Retinitis or CMV infection affecting another organ, with onset at
age over 1 month.
Extra pulmonary Cryptococcosis (including Meningitis)
Chronic Cryptosporidiosis
Chronic Isosporiasis
Disseminated non-Tuberculosis Mycobacteria infection
Cerebral or B cell non-Hodgkin Lymphoma
Progressive Multifocal Leukoencephalopathy (PML)
Symptomatic HIVassociated Nephropathy or HIV-associated Cardiomyopathy
Unexplained refers to where the condition is not explained by other conditions.
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Pediatric vs Adults HIV/AIDS: Important Differences

Area of Focus
Children
Adults
Diagnosis
DNA PCR for children <18 months

OR
Confirmatory Antibody test after 18 months
Confirmatory
Antibody test, usually
by 6 months
Monitoring
CD4% for children below 5 years of age

CD4 count for Children above 5 Years
Have higher viral loads
CD4 cell count

Have lower viral loads
Disease Progression
More rapid
Less rapid
Opportunistic Infections
Often present as primary disease with

more aggressive course
Have more frequent recurrent invasive
bacterial infections (Otitis Media,
Respiratory infections
More chance of
CNS Involvement
PCP
Failure to thrive
NACO Guidelines for initiating ART for Children

Normal CD4 Counts For Children
Age
CD 4 Count
< 12 Months
1-5 Years
> 6 years
CD4 >1500 Cells/mm3 (25%)

CD4 >1000 Cells/mm3 (20%)
CD4 >550 cells/mm3
Under the national programme, CD 4 counts/% will be done to screen the medical eligibility for ART.
However, where CD 4 count/% is not available, there should be no delay in offering ART based on Clinical
staging.
Age
CD 4 Count
< 11 Months
12-35 months
36-59 months
CD4 < 1500 Cells/mm3 (25%)

CD4 < 750/ Cells/mm3 (20%)
CD4 < 350 Cells/mm3 (15%)
Follow adult guidelines i.e. start ART if < 350 cells/mm3,
especially if symptomatic
Initiate ART Before CD4 count drops below 200 cells/mm3
>5 years
Recommended ART according to NACO for Children

NRTIs
NNRTIs
Stavudine (d4T) OR
Zidovudine (AZT) PLUS
Lamivudine (3 TC)
Nevrapine (NVP) OR
Efavirenz (EFV)
If age < 3 years or weight <10 kgs, Nevrapine
If > 3 years or weight > 10 kgs, Nevrapine or Efavirenz

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PSYCHOSOCIAL ISSUES PAEDIATRIC HIV

Disclosure of Diagnosis
Provide age appropriate information

Disclosure in older children
of parents diagnosis
to family / friends
to school
Childrens concerns
Chronic illness
Why me, May blame parents
Taking medicines for many years
Antiretroviral drug resistance
Handling different stages of development
Life planning goals
Nurses Role
Care of Infants born to HIV+ve mothers
Infants born to HIV+ mothers, have unique needs and an understanding of their physical, developmental,
and psychological make-up is essential in order to understand the various dynamics in the management
of children with HIV.
Primary Care HIV Exposed Infants
Suspect and recognize HIV exposed infants

Ensure PCP prophylaxis (Cotrimoxazole-5 mg/kg/OD For 6 Months)
Review for TB at each visit
Make prompt referral for needed services
Educate parents to
Give immunizations as per schedule
Bring infant for routine evaluation of growth and development
Report any illnesses for prompt treatment
Provide good nutrition to the baby
Nutrition Education
Feeding options during infancy:

Exclusive Breast Feeding 4 months & then on top feeds with complementary foods
(Mashed soft diet)
OR
Exclusive artificial (replacement) feeding
Well balanced diet
Small frequent feeds
Food hygiene
Link to NGOs and CCC and CBOs, for support
Hygienic practices
Education - Continuing Care
Growth monitoring
Diet to support growing needs
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Prevent
injuries
infections
Regular check - ups
Recognize and report signs of infections
Long term care
School
Care takers
In Paediatric ART
Assess for ART readiness (Refer to Annexure 26 on Questions & Issues that must be assessed
by the Nurse to aid in preparing the child & family for ARV for more details)
Assess for factors that may be a block for adherence
Assess for signs of serious side effects or toxicities
Find ways to assist in adherence (refer to Annexure 27 on Ways to promote ART adherence in
Children for more details)
Educate and reinforce the need for adherence.
Key Messages :
Nurses should:
Educate and counsel on the need for HIV testing
Refer all pregnant women for HIV testing
Educate and counsel mothers with HIV exposed infants to
Follow safe infant feeding practices
Come for regular follow up
Give all immunizations for the infant
Report any signs of infection
Test the baby for HIV > 12-18 months
Assess for eligibility for ART
Give Cotrimoxazole prophylaxis for all infants till diagnosed as HIV ve or up to 5 years if
HIV +ve
Support children as they grow to cope with the various psychosocial issues of living with HIV
Link HIV+ children and their families to support groups

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UNIT 12 COMPLEMENTARY THERAPIES IN HIV/AID

Unit Objectives
Explain the role of Complementary Therapies in HIV/AIDS care
Describe the various types of Complementary Therapies
Identify the role of nurses in educating patient about complementary therapies
COMPLEMENTARY THERAPIES IN HIV/AIDS:
With most complementary therapies, health is looked at from a holistic (or whole picture) point of view.
From a holistic viewpoint, everything one does-from what they eat, to what they drink, and to how stressed
they are affects their health and well-being.
Complementary therapies are health treatments to go along with the medical care they get from their
doctor from ART centre.
Philosophy of Complementary therapy is that body works as one big system
Complementary therapies are sometimes wrongly called alternative because they dont fit into the
mainstream, i.e. the modern medicine - Allopathic science of medicine.
Some common complementary therapies include:
Yoga
Massage
Aromatherapy
Relaxation Techniques
Meditation
Visualization (Imagery)
Reflexology
Laughter Therapy
Music Therapy
Hydrotherapy
Yoga
Yoga is a set of exercises that people use to improve their fitness, reduce stress, and increase flexibility.
Yoga can involve breathing exercises, certain stretches and poses, and meditation.
Many people, including people with HIV, use yoga to reduce stress and to become more relaxed and calm.
Some people think that yoga helps make them healthier in general, because it can make a persons body
stronger.
Massage
Massage therapy is an excellent way to deal with the stress and side effects that go along with having an
illness, including HIV. During massage therapy, a trained therapist moves and rubs on muscles. There are
many kinds of massage therapy. The massage therapy can be used for muscle and back pain and
headaches and soreness it reduces circulation and tension.
Aromatherapy
Aromatherapy is based on the idea that certain smells can change the way you feel. The smells used in
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aromatherapy come from plant oils, and they can be inhaled (breathed in) or used in baths or massages.
Aromatherapy to help them deal with stress or to help with fatigue. For example, some people report that
lavender oil calms them down and helps them sleep better. If the patient is interested in aromatherapy
should consult an expert before using these oils because these oils can be very strong and even harmful.
Relaxation techniques
Relaxation therapies, such as Meditation and Visualization focus on how a persons mind and imagination
can promote overall health and well-being. The patient may be advised to contact experts for use of
relaxation therapies to reduce stress and relax.
a) Meditation
Meditation is a certain way of concentrating that allows the mind and body to become very relaxed.
Meditation helps people to focus and be quiet. There are many different forms of meditation. Most involve
deep breathing and paying attention to body and mind.
One sits still and closes their eyes to meditate. Meditation also can be casual. For instance, one can
meditate while taking a walk or watching a sunrise.
People with HIV can use meditation to relax. It can help them deal with the stress that comes with any
illness. Meditation can help to calm down and focus if one is feeling overwhelmed
b) Visualization
Visualization is another method used to feel more relaxed and less anxious. Most people use visualization
without realizing itfor example, daydream or remember a fun, happy time in their life. Visualization when
done in a comfortable place reduces stress and lessens the pain or side effects of the medicines.
Reflexology
Reflexology is an ancient Chinese technique that uses pressure-point massage usually on the feet, but also
on the hands and ears. It restores the flow of energy throughout the entire body. It is based on the premise
that there are reflexes in our hands, feet and ears that relate to every organ and part of our body and by
stimulating these reflexes with pressure and manipulation, nerve function and blood supply may be improved.
It can also help in alleviating stress and other health problems.
Stimulating specific reflex points in the feet can bring needed nutrients to poorly functioning areas of the
body.
Laughter Therapy
Laughter Therapy is the use of laughter for the relief of physical or emotional pain and stress. It improves
the immunity (increases level of Interferons). It proves to be a potent anti-stress factor, decreases asthmatic
attacks, increases stamina, relives arthritic pain, ensures good sleep and elevates mood.
Music Therapy
Music Therapy consists of systematic application of music by the Music Therapist to bring about the helpful
changes in the physical and emotional health of the client.
It enables to experience an altered state of physical arousal and subsequent mood by processing a
progression of musical notes of varying tone, rhythm and instrumentation for a pleasing effect.
Hydrotherapy
Hydrotherapy is the use of water (hot, cold, steam or ice) to relieve discomfort and promote well being.
The recuperative and healing properties of Hydrotherapy are based on its mechanical and/or thermal
effects. It exploits the bodys reaction to hot and cold stimuli, to the protracted application of heat, to
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pressure exerted by the water and to the sensation it gives. The nerves carry impulses felt at the skin
deeper into the body, where they are instrumental in stimulating the immune system, influencing the
production of stress hormones, invigorating the circulation and digestion, encouraging blood flow, and
lessening pain sensitivity.
The above therapies help the PLHIV to:
Relieve tension and other symptoms

Relax, revitalize and nurture
Improve circulation and balance energy flow
Support Psycho-Neuro-Immunological responses
Release negativity and affirm positivity
Healthy people use these kinds of therapies to try to make their immune systems stronger and to make
themselves feel better in general. People, who have diseases or illnesses, such as HIV, use these therapies
for the same reasons. They also can use these therapies to help deal with symptoms of the disease or side
effects from the medicines that treat the disease.
Many people report positive results from using complementary therapies.
(In most cases, however, there is not enough research to tell if these treatments really help people
with HIV)
Nurses role
If patients want to try complementary treatments to help them to cope with HIV/AIDS, the nurses
should :
Educate the patients about Complementary therapies

Help them in making the choice among Complementary therapies according to their needs
Refer to the relevant AUTHORIZED agencies ONLY.
Instruct them to ALWAYS discuss with their doctor before starting any kind of treatment, even
if they think it is safe, because something is natural (an herb, for example) doesnt mean that it is safe
to take. Sometimes these products can interact with ART therapy or cause side effects on their own.
Convey that it is always a risk to take something or try something that hasnt been fully studied of how
well the complementary therapies work to treat HIV/AIDS. Hence one needs to be careful before
intiating complementary therapy.
Caution the patients of treatments that claim to be miracle curesones that claim to cure HIV/AIDS.
There are people out there who may try to trick you into buying an expensive product that doesnt work.
Instruct the patients to consult their doctor for help.
Emphasize that Complementary therapies are not substitutes for the treatment and drugs they receive
from the doctor. Instruct the patient never to stop taking the ART therapy just because they have started
another therapy.
CAUTION:
Warn the patients to consult their doctor before taking anything new.
NO THERAPY IS TO BE PRACTICED WITHOUT THE SUPERVISION OR CONSULTATION WITH AN
EXPERT.
THE NURSES SHOULD NOT TEACH ANY OF THE THERAPIES TO PLHIV THEMSELVES.
JUST BECAUSE SOMETHING IS NATURAL OR NON-DRUG DOESNT MEAN THAT IT IS SAFE
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Key Messages :
Complementary therapies include Yoga, Massage, Relaxation techniques (such as meditation),
Laughter and Hydrotherapy.
Complementary therapies may make HIV patients feel better and help with some symptoms and side
effects.
Remember that not all complementary therapies are safe as some therapies can be very dangerous
because they can interact with ART therapy or cause severe side effects.
Make the patient aware about various complementary therapies available and help them to select
according to patients choice.
Instruct the patient the doctor should be consulted for initiating complementary treatments in addition
to getting mainstream medical care.

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UNIT 13 PALLIATIVE CARE FOR PEOPLE LIVING

WITH HIV/AIDS (PLHIV)
Unit Objectives
Explain the philosophy, principles and practices of palliative care and how they relate
to nursing care of PLHIV
Discuss the importance of symptom management
Describe methods of assessing and managing pain
Explain the nurses role during grief and bereavement
List nursing interventions which can assist the patient and family during end-stage
HIV disease
1. PALLIATIVE CARE
Palliative care is the active total care of patients whose disease does not respond to curative treatment.(WHO
definition)
The primary goal of Palliative care relief from suffering and the enhancement of the quality of life through
effective symptom management.
Principles of palliative care are Integrated in quality of life model. It gives a deeper perspective and a more
holistic approach to the patient.
COMPONENTS OF QUALITY OF LIFE MODEL
Quality of life model includes four components:
Physical well being (freedom from pain and discomfort, functional ability, etc.)
Psychological well being (freedom from undue anxiety/fears, ability to experience happiness, etc.)
Social well being (purposeful life role, freedom from financial burden, etc.)
Spiritual well being (feelings of hope, meaning to life, etc.)
Quality of Life Model aims at:
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Palliative care in any chronic care situation starts at the time of diagnosis. As illness progresses, there is
a shift in the balance between aggressive treatment oriented care and palliative care. The patient or the
family decide to stop the treatment and the focus is on supportive care till the death of the patient.
COMPONENTS OF PALLIATIVE CARE:
Palliative care is most successful, when initiated early in the disease process since it takes time to develop
the necessary supportive relationships between the patient and the interdisciplinary team. It can be initiated
at any time through the continuum of care.
The focus is to reduce symptoms, pain as well as emotional & spiritual distress so that ultimately the patient
could have a comfortable and peaceful death.
PRINCIPLES OF PALLIATIVE CARE
Respect the identity and integrity of the patient

Be sensitive and non-judgmental
Know when to listen and when to speak
Have the knowledge and skills to intervene in a way that promotes best possible quality of life
DIMENSIONS OF PALLIATIVE CARE

Although palliative care can begin anytime after diagnosis of HIV, it usually begins when PLHIV have:
Diminished functional status

Spending >50% of day in bed
Progressive dependencies
Dementia
When medical treatment is no longer effective
Advanced disease
CD4 persistently low <50 cells/cc
End-stage organ disease - Renal, hepatic, or cardiac failure
When side effects of aggressive treatment outweigh the benefits
Progressive hepatitis C, Hepatic failure; drug intolerance
Multi-drug resistance or failure
When the patient decides that he/she no longer wants aggressive treatment

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Desire of patient for death

Acknowledgment by patient and family of poor prognosis
PRIMARY GOALS OF PALLIATIVE CARE
Relief of suffering
Enhancement of the quality of life through effective management of
Symptoms
Pain
Psychosocial aspects
PHILOSOPHY OF PALLIATIVE CARE
Affirms life and makes dying a normal process

Neither hastens nor postpones death
Provides relief from pain and other symptoms
Takes a holistic approach to care - integrates the clinical with the psychological & spiritual
Provides support to both the patient and family
2. SYMPTOM MANAGEMENT
Common Symptoms of Advanced HIV Disease
Common Physical Symptoms
Common Psychological
Symptoms
Pain
Anorexia
Fear
Malaise
Severe wasting
Guilt
Fatigue
Dehydration
Social withdrawal
Fever
Constipation
Depression
Dyspnoea
Headache
Dementia
Diarrhoea
Convulsions
Agitation
Nausea/Vomiting
Decubitus ulcers
Dysphagia
Two Important Points for Managing Symptoms at End of Life:
Identifying and defining the problem

Assessing the severity of the symptom
Pain Management
During end stage of life, PLHIV can experience tremendous pain and suffering. Providing relief from this
pain is a crucial component of palliative care. Knowing about the types of pain listed below in the table will
help nurses provide appropriate care and treatment to their patients.
There are different definitions for pain: Pain is an unpleasant sensory and emotional experience associated
with actual or potential tissue damage or described in terms of such damage; Pain is whatever the experiencing
person says it is, existing whenever the person says it does.
During end stage of life, PLHIV can experience tremendous pain and suffering. Providing relief from this
pain is a crucial component of palliative care. Knowing about the types of pain listed below in the table will
help nurses provide appropriate care and treatment to their patients.
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Types of Pain
Type
Characteristics
Acute
Identified with a specific event

Patient can identify when the pain begins and when it ends
Person looks sick
Produces a change in vital signs, diaphoresis, pallor
Chronic
Pain for more than three months

No beginning; persists beyond reasonable time for injury to heal
Person does not look sick
No physical or objective signs of pain
Somatic
Direct stimulation of intact receptors in muscles and bones

Usually localized
Soft tissue and bone pain; sharp, throbbing, aching
Muscle pain: cramping, gripping, clenching
Visceral
Direct stimulation of intact receptors in deep visceral organs

like heart, lungs etc
Difficult to localized
May be referred to another site
Characteristically: deep aching, cramping, pressure or colicky
Neurologic
Results from disordered function or / and direct damage to nerves of

peripheral, spinal or central nervous systems
Difficult to treat effectively
Peripheral: burning, shooting
Spinal cord: Constant, dull aching with neurologic deficits
CNS: Changes in vital signs, nausea, vomiting, increased intracranial pressure
Sources and Locations of Pain in Persons with HIV
Assessment of Pain
The first step nurses can take in managing pain in PLHIV is to assess the pain. As the experience of pain
differs so greatly from one person to another, it is important to consult the patient as far as possible in
determining what the nature and intensity of the pain is. Following this, nurses can apply patient specific
care and treatment plans.
Assessing Quality of Pain
Use the acronym PAINT given below as a guide to assess the nature or quality of pain being experienced
by PLHIV:
P Part
Which part is involved?

Is it localized or radiating?
Is it referred?
A Associating Factors
What other symptoms are present? Anorexia, cognitive problems, constipation, diarrhoea, difficulty
swallowing, dyspnoea, fatigue, fever, nausea, neck stiffness, neurological symptoms, seizures, skin
problems, vomiting, etc

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I Interacting Factors That Aggravate Pain
What increases the pain change of position, lack of medication, fear, lack of support, family problems,
lack of care, mood etc
Why hasnt the patient done any thing about the pain? Religious reasons, social reasons, emotional
reasons, lack of knowledge
N Neutralizing Factors
What decreases pain? Position, medication, support, acceptance of disease, knowledge of prognosis
and management of the disease, mood etc
Is the patient already on any medications for pain?
What has been done to reduce pain so far?
T Type of Pain
Is it burning, sharp, pulsing, tingling, flashes of pain? Or is it unremitting pain that is sharp, aching or
dull? What is the duration?
Is the patient chemically dependent on painkillers?
Assessing the quantity/amount of pain:

Use the descriptive numerical scale below and ask people to rate where their pain lies on a scale of
1 to 10.
Treating Pain
The pharmacological approach is the most common way to treat pain. See the detailed WHO approach to
pain management provided below.
Pharmacological Approaches to Pain Management: World Health Organisation (WHO) Ladder
Goal: Achieve best possible baseline pain control within 24 hours of assessment and initiation of treatment
plan as defined by resident and family. The WHO Ladder focuses on proper selection, dosing, titration, and
administration of analgesics in relation to persons self-described pain intensity and type of physical pain
responsive to opioid therapy.
Five Concepts
By mouth
By the clock
By the ladder
For the individual,
With attention to detail
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STEP
LEVEL OF PAIN
DRUGS
Mild pain: Between 1 - 3 on a

10 point scale
Non steroidal anti inflammatory drugs

Paracetamol
Asprin
Ibuprofen
Diclofenac
Acetaminophen
Moderate pain: Between 4 - 6 on

10 point scale
Weak opoids
Codeine
Propoxyphene
Combine Paracetamol with
Dextropropoxyphene
Severe Pain: Between 7 - 10 on a

10 point scale
Strong opoids
Oral Morphine
Buprenorphine
Pain Management Drug Treatments
Adjuvant drugs are used in

combination with non-opioid and
opioid drugs to enhance pain
management, most frequently in
complicated neuropathic pain
syndromes e.g. corticosteroids,
antidepressants, anticonvulsants
etc.
Complimentary Pain Control Measures

Apart from providing relief with drugs, nurses can also provide a lot of relief by
Giving massages, back rubs, cool cloths, touch

Keeping patient rooms quiet, well ventilated
Addressing any emotional and spiritual concerns that may impact pain and discomfort
Ensuring a comfortable bed and peaceful atmosphere
Within the limited mobility of the patient, some occupational assignments to be given to keep them busy
Teaching and breathing exercises
Management of Psychological Aspects

The third and equally important component of palliative care after symptom and pain management is
management of psychosocial aspects. Nurses can address the emotional needs of both a dying patient and
the family using the acronym SPIKES given below as a guide.

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Set the environment for adequate support

Maintain privacy
Prevent interruptions
See that there is sufficient time for discussions
Listen actively
Discuss issues that the patient or the family feels a need to discuss
Show concern
Do not hesitate to touch the patient
Perform patient and family self evaluation of condition and prognosis

Use open-ended questions. E.g. How do you think you are presently doing? or
what do you feel about your present condition?
Invite patient and family with regards to how much information they would want
Inform patient about available help for emotional and spiritual needs
Use open-ended questions. E.g. what would you want information on? or
I wish to tell you about the patients present condition/talk to you about your
present condition. How much would you want to know?
Know how much the patient perceives about his/her condition;

Know the facts in the present context
Use open-ended questions. E.g. what do you know about your (his/her) present
condition? or I have some bad news for you this is a very difficult time and
I want you to be prepared
Explore emotions (Denial, anger, bargaining, depression and acceptanceDABDA); empathize

Use open-ended questions like, e.g. Before I talk, tell me how you think you are
(he/she is) doing? What are your concerns at this time?
Summarize and Strategize

Inform about future conversationswhat else they would like to discuss?
Use open-ended questions. E.g. Lets take it one step at a time.
On what aspects would you want us to make a plan for?
Challenges of Palliative Care in HIV Disease

Providing palliative care can be challenging for PLHIV and health care providers due to a number of factors
such as:
Majority of people with AIDS are young and it is especially difficult to watch people in their prime
years, and children suffer and die of AIDS
Stigma associated with HIV can be towards the patients, their families, or even towards health care
providers who work with PLHIV. All of these can mean less support from the outside, both for the
patient as well as hospital staff
Physical and emotional burden high
Others in the family may be infected with HIV which makes the quality of life for the patient low, and
the care burden on the staff higher
Care often left to family/friend that is untrained this may not be the best option for the patient who
is need of specialized care, but may be the only choice left, especially if they opt for home based care,
especially if the family cant afford hospital treatment
Home Based Care plays an important role in the management of AIDS patients. It consists of clinical
care, HIV prevention and education, counseling on diet and living with AIDS.
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Apart from reducing competition for hospital based care against other diseases, family members and friends
can provide affection and psychological support required by these patients.
Please see Annexure 8 for more on Situational Guide - Care of the Body after Death of a PLHIV
Please see Annexure 19 for more on What a Nurse needs to know about Dementia and Delirium
Key Messages :
Palliative care begins with the diagnosis of HIV
Nurses should empathize with PLHIV and meet their needs accordingly
Nurses take an active part in
managing symptoms
controlling pain
alleviating the psychosocial stress and discomfort in the end of life
supporting the family after the death of the PLHIV

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UNIT 14 POSITIVE LIVING FOR PLHIV

Unit Objectives
Explain the concept of positive living
Describe various aspects of positive living for PLHIV
Positive living with HIV
Nurses Role in promoting Positive living for PLHIV
Concept of Positive Living

Positive Living is a coalition of persons with HIV infection providing tangible social support to fellow
individuals living with HIV through the sharing of mutual experience, information and insight, while promoting
AIDS awareness, basic human rights and a positive, dignified, hopeful attitude to HIV positive individuals
in our community.
The men and women, from a variety of backgrounds, lifestyles and life experiences who are HIV positive
and have partners, family, children, friends, doctors and other professionals to talk to.
Positive Living provides emotional, spiritual and psychological support to all those living with HIV.
Aspects of Living positively with AIDS
Spiritual well-being
Acceptance of diagnosis
Acceptance and compliance to the treatment
Adequate Nutrition
Maintain oral hygiene, Personal and environmental hygiene
Safe sex practices
Regular exercise
Quit smoking
Join support groups
Role of Nurse
Enhance spiritual well-being

Assist the PLHIV to accept the diagnosis and the treatment
Assist the PLHIV to adhere to the treatment
Assist the PLHIV to cope with side effects of ART therapy
Assist the PLHIV to plan for diet and nutrition
Assist the PLHIV to maintain hygiene
Advocate for safe sex practices
Motivate for regular exercise
Advocate no smoking
Assist PLHIV to join support groups
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Nutrition
Take adequate and regular meals

Fibre supplements should be taken at least a couple of hours apart from HIV drugs or they can affect
drug absorption.
Clear juices such as apple or pear are good, but avoid most other fruit juices, which can aggravate the
problem.
Bananas and white rice are high nutrition foods with the right type of fibre.
Maintain fluid intake to avoid dehydration.
Eat small amounts of food five or six times a day instead of trying to consume normal-sized meals.
Avoid foods which can make diarrhoea worse: coffee and other caffeinated beverages such as cola,
alcohol (especially beer), fried or spicy foods, and foods high in insoluble fibre such as raw vegetables,
vegetable and fruit peels, salads, beans and brown rice.
Dairy products can also sometimes be a problem.
Avoid canned foods
Artificial sweeteners can also have a powerful laxative effect.
Quit alcohol
Eat well cooked food
Wash thoroughly before eating
Eat food that stimulate weight gain. It should have high protein, fat and carbohydreate content.
Examples: Avocado, coconut, full-cream millk prowder, yoghurt or sour millk soya products, cheese,
meat, fish, chicken, peanut butter, nuts and seeds, dried fruit, eggs, beans, dal, potatoes, sweet
potatoes (Shakarkand), bananas, olives, tapioca (shimla Aloo), millet, sorghum, oats, rice barley,
wheat, maize.
Avold sugar and sweets as these increase the risk of dental and/or oral problems.
What one should eat?

What should one eat
Foods that make you gain weight:
nuts and dried fruit
milk
eggs
fruits
pulses dal,
chana, soya
rice, sabzi
and roti
meat and fish

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Eating tips to help intake and digestion of food

Eat papaya with food
to help digest it.
Eat many small

meals a day.
No!
Eat termented toc

(adapt locally)
Avoid excessive alcohol,

smoking or non-prescribed
drugs.
Drink between meals,

not with meals.
Squeeze fresh lemon juice
over meat and nuts.
Oral care
Good oral health is of critical importance for PLHIV as ART therapy can lead to development of a dry
mouth. This also happens with other medicines some antidepressants, antihistamines and anti-blood
pressure treatments, to name a few. Some people with HIV have reduced saliva levels even if they arent
on treatments and despite having fairly good T-cell counts. This condition is referred to as HIV-associated
salivary disease.
Dental services for people with HIV are a crucial issue.
PLHIV need to see a dentist regularly because of the particular problems.
Dental care tips

PLHIV need to take extra care of their teeth,
Do not smoke as smoking effects the circulation of blood in the mouth and hinders it from getting rid
of harmful substances in the mouth.
Drink plenty of water most people dont drink enough to keep properly hydrated.
Limit your intake of caffeine. Caffeine (in tea, coffee, chocolate and some soft drinks) affects the
salivary glands and is a diuretic (makes you pee more), leading to a loss of water.
Do not drink aerated drinks as they are very high in sugar, caffeine and acid. They diminish salivary
flow due to their caffeine content
Limit your alcohol intake alcohol is also a diuretic and contributes to hydration problems
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Daily fluoride rinses or gels can decrease decay rates and help with tooth sensitivity, but they can be
expensive.
Use a soft toothbrush and brush and floss regularly.
Toothpicks are not a good idea unless you have wide gaps in your teeth and an interdental or
interproximal brush (a narrow brush which cleans between the teeth) is probably a better idea then
anyway.
An electric toothbrush (brushing one tooth at a time) is a good idea particularly to maintain the gums
although a manual one used properly can be just as good.
Do not brush your teeth immediately after eating, particularly if youve been eating acidic foods (such
as oranges).
One should rinse, after eating, with plain water or mouth wash
Sugar-free chewing gum is a good idea as it helps stimulate saliva and decrease the amount of acid
in the mouth.
Regular exercise is of benefit to everyones health, especially people with HIV. It can have a positive effect
on the patients with HIV/AIDS in
Improving immune system
Lowering the stress levels,
Lwering the blood pressure
Reducing the weight.
Improving cardiovascular function
Increasing muscle mass and strength
Improving energy levels
Improving appetite
Help restoring normal sleep patterns
However, some factors need to be taken into consideration before starting an exercise program.
Discuss the exercise program with their doctor and trainer to customize the program.
The goals of the program
A baseline and ongoing monitoring program to assess the progress
Clearly define the limits of the program to avoid over-doing it
Consult a HIV dietician to make recommendations regarding changes to the nutritional needs.
The potential health impacts of smoking in HIV patients are as follows:
Periodontal (gum) disease, oral candidiasis (thrush), oral hairy leukoplakia, and oral lesions are all more
common
Opportunistic infections affecting the lungs. (- Pneumocystis carinii pneumonia (PCP) pneumonias.
Mycobacterium avium complex (MAC or MAI) infection,
Lung cancer
Cardiovascular disease. Over time, these changes can lead to heart attacks, strokes and peripheral
vascular disease.
Osteoporosis, a weakening of the bones which can lead to fractures
Its also a good idea to tell the patient to visit their doctor and discuss their plan to quit smoking. While
smoking does not interfere with HIV medications, the patient may be taking other medications which may
be affected like medications for depression, diabetes and asthma can be affected by smoking. Patient
should discuss the options for recommended nictoine- quitting products and support services.
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Support Groups
Regardless of which support group chosen, getting good support increases the chances of successful
coping. Seeing a counsellor or joining a support group is strongly recommended. Some of the AIDS support
groups for PLHIV are PPN, NGOs, FBOs
Positive Peoples Network (PPN)
These support groups have weekly program, based on group therapy and peer support. The group therapy
and peer support models are the most effective methods of support for PLHIV for promoting positive living
and are also taught stress management and self management techniques. The objectives of support groups
are to increase self-esteem and wellbeing by giving PLHAs the opportunity to set and achieve goals of
taking control of their health and well-being.
Stress and Destress
Contributing Factors
Stress increases if blame is internalized and decreases with a large, strong, supportive network
Assessment and interventions for stress reaction
stress reduction
prevention of breakdown (psychopathology)
self regulation techniques
intensive training in progressive relaxation techniques
To help people who are in physical and emotional pain, the nurse must be caring, empathetic and supportive.
Role of Nurse:
Advise how to prevent other infections.

Encourage physical activity as appropriate.
Advise to avoid harmful or ineffective expensive treatment (adapt locally)
Support nutrition.
Have peer demonstrate preparation of nutritious foods.
Address food security: (adapt locally)
Avoid reinfection and
transmission to
partner by using
condoms.
Wash hands
carefully.
Use safe drinking
water: drink boiled
water or tea when
possible.
Apply local
antiseptic
to minor
wounds.
Store water.
Cover food.
Use insecticide-treated
bednets.
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Eat well-cooked
food.
Wash fruits and

vegetables with
clean water.

Key Messages :
People with HIV can live full and healthy lives if they take care of themselves and access treatments.
Avoid STIs and re-infection with other strains of HIV
Avoid others with infections (flu, boils, impetigo, herpes zoster, chickenpox, pulmonary TB until 2
weeks on treatment).
Use safe drinking water chlorinate or drink boiled water or tea when possible. Store water in
container which prevents contamination.
(Use spigot; do not dip hand or used cup into water.)
Eat well-cooked food.
Wash fruits and vegetables (with Common salt/Iodine/Chlorine tablets in water, especially if eating
raw).
Practice good hand washing especially after toilet of themselves or others. Caregivers and patient
should wash hands often: after using toilet; before preparing food; after sneeze or cough; after
touching the genitals; after handling garbage; after touching any blood, semen, vaginal fluid, feces.
HIV patients should have a local antiseptic (such as Gentian Violet or Chlorhexidine) at home to
apply to minor wounds after washing.
Use insecticide-treated bednets to prevent malaria (in endemic areas) and dengue/chikungunya
(seasonal)
Help patient develop his/her own programme.
Exercise can make the person feel better and maintain muscle tone.
Physical activity is important to prevent weight loss
Avoid harmful or ineffective expensive treatments or food supplements.

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UNIT 15 CHALLENGES FACED BY NURSES IN

HIV/AIDS CARE
Unit Objectives
Discuss the challenges faced by nurses in HIV / AIDS care and treatment
Explain measures to reduce stress and burnout amongst nurses who care for PLHIV
Develop a plan of action to implement lessons learned during the training in nurses
individual institutions
Nurses who care for patients with HIV face several challenges to name a few are: the Stigma that
the illness/disease carries, lack of resources; whether it be lack of drugs, testing kits or shortage
of staff. Therefore, nurses may feel that it is not worth the time and energy to care for PLHIV as the
illness does not have the cure. Hence, it is better for care of clients with curable diseases. This may
lead to stress
What Factors Cause Stress in Nurses Providing HIV/AIDS Care?
PLHIV Factors
Nurse Factors
Profound suffering
Young people mainly affected with infection
Multiple losses
Limited available treatment
Inadequate staffing
Insufficient resources
At risk for infection
Little support from family or friends for
your work
Increased responsibilities - counselling,
learning about ART, more paperwork
Poor compensation
May be personally affected by HIV
Impact of Stress on Nurses Providing HIV/AIDS Care
Over time, stress could lead to burnout

Signs of burn-out include:
- Indifference or lack of sensitivity to patients needs
- Inability to invest emotionally in patients
Burnout may or may not be recognised by the nurse
Symptoms of Burnout
Physical
Behavioural
Emotional
Headaches
Exhaustion
GI disturbances,
Insomnia
Irritability, easily angered

Withdrawal
Making mistakes on the job
Over identification with patient

Feelings of hopelessness
Depression
Sarcastic / suspicious
Not able to make decision
Profound grief and sadness
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How to cope with stress
Focus on something that you can control help change, or improve

- Is there something within you causing stress, or is it within the work environment?
- What are specific things you can do within yourself and within the work environment to reduce
stress and avoid burnout?
- Will you do this alone or with the help of others?
Evaluate the effects of stress on an ongoing basis
- Are things out of balance?
Become self-aware
Get help from colleagues, family, and friends
Work with other nurses to create a supportive environment
Find something out side of work that you enjoy
If your are a spiritual person, seek spiritual guidance
Take time to reflect on a difficult situation & acknowledge the difficulty
Issues (field experiences shared by nurses):
Labeled as HIV nurses

Even friends stopped talking to them after they had a needle stick injury
Families said find your partner after they came to know the HIV positive status.
Key Messages :
Be aware of the several challenges nurses can face when providing HIV care and treatment
Work together with the multidisciplinary team to address challenges and thereby reduce stress and
burnout
Advocate for a safe and supportive working environment for staff in your institution
Take an active role in advocating for the rights of PLHAs in your institution

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SECTION THREE
Exercises
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Section Three: Exercises
Unit 1: HIV /AIDS and the NURSES ROLE

Exercise 1: Small Group Exercise: Components of Baseline Assessment
INSTRUCTIONS:
Divide participants into 5 groups. Let them read the case given below amongst themselves
Assign each group one component of a baseline assessment. They have 5 minutes to come up with
the type of information required to be collected under each heading (i.e. what questions would they
ask the patient/what steps would they undertake). Use the examples given to guide you and the
space provided to write your notes.
Each group should choose someone to write up the answers and someone else to present the
answers to the large group
It is important to stress that the group should focus only on one piece of the assessment, and report
only on that assigned component
Give each group 3 to 5 min to share their responses and get feedback from the larger group.
Use the slides and the notes provided in the presentation to facilitate your discussion.
Case Scenario:
Mrs. A is a 24 year old who was diagnosed with HIV 3 years ago. She is admitted to the ward with a history
of diarrhoea and fever since two week. She has not visited the hospital or had any medical care since her
diagnosis.
Group I: Medical History (e.g. when were you diagnosed with HIV?)
Group II: Social History & Sexual History(e.g. Are you married?/are you using condoms?)
Group III: Patients own evaluation of his/her problems (e.g. How do you feel today?)
Group IV: Physical Examination (e.g. Examine the mouth)
Group V: Lab Findings (e.g. Different types of lab tests that need to be conducted)
Exercise 2: Developing and Presenting Case Studies for Nurses

INSTRUCTIONS:
Purpose: To take the information participants have learned in the HIV training program and apply it
to a real PLHIV case. They should be able to present the case, discuss the medical and nursing
issues and develop a comprehensive plan of care for the patient.
Inform participants that at some point in the weeks training they will have an opportunity to go in
small groups to see and interview a patient with HIV, either in the hospital or clinic setting.
They will use this worksheet as a guide to do the patient assessment, and make a plan of care
suggesting appropriate nursing interventions.
They will then present the case as a group to all the participants toward the end of the week.
After each case is presented, the facilitator/s will ask participants if there are any other issues that
could be addressed for the case and facilitate a large group discussion, if needed.
BASELINE ASSESSMENT (STANDARD FORMAT IN ANNEXURE 1)

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UNIT 2: STIGMA AND DISCRIMINATION: LEGAL AND

ETHICAL ISSUES IN HIV/AIDS CARE.
Exercise 1: Small Group Discussion : Legal, and Ethical Case Scenarios
INSTRUCTIONS:
Divide up into 5 groups as directed by the facilitator

Participant should given 5-10 minutes to discuss wither the groups assigned case and answer the
questions
Use the space provided to note down your answers
Choose one person to read out the case to the large group and another to present your points of
discussion when the facilitator calls your group
Remember to focus the discussion only to the Legal, and Ethical issues pertaining to the case
Case scenario - 1
Mrs. A, who is 6 weeks pregnant, has come to the hospital for the first time. The doctor examines her and
orders some tests. One of the tests is an HIV test
Questions
1. Can the doctor order for HIV test without Mrs. As knowledge?
HIV test should NOT be conducted without patients knowledge
2. What is essential before HIV test is done?
Informed consent and pre-test counselling are a MUST before testing
3. What is important when giving the test results to Mrs. A?
Post-test counselling is essential when revealing HIV test result
Case Scenario - 2
Mr. B, suffering from TB was admitted to the ward. Informed consent was taken and his blood was tested
for HIV. Once the HIV test result came to the ward, the head nurse informed all ward staff including sanitary
workers that Mr. B was HIV positive, and told them to be careful. Mr. Bs case sheet was marked with a
red stamp saying HIV positive
Questions
1. What steps were followed correctly? Give reasons for your answers
Informed consent was taken from Mr. B
2. Which important person has not been told about the HIV test result?
Mr. A has not been informed about the test result!!
3. What steps should not have occurred? Give reasons for your answers
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Incorrect steps:
The head nurse should not have disclosed the status to ALL ward staff only staff providing direct
patient care need know about the HIV status of the patient.
A red stamp on the case sheet cover identifying him as HIV positive should not have been put as
this is discriminatory and allows anyone who glances at the file to know the status of the patient.
Case scenario - 3
Mr. C recently was tested positive for HIV . He was counselled to inform his wife, but he refuses to do so.
Questions
1. What must be done first?
Mr. C must be repeatedly counselled and encouraged to disclose his HIV status
2. Can the HIV status be disclosed to the wife by a doctor?
If Mr. C continues to refuse to disclose his HIV status, he must be told that his HIV status would be revealed
to his wife by his primary health care provider
This could facilitate his wife to know her HIV status by testing and access appropriate care and
treatment if HIV+
3. What other measures must the doctor/health care worker take?

Mr. C and his wife should be educated about safer sex and other secondary prevention strategies
Case scenario 4
Mrs. X and Mr. Y, a married couple, come and tell you that they wish to have a child. They are both HIV
positive.
Questions
1. What is the appropriate reaction of the nurse in this situation?
Respect the couples decision regardless of initial reactions and personal feelings
2. What information would you give them?
Information should be given with regards to
Risks of HIV transmission to the baby

Risk of transmission of a different strain of HIV during sexual contact between partners
PPTCT programme and steps for risk reduction
The option of adoption which is legal for PLHIV
Case scenario 5
Mrs. A came to the hospital with labour pains. The doctor noticed that she had severe vaginal candidiasis
and ordered a rapid HIV test. The result was positive, and she was sent away with the pretense that no
bed was available
Questions
1. What are the ethical issues in this scenario?
Doctor did not obtain informed consent before ordering the HIV test
The patient was denied healthcare on the basis of her HIV status

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2. What opportunity is being lost here?
The opportunity to provide

- The Anti retroviral medication to reduce the risk of HIV transmission to baby is lost.
- Care and treatment services to both the woman and her partner is lost.
Exercise 2: Examples of stigma and discrimination: large group discussion

Purpose
To consider examples of stigma and discrimination from your setting.
Duration
15 minutes
Instructions
Share examples of stigmatising and discriminatory messages or attitudes

that you have seen in each of the following places:
Media (newspapers, television, or radio programmes)
Health services
Workplace
Religion
Family
Community
Examples of stigmatisation and discrimination

In the media
Suggesting in the media that there are specific groups of people with HIV who are guilty (such as
sex workers or injection drug users) whereas others (such as infants) are innocent
Depicting HIV/AIDS as a death sentence, which perpetuates fear and anxiety, and labels HIV as a
disease that cannot be managed like any other chronic disease
Using stereotypical gender roles, which may perpetuate womens vulnerability to sexual coercion and
HIV infection
In health services
Refusing to provide care, treatment, and support to PLHIV

Providing poor quality of care for PLHIV
Violating confidentiality
Using infection-control procedures (such as gloves) only with patients thought to be HIV-positive,
rather than with all patients
Advising or pressuring PLHIV to undergo procedures, such as abortion or sterilisation, that would not
be routinely suggested for others
In the workplace
Requiring testing before employment

Refusing to hire people who are HIV-infected and HIV-affected
Mandating periodic HIV testing
Being dismissed because of HIV status
Violating confidentiality
Refusing to work with colleagues who are HIV-infected because of fear of contagion
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In the context of religion
Denying participation in religious/spiritual traditions and rituals (such as funerals) for PLHIV
Restricting access to marriage for PLHIV
Restricting participation of PLHIV in religious activities
In the family and local community
Isolating people who are HIV-infected
Restricting participation of PLHIV in local events
Refusing to allow children who are HIV-infected or HIV-affected in local schools
Ostracising of partners and children of PLHIV
Using violence against a spouse or partner who has tested HIV +ve
Denying support for bereaved family members, including orphans

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UNIT 3: HIV EPIDEMIOLOGY, DIAGNOSIS AND

DISEASE PROGRESSION
Exercise 1: Clinical Staging Case Scenarios
INSTRUCTIONS:
Participants have 2 minutes to discuss the case as a large group and answer the related questions.
Use the section on Clinical Staging (page 16) in the manual as reference
Case 1: Mr. A, a 35-year-old, HIV +ve truck driver, is admitted to the ward with a history of persistent
diarrhoea since five months. His stool exam reveals cryptosporidium.
Questions:
1. Which clinical stage of HIV is Mr. A in?
2. What are your reasons for stating so?
Case 2: Ms B, a 24-year-old student was raped. Two months later she went to the doctor complaining of
fever, malaise, fatigue, and swollen lymph nodes. At that time, she was diagnosed with influenza. One
month later, she is now asymptomatic and has come for an HIV test her result is positive.
Questions:
1. Which clinical stage of HIV is Ms A in?
2. Was the diagnosis made 2 months ago correct?
3. If not, what should the diagnosis have been?
Case 3: Ms C, a young woman comes to the clinic complaining of fever for 6 weeks. From her previous
record, you see that six months ago she weighed 54 kg. She now weighs 46 kg. She has scars on her
back that are due to herpes zoster. Her HIV test done now comes back positive.
Questions:
1. Which clinical stage of HIV is Ms C in?
2. What are your reasons for stating so?
Exercise 2: Role Play: Typical Patient Questions

Patients often have many questions about HIV/AIDS and nurses need to know how to answer these
questions. Nurses will get better as they learn more and with experience. This exercise is to participants
practice their knowledge and communication skills.
1. What is the difference between HIV and AIDS?
2. Will my family members also get infected?
3. How does HIV make me sick?
4. How much time do I have to live now that I have HIV infection?
5. How could I have gotten HIV infection if I had sex with no one else but my wife?
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UNIT 4: COUNSELING AND TESTING FOR HIV/AIDS

Exercise 1: Counselling Role Plays
INSTRUCTIONS:
No of Trainers: 4 (1 Trainer, 1 Training Coordinator, 2 Co Trainers) as Observers

Divide participants into five small groups of 7 participants and assign each group one role play
scenario.
All group members need to participate ,either as a Client or as a Counselor (Choosing their partners
from the group)
Inform participants that the patient and counselor will meet as if they are having a regular visit.
Give the groups 10 minutes to plan and practice their role play amongst themselves.
Give each pair 3 to 5 minutes to perform the role play in rotation while the observers in the group
use the Counseling Assessment Checklist.
Stop the role play when the Trainer feel the important points have been covered.Each Trainer
observes the performance of all their group with the help of the Answers provided & Check List
For Counselling Skills Assessment
(Exercise 1 & 2)
When all the groups have finished enacting the role plays, de-brief each role play and ask for
feedback from:
Role players (e.g., How do you think it went? How did it feel taking on the role?)
Each Trainer would present the positive and the negative points of their respective groups.
They would also project the Answer slides given after each case scenario.The Trainers would also
choose team of 4 Best Performers across all the groups, who would then present the subsequent
4 Ideal Role Plays to be conducted in Session 3 on Counselling (Day 4)
Remember the following points while giving feedback to the group:
Be respectful. Remember, it is hard to be in the counsellor position!
Emphasise the positive aspects of the counselling session.
Offer gentle, constructive suggestions to improve what didnt work so well.
Avoid being too critical since this is only a practice session
Avoid using terms like should have must have etc
Highlight important points for each counselling situation
Group I Case:
Ms X, a 20 year old woman comes to the ART clinic. She received a positive HIV test result 2 weeks ago.
You check her laboratory investigations; find it is all within normal limits and her CD4 count is 475. She
asks you What should I do to stay healthy?
Group II Case:
Mr. A, a 25 yr old HIV + man reports to the medicine out patient department with white patches on his
tongue, throat, pain on swallowing, and weight loss.
Group III Case:
Mrs. Y, 42 year old woman, diagnosed as HIV + 5 years ago, is admitted with a one month history of poor
appetite, diarrhea and weight loss. She pleads with you, Please help me gain some weight and get my
energy back.

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Group IV Case:
Mrs. X, a 28 year old woman was recently diagnosed with HIV and is admitted to the hospital with advanced
HIV and wasting syndrome. She is depressed and suicidal. She has disclosed her status only to her
husband, and really does not know much about HIV disease. She is sure she is going to die.
Group V Case:
Mr. Z, a 22 year old truck driver is determined to be eligible for free ART. He comes to the ART centre
for counselling related to starting his medication.
Exercise 1: Counselling Role Plays (II)

Assign one role play to each of the 4 Best Performers, chosen on the previous day. Inform participants that
the patient and counselor will meet as if they are having a regular visit.
Give the groups 10 minutes to plan and practice their role play amongst themselves.
Give each pair 10 minutes to perform the role play in rotation while the Trainers use the Counseling
Assessment Checklist.
Stop the role play when the Trainer feel the important points have been covered.
Give feedback to the group.

Remember the following points while giving feedback to the group:
Be respectful. Remember, it is hard to be in the counsellor position!
Emphasize the positive aspects of the counselling session.
Offer gentle, constructive suggestions to improve what didnt work so well.
Avoid being too critical since this is only a practice session.
Avoid using terms like should have must have etc
Group 1 Case:
Ms A ,22 Year old, student ,has been diagnosed with HIV infection recently. She is very scared and does
not have much information about HIV infection and its management. She has not disclosed her positive
status to her family or friends due to fear of rejection.
She says to you I am having AIDS. My life is over and I am going to die soon
Demonstrate how will you counsel her?
Group 2 Case:
Mrs. X approaches the nurse at a PHC, with complaints of white discharge and weight loss. She also
reveals that her daughter is likely to get married soon.
What are the important issues the Nurse should keep in mind while counseling the mother and daughter?
Group 3 Case:
Nurse A, during a Health Check Up Camp, in a Red Light Area, meets Ms B .a 26 year old Commercial
Sex Worker. She complains of
Dull, persistent pain in the lower abdomen

Burning sensation while urinating
Fever, Diarrhoea, lack of appetite and lack of energy since 3 weeks
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On examination, Nurse A finds sore and swelling of Lymph Nodes in the groin area.
How will you counsel her?
Group 4 Case:
Mr. Y, a young IDU, reports to Medical OPD, with a large and painful lump on his left arm.He tells the nurse
that he and his two friends share the needles to inject drugs because they feel a strong bond with each
other. On further probing he reveals that sometimes he and his friends provide sexual favors in exchange
of drugs.
Demonstrate how the nurse would counsel him?
Counselling Assessment Tools

Counselling Skills and Techniques
Done
Establishes therapeutic relationship
Creates comfortable external environment
Uses culturally appropriate greeting gestures that convey respect and caring
Offers seat
Uses appropriate body language and tone of voice
Makes eye contact
Active Listening
Looks at client when speaking
Attentive body language and facial expression
Continuous eye contact
Occasional gestures, such as nods to acknowledge client
Effective Questioning
Uses open ended questions to elicit information
Asks relevant questions
Reflects statements back to client for conformation
Summarizing
Takes time to summarize information obtained from client
Checks with client to ensure understanding of important concerns and issues

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UNIT 5: PREVENTION OF HIV TRANSMISSION

Exercise 1: Steps in Demonstrating Use of a Male Condom on a Penis
Model
Steps
Done
Check the expiry date and make sure condom is not damaged by
Reading the date
If the individual is illiterate check by moving the condom from

side to side and bending it before opening the packet.
Checking if the packet is damaged
Tear the packet carefully without damaging the condom and remove the condom
Hold the space at the end of the condom to squeeze out air, and then
gently roll it onto the penis model
Check to make sure there is space at the tip and that the condom is not broken
Hold the condom at the base of the penis model (This presumed to be during
penetration to ensure that the condom does not slip out)
The condom should be removed carefully, (without spilling the semen)
BEFORE it gets soft
A knot should be tied in the used condom, and it needs to be thrown in
a covered dustbin or pit
Female condoms checklist
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UNIT 6: PREVENTION OF PARENT TO CHILD

TRANSMISSION (PPTCT)
Exercise 1: Small Group Exercise: Patient Education
INSTRUCTIONS:
Divide participants into 5 groups, with each group being assigned one case
Give them 5 minutes to discuss and write out main points they would consider to prevent PTCT of
HIV for their particular situation
One representative would have to come forward and present the points to the large group
Other groups will be asked to provide feedback to the responses.
Make sure to clarify any questions participants have
Group 1:
An 18-year-old girl comes to you. She says she is likely to get married in a years time but she is scared
about HIV. Her friend had got married last year and was discovered to be positive after her marriage during
her antenatal check up. What points would you keep in mind when counselling her?
Group 2:
A 23 years old, HIV positive woman, comes for her first antenatal check up. She is 6 weeks pregnant and
you are there in the OPD. What key points would you keep in mind while counselling her to prevent MTCT?
Group 3:
A 24 years old, HIV positive woman, comes to the hospital with labour pains since half an hour. What will
you assess and do for her, if you were present through out her labour period to reduce MTCT?
Group 4:
A 24 years old, HIV positive woman, delivered her baby asks you about feeding her baby. You have not
seen her in the past, during her prenatal period. What points would you keep in mind while counselling her
to reduce MTCT?
Group 5:
A 24 years, HIV positive woman has doubts about her and her babys follow up care after delivery. What
key points would you keep in mind while counselling her to reduce the risk of PTCT?

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UNIT 7: INFECTION CONTROL AND PEP

Exercise 1: Hand Washing Technique
Split the participants into pairs .Ask each pair to act out the steps of hand washing techniques,
using the guidelines.
Exercise 2: Use of Personal Protective Equipments

Ask for a volunteer and ask her or him to demonstrate how to put on and remove Personal Protective
Equipments.
Exercise 3: Preparation of Bleach Solution

Ask for a volunteer and ask her or him to demonstrate how to prepare the Bleach Solution.
Exercise 4 : Proper Needle Disposal

Ask for a volunteer and ask her or him to demonstrate the proper disposal of a needle.
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UNIT 8: SEXUALLY TRANSMITTED INFECTIONS

(STIs)
Exercise 1: Role Play: What, How, Why of History and Clinical
Examination
INSTRUCTIONS:
Divide participants into two groups and assign each one of the two role play scenarios
Tell groups to choose someone to play the part of a nurse, a patient, and a relative
The others in the group will be observers.
They have 5 minutes to practice the play and then 5 minutes to perform the play in front of the class
While the play is going on, remind observers to use the checklist provided in the following page
(Exercise 2: Checklist How and What of History Taking with Patients with STIs) to guide their
observation
The observers will be asked to comment on what was done poorly and why, and what was done
well and why, according to the checklist with the large group
Provide your own feedback in a positive manner
GROUP I: ROLE-PLAY GUIDELINES

ROLES: Nurse (D), woman with vaginal discharge (Mrs. X), relative of the woman (Mrs. Y).
Setting: In the ward or OPD.
THE SCENE:
Mrs. X mentions to the nurse D that she has had the problem of vaginal discharge for the past two weeks.
The nurse is busy with a lot of things in the ward or the OPD and so she hurriedly asks her questions
without being sensitive to the environment, people around, or Mrs. X herself.
POINTS TO KEEP IN MIND:
The nurse should focus on the history to be collected, but not pay attention to the environment, the
sensitivity of the issue when asking Mrs. X about personal details, or the fact that she is amidst all other
people in the ward/OPD. While Mrs. X is giving details of the history the nurse is also busy answering the
phone or answering questions directed to her by other people/colleagues in the ward.
GROUP II: ROLE-PLAY GUIDELINES
ROLES: Nurse (D), woman with vaginal discharge (Mrs. X), relative of the woman (Mrs. Y).
Setting: In the ward or OPD.
THE SCENE:
Mrs. X approaches the nurse and mentions that she has a problem of vaginal discharge. Despite being
busy, the nurse takes some time to sit down with her in a room when she sees that she is obviously
distressed. She is sensitive to the details collected and to all other factors in the environment.
POINTS TO KEEP IN MIND:
The nurse should focus on the history to be collected, and pay attention to the environment, the sensitivity
of the issue when asking Mrs. X about personal details, and the fact that she is there with her relative and
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is amidst all other people in the ward/OPD. While Mrs. X is giving details of the history the nurse makes
sure that any other disturbance is taken care of by her colleague such as answering the phone or answering
questions directed to her by other people/colleagues in the ward.
Checklist How and What of History Taking with Patients with STIs
Exercise 2: Case Studies: Applying Syndromic Case Management (SCM)
INSTRUCTIONS:
Divide participants into two groups and assign each one of the two cases given below
They have 5 minutes to read the case, discuss the question, and note down their answers
Inform groups to choose one person to read out the case to the class and another one to present
their findings
Ask participants to listen closely when the other group presents their case and share any additional
points they may have with the large group
Ensure that answers are correct by referring to the appropriate flowchart provided in the annexure
CASE 1:
Mrs. A, a recently married, 23 year old woman, presents with dull, persistent lower abdominal pain. She
is not sure of increased vaginal discharge, and her periods are of normal cycle. She has never been
pregnant.
Q: How would you apply the Syndromic Case Management approach to her case?
Refer flowchart on Vaginal Discharge
CASE 2:
Mr. X, a 32 yr male presents with swelling in right inguinal region of 1 week duration. He had an exposure
3 weeks ago. He has no ulcers or any other lesions on the genitalia and no previous history of same.
Q: How would you apply the Syndromic Case Management approach to his case?
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UNIT 9: SYMPTOM MANAGEMENT AND OIs

Exercise 1: Role Play: Educating Patients on Prevention of Diarrhoea
INSTRUCTIONS:
Ask for volunteers to perform the role play.

Give volunteers 5 minutes to read the information below and prepare a short role play to perform
in front of the class.
Ask remaining participants to read the situation below and think about how they as nurses will
counsel the patient, and share any additional points they may have at the end of the role play.
Provide feedback positively, ensuring that the nurse covers all the necessary points as given below.
Role Play Instructions: The Patient
You will play the role of a hospitalised patient with HIV.

You will take on the characteristics in the scenario listed below.
As much as possible, try to act like the patient described in the scenario.
Your partner will play the part of a health care provider. He or she will need to ask you questions to
find out about your lifestyle and will then need to advise you on how to avoid contracting Cryptosporidium.
You can use the space provided to make any notes while you prepare for the role play.
HIV Patient Scenario:

You are a woman in 30s , infected with HIV. You have three children, ages 4 months, 3 years, and 5 years.
You are responsible for the care of your children, including feeding, cleaning, and changing diapers. You
grow some of your own food in your garden. Your home is near a river which is used by many people in
the community for bathing and supplying water for animals to drink. About once a week, you and your family
go to the river to bathe. This is something the children really love to do, especially when the weather is
hot. You would strongly resist the idea of giving up bathing in the river.
You have been to the hospital twice before with diarrhoea. You tell your doctor, While I am here, I am ok.
The diarrhoea goes away. When I go home, I get diarrhoea again.
Role Play Instructions: The Nurse
You will role play the part of a nurse to practice counselling and educating patients.
Your partner will take on the role of a patient infected with HIV. She has been given specific characteristics
as a patient.
As a health care provider, you will need to:
Explain what Cryptosporidiosis is, and how it can be contracted.
Find out about the patients lifestyle and what may put her at risk of contracting cryptosporidiosis.
Give specific advice to the patient to reduce their risk of contracting the disease.
Answer any questions the patient may have.
Here are some other tips you might give the patient to prevent diarrhea:
Use only boiled water for drinking.

Do not eat hotel foods or eat outside the home. If you must do so, follow the advice below.
Avoid spicy food.
Eat only well-cooked food.
Do not eat chutney.
Do not eat leftovers from the day before.

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UNIT 10: INTRODUCTION TO ART

Exercise 1: Common Questions about ARVs
INSTRUCTIONS:
Ask participants to choose a partner to do this exercise with

Give them 5 minutes to go over the questions below and quiz each other
Clarify any questions they might have, and ask them to use the participant manual for reference later
1. How do ARV drugs affect HIV disease?

ARVs reduce the ability of HIV to replicate, and this increases the bodys ability to fight disease. ARVs
thus change HIV from a terminal (fatal) disease to a chronic disease
2. Name the three main classes of ARV drugs
Nucleoside Reverse Transcriptase Inhibitors

Non-nucleoside Reverse Transcriptase Inhibitors
Protease Inhibitors
3. What are the two main enzymes which current ARV drugs inhibit?
The two main enzymes that current ARV drugs inhibit are Reverse Transcriptase and Protease
4. What is the main goal of ARV therapy?
The main clinical goal of ARV therapy is to prolong and improve the quality of life in PLHIV.
5. What are the main advantages of ARV drugs?
See answer 1 and 4
6. When should ARV drugs be started?
ARV drugs should be started according to CD4 counts and WHO staging in keeping with NACO
guidelines
Classification of HIV-associated
clinical disease
WHO
clinical stage
CD4 test available
Asymptomatic
Treat if CD4 < 25 (if between 251 to 300,

repeat CD4 count after 4 weeks)
Mild symptoms
Advanced symptoms
Consider treatment if CD4 < 350
Severe/advanced symptoms
Treat irrespective of CD4
7. What main factors are taken in to consideration before starting PLHIV on ARV drugs?
There are many factors that affect how a person will do on ART, and all of these need to be considered
carefully before ART initiation.
National guidelines around ART eligibility

PLHIVs stage of disease progression and concurrent health conditions
Potential side effects and drug interactions
PLHIVs readiness for ART

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UNIT 11: PAEDIATRIC HIV INFECTION

Exercise 1: ARVs in Children: Case Study
INSTRUCTIONS:
You have 5 minutes to read the case on your own and answer the questions
Be prepared to share your answers and discuss the case together with the rest of the class
CASE STUDY SCENARIO:

Mrs. A is a 29-year-old mother. Both Mrs. A and her two-year-old daughter, Baby B, are HIV positive. Mrs.
A has been very unwell over the past six months. After treatment for Cryptosporidiosis, she started ARVs.
Unfortunately, whilst she has recovered from Cryptosporidiosis, her overall health has remained poor. She
gets recurrent chest infections.
At the clinic, Mrs. A reveals that she frequently forgets to take her ARVs. In further discussion, she informs
you that her husband died 8 months ago and she is feeling very depressed.
At the same clinic appointment, Baby B is also seen by the doctor. The doctor informs Mrs A that Baby
B also requires ARV treatment now as her CD4 count has fallen below 200 cells/mm3. Baby B has also
been unwell with recurrent chest infections, severe weight loss and now shingles.
Questions:
1. What concerns are there over Baby B starting ARV treatment?
2. What measures are required to ensure that Baby B receives the drugs she requires?

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UNIT 12: COMPLIMENTARY THERAPY IN HIV/AIDS

Exercise 1 : Brainstorming Exercise
Brainstorm regarding the difference between Complimentary Therapies and Alternative Therapies.
Exercise 2 : Demonstration Exercise on Yoga & Meditation
Exercise 3 : Practical Exercises and Group Work

Divide the participants into 4 groups
Group I: Yoga
Group II: Touch massage and Reflexology
Group III: Relaxation, Meditation and Visualization
Group IV: Herbal
Ask them to develop presentations after 10 minutes of Group discussions. One person will present ,on
behalf of the group, for 2-3 minutes, each of the therapies and explain their uses for HIV infected patients.
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UNIT 13: PALLIATIVE CARE IN PEOPLE LIVING

WITH HIV/AIDS
Exercise 1: Case Scenario of Patient with Advanced Stage AIDS
INSTRUCTIONS:
Give participants 10 minutes to read the case below and answer the questions on their own
Remind them to be ready to share answers with the large group and participate in the discussion
Go over the answers using the notes provided below
Case Scenario:
Mr. A, 25-year-old PLHIV has been hospitalized with pain, dehydration, fever, and diarrhea. He can no
longer take ART because of severe side effects, and has no more treatment options. He is very depressed
and talks about suicide
Questions:
1. Prioritize the symptoms to be addressed, giving your reasons
2. How will you manage these symptoms?
Case Scenario continued:
Mr. As wife and 2-year-old son are both HIV+. The wife does not understand how serious her husbands
illness is, and she has not received any medical care for herself.
Questions:
3. What will you do to help the patients wife and child?

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Unit 14: POSITIVE LIVING FOR PLHIV

Exercise 1 : Positive Living With HIV Infection
Divide the participants into 5 groups.
Each group to present on different aspects of positive living with HIV/AIDS.
Group I: Aspects of living positively with HIV/AIDS
Group II: Role of Nurse & Support Group
Group III: Nutrition For PLHIV
Group IV: Oral & Dental care
Group V: Physical Exercises
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UNIT 15: CHALLENGES FACED BY NURSES IN

HIV/AIDS CARE
Exercise 1: Brainstorming Exercise
Brainstorm with participants on the challenges faced by Nurses in HIV/AIDS care
Encourage the participants to share real life experiences.

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SECTION FOUR
Annexures
Annexures
Annexure 1
Baseline Assessment
162
Annexure 2
Quick Reference Steps in using a Male and a Female Condom
165
Annexure 3
Disinfection of Needles and Syringes with Bleach
167
Annexure 4
Hand Hygiene Checklist
168
Annexure 5
Guidelines for Disposal of Used Disposable Needles and Syringes
169
Annexure 6
Guidelines for Disinfection and Sterilization
170
Annexure 7
Situational Guide Cleaning up a Blood Spill on the Floor
171
Annexure 8
Situational Guide Care of the Body after Death of a PLHIV
173
Annexure 9
NACO PEP Policy: Procedure to be followed after an Accidental

Exposure to HIV Infectious Fluid
174
Annexure 10
STI Syndrome Flowchart Lower Abdominal Pain
185
Annexure 11
STI Syndrome Flowchart Inguinal Bubo
186
Annexure 12
STI Syndrome Flowchart Painful Scrotal Swelling
187
Annexure 13
STI Syndrome Flowchart Ophthalmic Neonatorum
188
Annexure 14
STI Syndrome Flowchart Genital Ulcers
189
Annexure 15
STI Syndrome Flowchart Urethral Discharge
190
Annexure 16
STI Syndrome Flowchart Vaginal Discharge (1)
191
Annexure 17
STI Syndrome Flowchart Vaginal Discharge (2)
192
Annexure 18
Guide to Common Symptoms and Possible Aetiologies
193
Annexure 19
What a Nurse needs to know about Dementia and Delirium
195
Annexure 20
Comprehensive laboratory evaluation in HIV/AIDS
197
Annexure 21
Specimen Collection (by heel prick) and handling procedure for

HIV DNA PCR testing by Dried Blood Spot (DBS) sample collection
198
Monitoring and follow up patients on ART: Recommendations in

the National Programme
203
Annexure 23
PPTCT True or False Statements and Answers
205
Annexure 24
PPTCT: Three Safe Infant Feeding Options Some Important Points

You Could Keep In Mind When Counselling Mothers On Feeding Options
206
Annexure 25
Replacement Feeding Checklist
208
Annexure 26
Questions and Issues that must be assessed by the Nurse to Aid

In Preparing the Child And Family For ARV
209
Annexure 27
Ways to Promote ART Adherence in Children
210
Annexure 28
Assuming the quality /amount of PTH
211
Annexure 29
Music Therapy
212
Annexure 30
National AIDS Control Organization (Phase III)
214
Annexure 31
List of State AIDS Control Societies (SACs)
215
Annexure 32
List of ART Centres
218
Annexure 33
List of Community Care Centres (CCCs)
225
Annexure 34
Ice Breakers & Energizers
247
Annexure 35
Role of Nurse at ART & CCCs
250
Annexure 22

Section Four: Annexures
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ANNEXURE 1: BASELINE ASSESSMENT

BASELINE ASSESSMENT:
Focus on information that is significant to HIV care. Approach the assessment in a systematic, organized
manner using the information below as a guide.
Baseline assessment: Presented below is a checklist , one could use when assessing a patient
Focus on information that is significant to HIV care. Approach the assessment in a systematic, organized
manner using the information below as a guide.
I.
FACTOR
II. DETAILS
Age
Gender
Date of admission or clinic visit
III. HIV status
When was the patient diagnosed with HIV?
Any complications (e.g. OIs)
What does patient know about HIV/AIDS?
Is patient being tested for HIV
If yes, is report available
HIV Status
If positive, any complication
If No, Check for window period
Repeat test if required
Has patient received counselling or medical care?
IV. Chief complaint
What is the main reason for which the patient
was hospitalised or came to clinic?
Significant presenting symptoms, complaints
V. Significant recent medical history
Malaria, TB, STIs? Other diseases?
Is patient taking any medications? ART?
Prophylactic medications? Traditional remedies?
History of mental illness? Depression?
Previous hospitalisations? Surgery?
For women: LMP (last menstrual period), pregnancy,
contraception and gynaecologic history?
VI. Relevant social history
Primary language
Family structure? Married, no of children?
Family income? Financial status?
Employment? Living situation?
Educational status/ literate?
Is anyone else in the family ill?
What is the partner spouse status
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Section Four: Annexure-1
I.
FACTOR
II. DETAILS
Have HIV? Spouse status

Who is the decision- maker in the family?
What is the Childrens status
Does anyone else know of patients HIV status?
Their reaction to the clients HIV status
Can the patient identify family member
community, faith based organization group
where they may receive support?
Does the patient use alcohol/drugs/cigarettes?
VII. Relevant sexual history
Nature and status of current sexual relationship(s) currently sexually active with spouse or one
significant partner or with multiple partners?
Men, women or both?
Current sexual practices vaginal, anal, oral sex?
Exchanging sex for money, drugs or other?
Use of condoms?
Other safe practises Eg. Mutual masturbation
Patient Self Appraisal
How is s/he feeling?
Change in weight - current weight and previous
weight if available
Mood changes
Weakness or fatigue
Respiratory symptoms (cough, breathlessness, chest pain)
GI symptoms (nausea, vomiting, loss of
appetite, diarrhoea, thrush)
Neurological symptoms (memory loss,
headaches, visual changes, neurological deficit)
GU symptoms (genital itching, sores, dysuria,
incontinence)
Dermatological (rash, itching)
Pain (assess using the visual analogue pain scale)
Other
VIII. Significant physical exam findings
Significant vital signs at presentation
Weight, height, including assessment of wasting
& severity of dehydration
Note general appearance
Head & neck, including mouth & oral cavity
(Candidiasis, Hairy cell Leukoplakia)
Lymph nodes
Examination of eyes for jaundice, anaemia, etc
Examination of genitals for sores, rash, discharge
Examination of skin and mucous membrane for
rashes, common skin infections (fungal
infections, dermatitis, KS, HZV)
Examination of mental status: appearance,
behaviour, orientation and memory
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I.
FACTOR
II. DETAILS
Significant results of lab and other investigations

If needed, confirmatory HIV test
CD4 count
Hemogram (CBC)
Full chemistry panel
Sputum AFB
TST (Mantoux) chest x-ray
Others, if needed
Current diagnosis or multiple diagnoses if available
Some questions to answer:
What is the WHO clinical stage of this patient?
Is this patient eligible for ART?
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Annexure 2: Quick Reference Steps in Using a Male and

Female Condom
Steps in Using a Male Condom
Do
Dont
Check expiry date
Re-use condoms
Use condom correctly and consistently
Store condoms in the sun
Use each condom only once
Use the teeth or nails to tear the condom packet
Use water based lubricants
Use oil-based lubricant
Think of dual protection
Use condoms made with natural products

like lambskin as these are not protective
against HIV
Use the male and female condom together

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Steps in Using the Female Condom

Behaviour change communication: HIV transmission
1.
OPEN END (Outer ring): Covers the
area around the opening of the vagina.
INNER RING used for insertion. Helps
hold the pouch in place.
2.
HOW TO HOLD THE POUCH: Hold
inner ring between thumb and middle
finger. Put index finger on pouch
between other two fingers.
3.
HOW TO INSERT IT: Squeeze the
inner ring. Insert the pouch as far as
possible into the vagina. Make sure the
inner ring is past the public bone.
4.
MAKE SURE PLACEMENT IS
CORRECT: The pouch should not be
twisted. Outer ring should be outside
the vagina.
Fig. 2.7 How to use a female condom for vaginal sex

Proper use of the female condom (vaginal sex)
It is advisable to decide on the use of a condom with your partner beforehand as you may forget in
the heat of the moment.
Always check the expiry or manufacture date on the condom package to make sure it has not expired.
Make sure it is not more than 4 years old.
Using your fingers, carefully open the condom at the indicated place. Make sure your fingernails do not
damage the condom. DO NOT use sharp objects, such a scissors or a razor as they may cut the
condom.
Inspect the condom to make sure it is intact.
Rub the outside of the condom to evenly spread the lubricant inside the condom. Add the lubricant as
desired.
Find a comfortable position for inserting the condom.
Hold the condom at its closed end. Squeeze the inner ring (the ring at the closed end of the condom)
between the thumb and the middle finger with the forefinger between the two.
Spread the vaginal lips with the other hand, and insert the condom in the vagina.
Use your forefinger to push the inner ring all the way up in the vagina until you feel the pubic bone
with your finger.
Make sure the outer ring (at the open side of the condom) lies against the outer lips.
Guide and insert the penis inside the condom. Make sure the penis does not go underneath or beside
the condom.
If during intercourse the penis does not move freely, there is a sound, or the condom is moving in and
out with the penis, add lubricant (to the penis or inside the condom).
If the outer ring is pushed in the vagina or the penis goes beneath or to the side of the condom, stop
and put on a new condom.
Keep the condom on during intercourse. After ejaculation and after the penis is pulled out, squeeze and
twist the outer ring to avoid spilling semen and pulling the condom out of the vagina.
Wrap the condom in toilet paper and, as soon as possible, throw it away out of reach of others. Do
NOT flush the condom down the toilet.
NEVER reuse the condom.
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Annexure 3: Disinfection of Needles and Syringes with Bleach

Injecting drug users often do not have access to a steady supply of disposable syringes, and re-use/share
needles with other IDUs. The procedure below can be taught to them to minimize the risk of HIV transmission
under such circumstances. Remember, where available disposable, unshared needles are always the first
choice.
Procedure:
It will probably take 5-10 minutes to follow the recommended procedures for
cleaning and disinfecting.
Fill the needle and syringe completely with clean water

Shake vigorously for 30 seconds, and shoot out the water into the sink or
onto the ground
Repeat the process
Then, completely fill the needle and syringe (to the top) with full-strength (not
diluted) liquid household bleach several times.
Keep the bleach for at least 30 seconds
Shoot out the bleach and repeat
Rinse the syringe and needle by completely filling several times with CLEAN
water.
Remember:
Cleaning and disinfecting should be done at two points of timeonce

immediately after use and again just before re-use of needles and syringes.
ALL used solutions should be disposed of (e.g. by placing in a waste container
or pouring down a sink or toilet or on the ground). DO NOT REUSE.
Every time the cleansing process is repeated, the more likely HIV and other
blood borne pathogens will be inactivated
Taking the syringe apart by removing the plunger may also improve the
cleaning/disinfection of parts that might be hard to reach (e.g., behind the
plunger).
Although it is important to follow all steps in the bleach disinfection procedures
to ensure maximum effectiveness, drug users who indicate they may be
unable to do so should be encouraged to perform as much of the process
as possible.
The more steps done, the more effective the disinfection process is likely to
be in reducing risk of HIV transmission.

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Annexure 4: Hand Hygiene Checklist

Procedure
Done
Ensure short finger nails

Ensure water supply/ alcohol hand - rub solution
Remove accessories from hands
Pour soap solution / alcohol rub into hand or apply soap uniformly on the hand
Scrub
Scrub
Scrub
Scrub
Scrub
Scrub
Scrub
both hands
palms and fingers
back of hands
fingers and knuckles
thumbs
finger tips and nails
wrists and up to elbows if needed
Wash hands ensuring removal of soap from all applied areas / if using
alcohol rub, rub all surfaces till dry (Do not wash with water)
Air dry or dry using clean towels
Keeping the above points in mind, think about what resources are required for regular efficient hand
hygiene and make a mental note to check if these are available at your centre.
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Annexure 5: Guidelines for Disposal of Used Disposable

Needles and Syringes
No.
Steps / Stages
Sever needles from disposable syringe immediately after administering injection using a needle
cutter/hub-cutter that removes the needle from disposable syringes or cuts plastic hub of
syringe from AD syringes
The cut needles get collected in the puncture proof container of the needle cutter/hub-cutter.
The container should contain an appropriate disinfectant and the cut needles should be completely
immersed in the disinfectant
Segregate and store syringes and unbroken (but discarded) vials in a red bag or container.
Send the collected materials to the common bio-medical waste treatment facilities. If such
facilities do not exist, then go to the next step.
Treat the collected material in an autoclave. If this is unavailable, treat the waste in 1%
hypochlorite solution or boil in water for at least 10 minutes. It shall be ensured that these
treatments ensure disinfection
Dispose the autoclaved waste as follows: (i) Dispose the needles and broken vials in a pit /
tank, (ii) Send the syringes and unbroken vials for recycling or landfill.
Wash the containers properly for reuse
Make a proper record of generation, treatment and disposal of waste

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Annexure 6 : Guidelines for Disinfection and Sterilization

Device Classification
Devices Examples
Type of Process
Process Examples
High Risk
Enters sterile tissue
or vascular system,
includes dental
instruments
Implants, scalpels,
needles, other
surgical instruments
and Endoscopic
accessories
Sterilisation
(cycle time per
manufacturer)
Steam under pressure,

Dry heat, Ethylene oxide gas,
Chemical gas sterilizers
Intermediate Risk
Touches mucous
membranes or
broken skin
Flexible endoscopes,
Laryngoscopes,
Endotracheal tubes,
Respiratory therapy
and Anaesthesia
equipment, Diaphragm
fitting rings, and other
similar devices.
High-level
disinfection
(exposure time
20 minutes)
Glutaraldehyde based
formulations (2%) Stabilized
hydrogen peroxide (6%)
Household bleach (sodium
hypochlorite 5.25%
1,000 ppm available
chlorine = 1:50 dilution)
Thermometers
(oral or rectal)
Intermediate-level
disinfection
(exposure time
10 minutes)
Ethyl or Isopropyl alcohol

(70% to 90%)
(do not mix oral and rectal
thermometers)
Smooth, hard
surfaces such as
hydrotherapy tanks
Intermediate-level
disinfection
(exposure time
10 minutes)
Ethyl or isopropyl alcohol

(70 to 90%) Phenolic
detergent (dilute per label)
Iodophor detergent (dilute
per label) Household bleach
(sodium hypochlorite 5.25%
1,000 ppm available
Stethoscopes,
tabletops, floors,
bedpans,
furniture, etc.
Low level
disinfection
(exposure time
10 minutes)
Ethyl or isopropyl alcohol

(70 to 90%) Phenolic
detergent (dilute per label)
Iodophor detergent (dilute
per label) Household bleach
(sodium hypochlorite 5.25%
100ppm available
Low Risk
Touches intact skin
Copyright 1996 The Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) 1016
Sixteenth Street NW, Sixth Floor, Washington, DC 20036
202-296-2742 Fax 202-296-5645 E-mail APICinfo@apic.org
Nurses Manual
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Annexure 7: Situational Guide - Cleaning up a Blood Spill on

the Floor
1. Instruct the hospital worker or cleaner to wear appropriate personal protective equipment: plastic
apron, shoes and disposable gloves.
2. Put a towel / gauze / cotton over the spill area to cover it completely.
3. Pour hypochlorite solution 10% over the covered cloth to soak it completely.
4. Leave the solution on the cloth for another 30 minutes without disturbance.
5. Carefully lift the cloth from the floor, mopping the whole spill onto the cloth and dispose into the
yellow bin.
6. Using a routine mop and soap water solution swipe the area and wash the mop and hang it out to
dry.
7. Remove gloves and dispose into red bin.
8. Wash hands under running water with soap and dry hands.

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Nurses Manual
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Annexure 8: Situational Guide - Care of the Body after Death

of a PLHIV
HIV can survive in cadavers for a considerable amount of time (up to 16 days after death if stored at 2
C. Viable HIV has also been isolated from bone fragments, spleen, brain, bone marrow, and lymph nodes
at autopsy 6 days post-mortem.
Do
Protect self by using PPE and avoiding

injuries
Gloves, especially if the body has many
wounds.
Wear other PPE only if large quantities of
splashes of blood are anticipated.
Bodies that need to be handled especially
directly from emergency rooms or after
resuscitation procedures may contain
needles or other sharps. Care should be
taken to avoid needle stick and sharps
injuries.
Remove PPE after the procedure
Discard PPE into linen bin for laundering
or dispose appropriately.
Wash hands after removing PPE.
A shower should be taken before leaving
the room.
Disinfect the environment and any other
place or item that is contaminated with body
secretions with 1% hypochlorite solution.
Educate relatives of deceased about
Need for burial or cremation as early as
possible, sealing the coffin is not required.
Disinfecting if needed and then washing
patients clothing, bed linen, and other
personal items.
Dont
Give bath to the dead body.

Embalming bodies, especially when infected
with hepatitis B, hepatitis C, HIV or rabies.
If absolutely essential, use all PPE
Infection Hazards of human cadavers WEEKLY EPIDEMIOLOGICAL REPORT Vol 32: No. 23 (4-10 June,
2005). A publication of the Epidemiological Unit, Ministry of Healthcare, Nutrition & Uva Wellassa Development,
231, de Saram Place, Colombo 01000, Sri Lanka. E-Mail: epidunit@sltnet.lk (http://www.epid.gov.lk/pdf/
VOL%2032%20NO%2023.pdf)

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Annexure 9 : NACO PEP Policy: Procedure to be followed

after an Accidental Exposure to HIV Infectious Fluid
Do
Do Not
Remove gloves, if appropriate
Do not panic
Wash the exposed site thoroughly with

running water
Do not put pricked finger in mouth
Irrigate with water or saline if exposure sites

are eyes or mouth
Do not squeeze wound to bleed it
Wash skin with soap and water
Do not use bleach, chlorine, alcohol, betadine,

iodine or other antiseptics/detergents on
the wound
** Do - Consult the designated physician immediately as per institutional guidelines for

management of the occupational exposure **
Step 1: Management of Exposure Site First Aid

For skin if the skin is broken after a needle-stick or sharp instrument:
Immediately wash the wound and surrounding skin with water and soap, and rinse. Do not scrub.
Do not use antiseptics or skin washes (Bleach, Chlorine, Alcohol, Betadine)
After a splash of blood or body fluids:
To unbroken skin:
Wash the area immediately
Do not use antiseptics
For

For

the eye :
Irrigate exposed eye immediately with water or normal saline
Sit in a chair, tilt head back and ask a colleague to gently pour water or normal saline over the eye.
If wearing contact lens, leave them in place while irrigating, as they form a barrier over the eye and
will help protect it. Once the eye is cleaned, remove the contact lens and clean them in the normal
manner. This will make them safe to wear again
Do not use soap or disinfectant on the eye.
mouth :
Spit fluid out immediately
Rinse the mouth thoroughly, using water or saline and spit again. Repeat this process several times
Do not use soap or disinfectant in the mouth
Consult the designated physician of the institution for management of the exposure immediately.
Step 2: Risk assessment

The HIV sero-conversion rate of 0.3% after an AEB (for percutaneous exposure) is an average rate. The
real risk of transmission depends on the amount of HIV transmitted (= amount of contaminated fluid and
the viral load).
A designated person/trained doctor must assess the risk of HIV and HBV transmission following an AEB.
This evaluation must be made rapidly, so as to start any treatment as soon as possible after the accident
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(Ideally within 2 hours but certainly within 72 hours). This assessment must be made thoroughly (because
not every AEB requires prophylactic treatment).
PEP must be initiated as soon as possible, preferably within 2 hours
Two main factors determine the risk of infection: the nature of exposure and the status of the source patient.
Step 2 (a): Assessing the nature of exposure and risk of transmission

Three categories of exposure can be described based on the amount of blood/fluid involved and the entry
port. These categories are intended to help in assessing the severity of the exposure but may not cover
all possibilities.
Categories of exposure
Category
Definition and example
Mild exposure:
Mucous membrane/non-intact skin with small volumes

E.g. : a superficial wound (erosion of the epidermis) with a plain or low
calibre needle, or contact with the eyes or mucous membranes,
subcutaneous injections following small-bore needles
Moderate exposure:
Mucous membrane/non intact skin with large volumes OR

Percutaneous superficial exposure with solid needle
E.g.: a cut or needle stick injury penetrating gloves.
Severe exposure:
Percutaneous with large volume e.g.:

An accident with a high calibre needle (>=18 G) visibly
contaminated with blood;
A deep wound (haemorrhagic wound and/or very painful);
Transmission of a significant volume of blood;
An accident with material that has previously been used
intravenously or intra-arterially.
The wearing of gloves during any of these accidents constitutes a protective factor.
Note: In case of an AEB with material such as discarded sharps/needles, contaminated for over 48 hours,
the risk of infection becomes negligible for HIV, but still remains significant for HBV. HBV survives longer
than HIV outside the body.
Step 2 (b): Assessment of the exposed individual

The exposed individual should have confidential counselling and assessment by an experience physician.
The exposed individual should be assessed for pre-existing HIV infection as PEP is intended for people
who are HIV negative at the time of their potential exposure to HIV. Exposed individuals who are known
or discovered to be HIV positive should not receive PEP. They should be offered counselling and information
on prevention of transmission and referred to clinical and laboratory assessment to determine eligibility for
antiretroviral therapy (ART). Besides the medical assessment, counselling of the exposed HCP is essential
to allay fear and start PEP (if required) at the earliest.
Step 2(c): Assessing the HIV status of the source of exposure

PEP needs to be started as soon as possible after the exposure and within 72 hours. In animal studies,
initiating PEP within 12, 24 or 36 hours of exposure was more effective than initiating PEP 48 hours or 72
hours following exposure. PEP is not effective when given more than 72 hours after exposure.
A baseline rapid HIV testing should be done before starting PEP.
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Initiation of PEP where indicated should not be delayed while waiting for the results of HIV testing of the
source of exposure. Informed consent should be obtained before testing of the source as per national HIV
testing guidelines.
Categories of situations depending on results of the source
Source HIV Status
Definition of risk in source
HIV negative
Source is not HIV infected but consider HBV and HCV
Low risk
HIV positive and clinically asymptomatic
High risk
HIV positive and clinically symptomatic (see WHO clinical staging)
Unknown
Status of the patient is unknown, and neither the patient nor his/her blood
is available for testing (e.g. injury during medical waste management the
source patient might be unknown). The risk assessment will be based only
upon the exposure (HIV prevalence in the locality can be considered).
HIV infection is not detected during the primary infection period by routine-use HIV tests. During the
window period , which lasts for approximately 6 weeks, the antibody level is still too low for detection
but infected persons can still have a high viral load. This implies that a positive HIV test result can help
in taking the decision to start PEP, but a negative test result does not exclude HIV infection. In countries
or population groups with a high HIV prevalence, a higher proportion of HIV-infected individuals are found
in the window period. In these situations, a negative result has even less value for decision-making on PEP.
Step 3: Informed consent from exposed person

Exposed persons (clients) should receive appropriate information about what PEP is about and the risk and
benefits of PEP in order to provided informed consent. It should be clear that PEP is not mandatory.
Key information to provide informed consent to the client after occupational exposure
Key information to exposed person (client)
Specific Details include
The risk of acquiring HIV infection from

the specific exposure
What is known about PEP efficacy
Nurses Manual
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Ask client for understanding of HIV

transmission risk after exposure
The risk of getting HIV infection from a
person known to be HIV positive is estimated
to be
Sharps injury: 3 in 1000 exposures (0.3%)
Mucous membrane splash: 1 in 1000
exposures (0.1%)
the risk in increased with large exposure e.g.
needle-stick from hollow bore needles with
visible blood, from artery or vein and from
source patients with high viral load
(usually very sick persons with OIs)
Ask clients understanding of PEP
PEP is provided to prevent potential
transmission of the HIV virus
PEP is not 100% effective and should be
given within 72 hours (ideally as soon as
possible, if eligible).
Balance risk and benefits of PEP: PEP may
prevent HIV transmission, versus possible
risk of side effects
Information about clients risk of HIV

infection based upon a risk assessment
(if s/he has not had a recent HIV test)
The importance of being tested and
receiving appropriate post-test counselling
(although HIV testing can be delayed
if needed)
That PEP medicines will be discontinued
if their initial (baseline) HIV test is positive
Importance of adhering to medication

once started
Duration of the course of medicine
(4 weeks)
Common side effects that may be

experienced
That they can stop at any time but will

not get the benefit of PEP if the source
is HIV positive
Prevention during the PEP period e.g.

sexual intercourse and unplanned pregnancy
If client is pregnant she can still take

PEP during pregnancy

Clients possibility of prior HIV infection

should be assessed
Counsel for HIV testing and follow-up
psychosocial support where possible rapid
testing should be used based on national
testing guidelines
Inform if the baseline HIV test is positive,
then the PEP will be discontinued
Arrange referral to ART centres for
assessment if found HIV positive
Discuss dosing of the PEP medicine e.g.
pill should be taken twice a day for 28 days,
once in the morning and once in the evening
Depending on the nature and risk of exposure,
2 drugs or 3 drugs may be used
Side effects may be important with use of 3 drugs
Expert opinion/consultation by phone or
referral may be needed with a HIV specialist
if 3rd drug is to be used
Arrange for special leave from work
(2 weeks initially)
Discuss possible side effects of the PEP
medicines e.g. nausea, fatigue, headache
(depending on which drugs given)
Side effects often improve over time. It is
often minor and do not need specialised
supervision.
Symptomatic relief can also be given by
using other drugs
Animal studies suggest that taking less than
4 weeks of PEP does not work
If client decides to stop at any time, s/he
needs to contact the physician before
stopping the medications
Arrange for follow-up visit and decide further
course of action/follow-up
After any AEB, the exposed person should
not have unprotected sexual intercourse until
it is confirmed, 3 months after the exposure,
that s/he is not HIV infected.
It is also advised to avoid pregnancy.
Use of condoms is essential
The PEP drugs used are safe for pregnancy
If the client gets HIV during the pregnancy
due to the exposure, the baby will have
some risk of becoming HIV infected
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Safety of PEP if the client is breastfeeding
The PEP drugs used are safe during

breast-feeding
May consider stopping breastfeeding if
PEP is indicated.
Educate client on the possible signs and

symptoms of early HIV sero-conversion
Signs and symptoms of early HIV seroconversation: fever, rash, oral ulcers,
Pharyngitis, malaise, fatigue, joint pains,
weight loss, Myalgia, headache
(similar to flu-like symptoms)
Risk of acquiring Hepatitis B and C from

a specific exposure and availability of
prophylaxis for this
Risk of Hepatitis B is 9-30% from a needle

stick exposure the client can be given
vaccinations
Risk of Hepatitis is 1-10% after needle stick
exposure there are no vaccinations for this.
* Provider should correct misconceptions at all times during the counselling sessions
Psychological support:
Many people will feel anxious after exposure. Every exposed person needs to be informed about the risks
and the measures that can be taken. This will help to relieve part of the anxiety, but some may require
further specialised psychological support.
Documentation on record is essential. Special leave from work should be considered for a period of time
e.g. 2 weeks (initially) then, as required based on assessment of the exposed persons mental state, side
effects and requirements.
Practical application in the clinical settings:
Once prophylactic treatment has begun, the exposed person must sign form A1 (see annex 3).
Informed consent also means that if the exposed person has been advised PEP, but refuses to start
it, s/he should sign Form A1 (see annex 3). This document should be kept by the designated officer
for PEP.
An information sheet covering the PEP and the biological follow-up after any AEB (see Annex 4) may
be given to the person under treatment. However, this sheet cannot replace verbal explanations.
Arrange for follow-up visit and leave from work.
Step 4: Deciding on PEP Medications/Regimen

Deciding on therapy
There are two types of regimens:
a) Basic regimen: 2-drug combination
b) Expanded regimen: 3-drug combination
The decision to initiate the type of regimen depends on the type of exposure and HIV serostatus of the
source person. See Table 6.
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HIV Post-exposure Prophylaxis Evaluation

Exposure
Status of source
HIV+ and
asymptomatic
HIV+ and Clinically

symptomatic
HIV status unknown
Mild
Consider 2-drug PEP
Start 2- drug PEP
Usually no PEP or consider 2-drug PEP
Moderate
Start 2-drug PEP
Start 3-drug PEP
Severe
Start 3-drug PEP
Start 3-drug PEP
HIV testing of the source patient should not delay the decision about whether or not to start PEP. Start
2-drugs first if required, then send for consultation or refer.
In the case of a high risk exposure from a source patient who has been exposed to or is taking
antiretroviral medications, consult an expert to choose the PEP regimen, as the risk of drug resistance
is high. Refer/consult expert physician. Start 2 drug regimens first.
Expert opinion may be obtained for the following situations:

(Refer to list of PEP experts on www.nacoonline.org)
Delay in reporting exposure (> 72 hours)

Unknown source: use of PEP to be decided on case to case basis after considering the severity of
exposure and the epidemiologic likelihood of HIV transmission. Do not delay PEP initiation if indicated
Known or suspected pregnancy: do not delay PEP if indicated
Breastfeeding issues in the exposed person: do not delay PEP if indicated. Consider stopping breast
feeding if PEP is indicated.
Source patient is on ART or possibly has HIV drug resistance : refer/consult as soon as possible
Major toxicity of PEP regimen: minor side effects may be managed symptomatically. Refer to expert
if non-tolerance or non-adherence
Refer/ consult if in doubt or complicated cases (e.g. major psychological problem)
Step 5: Starting PEP

Various animal studies done over the years have provided encouraging evidence of post exposure
chemoprophylactic efficacy. Studies have also shown that delaying initiation, shortening the duration or
decreasing the antiretroviral dose of PEP, individually or in combination, decreased its prophylactic efficacy.
In a retrospective case control study of HCP, it was demonstrated that use of Zidovudine as PEP was
associated with a reduction in the risk of HIV infection by approximately 81%. Also the experience in HIV
infected patients has shown that combination of different antiretroviral agents is superior to monotherapy
regimen, so a combination of two or three drugs in PEP regimen should be more beneficial than a single
drug. One needs to consider toxicity of a combination regimen vis--vis risk of transmission.
PEP must be initiated as soon as possible, preferably within 2 hours
Initiate HIV Chemoprophylaxis
Because post-exposure prophylaxis (PEP) has its greatest effect if begun within 2 hours of exposure, it is
essential to act immediately. There is little benefit if >72 hours later. The prophylaxis needs to be continued
for 4 weeks.
Report exposure immediately to appropriate authority.

Fill in the medical form
Never delay start of therapy due to debate over regimen. Begin with basic 2-drug regimen, and once
expert advice is obtained, change as required.
The 3rd drug can be added after consultation with an expert.

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Dosages of the Drugs for PEP

Medication
2-drug regimen
3-drug regimen
Zidovudine (AZT)
300 mg twice a day
300 mg twice a day
Lamivudine (3TC)
150 mg twice a day
150 mg twice a day

1st choice : Lopinavir/ritonavir (LPV/r)
400/100 mg twice a day or 800/200 mg
once daily with meals
Protease Inhibitors
2nd choice : Nelfinavir (NLF)1250 mg

twice a day or 750 mg three times a
day with empty stomach
3rd choice : Indinavir (IND)800 mg
every 8 hours and drink 6-8 litres
of water daily
Note: If protease inhibitor is not available and the 3rd drug is indicated, one can consider using Efavirenz
(EFV 600 mg once daily). Monitoring should be instituted for side effects of this drug e.g. CNS toxicity
such as nightmares, insomnia etc.
* Fixed Dose Combination (FDC) are preferred, if available. Ritonavir requires refrigeration.
PEP regimens to be prescribed by health centres:
2-drug regimen
(basic PEP regimen)
Preferred
Alternative
1st choice:
Zidovudine (AZT) +
Lamivudine (3TC)
2nd choice:
Stavudine (d4T) +
Lamivudine (3TC)
3-drug regimen (expanded PEP regimen) consult expert opinion for starting 3rd drug e.g.
LPV/r, NLF or IND
Not recommended
ddI + d4T combination

NNRTI such as Nevirapine should not be used in PEP
More information on alternative schedules is available in the latest update USPHS guidelines issued 30
September 2005. (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm) or www.who.int
Selection of the PEP regimen when the source patient is known to be on ART: The physician should
consider the comparative risk represented by the exposure and information about the exposure source,
including history of and response to antiretroviral therapy based on clinical response, CD4 cell counts, viral
load measurements (if available), and current disease stage (WHO clinical staging and history). When the
source persons virus is known or suspected to be resistant to one or more of the drugs considered for the
PEP regimen, the selection of drugs to which the source persons virus is unlikely to be resistant is
recommended. Refer for expert opinion.
If this information is not immediately available, initiation of PEP, if indicated, should not be delayed.
Give the 2 drug (basic) regimen. Changes in the PEP regimen can be made after PEP has been started,
as appropriate. Re-evaluation of the exposed person should be considered within 72 hours post-exposure,
especially as additional information about the exposure or source person becomes available.
Antiretroviral Drugs during Pregnancy
If the exposed person is pregnant, the evaluation of risk of infection and need for PEP should be approached
as with any other person who has had an HIV exposure. However, the decision to use any antiretroviral
Nurses Manual
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drug during pregnancy should involve discussion between the woman and her health-care provider(s)
regarding the potential benefits and risks to her and her fetus.
Data regarding the potential effects of antiretroviral drugs on the developing fetus or neonate are limited.
There is a clear contraindication for Efavirenz (first 3 months of pregnancy) and Indinavir (pre natal).
In conclusion, for a female HCP considering PEP, a pregnancy test is recommended if there is any chance
that she may be pregnant. Pregnant HCP are recommended to begin the basic 2-drug regimen, and if a
third drug is needed, Nelfinavir is the drug of choice.
Side-effects and Adherence to PEP
Studies of HCP taking PEP have reported more side effects than PLHIV taking ART, most commonly
nausea and fatigue. Possible side-effects occur mainly at the beginning of the treatment and include
nausea, diarrhoea, muscular pain and headache. The person taking the treatment should be informed that
these may occur and should be dissuaded from stopping the treatment as most side-effects are mild
and transient, though possibly uncomfortable. Anaemia and/or leucopoenia and/or thrombocytopenia may
occur during the month of treatment. A complete blood count and liver function tests (transaminases) may
be performed at the beginning of treatment (as baseline) and after 4 weeks.
In practice and from HCP studies, many HCP did not complete the full course of PEP because of side
effects. Side effects can be reduced by prescribing regimens that do not include a protease inhibitor (PI),
by giving medications to reduce nausea and gastritis and by educating clients about how to reduce side
effects e.g. taking PEP medications with food. It is important that side effects should be explained before
initiating PEP so that the symptoms are not confused with symptoms of seroconversion to HIV.
Adherence information is essential with psychological support. More than 95% adherence is important in
order to maximise the efficacy of the medication in PEP.
Management of Minor ARV drug side effects
Signs or symptoms
Management at health facility
Nausea
Take with food. If on AZT, reassure that this is common, usually self-limited.
Treat symptomatically.
Headache
Give Paracetamol. Assess for meningitis. If on AZT or EFV, reassure that

this is common and usually self-limited. If persists more than 2 weeks,
call for advice or refer.
Diarrhoea
Hydrate. Follow diarrhoea guidelines. Reassure patient that if due to ARV,

this will improve in a few weeks. Follow up in 2 weeks. If not improved,
call for advice or refer.
Fatigue
This commonly lasts 4 to 6 weeks especially when starting AZT. Give

sick leave from work. If severe or longer than this, call for advice or refer.
CNS side effects:

Anxiety, nightmares,
psychosis, depression
This may be due to EFV. Take EFV at night before sleeping; counsel
and support (usually lasts < 3 weeks). Initial difficult time can be managed
with amitriptyline at bedtime.Call for advice or refer if severe depression
or suicidal tendencies or psychosis. (Stop EFV).
Blue /black nails
Reassure. It is a non-threatening side effect, common with AZT
Rash
If on EFV, assess carefully. Is it a dry or wet lesion? Call for advice.

If generalised or peeling, stop drugs and refer for expert opinion.
Fever
Assess clinically for hepatitis or if this could be primary (acute) HIV

infection or other non-HIV related infections e.g. concurrent common cold.
Call for advice or refer.

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Signs or symptoms
Management at health facility
Jaundice or
abdominal or
flank pain
Stop drugs. Call for advice or refer.

(Abdominal pain may be pancreatitis from d4T.) If jaundice or liver
tenderness, send for ALT test and stop ART. Call for advice or refer.
Pallor
Measure Haemoglobin. Refer if sever pallor or symptoms of anaemia or

very low haemoglobin (<8 grams). This may be due to AZT.
Tingling, numbers
or painful feet/legs
If new or worse on treatment, call for advice or refer. Patient on d4T/3TC

should have the d4T discontinued substitute AZT if no anaemia
(check haemoglobin).
Amount of medication to dispense for PEP

All clients starting on PEP must take 4 weeks (28 days) of medication. In all cases, the first dose of PEP
should be offered as soon as possible, once the decision to give PEP is made. HIV testing or results of
the source HIV test can come later. As usage of PEP drugs is not frequent and the shelf life is 1 to 1.5
years, it is proposed that:
Starter packs for 7 days can be put in the emergency department with instructions to go to a
designated clinic/officer within 1-3 days for a complete risk assessment, HIV counselling and testing
and dispensing of the rest of the medications and management. At least 3 such kits are provided in
the casualty department.
It is important to monitor and regularly follow-up the person once PEP is started.
Post-exposure measures against hepatitis B and C
20
HEPATITIS B
All health staff should be vaccinated against hepatitis B. The vaccination for Hepatitis B consists of 3
doses: initial, 1 month, and 6 months. Sero-conversion after completing the full course is 99%.
HBV vaccination after an AEB:

HBV vaccination status of exposed person
Action after AEB
* Anti-HbS level > 10 IU/L
No action
* Anti-HbS level <10 IU/L
Hep B Vaccine Booster
Vaccinated, anti-HbS not known
Vaccinated more than 5 years ago
Never vaccinated
Give complete hepatitis B vaccine series
* Antibody test (anti-HbS level), if available, is not necessary.
HEPATITIS C
There is presently no prophylaxis available against hepatitis C. There is no evidence that interferon,
pegalated or not, with or without ribavirin is more effective when given at this time than when given at
the time of disease. Post-exposure management for HCV is based on early identification of chronic
HCV disease and referral to a specialist for management.
Step 6: Follow up of an exposed person

Whether PEP prophylaxis has been started or not, follow up to monitor possible infections, and psychological
support are indicated.
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Laboratory follow-up
Laboratory tests after AEB
Timing
In persons taking PEP

(standard regimen)
In persons not taking PEP
Baseline
(within 8 days after AEB)
HIV-Ab, anti-HCV, HBsAg *

Complete blood count
Transaminases
HIV-Ab, anti-HCV, HBsAg *
Week 2 and 4
Transaminases **
Complete blood count ***
clinical monitoring for hepatitis
Week 6
HIV-Ab
HIV-Ab
Month 3
HIV-Ab, anti-HCV, HBsAg

Transaminases**
Month 6

Transaminases**
*HIV, HBV and HCV testing of exposed staff within 8 days of an AEB is required (baseline serostatus).
Offer an HIV test in case of an AEB, as a positive HIV status may indicate the need to discontinue
PEP. The decision on whether to test for HIV or not should be based on informed consent of the exposed
person.
** Transaminases should be checked at week 2 and 4 to detect hepatitis in case the exposed person
contracted HBV from the AEB.
*** For persons started on AZT-containing PEP regimens
Clinical follow-up
In addition, in the weeks following an AEB, the exposed person must be monitored for the eventual
appearance of signs indicating an HIV seroconversion: acute fever generalised Lymphadenopathy, cutaneous
eruption, pharyngitis, non-specific flu symptoms and ulcers of the mouth or genital area. These symptoms
appear in 50%-70% of individuals with an HIV primary (acute) infection and almost always within 3 to 6
weeks after exposure. When a primary (acute) infection is suspected, referral to an ART centre or for expert
opinion should be arranged rapidly.
An exposed person should be advised to use precautions (e.g., avoid blood or tissue donations, breastfeeding,
unprotected sexual relations or pregnancy) to prevent secondary transmission, especially during the first 612 weeks following exposure. Condom use is essential.
Adherence and side effect counseling should be provided and reinforced at every follow-up visit. Psychological
support and mental health counseling is often required.
Follow-up HIV testing:
Exposed persons should have post-PEP HIV tests. Testing at the completion of PEP may give an initial
indication of seroconversion outcome if the available antibody test is very sensitive. However, testing at 46 weeks may not be enough as use of PEP may prolong the time to seroconversion; and there is not
enough time to diagnose all persons who seroconvert. Therefore, testing at 3 months and again at 6
months is recommended. Very few cases of seroconversion after 6 months have been reported. Hence,
no further testing is recommended if the HIV test at 6 months is negative.

Nurses Manual
Page 183
Flow chart: Management of an AEB and PEP

Steps
Actions
timing
Accidental exposure to blood
0 h 0 min

Step 1
Immediate first aid

Step 2
Risk assessment by a medical doctor
As soon as possible

Step 3
Decision on therapy (medical doctor and exposed person)

Counselling and information
Offer of psychological support
Special leave from work/duty
Step 4Step 5
Prophylactic treatment against HIV Infection

and HBV vaccinations as required

Yes
Step 5

Start 2-drug

Start 3-drug
Ideally within
2 hours but
certainly
within 72 hr
No

Offer follow-up &
counselling as required
Step 6
Nurses Manual
Page 184
Monitor and follow-up of HIV, HBV and HCV status
6 months

Annexure 10: STI Syndrome Flowchart Lower Abdominal

Pain
Lower Abdominal(inPain
females)
Patient complaints of lower abdominal pain
Take history and do abdominal and
pelvic examination
Missed / overdue period,
Vaginal bleeding?
Recent delivery/abortion?
Rebound tenderness?
Guarding?
Pelvic mass?
Refer immediately to
higher-level facility
Yes
No
Mucopue exuding from cervix?
And / or tenderness on cervical
movements?
And / or adnexal tenderness?
And / or temperature 38C higher?
Yes to any
No
Yes
No
Advise patient to return for
re-evaluation if pain persists
Treat for PID

(Gonorrhoea + Chlamydia + Anaerobic infection)
Use this regimen only if patient is well enough to
take food and liquids, walk unassisted,
take her medication and return for follow-up. Other
wise refer to higher level cars.
Treat for Gonorrhoea:
Cefixime 400 mg orally as a single dose
or
Ink. Ceftriaxone 250 mg IM as a single dose
Treat for Chlamydia:
Doxycycline 100mg twice daily for 14 days.
Plus
Treat for Anaerobic Infection:
Metronidazole 400 mg twice daily for 14 days.

Adnexal mass present
Refer to higher-level
medical care
Return after 7 days for follow up

or even earlier if pain persists
or gets worse
Improved?
No
Refer to higherlevel facility
Yes
Complete treatment
Advice to return
if pain persists
Refer to VCTC
Treat partner even if

asymptomatic.
Treat partner for
Gonorrhoea & Chlamydia
Educate on safe sex
Counsel
Provide condoms and
promote usage
Refer to VCTC
Nurses Manual
Page 185
Annexure 11 : STI Syndrome Flowchart Inguinal Bubo
Inguinal Bubo (Swelling)

(Both sexes)
Patient complains of enlarged and/or painful inguinal lymph nodes
Take history and examine

for genital ulcer ?
Use the flow-chart for

genital ulcers
Yes
No
Treat for LGV

Doxycycline 100 mg orally twice daily
for 14 days.
Alternate regimen:
Erythromycin stearate 500 mg orally
4 times daily for 14 days
A fluctuant bubo needs to be aspirated
with a wide-bore needle and syringe every
2nd or 3rd day till there is no aspirate.
Bubo should never be incised.

asymptomatic.
Educate on safe sex
Counsel
Provide condoms and
promote usage
Refer to VCTC
Nurses Manual
Page 186
Return after 7 days for follow up

or even earlier if pain persists
or gets worse
Responds to treatment
Yes
No
Complete treatment
Educate
Counsel
Provide condoms
and promote usage

Annexure 12 : STI Syndrome Flowchart Painful Scrotal

Swelling
Painful Scrotal Swelling

Patient complains of painful scrotal swelling
History of injury to scrotum
Yes
Refer to higher level facility
No
Examine scrotum
Swelling of scrotum
No
Reassure patient / educate

Provide condom and promote usage
Yes
Testis rotated or retracted?
Yes
No
Treat for Gonorrhoea & Chlamydia
Tablet Azithromycin 2G Single Dose
Or
Cefixime 400 mg + Tab Azithromycin 1G
Or
Inj. Ceftriaxone 250 mg IM
in a single dose + Tab Azithromycin 1G
Refer immediately to higher level facility

asymptomatic.
Advise return after 7 days
Educate on safe sex
Counsel
Provide condoms and
promote usage
Refer to VCTC
Tenderness and swelling persists?

No
Cured

Yes
Refer to higher
level facility
Nurses Manual
Page 187
Annexure 13 : STI Syndrome Flowchart Ophthalmia

Neonatorum
Ophthalmia Neonatorum
(Neonatal Conjunctivities)
Newborn baby with discharing eyes
Take history and examine baby
Conjunctivities present?
No
Other illness
present?
Yes
No
Reassure mother
Reivew, if
symptoms persist
Yes
Manage appropriately
Treat baby for Gonorrhoea &

Chlamydia
Inj. Ceftriaxone 50mg/kg single dose
(Maximum 125 mg)
Plus
Erythromycin syrup 50 mg/kg in
4 divided doses for 14 days.
Improved
Yes
No
Treat both parents for

Gonorrhoea & Chlamydia
Reinforce education
Complete the treatment

Or
Or
Inj. Ceftriaxone 250 mg IM in a single dose +
Tab Azithromycin 1G
Nurses Manual
Page 188

Annexure 14 : STI Syndrome Flowchart Genital Ulcers
Genital Ulcers
Patient complains of
genital sore ulcer
Vesicles found and/or
history of recurrences?
Treat for
Herpes Genitalls
Ulcer present?
Genital hygiene
Acyclovir 400mg orally
3 times daily for 7-10 days
There is no known cure for
herpes. The course of
symptoms can be altered
by acyclovir
Treat partner if
symptomatic
Educate on safe sex
Council
Provide condoms and
promote usage
Advise return after
7 days for follow up
Refer to VCTC
Treat for Syphilis & Chancrold

Inj. Benzathine Penicillin G 24 Lakhs
I.M. in 2 equally divided doses
(After skin test)
Plus
Inj. Ceftriaxone, 250mg, single dose I.M.
or
Azithromycin 1 G, single dose,
orally under supervision
or
Ciprofloxacin 500 mg two times
a day orally for 3 days
For persons sensitive to penicillin:
(men & non-pregnant women)
Doxycycline 100mg orally 2 times
daily for 15 days
(for pregnant women)
Erythromycin stearate 500 mg
orally 4 times daily for 15 days
Treat partner even if asymptomatic

Educate on safe sex
Counsel
Provide condoms and promote usage
Refer to VCTC
Refer after 7 days

for follow up
Ulcer Healed
Yes
Educate on safe sex

Counsel
Provide condoms and
promote usage
Refer to VCTC
No
Refer to higher
level facility
In case of doubt with regards to the classification of the ulcer, treat for Syphilis, Chancrold and Herpes

Nurses Manual
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Annexure 15 : STI Syndrome Flowchart Urethral Discharge
Urethral Discharge
Patient complains of urethral discharge
Take relevant history & examine withdrawing foreskin in uncircumsized male.
Milk urethra if necessary
Discharge seen?
Any other
STI present?
Yes
No
Yes
Educate on safe sex

Counsel
Provide condoms and
promote usage
Refer to VCTC
Use appropriate flow-chart
Treat for Gonorrhoea & Chlamydia
Treat partner even

if asymptomatic
Educate on safe sex
Counsel
Provide condoms and
promote usage
Refer to VCTC

Or
Or
Inj. Ceftriaxone 250 mg IM in a single dose +
Tab Azithromycin 1G
Treat for Trichomoniasis
Tab. Metronidazole or Tinidazole 2 gms
single dose, orally
Examine after 7 days
Nurses Manual
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Cured
Yes
Educate on safe sex

Counsel
Provide condoms and
promote usage
Refer to VCTC
No

Annexure 16 : STI Syndrome Flowchart Vaginal

Discharge (1)
Vaginal Discharge
(Without Speculum Examination)
Patient complains of vaginal discharge
No
Lower abdominal Pain
Yes
Assess the risk

Recurrent Vaginitis
Symptomatic partner?
Recent new partner?
Multiple partners?
Spouse returning after a
long stay away from home?
No
Yes
Treat for Cervicitia (Gonorrhoea & Chlamydia)
Tab. Azithromycin 2G Single Dose OR
Tab. Azithromycin 1G + Cefixime 400 mg OR
Tab. Azithromycin 1G + Inj. Ceftriaxone 250 mg
IM in a single dose
Treat for Vaginitis
Tinidazole or Metronidazole 2G stat
Plus
Fluconazole 150 mg stat
Treat partner even
if asymptomatic
Treat partner for
Gonorrhoea,
Chlamydia &
Trichomoniasis
Educate on safe sex
Counsel
Provide condoms and
promote usage
Refer to VCTC
Treat for Vaginitis only

Tinidazole or Metronidazole
2 G stat
Plus
Educate on safe sex
Counsel
Provide condoms and
promote usage
Advice return after 7 days
Vaginal discharge persists
Yes
Treat for Cervicitis

(Gonorrhoea & Chlamydia)
Tab. Azithromycin 2G
Single Dose
OR
Cefixime 400 mg +
OR
Inj. Ceftriaxone 250 mg IM
in a single dose +
No
Educate on safe sex

Counsel
Provide condoms
and promote usage
Refer to VCTC
No
Discharge persists
Yes

Use appropriate Flow-Chart
Refer to higher-level facility
Nurses Manual
Page 191
Annexure 17: STI Syndrome Flowchart Vaginal

Discharge (2)
Vaginal Discharge
(Speculum Examination)
Patient complains of vaginal discharge
Lower abdominal Pain
Yes
Use appropriate Flow-Chart

Treat for Vaginitis only
Tinidazole or
Metronidazole 2 G stat
Plus
No
Assess the risk

Symptomatic partner?
Endo-cervical discharge present Recent new partner?
on speculum examination?
Multiple partners?
Spouse returning after a
long stay away from home?
No
Educate on safe sex

Counsel
Provide condoms and
promote usage
Refer to VCTC
Yes
No
Yes
Educate on safe sex

Counsel
Provide condoms
and promote usage
Refer to VCTC
Treat partner even
if asymptomatic
Treat partner for
Gonorrhoea,
Chlamydia &
Trichomoniasis
Educate on safe sex
Counsel
Provide condoms and
promote usage
Refer to VCTC

OR
Cefixime 400 mg + Tab. Azithromycin 1G
OR
Inj. Ceftriaxone 250 mg IM in a single dose
+ Tab Azithromycin 1G
Treat for Vaginitis
After 14 days, if Vaginal

discharge persists?
Tinidazole or Metronidazole 2G stat

Plus
Plus
No
Yes

OR
Tab. Azithromycin 1G + Cefixime 400 mg
OR
Tab. Azithromycin 1G +
Inj. Ceftriaxone 250 mg
IM in a single dose
After 7 days, If Vaginal discharge persists refer to higher-level facility.
Nurses Manual
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Annexure 18 : Guide to Common Symptoms and Possible

Aetiologies
Symptoms
Requiring
Attention
Possible Aetiologies
Dyspnoea
Pulmonary infection (e.g., pneumonia-bacterial or fungal)

Invasive pulmonary disease (e.g. pulmonary)
Obstructive airway disease, Emphysema
Severe anaemia
New Fever or
Change in
Fever Pattern
Central nervous system (CNS) mass lesion-often accompanied by headache

Meningitis
Sinusitis
Oesophagitis
Lymphoma
Fungal infections-often caused by characterized by hepatomegaly;
if respiratory, characterized by cough
Mycobacterium avium complex (MAC) - often accompanied by chronic
diarrhoea and abdominal pain
Bacterial parasites - Clostridium difficile, cytomegalovirus (CMV),
accompanied by diarrhoea
Pneumonia - often accompanied by dyspnoea , Tuberculosis - often
accompanied by dyspnoea
Pneumocystis - often accompanied by cough
Drug reactions
Advanced HIV disease
New or Persistent
Headache
Medications
CNS lymphoma
Cryptococcus Meningitis, Toxoplasmosis
Altered Mental State
AIDS dementia
Complex CNS infection
Tumours
Seizures or Loss
of Consciousness
CNS lymphoma
Medications
AIDS dementia
Toxoplasmosis
Peripheral
Neuropathy
Medications
HIV infection
CMV
Herpes Zoster
Visual Changes
CMV retinitis (most common)

VZV, HSV, Toxoplasmosis
Syphilis
New or Persistent
Diarrhoea
Medications, Diet
Bacterial infections - Salmonella, Shigella, Campylobacter, C. difficile
Invasive diseases affecting the bowel - M. avium- intracellular, lymphoma,
CMV, Wasting syndrome

Nurses Manual
Page 193
Symptoms
Requiring
Attention
Possible Aetiologies
Gastrointestinal
Bleeding
Herpes simplex, CMV, Candidiasis

Kaposis sarcoma, Lymphoma
Cryptosporidium
Salmonella, C. difficile
Dysphagia and
Odynophagia
Candidiasis
Herpes simplex
CMV
Neurologic impairment
Oedema
Obstruction of venous or lymphatic vessels (e.g., from Kaposis sarcoma,

venous thrombosis, lymphoma)
Hypoalbuminemia
Renal failure, Congestive heart failure
Liver disease
Nauseous and
Vomiting
Medications
Infections, Massive disease of GI tract
CNS disease
Adrenal insufficiency
Inadequate
Oral Intake
Anorexia
Nauseous and vomiting
Dysphagia
Odynophagia
Inadequate access to food
Altered nutrition
Skin, Mucous
Membrane lesions
Drug reactions
Dry skin
Viral infections - Molluscum, herpes simplex or zoster
Bacterial infections - Bacillary angiomatosis, folliculitis, Impetigo, ecthyma,
abscesses
Fungal infections - Tinea, candida
Malignancy - Kaposis sarcoma
Pressure ulcers
Source: Adapted from Kirton, C. Talotto, D. & Zwolski, K. (2001) Handbook of HIV/AIDS Nursing
Nurses Manual
Page 194

Annexure 19 : What a Nurse needs to know about Dementia

and Delirium
Dementia
Definition:
An organic mental disorder characterised by loss of intellectual abilities of sufficient severity to interfere with
social or occupational functioning. HIV-associated dementia is known as AIDS Dementia Complex (ADC)
Patients may present with ambulation/gait problems, mania, panic, psychosis, withdrawal or anxiety. Dementia
is progressive with a variable course. Patients with HIV-related dementia are often acutely aware of their
deterioration, which may lead to an adjustment disorder with profound fear, anxiety or depression.
Aetiology
HIV associated dementia HIV directly invades the brain tissue shortly after infection-was the most frequently
seen single neurologic complication of AIDS before the HAART era in the U.S.
Drug withdrawal
Pain
Clinical Manifestations of Dementia
Early manifestations:
Memory loss, Impaired concentration

Depressed mood, Apathy
Motor weakness, Tremor, poor handwriting
Irritability, Agitation
Personality change
Late manifestations:
Global cognitive dysfunction

Amnesiac features
Organic hallucinations
Parkinsonism
Vegetative state
Mutism, Aphasia, Spasticity, Ataxia
Assessment
Screening tool for dementia

Thorough physical examination to determine potential reversible causes:
Toxoplasmosis, Cryptococcoma, MAI, lymphoma, CMV ventriculitis or encephalitis, or meningitis
associated with syphilis, TB, or Cryptococcus neoformans.
Neurologic exam
CT scan or MRI to check for cortical atrophy, ventricular enlargement, or masses
Labs: Thyroid function, RPR, LFTs, chemistry, haemogram
Educate patient and family.

Teach behavioural management strategies so patient with early manifestations of dementia can live
with some degree of independence, yet be safe in the home environment. (E.g. establishing a daily
routine and sticking to it).
Memory aids such as notes, calendars, alarm clocks, etc

Nurses Manual
Page 195
Referral to home care agency, may need 24 hour supervision

Because disease is frightening and may be progressive, the patient and family need assistance to plan
for the future.
Pharmacologic: ART, SSRI for depression, Anti-psychotics for agitation and hallucinations
Delirium
Definition:
Characterized by disturbance of consciousness and a change in cognition that develops over a period of
time and is caused by the direct physiologic consequences of a medical condition. Delirium is the most
common neuron-psychiatric complication in hospitalised AIDS patients.
Risk factors for Delirium in AIDS patients:
Advanced stage of immuno-suppression

History of OIs, especially affecting CNS
Substance use
Head or brain injury
Episodes of delirium or dementia
Aetiology May be single or multiple

Infectious: Cryptococcal or Toxoplasmosis encephalitis
Assessment
Sudden change in mental status

Level of alertness may vary from agitation to lethargy, stupor or coma. Patients are usually drowsy and
may require repeated explanations from caregivers and examiners. Early signs of delirium may be
inaccurately attributed to anxiety.
Abrupt disturbances in sleep patterns or changes in level of activity should raise suspicion.
Interview caregiver and observe patient to assess functional status
Clinical Manifestations
Impaired memory, orientation: difficulty with abstractions, difficulty with sequential thinking, impaired
temporal memory, impaired judgment
Disturbances in thought and language with decreased verbal frequency
Disturbances in perception: visual hallucinations, paranoid delusions
Disturbances in psychomotor function: hypoactive, hyperactive or mixed
Disturbances in sleep-wake cycle with daytime lethargy, night time agitation
Affective lability: rapidly changes from one emotional state to another
Neurologic abnormalities: tremors, myoclonus, nystagmus, ataxia, cranial nerve palsies, and cerebellar
signs
Address underlying condition such as metabolic abnormalities, sepsis, anaemia, CNS infections and
malignancies, antiretroviral therapy, opioids, and illicit substance use
Provide safe and consistent environment and increase supervision of patient as indicated
Communicate in clear simple terms to avoid misconceptions
Educate patient and family regarding care and procedures, medications, expected outcomes, and need
to orient patient to person, time, place, and situation
Ensure patients activities of daily living are met
Pharmacologic: Low doses of neuroleptics (Haldol or Risperdal) to treat confusion or agitation
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Annexure 20: Comprehensive Laboratory Evaluation in

HIV/AIDS
The purpose of the baseline laboratory evaluation is to 1) stage the HIV disease, 2) rule out concomitant
infections and 3) determine baseline safety parameters. The following tests are recommended
Essential
Optional
Confirm HIV infection: HIV status must be

documented. Refer to ICTC if in doubt.
Fasting lipid profile: May be recommended

in patients with established coronary disease
risk factors or if Stavudine, Efavirenz, protease
inhibitor (PI) use is contemplated.
Specific investigations to rule out OIs

depending on the clinical need
Pregnancy test: EFV is contraindicated in

pregnancy
CD4 counts: all patients should have a

baseline screening
Anti-HCV Screening: The prevalence of HCV is

low in HIV infected patients except, such as in
north-eastern states of India where injection drug
use is a risk factor. It is also recommended in
HIV infected haemophiliacs and thalassaemics.
CBC: Hb, TLC, DLC, ESR, GBP
Chest X-ray : To rule out TB or other pulmonary

infection
LFTs: Necessary to find evidence of hepatitis,

particularly when NVP use is contemplated.
Plasma viral load (PVL): A baseline PVL may

not be necessary. With optimum adherence and
a potent regimen, undetectable levels at 6 months
after ART initiation should be achieved.
Urine routine: To evaluate proteinuria and

sugar (necessitate estimation of blood glucose)
HBsAg: To rule out concomitant hepatitis B
infection as this can influence choice of ARV
regimen. Additionally, abrupt stopping of anti-HBV
drugs like Lamivudine and Tenofovir is not
recommended in patients with chronic hepatitis B
co-infection since it may result in hepatitis B
flare-up. This screening is mandatory for IDUs
and transfusion-associated HIV infection
HCV screening: mandatory for IDU and
transfusion- associated HIV infection
VDRL/TPHA (syphilis screening): especially
with persons of high risk behaviour group, history
of STIs and/or suggestive symptoms of syphilis
Pap smear : Helps in earlier diagnosis of
cervical intraepithelial neoplasia (CIN)

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Annexure 21 : Specimen Collection (by heel prick) and

handling procedure for HIV DNA PCR testing by
Dried Blood Spot (DBS) sample collection
Introduction
Pediatric HIV infection is an evolving entity and continues to be a challenge for the medical community. The
standard diagnostic tool for HIV infection in adults, testing for antibodies to HIV antigens, has limited utility
in infants less than 18 months of age because of the transplacental transfer of maternal antibodies. An
essential priority in caring for HIV-infected children is accurate and early diagnosis of HIV.
The diagnosis of HIV in infants under eighteen months of age must therefore be conducted by direct
detection of the virus-specific genetic material. The assay can be conducted successfully on DBS specimens.
Use of DBS facilitates access to DNA PCR testing given its high sample stability and low biohazard, which
facilitate sample handling and transport from the clinic to the laboratory. This sample type, which can be
taken from a heel prick, requires a reasonably small amount of blood and is therefore well suited for routine
testing in infants, where blood volumes are small and blood draws are challenging. The use of DBS with
this assay is a strong advantage and is the preferred method of sample collection.
This describes a procedure for collection, packaging and transport of a dried blood spot (DBS) sample from
an infant below 18 months of age. A correct performance of the DBS collection using the aseptic technique
is critical to ensure the safety of the procedure and to assure the quality of the test results obtained thereof.
An optimal sample collection also contributes significantly to the comfort and satisfaction of the donors thus
encouraging retesting as and when required
Dried blood spots (DBS) should be made only by nursing personnel who have been appropriately trained
in both the making of dried blood spots and in universal blood and fluid precautions
Material Required
Sterile disposable lancet with tip less than 2.4mm

Sterile alcohol preparation ( 70% isopropanolol)
Sterile gauze pad
Soft cloth
Blood collection form
DBS card[ specially formulated commercially available absorbent filter paper( Schleicher & Schuell 903
or Whatman BFC 180); (do not use ordinary filter paper)]
Gloves( powderless)
Discard jar with 5% Sodium Hypochlorite
Nurses Manual
Page 198

Preparation
Observe Universal Precautions at all times by wearing gloves, lab coat and safety glasses.
Put down a clean paper towel.
Lay out all the supplies you will need
Method
1. Obtain proper written informed consent from the parent/ guardian with appropriate
pre test counselling
2. Complete ALL information on the collection/ test requisition form. Write patient identification
information on a new clean filter paper card
3. Select the
appropriate site for
puncture. Hatched
area indicates safe
areas for puncture
site.
4. Warm site with

soft cloth, moistened
with warm water
up to 41C, for
three to five
minutes.
5. Cleanse site with

alcohol preparation.
Wipe DRY with
sterile gauze pad.
6. Puncture heel. Wipe

away first blood drop
with sterile gauze pad.
Allow another LARGE
blood drop to form.
Discard the lancet
safely into the discard
jar for sharps containing
5% freshly prepared
sodium hypochlorite solution
7. Lightly touch filter paper

8. Fill remaining circles in
to LARGE blood drop.
the same manner as
Allow blood to soak
step 7, with successive
through and completely
blood drops. If blood
fill circle with SINGLE
flow is diminished,
application to LARGE
repeat steps 5 through
blood drop.
7. Once the required
(To enhance blood
amount of sample has
flow, VERY GENTLE
been collected,
intermittent pressure
pressure must be
may be applied to area
applied gently at the
surrounding puncture site). Apply blood to one
puncture site with a sterile gauze ensure
side of filter paper only (the side with printing).
that there is no further bleeding from the
Do not contaminate filter paper circles by
site following which the skin puncture site
allowing the circles to come in contact with
should be dressed and protected with an
spillage or by touching before or after
occlusive bandage.
blood collection

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9. Dry blood spots on a dry, clean, flat non-absorbent

surface for a minimum of four hours. Avoid touching
the part of the card where blood has been applied
to see of the blood has dried. As the blood dries
on the filter paper it will change from a bright red
color to a darker red-brown color, also the paper
will buckle slightly. Once dry, send completed form
to testing laboratory within 24 hours of collection
10. This figure below shows how an acceptable good quality DBS should appear. ID information
should be placed on the card. Each printed circle should have been filled with blood
Acceptable Sample
11. A figure demonstrating an unacceptable sample is also shown below.

Unacceptable Sample
Documentation
Document and maintain all consent forms

All necessary documentation and pertinent information of every sample collected and dispatched to the
lab for testing must be made in the designated register / computer
All samples sent to the lab for testing must be accompanied by the test requisition forms and a compiled
delivery checklist that carries a list and pertinent information of all the samples being dispatched from
the collection site to the testing laboratory
Record of failed attempts at taking a heel prick sample must be recorded .
Packaging and transport of samples to the testing laboratory

Material Required
Plastic ziplock storage packs

Dessicant packs
Humidity indicators
Biohazard labels
Glassine paper
Paper envelopes
Padded envelopes
Stapler
Gloves( powderless)
Nurses Manual
Page 200

Preparation
Observe Universal Precautions at all times by wearing gloves and lab coat .
Lay out all the supplies you will need
Ensure that all the DBS samples are of acceptable quality and well dried
Method
Packaging and storing DBS
1. When packaging DBS into zip lock bags,
separate each card with a sheet of
weight/glassine paper.
2. You can store up to 15 cards in a single

zip-lock bag.
3. Place DBS cards inside the storage

bag gently
4. Add 5-10 silica packets per zip-lock bag and

push the silica packets to the bottom of the bag.

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Page 201
5.
Add a humidity indicator card.

Push as much air out of the bag as possible.
Double check that the bag is sealed completely.
Apply a biohazard sticker to the outside of this
zip lock bag
If refrigeration is available use this to store DBS or
send it to testing Lab.
When ever possible avoid exposing the DBS to sunlight
and high temperatures (try to avoid leaving DBS in
your vehicle in the hot sun). If storage is being done
store the entire package of samples in a refrigerator
(4C) or freezer (-20C).
Transportation
1. Place the zip-lock bag containing the DBS
inside an envelope.
2.
Place the previous envelope inside a padded labelled
envelope to avoid damage to the DBS during postage/
courier transportation.
Place the test requisition forms and the compiled
delivery checklist in a separate zip lock bag and
place it in this padded envelope
Staple the envelope shut.
Place another biohazard sticker on the side carrying
the address of the testing site
3. Use a reliable and tested courier/ mailing system for transportation of the sample packages
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Annexure 22 : Monitoring and follow up patients on ART Recommendations in the National Programme
Day 0
(baseline)
Before or at
start of ART
At
15 days
At 1
month
At 2
month
At
3 month
Every
6 month
Clinical and
adherence
counselling
Weight
Hb

(if on AZT) (if on AZT)
ALT*

(if on NVP) (if on NVP)
*
*
Urinalysis

(if on TDF)
Lipid profile

(if on EFV
and PI)

(if on d4T,
EFV or PI)
Random
Blood sugar

(if on PI)
CD4
Pregnancy
testing for
women with
pregnancy
potential

(if planning
for EFV)
Plasma Viral
Load**
As needed
(symptomDirected)
Notes:
* For HBV and/or HCV co-infected patients, 3-monthly screening of liver function is recommended.
** Plasma Viral Load (PVL): The national programme does recommend routine viral load monitoring as part
of the programme. Viral load measurement is not recommended for decision-making on initiation or regular
monitoring of ART in resource-limited settings (WHO 2006). It may be considered for making diagnosis of
early treatment failure or to assess discordant clinical and CD4 findings in patients suspected of failing ART.
Scheduled follow up during the initial months of ART is necessary to diagnose and efficiently manage acute
adverse events, work with the patient on adherence issues, and diagnose clinical conditions like IRS and
new episodes of OIs.
Estimation of CD4 count for patients receiving ART:
Is recommended at 6 months to document immunological improvement on ART. After initiation of a NVP
based regimen, ALT measurement is recommended in the first month to detect drug-induced hepatitis. With
an AZT- based regimen it is important to monitor CBC for earlier detection of haematological toxicity. The
Nurses Manual
Page 203
prevalence of lipid abnormalities is significant on ART, particularly if a patient is on d4T, EFV or PIs. In
these patients and in patients with significant risk factors for coronary artery disease a fasting lipid profile
should be done at 6 months, otherwise yearly estimations suffice. Random Blood sugar (RBS) is recommended
in the baseline screening of all patients to be started on ART, as currently one of the major causes of
morbidity in India is diabetes and hence screening should be done for pre-morbid status.
Questions to be asked During History Taking
History taking
3rd
months
6th
months
9th
months
Every 3-6
months
thereafter
HIV related diseases

incl. TB
Cough > 2 weeks
Fever
Weight loss
Diarrhoea
Other symptoms
as GI,CNS,
neurology, skin rash
Other medicationstaken
Nurses Manual
Page 204
2
weeks
1st
month

Annexure 23 : PPTCT True or False Statements and Answers

1. Pregnancy makes HIV disease worse.
False - Pregnancy does not accelerate the progression of HIV disease.
2. HIV-infected sperm can directly infect the infant even if the mother does not have HIV infection.
False- Although there is HIV in male semen, there is no HIV in the sperm. Therefore, the mother could get
HIV infection from the male semen but the foetus could not get HIV infection from the males sperm. The
foetus can only acquire HIV infection from exposure to the mothers blood or vaginal/cervical secretions
during pregnancy, birth, or breast milk during breast feeding. Remember that about 70% of time, the foetus
will not get HIV infection at all.
3. If a woman is HIV+, there are medications she can take to reduce the likelihood of passing the
virus to her infant
True- If a woman is HIV+, she can be prescribed ART depending on clinical criteria either during her
pregnancy. She should be given ART during labour, and the baby must be given ART within 72 hours of
birth. Details of ART to prevent mother to child transmission will be dealt with in this unit. If she is on ART
and her viral load is suppressed, her risk of transmission is very low, about 1 or 2%
4. If both parents are HIV +, using condoms during pregnancy isnt necessary
False - One partner may transmit a resistant virus to the other through sexual intercourse so it is essential
that the couple practice safe sex with use of condoms.
5. If a woman is HIV positive, all her babies will be HIV-infected because they share the same
blood.
False - The mother and baby do not share the same blood. The mothers blood is filtered by the placenta
so the baby gets oxygen and nutrients without exchange of blood. The baby can only become infected if
she/he is exposed to the mothers blood. This may happen from an infection in the placenta, a maternal
abruption or abdominal trauma causing bleeding into the amniotic sac, or during birth. It is also important
to note that even with exposure to the mothers blood during pregnancy and birth, there is only about a
30% chance of the baby becoming infected.
6. Procedures during delivery that may cause exposure of the newborn to maternal body fluids
should be avoided whenever possible
True - This includes artificial rupture of membranes, forceps or vacuum delivery, episiotomy, or vigorous
suctioning of the infant.
7. If an HIV positive woman has a Caesarean section (C/S), her risk of having a baby with HIV
is 0%.
False - Although in some cases, when the womans virus is not suppressed or she has advanced HIV
disease, a C/S may reduce the risk of infection, it will never reduce it to 0%. The actual risk depends on
the severity of disease and the actual viral load. When a woman is on ART and her viral load is fully
suppressed, there does not appear to be an advantage to C/S. Also, there is a higher risk of maternal
infection and mortality with C/s and the higher cost to consider.
8. Giving Nevirapine to babies after they are born is like giving a nurse post-exposure prophylaxis
after a needlestick injury.
True. Giving Nevirapine is like giving PEP to a nurse after a needle stick injury.
Nurses Manual
Page 205
Annexure 24 : PPTCT: Three Safe Infant Feeding Options

Some Important Points You Could Keep In Mind When
Counselling Mothers On Feeding Options
No Breastfeeding
at all Providing
Cows/Tinned milk
Advantages
Breastfeed Exclusively
For 4 Months
Stopping Abruptly
Switching to
Weaning Foods
Continue breastfeeding
if at 4 months
replacement feed is not
acceptable, affordable,
feasible, safe and
sustainable with
complementary foods
Breast milk increases

Breastfeeding provides infants with optimal nutrition,
PTCT risk by up to 20%.
reduces morbidity and mortality associated with
Not breastfeeding at
infections other than HIV, and delays the mothers
all eliminates this risk
return to fertility.
completely
Baby would have received all the anti-infective
available in breast milk
Bonding between the mother and baby is better
The babys gut is safe from any mucosal injury
reducing the chance of infection
It is economical and considerably more safe to
breast feed than to bottle or spoon feed the baby
At 6 months of age, breast milk alone may not be
enough to meet the nutritional needs of the baby,
hence complementary or weaning foods could be
introduced
Disadvantages Infant gets no colostrum Baby is exposed to

It is an expensive option
virus in breast milk
In India the chance of
Colostrum along with
baby dying due to
its advantages is also
gastroenteritis (because
considered to be
of poor hygienic
highly infectious
practices, ignorance of
mother about sterilizing
feeding bottles, etc.)
is higher than it dying
of HIV!
Risk of over dilution of
formula could result in
malnutrition of the baby
Microscopic mucosal
injury of the gut is very
high with formula feeds
Social stigma if mother
does not breastfeed
Baby is exposed to virus

in breast milk
Colostrum along with its
advantages is also
considered to be highly
infectious
The longer the duration
of the breast feeding
the higher the risk of
transmission
What To
Assess To
Help Mother
Decide Option
All under second option

plus
If socio-economic
situation is such that
Nurses Manual
Page 206
Formula feeding will be

acceptable
affordable
feasible
Formula feed is
considered to be
expensive
unsustainable over

Additional
Information
To Provide
To Mothers
No Breastfeeding
at all Providing
Cows/Tinned milk
Breastfeed Exclusively
For 4 Months
Stopping Abruptly
Switching to
Weaning Foods
safe
sustainable
the long term

unsafe
cause for social
problems
risk for mixed feeds
unacceptable
Why never to give

mixed feeding.
With formula feeds
microscopic mucosal
injury to gut is high
If mixed feeds (i.e.
breast milk and other
milk such as cows
milk) are given the
chance of HIV to
enter the increases
risk of HIV transmission.
Infant feeding hygiene.
Preparation of formula
milk
References to NGOs/
support centres which
may provide free/
subsidized alternate
feeds
Teach mothers how to express breast milk and give

it safely if there is risk for cracked nipples, mastitis
that could increase the risk of HIV transmission
Reinforce feeding hygiene if expressed breast
milk is given
Good breast feeding practices: position of the
mother and the baby as well as breast hygiene
How to stop breast-feeding abruptly - it is important
if mother has been feeding directly to teach mother
how to express breast milk at least two weeks
before stopping abruptly.
Baby gets used to feeding with a cup/spoon/ palada
Amount of breast milk supply reduces
To practice safer sex while breastfeeding to prevent
reinfection and higher viral load

Continue breastfeeding
if at 4 months
replacement feed is not
acceptable, affordable,
feasible, safe and
sustainable with
complementary foods
safe and sustainable
exclusive alternate feeds
cannot be provided
even after 6 months
Nurses Manual
Page 207
Annexure 25 : Replacement Feeding Checklist

Yes
No
Can she afford to buy enough milk/milk powder?

Does she have access to clean water?
Can she prepare milk safely?
Boil the water
Make the correct concentration of milk if
using the tin milk
Can she clean and sterilize the feeding articles?
Will she have enough support from significant
others in the family?
Does she know how much of milk the baby can
be given
each time
for a day
how often
If answers are No, see what patient education/ linkages can be provided to support replacement feeding
OR advise safe breastfeeding.
Nurses Manual
Page 208

Annexure 26 : Questions and Issues that must be assessed

by the Nurse to Aid In Preparing the Child And Family
For ARV
What does the child understand about HIV?
Does the child know about his/her own HIV diagnosis?
If so, has the child felt any difference in treatment from family members, school authorities (stigma)?
Does the child (if old enough) understand the need to take ARVs?
How will ARVs fit into childs daily activities?
How will ARVs fit into the childs going to school?
Does the child know that ART is to be taken life long?
Is the child aware of how to store the medication?
Is the child aware of the side effects?
Is the child aware of toxicities?
Is the parent alive?
If yes (i.e. parent alive),
Is the parent sick/unable to administer ARVs?
Has the parent had any prior negative experience with ARVs?
Is the parent adherent himself or herself?
Does the parent know the implications of ART (life long, non adherence, administration
and toxicities, storage)?
If no (i.e. parent not alive), who is the support person for the child?
Does the support person know the importance of taking ARV?
Does the support person know the implications of ART
(life long, non adherence, administration and toxicities, storage)?
How
How
How
How
did
did
did
did
the
the
the
the
parent cope with his or her own HIV diagnosis?

family coping with the HIV diagnosis of the parent/s?
parent/s cope with the childs HIV diagnosis?
family cope with the childs HIV diagnosis?
What is the parents perception of the childs illness?

Nurses Manual
Page 209
Annexure 27 : Ways to Promote ART Adherence in Children

Promoting adherence is multi-faceted and must be a continuous process. This is a task that requires
excellent skills, addressing both the childs needs and issues and those of the caregiver:
The child MUST be involved

Assessment of child & family prior to child commencing ARVs
Assist families in developing routine for ARVs; ARVs should NOT dictate every aspect of daily life
Open, supportive approach
Age-appropriate explanations to child regarding need for medication
Children cope far better when they are able to understand what is happening to them and
have a sense of control
Use child-sensitive, age-appropriate explanations such as you need the medicine to keep
you strong and prevent infections
Continuing support and re-assessment of each child and familys situation
Peer support: Support from other parents and children
A variety of strategies may be used to help encourage the child to take ARVs and to assist and
support the caregiver. Some methods are mentioned below. They could be used one at a time or
in combination:
Trial runs: Finding out the best way that the child would take the medicine
Play therapy:
Having a doll /puppet and showing the child how the doll or the puppet felt better after taking
some medicine
Then asking the child whether they would like to try the same
Sticker charts:
Having a chart with dates mentioned and timing.
Every time the child takes the medicine with no trouble, giving the child a golden star, little
trouble a silver star and lots of trouble, a colour that the child does not like
At the end of the month, telling the child the child would be given some reward if there were
more golden stars on the chart. Rewards cold be simple like taking the child to the park,
giving the child a big hug, or doing something that child likes to do with the parent/caretaker
Art therapy:
Making the child draw out what he or she feels about taking medicines. This could be a
way for the child to express self
Taking medication with parent:
Giving the child the medicine along with the parent
Asking the child to put the medicine in the parent/s mouth and checking whether he/she has
taken it
Then the parent could do the same for the child
Support groups:
Arranging meetings of children taking ART so that they could express their challenges,
how they deal with it etc.
Nurses Manual
Page 210

Annexure 28 : Assuming the quantity/amount of PTH

(Take to annexure) Nurses can use of the Faces Pain Rating scale given below for children who might find
it difficult to describe the intensity of pain in terms of numbers.
When conducting an assessment of pain, remember to follow the guidelines given in the box below
A
Always ask! Ask about pain regularly; Assess pain systematically. Ask family members,
friends or caregivers, if necessary.Be aware of those persons who cannot communicate.
If potential for pain exists, assume it is present until proven otherwise!
Believe the patient and the family
Choose treatment options appropriate to the patient and family
Deliver medications round the clock with adequate break through medication
Evaluate results frequently; empower patient and family members to control

Nurses Manual
Page 211
Annexure 29 : Music Therapy

Music acts like a magic key, to which the most tightly closed heart opens.
Maria Von Trapp
Music therapy is defined as
the systematic application of music by the music therapist
to bring about helpful changes
in the emotional or physical health of the client.
And the ability to experience an altered state of physical arousal and subsequent mood by processing
a progression of musical notes of
varying tone,
rhythm, and
instrumentation
for a pleasing effect.

HOW MUSIC PROMOTES THE RELAXATION EFFECT?
Biochemical theory
states that music is a sensory stimulus that is
processed though the sense of hearing.
Sound vibrations are chemically changed into nervous impulses that
activate either the sympathetic or
parasympathetic nervous system
HOW MUSIC PROMOTES THE RELAXATION EFFECT ?

Entrainment theory suggests that oscillations produced by music are
received by the human energy field and
various physiological systems entrain with or
match the hertz (oscillation) of the music
Metaphysical theory suggests
that music is divine in nature.
Nurses Manual
Page 212

MUSIC THERAPY
For music therapy to be fully effective as a relaxation technique
it is best that the music be
instrumental
without lyrics
Type of music selected
listening environment
posture, and
attitude
also affect the quality of the relaxation response

Nurses Manual
Page 213
Annexure 30 : National AIDS Control Program, Phase III
HIV/AIDS prevention activities were undertaken immediately after the first case of HIV infection was
detected in Chennai (formally Madras)
A comprehensive National AIDS Control Program (NACP) was initiated in 1992 with the establishment
of the National AIDS Control Organization (NACO) within the Ministry of Health and Family Welfare,
Government Of India.
The first phase of the program, NACP I, was implemented by NACO and Dedicated State AIDS Cells
in all the states between 1992-2004.
The second pahse of the program,NACP II saw an expanded response against the HIV/AIDS epidemic
with the establishment of State AIDS Control Societies.This program was implemented between 1999
to 2006
Under NACP III, (2006-2011), the goal is to halt and reverse the epidemic in India over the next five
years.
The goal of NACP II is being achieved through a four pronged strategy :
Prevent infections through saturation of coverage of high-risk groups with targeted interventions (TIs)
and scaled up interventions in the general population.
Provide greater care, support and treatment to larger number of PLHIV.
Strengthen the infrastructure, systems and human resources in prevention, care, support and treatment
programmes at district, state and national levels.
Strengthen the nationwide Strategic Information Management System.

Office of NACO
National AIDS Control Organization
Chandralok Building,
36, Janpath,
New Delhi 110001
www.nacoonline.org
Nurses Manual
Page 214

Annexure 31 : List of State AIDS Control Societies (SACs)

Sr.
No.
States
Addresss of
the SACS
Name
STD
Code
Office
No.
Fax
No.
Email id
1.
Andaman
and Nicobar
AIDS Control Society,

G.B. Pant Hospital Complex,
Port Blair 744104
Shri S.N. Jha
PD
APD
JD
AD
03192
237941
231176
andmansacs@gmail.com
2.
Andhra
Pradesh
State AIDS Control Society,

Directorate of Medical and
Health Services, Sultan Bazar,
Hyderabad - 500059
Shri. R.V.Chandravadan
Dr. A. Rajaprasana Kumar
Kailash Ditya
Durga Prakash
PD
APD
JD
AD
040
24657221
24650776
24650776
24652267
vadanrv@gmail.com
sacsandhra@gmail.com
3.
Arunachal
Pradesh

Naharlagun,
New Itanagar - 791110
Dr.
No
Dr.
Dr.
PD
APD
JD
AD (TI)
0360
2351268
2245942
243388
244178
arunachalsacs@gmail.com
4.
Assam

Khanapara, Guwahati - 781022
M.H. Barman, IAS
PD
APD
JD
AD
0361
2620524
2261605
2620524
assamsacs@gmail.com
Emi Rumi
APD
Rikenrina (Basic Service)
Marto
Ms.Dhiriti Bani
5.
Ahmedabad
Ahmedabad Municipal Corpn.

Old Municipal Dispensary,
behind Lal Bungalow,
C.G. Road, Ahmedabad.
Dr. Umesh.N. Oza

Ms. Lata Brahmbhatt
Dr. Kartik Shah (Blood Saf)
PD
DD -TI
DD
AD
079
26409857
26468653
26409857
ahmedabadmacs@gmail.com
6.
Bihar

Health Department,
New Secretariat, Patna - 800015
Mr.
Mr.
Mr.
Mr.
PD
APD
JD TI
AD TI
0612
2290278
8986184695
biharsacs@gmail.com
7.
Chennai
Chennai Municipal Corpn.

82 Thiru Vi-Ka-Salai, Mylapore,
Chennai - 600003
B. Jothi Nirmala
Dr. Guganantam
Mr. N. Balaiah
No JD/AD
PD
APD
IEC
044
24980081
24986514
25369444
chennaimacs@gmail.com
8.
Chandigarh
State AIDS Control International

Youth Hostel, Madhya Marg,
Near PGI Sector 15-A,
Chandigarh-160018
Dr. Vanita Gupta
PD
NA
(TI) DD
AD
0172
APD
2544589
2783300
2700171
chandigarhsacs@gmail.com
Devottam Varma
C. V. Alex
Pankaj Priya Chaubey
Hare Ram Singh
Sh. Sandeep Mittal

NA
9.
Chhattisgarh
Chhattisgarh AIDS Control

Society, Directorate of Health
Services, State Health Training
Centre, Near Kalibari Chowk,
Raipur.
Sh. Ajay Kumar Pandey

Dr. Abdul Gafar Sheikh
Sh. Vikrant Verma (TI)
PD
APD
DD -TI
AD
0771
2235860
2221624
2221275
2235860
ajay.spandan@gmail.com
chattishgarhsacs@gmail.com
10.
Dadra &
Nagar Haveli
Dadra & Nagar Haveli

1st Floor, Shri Vinobha Bhave
Civil Hospital, Silvassa - 396230
Dr. L. N. Patra
PD
APD
JD
AD
0260
2642061
2642061
dnhsacs@gmail.com
11.
Daman
& Diu
Daman & Diu AIDS Control

Society, Primary Health Centre,
Moti Daman, Daman - 396220
Dr. S. S. Vaishya
PD
APD
JD
AD
0260
2230570
223070
pdsant@yahoo.co.in
12.
Delhi
Delhi AIDS Niyantran Samiti,

Dr. Baba Saheb Ambedkar
Hospital, Dharamshala Block,
Sector - 6, Rohini,
Delhi - 110 085
Sh. B. S.Banerjee
PD
APD
JD
AD
011
27055660
27055725
PD
APD
JD
AD
0832
2427286
2422519
2427286
Ms. Sapana Prasad (TI)
Sh. Prasad D. Sant (TI)
13
Goa
Goa State AIDS Control Society,

First Floor, Dayanand Smriti
Building, Swamy Vivekanand
Road, Panaji - 403001
Shri. J. K. Mishra (TI)
Sh. Pradeep Padwal

Sh. Ramesh Rathore (TI)

delhisacs@gmail.com
2422158
goaaids@gmil.com
Nurses Manual
Page 215
Sr.
No.
States
Addresss of
the SACS
Name
14.
Gujarat
Gujarat State AIDS Control
Smt. Vijaya Laxmi Joshi
PD
Society, 0/1 Block, New Mental
Dr. Pradeep Kumar
APD
Hospital, Complex, Menghani
Narendra Gohil (TI)
Nagar, Ahmedabad - 380016

15.
Haryana
Haryana State AIDS Control
STD
Code
079
Office
No.
Fax
No.
2680211-13
2680214
2685210
Email id
cohealth@gujarat.gov.in
drpkumar_55@yahoo.com
JD
gujaratsacs@gmail.com
AD
Dr. Narbir Singh
PD
Society, SCO - 10, Sector - 10,
APD
Panchkula, Haryana
JD
0172
2585413
2585413
haryanasacs@gmail.com
2621608
221314,
hpsacs@gmail.com
2625857
225857
0194
2476642
2471579
jksacs@gmail.com
080
22201438
22201435
ksapsho@gmail.com
0651
2309556
2562621
jharkhandsacs@gmail.com
2304882,
2305183
keralasacs@gmail.com
2305183
09447030470
262316,
262817
lakshyadweepsacs@gmail.com
2584549(PD)
AD
16.
Himachal
Himachal Pradesh State AIDS
Pradesh
Control Society, Block No. 38,

Ground Floor, SDA Complex,
Ms. Sulakshna Puri
J&K
J & K State AIDS Prevention
Ms. Meena (TI)
JD
Dr. M. A. Wani
PD
AD
and Control Society,
APD
1st Floor, Khyber Hotel, Khayam
JD
Chowk, Srinagar
18.
Karnataka
Karnataka State AIDS Prevention
AD
Sh. R. R. Janu
Society, No.4/13-1, Crescent

Road, High Grounds,
Jharkhand
PD
APD
Ms. Chandrakanta (TI)
JD
Jharkhand State AIDS Control
Mrs. Aradhana Patnaik
PD
Society, Sadar Hospital Campus,
Dr. Raj Mohan
APD
Purulia Road, Ranchi
Ms. Kavita (TI)
DD -TI
Kerala State AIDS Control
Dr. Usha Titus
Bangalore - 560001
19.
0177
APD
Kasumppti, Shimla - 171009

17.
PD
AD
2490649
AD
20.
Kerala
Society, IPP Building, Red Cross

Road, Thiruvananthapuram,
Sh. Dennis (TI)
Kerala - 695037
21.
Lakshadweep Lakshadweep AIDS Control
PD
0471
APD
JD-TI
AD
Sh. K.P. Hamzakoya
PD
04896
Society, Directorate of Medical
APD
262317,
and Health Services,
JD
262114,
UT of Lakshadweep,
AD
263582
Kavaratti - 682555
22.
Madhya
Madhya Pradesh State AIDS
Pradesh
Control Society, 1, Arera Hills,
Arun Tiwari
Second Floor, Oilfed Building,

23.
Maharashtra
PD
0755
2559629
2556619
mpsacs@gmail.com
022
24113097,
24113123,
ramesh.devakar1@gmail.com
24115791
24115825
maharashtrasacs@gmail.com
manipursacs@gmail.com
APD
JD
Bhopal - 462011
Sh. Rajneesh Bhatnagar
AD-TI
Maharashtra State AIDS Control
Sh. Ramesh Devakar (IAS)
PD
Society, Ackworth Leprosy
APD
Hospital Campus, Behind SIWS
Ms. Shivaranjani
Collete, R.A. Kidwai Marg,
JD-TI
AD
Wadala (West), Mumbai - 400031

24.
Manipur
Manipur State AIDS Control
Sh. P.K. Jha
Society, Room no. 202,

Annexee Building, Western Block
Abhiram Mongjam
Medical New Secretariat,
2414796,
2310796,
APD
PD
0385
2411857,
2222629,
JD-TI
2229014
2224360
AD
Imphal - 759001
25.
Meghalaya
Meghalaya State AIDS Control
Dr. Mrs. S.M. Garod
PD
0364
2223140,
Society, Ideal Lodge, Oakland,
APD
2315452,
Shillong - 793001
JD
2315453
meghalayasacs@gmail.com
AD
26.
Mizoram
Mizoram State AIDS Control
Dr. Eric Zomawia
Society, MV-124, Mission Veng

South, Aizwal - 796005
PD
0389
2321566
2320922
mizoramsacs@gmail.com
APD
Betty
JD-TI
AD
Nurses Manual
Page 216

Sr.
No.
States
Addresss of
the SACS
27.
Mumbai
District
Mumbai District AIDS Control

Dr. S.S. Kudalkar
Society, Acworth Complex,
Behind SIWS College,
Ms. Uma Mehta
R.A. Kidwai Marg, Wadala (West),
Mumbai - 31
28.
Nagaland
Nagaland State AIDS Control

Society, Medical Directorate,
Kohima - 797001
29.
Orissa
Orissa State AIDS Control

Society, 2nd Floor, Oil Orissa
Building, Nayapalli,
Bhubaneshwar-12
Name
Dr. Niphe Kire

Dr. Barnice
Dr. Alekh Chandra Padhiary
Ms. Smita Jagdev
Santanu
STD
Code
Office
No.
Fax
No.
Email id
PD
APD
JD-TI
AD
022
24100245-49, 24100245,
24100250
24100250
mumbaimacs@gmail.com
PD
APD
JD-TI
AD
0370
2244218,
2241046,
2222626,
2233027
2242224
nagalandsacs@gmail.com
PD
APD
JD-TI
AD-TI
0674
2405134,
2405104-06
2393415
2407560,
2405105
2394560
orissasacs@gmail.com
pondicherrysacs@gmail.com
30.
Pondicherry
Pondicherry State AIDS Control

Society, No. 93, Perumal Kail
Street, Pondicherry
Dr.D. Gurumurthy, M.B.B.S. DD PD

APD
JD
AD
0413
2343596,
2337000
2343596
31.
Punjab
Punjab State AIDS Control

Society, 4th Floor Prayaas
Building Sec-38B, Chandigarh
Sh. Satish Chandra IAS
0172
2743442
pbsatishias@gmail.com
punjabsacs@gmail.com
Ms. Meenu, Deputy Director
PD
APD
JD
DD-TI
32.
Rajasthan
Rajasthan State AIDS Control

Society, Medical and Health
Directorate, Swasthya Bhawan,
Tilak Marg, C Scheme,
Jaipur - 302005.
Dr. R.N.D. Purohit

Dr Katara
Ms. Rolly Sinha
Dr Raja Chawla
PD
APD
JD-TI
DD-STI
0141
2381792,
2381707,
2383452,
2383282,
2382765
2381792
rajasthansacs@gmail.com
33.
Sikkim
Sikkim State AIDS Control

Society, STNM Hospital,
Gangtok, 737101
Dr. Namgyal T. Sherpa
PD
APD
JD
AD-TI
03592
225343,
220898,
32965
220896
sikkimsacs@gmail.com
34.
Tamil Nadu
Tamil Nadu State AIDS Control

Society, 417, Pantheon Road,
Egmore, Chennai - 600008
Tmt.P. Amudha, IAS
PD
APD
JD-TI
AD
044
28194917,
28190467
28190261
tnsacs@gmail.com
Tripura State AIDS Control

Society, Health Directorate
Building, Gurkhabasti,
P.O. Kunjaban, Agartala,
West Tripura - 799006
Dr. Keshab Chakraborty
PD
APD
381
2321614
dr.keshab@rediffmail.com
tripurasacs@gmail.com
Sh. Rabendra Sen
Sh. Karan Sharma
35.
Tripura
Vender Vendan
AD
36.
Uttar
Pradesh
Uttar Pradesh State AIDS

Control Society, A Block,
PICUP Bhawan, Vibhuti Khand,
Gomati Nagar, Lucknow - 10
Sh. S.P.Goyal (IAS)

Ms. Kumudlata
Ms. Preeti
Mr. Sheetal Prasad
PD
APD
JD-TI
AD-TI
0522
2721871,
2720360,
2720361,
2283168
37.
Uttaranchal
Uttaranchal State AIDS Control

Society, Chandar Nagar,
Dehradun.
Dr. D.C. Dhyani

Sh. Sanjay Bisht
PD
DD-TI
JD
AD
135
2728144,
2720377,
2728155
2728144
uttaranchalsacs@gmail.com
38.
West Bengal
West Bengal State AIDS Control

Society, Swasthya Bhavan,
GN-29, Sector-V, Salt Lake,
Kolkatta -700091
Dr. R. K. Vats
Dr. S. P. Banerjee
Ms. Kiran Mishra
Ms. Anindita Maity
PD
APD
JD-TI
AD-TI
033
23574400,
23570122,
23576000
23570122
wbsacs@gmail.com

upsacs@gmail.com
Nurses Manual
Page 217
Annexure 32 : List of ART Centres

Month - March 2010
S.No. State Name
District Name
ART Centre
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
Tamil Nadu
Chennai
Chennai
Madurai
Namakkal
Chennai
Salem
Tirunelveli
Coimbatore
Theni
Thanjavur
Vellore
Kanniyakumari
Tiruchirappalli
Chennai
Dharmapuri
Virdhunagar
Viluppuram
KARUR
Dindigul
Perambalur
Chennai
Ariyalur
Toothukudi
Tiruvanamalai
Thiruvallur
CUDDALORE
Vellore
Chennai
Nagapatinim
Erode
Sivaganga
The Nilgiris
Ramanathapuram
Kancheepuram
Thiruvarur
Pudukkottai
Govt. Hospital for Thoracic Medicine

Madras Medical College
Government Medical College
Government Hospital
Kilpouk Medical College
Medical College
Medical College
Coimbatore Medical College
Theni Medical College
Thanzavur Medical College
Vellore Medical College
Medical College
Trichy Medical College
Institute of Obstetrics & Gynecology MMC
District Hospital
District Hospital
District Hospital
District Hospital
Govt. District Headquaters Hospital, Dindugal
ART Centre, Govt Hospital, Perambalur
ICH
Govt. District Headquaters Hospital, Krishnagiri
Tuticorin Medical College Hospital, Tuticorin
Govt. District Headquaters Hospital, Thiruvannamal
Govt. District Headquaters Hospital, Thiruvallur
Govt. District Headquaters Hospital, Cudallore
CMC Vellor
Stanley Medical College
Nagapattinam District Headquarters Hospital,
Erode District Headquarters Hospital
Sivagangai Medical College & Hospital
Nilgiris District Headquarters Hospital
Ramanathapuram District Headquarters Hospital
Govt. Medical College and Hospital, Chengalpattu
Govt. Medical College and Hospital
Govt. District Hospital
37
Maharashtra
Mumbai
Sir J. J. Hospital
Nurses Manual
Page 218

S.No. State Name
District Name
ART Centre
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
Mumbai
Mumbai
Mumbai
Sangli
Akola
Pune
Yavatmal
Nagpur
BEED
Pune
Kolhapur
Aurangabad
Solapur
Dhule
Nanded
Latur
Chandrapur
Chandrapur
Mumbai
Thane
Nashik
Ahmadnagar
Satara
Ratnagiri
Wardha
Parbhani
Jalgaon
Osmanabad
Sangli
Raigarh
Pune
Nagpur
Mumbai
Jalna
Bhandara
Pune
Nandurbar
Gadchiroli
Mumbai
Mumbai
Hingoli
KEM Hospital
BLY Nair Hospital
LTMG Sion Hospital
Government Medical College, Sangli
Medical college, Akola
B.J. Medical college
Medical College, Yawatmal
Govt. Med. College, Nagpur
Medical College, Ambejogai
NARI, Pune
RCSM Government Medical College
Medical College, Aurangabad
Govt. Medical College, Solapur
Medical College, Dhule
Govt. Medical College
Civil Hospital and Govt. Medical College
BILT, Chandrapur
District Hospital ART Centre, Chandrapur
Godrej Mumbai
Vithal Sayanna General Hospital, Thane
Civil Hospital, Nashik
District Civil Hospital, Ahmednagar
District Civil Hospital, Satara
District Civil Hospital, Ratnagiri
ART Centre Civil Hospital, Wardha
Civil Hospital, Parbhani
Civil Hospital, Jalgoan
Osmanabad DH
Bharati Vidyapeeth Sangli
Reliance DAH Patalganga
AFMC Pune
IGMC Nagpur
NMMC Vashi
Jalna DH
Bhandara DH
Bajaj Auto ITD YCMH Pimpri
Nandurbar ART Center
GADCHIROLI ART Center
L&T Health Centre
LTMG Sion Hospital,Regional Pediatric ART Centre
ART Center, Civil Hospital, Risala Bazar, Darga Ro

Nurses Manual
Page 219
S.No. State Name
District Name
ART Centre
79
80
81
82
83
84
85
86
Buldana
Amravati
Satara
Thane
Kolhapur
Washim
Solapur
Gondiya
ART Centre, District General Hospital

ART Centre, District Civil Hospital
ART CENTER KARAD
Central Hospital Ulhasnagar 3
Sub District Hospital,Gadhinglaj
WASHIM DH
ART Center Sub District Hospital, Pandharpur
ART Centre, Gondia
Hyderabad
Guntur
Visakhapatnam
Anantapur
Krishna
Cuddapah
Chittoor
Prakasam
East Godavari
Rangareddi
Warangal
Karimnagar
Hyderabad
Nizamabad
West Godavari
Srikakulam
Khammam
Mahbubnagar
Kurnool
Nellore
Nalgonda
Vizianagaram
Medak
Adilabad
Hyderabad
East Godavari
Guntur
Visakhapatnam
Chittoor
Hyderabad
Krishna
West Godavari
Khammam
Osmania Medical College, Hyderabad

Govt. Medical College, Guntur
Govt. MC (King George Hospital), Vizag
GGH, Anantapur
GGH, Vijayawada
RIMS, Kadapa
SVRR GGH, Triupati Chittoor
Government District Hospital, Ongole
GGH, Kakinada , East Godavari
Gandhi Med College, Secundarabad
Medical College, Warangal
Govt. District Hospital, Karimnagar
Govt. Gen. Chest hospital, Hyd
District Head Quarters Hospital, Nizamabad
District Head Quarters Hospital, Eluru
District Head Quarters Hospital, Srikakulam
District Head Quarters Hospital, Khammam
District HQ Hospital, Mehboobnagar
Government General Hospital, Kurnool
District Head Quarters Hospital, Nellore
District HQ Hospital, Nalgonda
Government Medical College
District Headquarter Hospital,Medak
District HQ Hospital, Adilabad
Nillofer Hospital
Rajahmundry ART Centre
Area Hospital, Tenali
ART Center Anakapalli
District Hospital Chittoor
DH, King Koti, Hyderabad
DH, Machilipatnam,Krishna
Tadepalligudem ART center
Bhadrachalam ART center
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
Andhra Pradesh
Nurses Manual
Page 220

S.No. State Name
District Name
ART Centre
120
121
122
123
124
Prakasam
Cuddapah
Krishna
Guntur
Guntur
Markapur ART center

Produtur ART center
Tandur ART center
Guntur ART center
Narasaraopet ART center
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
Karnataka
BANGALORE
Mysore
Bellary
Dharwad
Raichur
Davanagere
Chikmagalur
Bijapur
Gulbarga
Belgaum
Kolar
Bagalkot
BANGALORE
Koppal
Chamarajanagar
Mysore
Gulbarga
Dakshina
Uttara
Udupi
Bidar
Tumkur
Haveri
Shimoga
BANGALORE
BANGALORE
BANGALORE
Mandya
Gadag
Chitradurga
Kodagu
Ramanagaram
Chikballapur
Bowring & Lady Curzon Hosp., Bangalore

Mysore Medical College
VIMS, Bellary
KIMS ART Centre, Hubli
District hospital, Raichur
District hospital, Davangeri
District hospital, Manglore
District hospital, Bijapur
District hospital, Gulburga
District hospital, Belgaon
District hospital, Kolar
District hospital, Bagalkot
IG Inst. of Child Health, Bangalore, (IGICH)
District Hospital, Koppal
District Hospital, Chamrajnagar
District Hospital, Hassan
Voluntary Counseling and ART Center, Wadi
Kannada District Hospital, Chikmagalur
Kannada District Hospital, Karwar
District Hospital, Udupi
District Hospital, Bidar
District Hospital, Tumkur
District Hospital, Haveri
District Hospital, Shimoga
St. John Hospital
Victoria hospital
KIMS Bangolare
District Hospital ART Center ,Mandya
District Hospital ART Center, Gadag
District Hospital, Chitradurga
District Hospital, Kodagu
District Hospital, Ramanagara
District Hospital, Chikballapur
158
159
160
Manipur
Thoubal
Imphal West
Imphal East
ART CENTRE, DISTRICT HOSPITAL Thoubal

ART CENTRE, RIMS HOSPITAL, Imphal West
J.N. HOSPITAL, ART CENTRE, IMPHAL EAST

Nurses Manual
Page 221
S.No. State Name
District Name
ART Centre
161
162
163
164
Ukhrul
Ukhrul
Churachandpur
Imphal East
ART CENTRE, DISTRICT HOSPITAL Chandel

ART CENTRE, DISTRICT HOSPITAL UKHRUL
ART Centre, District Hospital Churachandpur
J.N. Regional Pediatric ART Centre,Imphal East
165
166
167
168
Nagaland
Dimapur
MOKOKCHUNG
Kohima
Tuensang
Ditrict Hospital, Dimapur,

ART Centern, Imkongliba Memorial Hospital
Naga Hospital Authority, Kohima
Civil Hospital, Tuensang
169
170
171
172
173
174
175
176
177
Delhi
NEW DELHI
Central
NEW DELHI
WEST
NORTH EAST
South
South
NEW DELHI
NORTH
RML Hospital, New Delhi

LNJP Hospital, New Delhi
AIIMS, New Delhi
DDU Hospital, New Delhi
GTB Hospital, Delhi
LRS institute of TB, New Delhi
SAFDARJUNG HOSPITAL
Kalawati Saran Children Hospital
Dr. Baba Saheb Ambedkar Hospital
178
Chandigarh
Chandigarh
PGIMER
179
180
181
182
183
Rajasthan
Jaipur
Bikaner
Jodhpur
Udaipur
Kota
SMS Hospital, Jaipur

Bikaner, SP Medical College
SNMC, Jodhpur
RNT Medical College, Udaipur
Medical College
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
Gujarat
Ahmedabad
Surat
Rajkot
Bhavnagar
Mehsana
Surat
Vadodara
Surendranagar
Jamnagar
Junagadh
Kachchh
Surat
Ahmedabad
Banaskantha
Amreli
B.J. Medical College, Ahmedabad

Govt. Medical College, Majura Gate, Surat
Pandit Din dayal Upadhyay Hospital Rajkot
Medical Collage, Bhavnagar
Medical Collage, Mashana
Mora Choriyasi, Reliance HIV & TB Control Center
SSG Hospital ART Center
Mahatma Gandhi Smruti Hospital Surendranagar
G G HOSPITAL JAMNAGAR
General Hospital Junagadh
ART Center Bhuj
SMIMER HOSPITAL SURAT
ART Center V. S. G. Hospital
ART Centre, General Hospital, Palanpur
General Hospital, Amreli
199
200
West Bengal
Medinipur
Kolkata
Medinapur Medical College, Medinapur

School of Tropical Medicine
Nurses Manual
Page 222

S.No. State Name
District Name
ART Centre
201
202
203
204
205
206
207
Darjiling
BARDDHAMAN
Kolkata
Maldah
Kolkata
Kolkata
Uttar Dinajpur
North Bengal Medical College, Siliguri

Medinapur Medical College, Burdwan
R.G.Kar Medical College
Malda District Hospital
Medical College,Regional Pediatric ART Centre
M.R. Bangur District Hospital
Islampore SD Hospital, (Room No. 10 & 11)
208
209
210
211
212
213
214
215
216
217
Uttar Pradesh
Varanasi
Lucknow
Allahabad
Meerut
Aligarh
Gorakhpur
Agra
Etawah
Kanpur Nagar
Jhansi
Banaras Hindu University, Varanasi

KGMC, Lucknow
MLN Medical College, Allahabad
LLRM Medical College
J N Medical College, Aligarh
BRD Medical College, Gorakhpur
SN Medical College Hospital
ART Centre UP RIMS & R, Saifai,
I.D. Hospital, GSVM Medical College, Kanpur
MLB Medical College
218
Goa
NORTH GOA
Government Medical College, Bambolim
219
220
221
222
223
224
225
Kerala
Thiruvananthapuram
Kottayam
Palakkad
Kozhikode
THRISSUR
Alappuzha
Ernakulam
Hospital Trivandrum
Medical College Kottayam
USHUS District Hospital
ART Centre, Kozhikode
ART Centre, Thrissur
Medical College Allepy
ART Centre,General Hospital Ernakulam
226
227
Himachal Pradesh
Shimla
Hamirpur
IGMC, Shimla
ART Center R.H Hamirpur
228
Pondicherry
Pondicherry
Govt General Hospital
229
230
231
232
233
234
Bihar
Muzaffarpur
Patna
Darbhanga
Bhagalpur
Patna
Gaya
SKMCH, Muzaffarpur
PMCH, Patna
Dharbhanga Med Col, Laheriasarai,Darbhanga
J L N Medical Collge,Bhagalpur
ARTC, RMRI
ARTC, ANMMCH
235
236
237
238
239
Madhya Pradesh
Indore
Jabalpur
Bhopal
Ujjain
Rewa
M Y Hospital, Indore
Medical College, Jabalpur
Gandhi Medical College, Bhopal
R D G Medical College Ujjain (M.P)
ART Centre Rewa

Nurses Manual
Page 223
S.No. State Name
District Name
ART Centre
240
241
East Nimar
Gwalior
ART Center District Hospital KhanDwa

Department of Medicine, J.A. Hospital Gwalior
Kamrup
Dibrugarh
Cachar
Guwahati Medical College Hospital

AMC, Dibrugarh
Silchar Medical College & Hospital
242
243
244
Assam
245
Arunachal Pradesh Papum Pare
ART Centre, General Hospital, Naharlagun
246
Mizoram
Aizawl
Civil Hospital, Aizawal
247
248
249
250
251
Punjab
Jalandhar
Patiala
Amritsar
Ludhiana
Gurdaspur
Civil Hospital, Jalandhar

Medical Collage, Patiala
GMC, Amritsar
ART Centre, Lord Mahavir, Civil Hospital
ART Centre, Civil Hospital, Pathankot
252
Sikkim
East
STNM HOSPITAL
253
254
Jharkhand
Ranchi
Purbi Singhbhum
RIMS, Ranchi
MGM Medical College, Jamshedpur
255
Haryana
Rohtak
PGIMS
256
257
Uttaranchal
Dehradun
Nainital
Doon Hospital
Dr. Susheela Tiwari Memorial Forest Hospital,
Haldwani
258
Tripura
West Tripura
Agartala
259
260
Jammu & Kashmir
Jammu
Srinagar

Sher-i-Kashmir Institute of Medical Sciences (SKI)
261
262
263
264
Orissa
Cuttack
Ganjam
Sambalpur
Koraput
S C B Medical Collage Cuttak

MKCG Medical College and Hospital, Berhampur
V.S.S. Medical College. ART Centre
BILT ART Centre DHH
265
266
267
268
Chhattisgarh
Raipur
Durg
Bastar
Bilaspur
Govt
ART
ART
ART
269
Meghalaya
East Khasi Hills
Shillong
Nurses Manual
Page 224
Medical Collage, Art Center, Raipur

Centre, District Hospital
Center Jagdalpur
Centre CIMS Bilaspur

Annexure 33 : List of CCC (Community Care Centres)
The CCC plays a critical role in enabling PLHIV to access ART as as providing monitoring, follow up
and counselling support to those who are initiated on ART, positive prevention, drug adherence,
nutrition counselling etc. The monitoring of PLHIV, who do not require ART as yet (Pre ART) will also
be a critical function that needs to be carried out by CCC.
A Community Care Centre (CCC) is a place with facilities for Out Patient and In-Patient treatment where
a PLHIV receives the following services:
All PLHIV started on ART (at the ART Centre) will be sent to the CCC for a minimum of 5 days
of In patient care and be prepared for ART
Treatment of OIs
Appropriate referrals to ICTC,PPTCT and ART Centres
Out Patient Services
Home Based Care
Some CCCs will serve as Link ART Centres
Condom Distribution
Staff at CCC comprises of;

Doctor 1 Full time or 2 Part time
Project Coordinator 1 Full Time
Counsellor 1 Full Time
Out Reach Workers 4
Laboratory Technician 1 Part Time
Nurses 3
Cook 1
Helper 1
Janitor 2
Under NACP III, it is proposed to set up 350 CCC over a period of 2007-2012 through PLHIV networks,
NGOs and other Civil Society Organizations
The CCCs are being established on priority,in districts which have high levels of HIV prevalence and
high level PLHIV plod and will be linked to the nearest ART centre.

Nurses Manual
Page 225
List of 235 Community Care Centers (19 March 2009)

S.
No.
State
Name of
the CCC
District
District
Category
Address
Contact
Person
Phone No.
Andhra Pradesh
ASSISI
Dermatological
Centre
Krishna
ASSISI Nagar,
Konkepudi,
Via Pedana
Krishna-621366
SR. PR. Prashanti Mary
08672-08248335 /
9490635110 /
9441193550
Andhra Pradesh
Bethesda
Leprosy
Hospital
West Godavari
Rustumbada,
Narsapur,
West Godavari-534275
Dr. V. Rajeev Prasad,

Medical Officer Incharge,
V. Paul Raju
08814-274618 /
9440984979
Andhra Pradesh
Canossa
Hospital
Srikakulam
Veeraghattam,
Nadukooru, Srikakulam
Sr. Mercy Vullayil
8941-239878 /
239915 /
9490447068
Andhra Pradesh
Damian Leprosy
Centre
West Godavari
Vegavaram,
Gopannapale,
Sr. Mary
08812-226132 /
9490744875
Andhra Pradesh
Hand of Hope
Methodist
Hospital
Mahaboobnagar
Doulathabad Mandal,
Chandrakal,
Mahaboobnagar-509336
Prerana Maddela
8505-287947 /
287994 /
9849642457
Andhra Pradesh
Holy Family TB
Sanatorium
Guntur
Sathenapalli,
Guntur-522004
Sr. Anthony
9849114127
Andhra Pradesh
Mother Vanninni
Hospital
West Godavari
Kadakatla, K.N.Road,
Tadepalligudam,
Sr. Teresita Naralaly

Administrator/
Sr.Catherine
8818-244121 /
9395347991 /
9490789682
Andhra Pradesh
Raja Foundation
Kadapa
Mylavaram, Kadapa
Raja, Sleeva Reddy
9440650619 /
9290461051 /
08560-273881
Andhra Pradesh
Sivananda
Rehabilaitation
Home
Hyderabad
Kukatpally,
Hyderabad-500095
Dr. Rishikesh
040-23057679 /
9866337152
Meera: 9246160251
10
Andhra Pradesh
Soloman
Hospital
Complex
Prakasam
Soloman Gram
Panchayat, Soloman
Center, Chirala,
Prakasam-523155
Dr. A.Davidson,
S.Solomon
08594-237199 /
Dr. David
Cell: 9848129546
11
Andhra Pradesh
St. Anns Society, Krishna

Central Province
Nunna, Vijiyawada,
Krishna-520004
Sr. Teresa,
Administrator
0866-2852231
12
Andhra Pradesh
St. Catald
Rehabilitation
Centre
Krishna
Vattigudipadu
P.O., Teresanagar,
Nuzivid, Krishna-521224
Sr. Dr. Vincenza Mary,

Project Holder
8656-232611 /
9590607452
13
Andhra Pradesh
St. Marys
Hospital
Nalgonda
Srirangapuram,
Kodad, Nalgonda
Sr. Mercilla, Sr.Lilly
95863-255204 /
9848371137
14
Andhra Pradesh
St. Vincents
Hospital
Prakasam
Medharametla
P.O, Prakasam-523212
Vimal Rose, Sr. Saley
8593-252652 /
9985263137 /
9985263137
15
Andhra Pradesh
St. Xaviers
Hospital
Guntur
Nirmala Nagar,
Vinukonda, Guntur
Sr. Dr. Alphensa,

Sr. Felicita
8646-272084 /
9849788014
16
Andhra Pradesh
Suma Hospital
Adilabad
Bheemaram P.O,
Jaipur Mandal,
Adilabad-504204
Sr.Emi, Sr.Sancta Rose
48737-244029/
9440594517
17
Andhra Pradesh
Women
Development
Trust
Ananthpur
Bathallapalli,
Ananthapur
Sirappa
08559-242746
Cell: 98490 15677
Nurses Manual
Page 226

S.
No.
State
Name of
the CCC
District
18
Andhra Pradesh
Women
Development
Trust
Ananthpur
19
Andhra Pradesh
Rotary Abhaya
20
Andhra Pradesh
21
Address
Contact
Person
Phone No.
Kanekal Mandal,
Ananthapur
Sirappa
08559-242746
Cell: 98490 15677
Vijayanagaram
Rotary Abhaya
Modavalasa Village
Denkada Mandal
Mr. Kumaran /
S.Hanumantharao
9393100585 /
9440190979
Srinivasa
Voluntary
Organisation
Vijayanagaram
Srinivasa Voluntary
Organisation,
D.No. 59-112, Konki
Street, Salur
Dr. B.S.N. Murthy /

B. Padmavathi
9440183216 /
08964-252270
Andhra Pradesh
Emmanuel
Ministries
Association
Visakhapatnam
Emmanuel Ministries
Association,
Kondalaagraharam,
Makavarapalem Mandal
K. Jeevan Roy
08932-222531,
222231, 222236,
9440147329
22
Andhra Pradesh
NATURE
Visakhapatnam
NATURE, # 38-37-38/2,
Bhaskar Gardens,
Marripalem - 530018
S. Balaraju
08936-249228,
249408, 9441825181
23
Andhra Pradesh
St. Anns Social

Service Society
Krishna
St. Anns Social Service

Society, Prashanth
Bahvan (Care & Support
Center), Deshrajpally X
Roads, Velichala,
Ramadugu Mandal
Sr. Cyril
Sr. Joyce
Sr. Sudha
0878-2284404,
9989558912
9963459078
(Sr. Joycy)
24
Andhra Pradesh
Medak Catholic
Mission
Medak
Medak Catholic Mission,

(Asha Jyothi), Pregnapur
(po), Gajwel
Fr. Bali Reddy SVD,

Director
Mr. Anandhan
9440226823
9866998727
9885782599
08454-211289
25
Andhra Pradesh
David & Lois

Rees Hospital
Chittoor
David & Lois Rees

Hospital,
Yerpedu - 517619
P.T. Mohanadoss,
Deputy Director
Emrys I. Rees
9989799947
26
Andhra Pradesh
Arogyavaram
Medical Centers,
Union Mission
Tuberculosis
Sanatorium
Chittoor
Arogyavaram Medical
Centers, Union Mission
Tuberculosis Sanatorium,
Arogyavaram,
Madanapally,
Chittoor District.
Dr. B Wesley,
Director
08571-222228
9440893669
27
Andhra Pradesh
AIDS Patients
Care & Support
Center, Bhavani
Educational
Society
Nellore
AIDS Patients Care &

Support Center, Bhavani
Educational Society,
Mungamur Cross Road,
Near Kavali
K. Simhadri Rao
V. Bhavani
08626-657493
9440277524
08626-212434
28
Andhra Pradesh
St. Josephs
Care Center
Khammam
St. Josephs Care

Center, Asha Niketan
Hospital, Near Swarna
Bharathi Eng. College,
Collectorate P.O.,
Khammam
Sr. Therese Marie,

Project Holder
Sr. Annie
08742-255763
9440869648
29
Andhra Pradesh
St.Josephs
Hospital,
Prathipadu533432
Via Samalkot
East Godavari
St. Josephs Hospital,

Prathipadu-533432
Via Samalkot
Sr. Karuna
Sr. Vincentina
08868-246659,
9849520542
9963269271

District
Category
Nurses Manual
Page 227
S.
No.
State
Name of
the CCC
District
30
Andhra Pradesh
Rural India Slef

Development
Trust
East Godavari
31
Andhra Pradesh
Mariyanilayam
Social Service
Society
32
Andhra Pradesh
33
Address
Contact
Person
Phone No.
Rural India Slef

Development Trust,
PB No-56, # 90-1-5/1,
Swaraj Nagar,
A.C. Gradens,
Rajamandry -533101
N. Slesser Babu,
Coordinator
Mr. R. Praveen Das
0883-2425367,
2420094,
9848185494,
9440456772
Kurnool
Mariyanilayam Social
Service Society,
Gargeyapuram, Kurnool.
Sr. Samestha DSS,

Incharge
Sr. Deepthi
9849517026
9441336003
08518-200245
Perali Narasaiah
Memorial &
Charitable Trust
Nizamabad
Perali Narasaiah
Memorial & Charitable
Trust, C/O Sree Rama
Eye Hospital,
Khaleelwadi, Nizambad
Dr. P.B. Krishna Murthy

R. Venkat Gopi
08462-231060
9849290234
9490065888
Andhra Pradesh
Freedom
Foundation
Secundrabad
Freedom Foundation,
21, Cariappa Road,
Alwal, Bolarum,
Secundrabad.
Jayasingh Thomas
Kishore Kumar
9908582655
9848602446
040-27861023
34
Andhra Pradesh
Rakshana
Deepam
Ranga Reddy
Rakshana Deepam,
44-15/2, Survey No.113,
Himayat Nagar (Village),
Via CBIT
Sr. K. Clarit,
Project Holder
Sr. Swarnalatha
9441958720
9959543227
08413-235130
35
Andhra Pradesh
Viswakaruna
Dermotoligical
Center
Warrangal
Viswakaruna
Dermotoligical Center,
Fathima Nagar, NIT Post
Fr. Jyothish
Sr. Pennamma
9849571049
9440945756
08711-223457
36
Andhra Pradesh
Rajiv Gandhi
Asian Studies of
Immunology
(RASI)
Guntur
Rajiv Gandhi Asian

Studies of Immunology
(RASI) (CCC),
D.No.13-8-147, 8th Line,
G.V. Thota, Opp. R.T.C.
Dr. Venkatappa Reddy,

Director
Smt. M. Malleswari
9885623718
9848213718
0863-2223023
37
Andhra Pradesh
Ganne
Subbalakshmi
Medical
East Godavari
Ganne Subbalakshmi
Medical College (GSL)
Dr. Ganesh
B.V. Soma Sastry
Dr. Jammy Rajesh
9959999805
9959999802
9989924783
040-30421517/18/19
38
Andhra Pradesh
Kamineni Institute Nalgonda

of Medical
Sciences (KIMS)
Kamineni Institute of
Medical Sciences (KIMS),
Nalgonda
39
Andhra Pradesh
APAIDSCON
Medak
Dr. Ganesh
B.V. Soma Sastry
Dr. Jammy Rajesh
9959999805
9959999802
9989924783
040-30421517/18/19
40
Chandigarh
Chandigarh
Community
Care Center
Chandigarh
Khuda Ali Sher,

Opposite Shivalik
Nursery
Mr. Sachin Sharma

09463456747,
0172-2786040
09872888177
(Personal),
2786040 (Office)
41
Delhi
Ashraya Holistic
Care Centre
South
ASHRAYA - Holistic
Care Center, Multi
Purpose Community
Center, Village Rajokari,
Delhi-Gurgaon Highway,
(Near Shiv Murti),
New Delhi-110038.
Ms. Nafisa Ali

(9818449999),
Mr. Henry :
henryasimte@yahoo.com
9811548345
(Henry, PC)
9810398059
Nurses Manual
Page 228
District
Category

S.
No.
State
Name of
the CCC
District
42
Delhi
Akankshya /
Chelsea
North East
43
Delhi
Bhartiya
Parivartan
Sansthan
44
Delhi
45
Address
Contact
Person
Phone No.
Community Care Centre,

C-120, Gali No. 2,
Near Police Station,
Bhajanpura,
Delhi 110053
Tel: 325 66703.
wagchelsea@yahoo.com
wagchelsea@wagch
elsea.org
Project coord. Mr. Harish

Varma (9810571911),
Mrs. Doe Nair
9810705450,
wagchelsea@vsnl.net,
wagchelsea@yahoo.com
Mr Sumit Verma
coordinator: 9810255143
Dr Umesh Bhatnagar:
9811213747
Mrs Doe Nair:
9810705450
Tel: 22130451,
22130452
New Delhi
BPS-Care Home
C-42, Conductors
Colony, Burari,
New Delhi-110084
Tel: 22351052,
22351053,
bps_org@rediffmail.com
Project Coord. Ms. Pooja

(22356852, 9818233876),
Mr. Dinesh Kumar
(980064598)
Deepati
Foundation
West
H.No 8, Indira Service

Station, Main Dhansa
Road, Najafgarh 43
Mr. Joy Jacob
9910360825
Delhi
Aradhya
North West
H.No. 15, Bhalaswa

Colony, Harijan Basti,
Near Basti, Near G.T.
Road, Karnal Bypass
Mr. Umesh
9213429305
46
Delhi
Sahara Center
for Residential
Care &
Rehabilitation
Central
1765, Pataudi House,

Kucha Dakhni Rai,
Daryaganj,
New Delhi 110002
Ms. Riti
9818474619,
41639167
47
Delhi
Snehsadan/Child
Survival India
North West
SNEH SADAN - Care

Home, House No. 618,
Prahladpur Road,
Village Khera Khurd,
Delhi 110082,
csi_org@hotmail.com
Projct coord.
Ms. Sheela Mann
(9810986101),
Ms. Deepa Bajaj
(9810647807)
Tel:27874740,
27874182
48
Haryana
Red Cross
Society, Rohtak
Rohtak
Arpan Institute, Near

Govt. Sr. Sec. School,
Gandhi Nagar,
Rohtak 124001
Mr. Nahar Singh Deswal
01262- 310107
49
Karnataka
Accept,
Bangalore
Bangalore
AIDS Care Counseling

Education and
Prevention Training
(ACCEPT) 245m KRC
Road, (Next to Visthar),
Dodda Gubbi Post,
Bangalore - 562149.
Mr. Raju K Mathew
9448619619,
acceptindia@
gmail.com
50
Karnataka
Moolika
(Hariappa
Hospital),
Sanvruddhi
Shimoga
Moolika Samvrudhi
Arogyabhivrudhi
Prathishthana, Hariyappa
Hospital, R.P. Road,
Sagar Taluk,
Shimoga - 577401.
Dr. Chandrashekar
0818326618

District
Category
Nurses Manual
Page 229
S.
No.
State
Name of
the CCC
District
District
Category
Address
Contact
Person
Phone No.
51
Karnataka
Samraksha
Kushtagi
Asha Jyothi Samraksha # 10,

Gundi Road, NH 13,
Kushtagi - 584 121.
Ms. Sulekha
9448458301,
si@samraksha.org
52
Karnataka
SVYM, Mysore
Mysore
Swamy Vivekananda
Youth Movenent,
Handhipura Road,
Sangur, H.D. Kote Taluk,
Mysore - 571121.
Dr. Bindu
9448872708
53
Karnataka
Freedom
Foudation,
Bangalore
Bangalore
Freedom Foundation
# 180, Hennur Cross,
Bangalore - 560 035.
Ms. Madhuri
9945216412
54
Karnataka
Freedom
Foudation,
Bellary
Bellary
Freedom Foundation
#30B, Infantry Road,
Opp. T.B. Hospital,
Bellary Contonment,
Bellary- 583 102.
Ms. Rathi Kapadia
9880055140
55
Karnataka
Snehadan
Bangalore
Snehadaan,
St. Camillus Home of
Charity, Sarjapura Road,
Ambedkar Nagar,
Carmelaram Post,
Banglore - 560 035.
Fr. Sunny Joseph
9448242730
56
Karnataka
Snehasadan
Mangalore
Snehasadan,
St. Camillus Rotary
Rehavilitation Centre,
Kinnikambla Post,
Kaikamba,
Mangalore - 574151.
Fr. Joy George
9448118119
57
Karnataka
Sri Shakti
Belgaum
Sri Shakathi Association,

Sri Shakthi Multi
Speciality Hospital,
Belgaum.
Mr. Shashikumar
9945221004
58
Karnataka
Assissi Hospital
Raichur
Vidyanagar,
Raichur - 584103
Sr. Felicia Mary
08532-240991 /
240944
59
Karnataka
Holy Cross
Hospital
Chikmagalur
Holy Cross Hospital,

Jyothi Nagar,
Chikamagalur - 577102
Dr. Bhagyalakshmi
9448130268 /
08262-220077 /
220017
60
Karnataka
Holy Cross
Hospital
Chamarajnagar
Kamagere, Kollegal,
Chamarajnagar - 560068
Sr. Regi John
9740664598 /
08224-263681
61
Karnataka
Dayabhavan
Tumkur
Bhaktharahalli, Kunigal
Taluk, Tumkur - 572120
Fr. Jinesh Varkey
9448371298 /
08132-320909 /
9242620548
62
Karnataka
St. Marys
Hospital
Bellary
OPD Road, Cantonment,

Bellary 583 104
Sr. Mary Varghese
9449536191 /
08392-242641
63
Karnataka
Lourdes
Hospital
Dharwad
# 14337, Shanti Sadan,

Ward 13, Block No. K A
19/2429, Nirmal Nagar
12th Cross Road,
Dharwad - 580003
Sr. Nirmala Dsilva
9449483074 /
0836 -2448224
Nurses Manual
Page 230

S.
No.
State
Name of
the CCC
District
District
Category
64
Karnataka
C G Hospital
Belgaum
Cardinal Gracias Hospital Sr. Tessy

Nirmal Nagar, Modage,
Belgaum 591103
9448194244 /
0831-2418244
65
Karnataka
St. Luke Hospital
Gulbarga
Aurad - B,
Gulbarga - 585316
Dr. K A Abraham
9448042663 /
08472 -211831
66
Karnataka
Support
Bangalore
Magadi Road,
Sumanahalli,
Vishavaeedam Post,
Bangalore 560091
Fr. George K
9845811515 /
9945333122 /
23485317
67
Karnataka
Karwar Diocesan
Development
Council
Karwar
Bishops House,
Baithkol Road, Karwar,
UK - 581302
Fr. Lawrence Fernandes
9448129063 /
08382-220563
68
Karnataka
Haemophilia
Society
Davangere
No 352/1, 9th Cross,

P J Extn, Behind Mothi
Veerappa JR College,
Davanagere - 577002
Dr. Suresh Hanagavadi
9341004109
69
Karnataka
St Annes
Hospital
Bijapur
#54, Centre for Non

Fr. Vincent Crasta
Formal Education (CNFE),
Station Road,
Mukund Nagar,
Bijapur - 586104
9448308585 /
08352-256453
70
Karnataka
Freedom
Foundation
Udipi
Freedom Foundation
#3/3A, Survey No. 14/1,
C-2, Moolur Village,
NH 17, Post Uchila,
Udupi District - 574117
Mr. Manohara
9449167897 /
2530312
71
Karnataka
HEERA, (Health,
Education,
Empowerment,
Rehabilitation
Association)
Chitradurga
Community Care Center,

City Multispeciality
Hospital Premises,
Turuvanur Road,
Chitradurga
Dr. Nagendra Gowda.

M.R.
08194-230658,
9880096765,
9243205726
72
Karnataka
(ORBIT)
Organisation for
Bidar Integral
Transformation
Bidar
Asha Deepa, ORBIT

Community Care Centre,
Kristhashrama,
Kaudiyal (s) ,
Basavakalyan Raluka,
Bidar District
Fr Santhosh Dias
08483 271032
73
Karnataka
Our Lady of
Mercy SAB
Trust
Kolar
Nava Jeevan Health

Centre, Opp K.P.T.C.L,
M.B. Road, Mulbagal,
Kolar
Sr. Josena
8152223418
74
Karnataka
Sri Sai
International
Charitable Trust
Chikballapur
ARAIKE, Anakur,
off Siddlagatta Main
Road, Chikkaballapur
Ms. Rashmi R.
9945080817
75
Karnataka
Dakshina
Kannada Rural
Development
Society
Dakshina
Kannada
Navajeevana Care and

Fr. Thomas K.C.
Support Centre, Kakkinje,
Charmady P.O.,
Belthangady, D.K.,
Karnataka

Address
Contact
Person
Phone No.
9008606605 /
9448656926
Nurses Manual
Page 231
S.
No.
State
Name of
the CCC
District
District
Category
76
Karnataka
Asha Kiran
Hospital
Mysore
Asha Kiran Hospital,

Mr. Gururaja
CA-1, Ring Road,
Hebbal Industrial Housing
Area, Next to JK Tyres
Plant, Hebbal,
Mysore - 570016
9980055905 /
984511058
77
Maharashtra
Bel-Air Hospital,
Panchgani,
Satara
Satara
Bel Air Hospital,

Panchagani,
Satara - 412805
Fr. Tomy
09422606672,
02168241109
78
Maharashtra
Acharya Vinobha
Bhave Rural
Hospital, Wardha
Wardha
DMDPGMER, Sawangi
(Meghe), Wardha
Dr S Z Quazi, Dr Abhay
Gaidhane
09370043029,
9325191810,
07152- 320750
79
Maharashtra
Krupa Prasad
Kendra, Nasik
Nasik
Krupa Prasad Kendra,

Old Mumbai, Agra Road,
Behind Vasan Showroom,
Mumbai Naka,
Nasik 422001
Dr Dimple Chauhan,
kkrupaprasad@
yahoo.co.in,
digimol_2006@
yahoo.co.in
0253- 2595586
9422759960
80
Maharashtra
G.M. Priya
Hospital, Latur
Latur
G M P Hospital,
Dapegaon, Taluk Ausa,
Dist Latur - 413572
Dr D William
02383- 226069
81
Maharashtra
Jan Kalyan
Samiti, Sholapur
Sholapur
C/O Chaitanya Hospital,

538 Vithal Arcade,
North Kasba,
Sholapur - 413001
Mr. J Shilgekar
0217-2741870,
2741874, 2741872
82
Maharashtra
Nirmaya Niketan,
Mumbai
Mumbai
V N Purav Marg,
Dhobighat, Trombay,
Mumbai - 400088,
<chairman@nirama
yniketan.org>
Mr. John Lobo, Mr. A.S.

Gaikwad, ChairmanMr. Santan DSouza,
Eduljee Framjee Allbless
Niramay Niketan,
V.N. Purav Marg,
Dhobi Ghat, Trombay,
Mumbai-400088
022-25513314,
Fax:91-022-25581450
Tel: 91-022-2551
3314 (OPD)
Mob. No. Chairman 9869682397,
Treasurer 9867618832,
Co-ordinator (CCC) 9869289347
83
Maharashtra
Sarvodaya
Hospital,
Mumbai
Mumbai
Lal Bahadur Shastri

Marg, Ghatkopar (W),
Mumbai
Mr. Krishnan
022-25152237
84
Maharashtra
Snehalaya,
Ahmaednagar
Ahmednagar
Block No 239, Near

Super Ammonia Plant,
Shree Tile Chowk,
MIDC, Nimblak,
Ahmednagar-414001
Mr. Ambadas Chavan,

Mr. Anil Gawde
0241-2778353,
2327593,
9881946116
9890306407
85
Maharashtra
Priyadarshani
Rural and Tribal
Upliftment
Foundation,
Akola
Akola
Sant Tukaram Hospital,

Gorakshan Rd,
Tukaram Chowk,
Akola - 444001
Dr. Jagannath Dhone,

Anand Janotkar
0724-2433092
9923584209
86
Maharashtra
Godavari
Foundation,
Jalgaon
Jalgaon
Godavari Foundations
CCC, Mahesh Housing
Society, Near Hotel Step
Inn, Jalgaon - 425001
Dr. Ulhas Patil

Mr Yogesh Mahajan
0257-2200830
9371616716
Nurses Manual
Page 232
Address
Contact
Person
Phone No.

S.
No.
State
Name of
the CCC
District
District
Category
87
Maharashtra
Lotus Medical
Foundation,
Kolhapur
Kolhapur
Sona Towers, Survey

Dr. Kimaya Shah
No 644, Plot No. 143/B1,
YP Pawar Nagar Chowk,
Jawaharnagar Rd,
Kolhapur-416008
0231-2692411
9422051305
88
Maharashtra
Balvikas Mahila
Mandal, Latur
Latur
Swadhar Mahila
Vastigruh, Sudarshan
Colony, Indra Nagar,
Latur - 413512
Mr. Vilas Deshpande
02382-228773
02382-240418
89
Maharashtra
Mure Memorial
Hospital, Nagpur
Nagpur
Maharajbagh Road,
Sitabuldi,
Nagpur-440001
Mr. Vilas Shende
0712-2522370
90
Maharashtra
Bhartiya Adim
Jati Sevak
Sangh, Nagpur
Nagpur
Mr. R.K. Malviya

Amruta Joshi
0712-2290421
9372543322
9422804228
91
Maharashtra
Dhanvantri
Vaidyakiya
Pratishthan,
Nanded
Nanded
Infront of Water Tank,

Mahavir Society,
Nanded - 431602
Dr. B.K. Kardile
02462-234330
9422186245
92
Maharashtra
Sai Sneha
Hospital, Pune
Pune
Sai Sneha Hospital,

A/P Khed Shivapur
(Bagh) Near Police
Station, Tal. Haveli,
Dist. Pune-412213
Dr. Sunil Jagtap
020- 26959208,
9822036736
93
Maharashtra
Loknete
Rajarambapu
Patil Hospital
and Research
Centre, Sangli
Islampur
Loknete Rajarambapu
Patil Hospital and
Research Centre,
Islampur Sangli Rd,
Islampur-415409
Dr. Pramod Patil
02342-225792
94
Maharashtra
Sangli Mission
Society, Sangli
Sangli
Dilasa House, Darga

Mohalla, Aman Nagar,
Malgao Rd, Miraj,
Dist Sangli-416410
Fr. Sabu
0233-2211292,
9420678520
95
Maharashtra
Loknete Rajaram
Bapu Hospital &
Research Centre
Sangli
96
Maharashtra
Param Prasad
Charitable
Society
Pune
Dr. Jal Mehta Foundation Fr. Shaju

Campus, Survey No. 1,
Yevlewadi, Pune
0-9970963246
97
Maharashtra
Sai Prem
Gramina Vikas
Sanstha
Yavatmal
Dhanashre Rugnalay,
Behind Basaveshwar
Mangal Karyalaya,
Darwha Rd., Yavatmal
0723-2322929
98
Maharashtra
Kamlini Nilmani
Charitable Trust
Mumbai
Goel Hospital, J B Nagar, Ravi Patil

Andheri (East),
Mumbai - 400 059
022 28323659 /
28349714
982013653
99
Maharashtra
Jyotish
Charitable Trust
Raigad
Jyothis Care Centre,

Sector 11, Plot No 4,
Kalamboli, Navi Mumbai
022-27423399

Address
Contact
Person
Reeta Bhawnae
Sr. Infanta
Phone No.
Nurses Manual
Page 233
S.
No.
State
Name of
the CCC
District
District
Category
Address
Contact
Person
Phone No.
100
Maharashtra
Jeevan Vikas
Sanstha
Amravati
Navjeevan Care Centre,

C/O Leprosy Relief &
Rehabilitation Centre,
Nimbhora Khurd,
Badnera P.O.,
Amravati Dist. - 444701
Fr.Jolly
07223 221352 /
221576 / 07223 /
223740 /
09422156032
101
Maharashtra
Dhanvantaris
Organization for
Socio Health
Transformation
Parbhani
DOST CCC, Sadguru

Nagar, Old Pedgaon Rd,
Parbhani-431401
Dr.Jawade
(02452) 241122
9970764224
102
Maharashtra
Shanti Mandal Vimala Sadan
Aurangabad
Vimala Sadan Social

Service Centre, New
Shantiniketan Colony,
Jalna Road,
Aurangabad - 431005
Sr.Sheeba
103
Maharashtra
Diocese of
Chanda Society
Chandrapur
Christ Hospital,
Jyoti Nagar, Tukum,
Chandrapur- 442401
Dr. Gregory Ellyadom
07172-264387,
264389,
09423115594
104
Maharashtra
Shri Gajanan
Maharaj Krishi
Va Shishanak
Santha
Jalna
Shrikrishna Clinic,
Mantha Road, Jalna
Ganesh Sonunae
07261-232226,
232393,
9422880291,
9881719227
105
Maharashtra
Sangli Mission
Society
Ratnagiri
Navajeevan Arogya
Kendra, St. Thomas
Church Campus, MIDC
PO, Karwanchi Wadi
Road, PB-12,
Ravindranagar,
Ratnagiri - 415639
Fr. Siju
094211-22204
106
Maharashtra
DOSTHingoli-CCC
Hingoli
Hingoli
DOST-CCC Hingoli,
Near Civil Hospital,
Hingoli, Dist. Hingoli
9970764224
107
Maharashtra
Hope Centre
Mumbai
Andheri
The Catholic Nurses

Guild of India., C.N.G.I.
National Secretariate &
Hope Centre,
Mhatarpada Road,
Amboli, Andheri West,
Mumbai - 400058
9892950509
108
Maharashtra
Sparsh Hospital
Osmanabad
Sastur
SPARSH Rural Hospital,

At Sastur, Taluka Lohara,
Dist. Osmanabad-413606
094220 95053
109
Maharashtra
Ashakiran
Hospital
Pune
Pune
Ashakiran Jubilee Hope

Centre, Survey No. 138,
Chinchwad (East),
Near St. Andrews School,
Pune - 411018
020-27482626,
020-65320462
110
Maharashtra
Vanchit Vikas
CCC
Pune
Pune
Mogal Market, 2nd Floor,

CTS No: 1003, Budgwar
Peth, Pune - 411002
020 24454658/
24483050
Nurses Manual
Page 234

S.
No.
State
Name of
the CCC
District
111
Maharashtra
Late Shriram
Dhule
Ahirrao Memorial
Trust- Dhule-CCC
112
Maharashtra
Late Shriram
Ahirrao Memorial
TrustNandurbar-CCC
Nandurbar
113
Maharashtra
Sant Gulab Baba

CCC
Bhandara
114
Maharashtra
Yuva CCC
Beed
115
Manipur
Centre for
Organising
Labours
Development
(COLD)
Canchipur
Centre for Organising

Labours Development
(COLD), Canchipur,
Imphal West
116
Manipur
LEWS
Imphal
Leprosy Patients Welfare A. Tolen Singh

Society, Lei-Ingkhol,
Imphal
2421363(O),
94360-20161,
94360-27065
Email: lews2003man
@yahoo.co.in
117
Manipur
RUSA, Moreh
Moreh
Rural Service Agency

(RUSA), Moreh, Ward
No.9, Near Trade Center
98622-78785,
2231145
Email: rusapalace
compound@
yahoo.com
118
Manipur
SHALOM
Churchanpur
Society for HIV/AIDS and Ms. Lalruatpuii Pachuau

Lifeline Operation in
Manipur (SHALOM),
Churachandpur Bazar
953874-33891,
953874-22531,
953874-33541
Email: shalomccp@
yahoo.co.in
119
Manipur
Kha Manipur
Yoga and
Nature Cure
Thoubal
Kha Manipur Yoga and

Nature Cure, Kakching
Thoubal District
Dr. M. Rajkumar Singh
98620-88092,
953848-261320
Email: ayncrh@
yahoo.co.in
120
Manipur
PRDA
Bishnupur
Peoples Resources
Development Association
(PRDA), Ningthoukhong
of Bishnupur District
L.Suranjoy Singh
98561-92762
Email: prda@
rediffmail.com

District
Category
Dhule
Address
Contact
Person
Phone No.
CCC - Late Shriram

Ahirrao Memorial Trust,
Betawad, Tal. Sindkheda,
Dist.: Dhule
Pin: 425403
9422788421
Nandurbar
Jai Prakash Narayan

Hospital Compound,
Near Meera Agency,
Main Road,
Nandurbar
9422788421
Bhandara
Doctors Colony,
Takia Ward,
Behind MSEB Office,
National Highway-6,
Bhandara - 441904
9823593554
Late Suwalalji Wakekar

Community Care Center,
Parli (V), Near Over
Bridge, beside
Khandinala Complex,
Hindnagar, Parli (V),
Dist. Beed - 431515
(02446) 222891
Parli
Th. Promila
Y. Surchandra Singh
98562-15673,
2406411
Nurses Manual
Page 235
S.
No.
State
Name of
the CCC
District
District
Category
Address
Contact
Person
Phone No.
121
Tamil Nadu
YRG Centre for

AIDS Research
and Education
(YRG CARE)
Chennai
YRG Centre for AIDS

Research and Education
(YRG CARE), Voluntary
Health Services (VHS)
Campus, Taramani,
Chennai - 113
Thiru. SK. Satish Kumar
9381006380
suniti@yrgcare.org,
satish@yrgcare.org
122
Tamil Nadu
Sneha Sadan
Dharmapuri
Sneha Sadan,
Selliampatty Village &
Post, Palacode Taluk,
Dharmapuri
District - 636809
Sr. Shobhana,
9486091091,
snehasadan2007@
gmail.com
123
Tamil Nadu
The Association
of Arulagam
Hospice
Dindigul
The Association of
Arulagam Hospice,
Bangarapuram,
Reddiarchatram Post,
Dindigul District - 624622
Dr. Margret Kalaiselvi,

margaret_larbeer@
yahoo.com,
arulhos@yahoo.co.in,
arulagampc@yahoo.co.in
9944210076
124
Tamil Nadu
Family Planning
Association of
India (FPAI)
Dindigul
Family Planning
Thiru. A.K. Serumalai
Association of India
fpaidindigul@yahoo.com
(FPAI), Plot No. 69-70,
9952118640
AJMG Nagar, 4th Lane,
Opp. to Beschi College,
Karur Road,
Dindigul District - 624001
9952118640
125
Tamil Nadu
Centre for Action Erode

and Rural
Education (CARE)
Centre for Action and

Rural Education (CARE),
No. 6, Kambar Street,
Teachers Colony, Erode
9443736367
126
Tamil Nadu
Family Planning
Association of
India (FPAI),
Madurai
Family Planning
Dr. Louis S. Paulraj,
Association of India
9442035900,
(FPAI), Madurai Branch, fpaim@satyam.net.in
FPAI Bhavan, FPAI Road,
TNHB Colony,
Ellis Nagar, Madurai,
Madurai District - 625010
9442035900
127
Tamil Nadu
Meenakshi
Mission Hospital
and Research
Centre
Madurai
Meenakshi Mission
Hospital and Research
Centre, Lake Area,
Melur Road,
Madurai District - 625107
Thiru. S. Palaniappan,
9842161185,
charityrd@gmail.com,
palaniappan_law@
yahoo.co.in
9842161185
128
Tamil Nadu
HIV Positive
Namakkal
People Welfare
Society (HPPWS)
HIV Positive People

Welfare Society (HPPWS)
No.119-28B, Madha Koil
Street, Trichy Road,
Namakkal - 637001
Ms. S. Kausalya,
9840693679
9840693679,
hppwscare@gmail.com
<hppwscare@gmail.com>
129
Tamil Nadu
Human Uplift
Trust (HUT)
Perambalur
Human Uplift Trust (HUT) Dr. Raja Venkat

Meikandar Complex,
9842414711
Kalpalayam Road,
rajavenkat@hutindia.org
Mannachanallur,
Trichy - 621005
9842414711
130
Tamil Nadu
Sri Ponnalagi
Amman Trust
Pudhukottai
Sri Ponnalagi Amman

Trust, Thottiampatty,
Ponnamaravathy,
Pudukottai District
9344545449
Nurses Manual
Page 236
Thiru. Charles Prabhu,

9443736367,
carecharles@dataone.in
Dr. A. Alegesan,
9344545449,
dralagesan@yahoo.co.in,
spatrust@gmail.com
<spatrust@gmail.com>

S.
No.
State
Name of
the CCC
District
131
Tamil Nadu
Immaculate
Conception
Women
Development
Social Service
Society of
Sivagangai
Province Sirpi &
St. Joseph
Hospital
Sivagangai
132
Tamil Nadu
Mass Action
Network India
Trust (MAN)
133
Tamil Nadu
134
Address
Contact
Person
Immaculate Conception
Women Development
Social Service Society
of Sivagangai Province
Sirpi & St. Joseph
Hospital, Pulial,
Pulial (Post),
Devakottai (via),
Sivagangai - 630 312
Sr. Motchalangaram,
9486013389
9486013389,
st_jsph@rediffmail.com
<st_jsph@rediffmail.com>
Thiruvallur
Mass Action Network

India Trust (MAN), No.14,
1st Floor, West Sivan,
Kovil Street, Vadapalani,
Chennai - 600029
G. Babu,
9444275762,
massaction@
rediffmail.com
9444275762
St. Joseph
Leprosy Hospital
and HIV/AIDS
Care Centre
Tuticorin
St. Joseph Leprosy

Hospital and HIV/AIDS
Care Centre,
Arokyapuram,
Thoothukudi
Sr. Rose Francis,

9442948815,
joseind@gmail.com ,
Sr. Dr. Rita
9442948815
Tamil Nadu
Holy Family
Hansenorium
Trichy
Holy Family
Hansenorium,
Fathima Nagar (Post),
Trichy - 620 012
9443401125,
ritasr@sify.com
9443401125
135
Tamil Nadu
Sri Meenakshi
Educational and
Development
Organization
(SMEDO)
Ramnad
Sri Meenakshi
Educational and
Development
Organization (SMEDO),
No. 3/622 A3,
Bagawath Singh Road,
Paramakudi - 623707,
Ramanathapuram District
Dr. S. Sundarraj,
9443155181,
srimedu@rediffmail.com
9443155181
136
Tamil Nadu
Tamilnadu
Network of
Positive People
(TNP+)
Villupuram
Tamilnadu Network of
Positive People (TNP+),
No. 10, Kalaignar,
Karunanidhi Street,
Chennai Main Road,
Villupuram - 605 602
Thiru. Rama Pandian,

944040469,
tnpluz@yahoo.com
944040469
137
Tamil Nadu
N.A.A.DT. People Vellore

Welfare Service
Society
N.A.A.DT. People
Welfare Service Society,
Dharma Nagar, Vellore
Hospital back side,
Adukkambarai,
Vellore District
Thir. M.S. Rajendran,

9790571391
9790571391,
msrajendran@yahoo.co.in
138
Tamil Nadu
Community of
People Living
with HIV/AIDS in
Tamilnadu
(CPT+)
Community of People
Living with HIV/AIDS in
Tamilnadu (CPT+),
No. 5/74C, Katpadi Main
Road, Senrayanapalle,
Katpadi Taluk,
Vellore District
Mr.Pandian, 9894807208, 9894807208

knirmala@yahoo.co.in
<knirmala@yahoo.co.in>
Vellore

District
Category
Phone No.
Nurses Manual
Page 237
S.
No.
State
Name of
the CCC
Address
Contact
Person
Phone No.
139
Tamil Nadu
Sri Narayani
Vellore
Hospital &
Research Centre,
Sri Narayani Hospital &

Research Centre,
Thirumalaikodi,
Vellore District - 632055
Dr. J. Sundra Babu,

9952416822
snhrc_76@yahoo.com,
suresh1980edp@
gmail.com
9952416822
140
Tamil Nadu
Society of the
Sisters of the
Presentation of
the Blessed
Virgin Mary
Community
Health
Department
Theni
Society of the Sisters

of the Presentation of
the Blessed Virgin Mary
Community Health
Department, No. 5/73,
Theni District,
Theni - 625 531
Sr. Anestesia,
9443862311
9443862311
141
Tamil Nadu
Ramana
Maharishi
Rangammal
Hospital
Thiruvannamalai
Ramana Maharishi
Rangammal Hospital,
Shiva Nagar, Athiyandal
Village, Thiuvannamalai
District - 606603
Thiru. F. Jayaraj,
9442274235
9442274235,
sm_wright21@hotmail.com
142
Tamil Nadu
Society for
Education and
Economic
Development
(SEED)
Nagapattinam
Society for Education

and Economic
Development (SEED)
No.3/273, Main Road,
Thirumarugal,
Nagapaatinam
Tmt. A.G. Manimekalai,

9443847312,
seedngo@rediffmail.com
9443847312
143
Tamil Nadu
Indo Srilankan
Development
(Island) Trust
The Nilgiris
Indo Srilankan
Development (Island)
Trust, No. 14/56,
Club Road,
Kothagiri - 643217
Mr. Alphone Raj M.L.,

9443371224,
islandtrust@bsnl.in
9443371224
144
Tamil Nadu
TCNR
Padmavathi
Ammal Free
Medical Charties
(TCNRP),
Virudhunagar
TCNR Padmavathi
Dr. Kamalasekarn,
Ammal Free Medical
94431 22784,
Charties (TCNRP),
tcnrp86@yahoo.co.in
Bo. 121B, Hospital Road,
Rajapalayam - 262117
9443122784
145
Tamil Nadu
Selvi Memorial
Illam Society,
Kancheepuram
Selvi Memorial Illam

Society, No. 9, 2nd Main
Road, Jaya Nagar,
Tambaram Sanitorium,
Chennai - 600 047
Ms. Mary Thomas,

9840541108,
smis99@gmail.com,
selvi_mary@sify.com
9840541108
146
Tamil Nadu
We Care Social
Service Society
Kancheepuram
We Care Social Service

Society, No. 4/98,
Nethaji Road,
Singaperumal Koil Post,
Kancheepuram
District - 603 204
Mr. Antony, 9340001000,

wecareindia@gmail.com
9340001000
147
Tamil Nadu
Arogya Agam
Theni
Arogya Agam,
Palakombai Road,
Aundipatty,
Theni - 625 512
Mr. John Dalton

9842115449/
9842115449/9842142306, 9842142306
info@arogyaagam.org,
arogyaagam@gmail.com
148
Tamil Nadu
Indian Red
Cross Society
(IRCS),
Krishnagiri
Krishnagiri
Indian Red Cross Society Mr. P. Shanmugam,

(IRCS), No.8, Krishnappa 944331118
Layout,
Krishanagiri - 635001
Nurses Manual
Page 238
District
District
Category
9443331118

S.
No.
State
Name of
the CCC
District
149
Tamil Nadu
Vailankanni
Society for Rural
Construction and
Technical
Education
(VIRTUE)
Thiruvarur
Vailankanni Society for

Er. S. Xavier,
Rural Construction and
9842452597,
Technical Education
virtueorg@yahoo.co.in
(VIRTUE), No.18/94-V,
Hospital Street,
Tiruthuraipoondi - 614713
9842452597
150
Tamil Nadu
Anbalayam
Thanjavur
Anbalayam, No. 6/142,

Natarajapuram South,
10th Cross Street,
Thanjavur - 613 007
Thiru. K. Senthil Kumar,

9443167607,
anbalayam2001@
yahoo.co.in
9443167607
151
Tamil Nadu
Freedom
Foundation
Chennai
Freedom Foundation,
No. 15, Redhills Road,
United Colony, Kolathur,
Chennai - 600 099
Mr. Varadhan,
9444041619
9444041619
152
Tamil Nadu
Preshistha
Service Society
Coimbatore
Preshistha Service
Society, Unjavelampatty,
Pollachi Taluk,
Pollachi - 03,
Coimbatore District
Fr. Seby Vellanikaran,

9443006094,
pss_poy@yahoo.com,
sebyvellani@yahoo.co.in
9443006094
153
Tamil Nadu
Isha Yoga
Foundation,
Coimbatore
Isha Yoga Foundation,

Grama Puthunarvu
Iyyakkam, No. 13/24,
North End Road,
Krishnasamy Nagar,
Coimbatore - 45
Dr. Bhavani Balakrishnan 9840804496

9840804496,
isha.healthservices@
gmail.com,
bhavani.balakrishnan@
gmail.com
154
Tamil Nadu
Sharanalayam
Coimbatore
Sharanalayam, No. 34,

Thiruvengada Nagar,
Pollachi - 642 001,
Coimbatore District
N. Chandran,
94443054204,
aid@sharanalyam.org,
sharanalayam@
rediffmail.com
94443054204
155
Tamil Nadu
PEACE TRUST
Tirnelveli
PEACE TRUST, No. 15,

Kurichi Road,
Kulavanigar Puram,
Palayamkotta - 627 002
Dr. R. Anburajan,
9442612138,
anburajandoctor@
gmail.com
9442612138
156
Tamil Nadu
Modern
Educational
Social Service
Society (MESSS)
Karur
15/2 11th Cross Street,

1st Floor,
Sengunthapuram,
Karur - 2
R. Thirumal@
Rajanmessscuddalore@
yahoo.co.in
93676 20313
94424 40747
157
Tamil Nadu
Saraswathi
Women
Educational
Service
Training
Improvement
Center
(SWESTIC)
Dindigul
Saraswathi Women
Educational Service
Training Improvement
Center (SWESTIC),
Opp. to Lokayarkottai,
Solaipudur (Post),
Oddanchatram - 624619,
Dindigul District
S. Kalaiarasi
9442641104
swestic1990@yahoo.co.in
158
Tamil Nadu
James Memorial
Charitable Trust
Kanniakumari
James Memorial
Charitable Trust,
Colachel Post,
Kannyakumari
District - 629 251.
G. Frederick Raja Sekhar

9443326327
gmrsekhar@gmail.com

District
Category
Address
Contact
Person
Phone No.
Nurses Manual
Page 239
S.
No.
State
Name of
the CCC
159
Tamil Nadu
Centre for
Kanniakumari
Human Resource
and Rural
Developmental
Programmes
(CHARDEP)
Centre for Human

chardep_98@yahoo.com
Resource and Rural
Developmental
Programmes (CHARDEP),
No. 21B, Sargunaveedi,
Cross Street,
Ramavarmapuram,
Nagercoil - 1,
Kanyakumari District
G. Manikandan
9942979160
160
Tamil Nadu
The Modern
Educational &
Social Service
Society (MESSS)
Cuddalore
The Modern Educational

& Social Service Society
(MESSS), No. 10,
Srinivasa Pillai Street,
Pudupalayam,
Cuddalore - 1
R. Thirumal @ Rajan
messscuddalore@
yahoo.co.in
93676 20313
94424 40747
161
Tamil Nadu
Doctor Typhagne
Memorial
Charitable
(DTMC) Trust
Salem
Doctor Typhagne
Memorial Charitable
(DTMC) Trust, SMMI
Convent Staff Quarters
Arisipalayam,
Salem - 636 009
dtmctrust@gamil.com
dtmctrust@yahoo.co.uk
A. John Paul,
9894137826
Sr. Francina,
9443221482
162
Mizoram
Joy Adventist
Aizwal
Seventh Day Tlang,

Aizawl
aadhos@gmail.com
Dr. Eileen (94361-43503), (0389) 234-0326,

Cathy Lalnunpuii
94361-97768
(98630-42694)
163
Mizoram
Presbytarian
Hospital
Duruthalang
Presbytarian Hospital,
Dururthlang
Dr. Sanghluna
164
Jharkhand
Snehdeep,
Hazaribagh
Hazaribag
Snehdeep Holy
Cross CCC, Sitagarh,
Hazaribagh
Dr. Sandeep Mukerjee
165
Jharkhand
Ashadeep,
Ranchi
Ranchi
Ashadeep CCC,
Hefag Hatia, Ranchi
166
Himanchal
Pradesh
Swami Sri
Harigiri Hospital
and CCC,
Chamba
Chamba
Swami Shri Hari Giri

Hospital Cum Research
Centre, Kakira,
Distt. Chamba
167
Punjab
Community Care Amritsar

Center for people
living with
HIV/AIDS,
Amritsar
Inside Guru Nanak

Dev Hospital, Near
De-Addiction Centre,
Majitha Road,
Amritsar - 143001
168
Punjab
Community Care
Center Patiala
Information not received
169
Punjab
Community Care Kapurthala

Center Jalandhar,
Kapurthala
Information not received
170
Kerela
St Johns Health
Services
Trivandrum
St Johns Health Services Fr Jose Kizhakkedath

Pirappancode, Trivandrum,
0472-2872047
0472 2872047
171
Kerela
Amrita Kripa
Sagar Care
Centre
Trivandrum
Amrita Kripa Sagar Care

Centre, Nedumangad,
Trivandrum,
Phone: 0472 2891237
9447090075
Nurses Manual
Page 240
District
Patiala
District
Category
Address
Contact
Person
Phone No.
(0389) 236-1222,
0-94361-41739
Ph. 0183-2572401
Br Amarnath

S.
No.
State
Name of
the CCC
District
172
Kerela
Snehatheeran
Care Centre
Ernakulam
173
Kerela
174
Address
Contact
Person
Phone No.
Snehatheeran Care
Centre, West
Kadungallor, Aluva
10 Ernakulam Dist
Fr Naveen Mathew
9495676232
Asha Kiran,
Kottayam
Pampady, Near
KG College
Kottayam 686502
0481 2500431
Pampady,
Near KG College,
Kottayam - 686502
Ms Isha Jacob
0482 2500431
Kerala
Nazarath Care
and support
Center
Palakkad
Narareth Sabs Centenary srtessinmynatty@

Charitable Trust,
gmail.com
Kinasery PO,
Muthukad - 678707
0491-2910035
175
Kerala
Institute of
Palliative
Medicines
Calicut
Medical College PO,

Kozikode - 673008
dr.suresh.kumar@
gmail.com
9349113532
176
Assam
Borukha Public
Trust, Guwahati
Guwahati
guwahati@bpwt.org
Mr. Ratul Kalita,

Dr. J.N. Bhattacharya
98642-16627,
0361-223-1104,
0361-223-4104
177
Assam
Anubhuti
Community
Care Center
Silchar
Deshasandhu Club,
Sahid Bazar, Sibburi
Road, Silchar, Cachar
Mousami Roy
communitycarecenter
dbc@gmail.com
178
Assam
Astha CCC
Dibrugarh
Chiring Chapori,
Opposite Bhattacharjee
Press, Behnid Assam
Tribune,
Dibrugarh-786001
Ranjita Tayeng
Dr. H Das
03732316917,
03732310060,
9435112933
179
Goa
CARITAS
Goa
Near Church Cavelossim, Sr. Vinita Joseph

Salcete, Goa - 403802
0832-2871745
180
Goa
Freedom
Foundation
Goa
105/A-2, Opp. Hotel

Green Park, Sorvem,
Guirim, Bardez,
Goa 403507 (North Goa)
0832-2264262
181
Nagaland
ECS Hospice
Tuensang
Eleutheros Christian
Dr. Panker,
Society (ECS) Tuensang, M - 09436658220
Nagaland PO Box -51
Tel: 0361-220127
0361-220127 /
09436658220
182
Nagaland
HIV/AIDS Care
Hospice
Kohima
Naga Mothers
Association (NMA)
HIV/AIDS Care Hospice
Cradle Ridge, Seithogei,
PO Box No. 160,
Kohima- 797001,
Nagaland
Tel: 0370-2800356
Dr. Kekhrievilhou Nakhro

Mobile No. 09856150359
0370-2800356 /
09856150359
183
Nagaland
Impur Christian
Hospital,
Mokokchung
Mokokchung
Impur Christian Hospital,

Mokokchung.
Mr. Talitemsu, Manager

M-9436408316
0369-2262441

District
Category
Ms. Zinya DSouza
Nurses Manual
Page 241
S.
No.
State
Name of
the CCC
District
District
Category
184
Nagaland
Western Sumi
Community
Development
Project
(WSCDP)
Dimapur
Dimapur
Western Sumi Community Khekiho Katy

Development Project,
(Development Officer)
Akuvuto, P.O. Box-34,
9856544303 (M)
Thakhekhu
Village-797112, Dimapur
E-mail: wsbak_
development@yahoo.com
(03862)245033 (R)
185
Uttar Pradesh
Umang CCC
Foundation
for Social Care
Lucknow
Near Petrol Pump,

Andhe ki Chowki,
Hardoi Road
Mr. Arif
9935859534 /
9935451159
186
Uttar Pradesh
Umang CCC
Adarsh Sewa
Samaiti
Merrut
B-104, Takshila Colony,

Garh Road, Meerut
Mr. Arun Kumar
(0121) 3208543
187
Uttar Pradesh
Umang CCC
Centre for Social
Research
Varanasi
Umang Community Care

Centre, Plot No.17,
Sukhi Sansar Colony,
Giri Extention,
Mahmoorganj,
Varanasi
Ms. Kanchana Singh
09415223387,
09336747468
188
Uttar Pradesh
Umang CCC
Gramin Seva
Sansthan
Gorakhpur
C-362, Raptinagar,
Phase-4, P.O.
Charaganva,
Gorakhpur
Mr. Arvind Kumar
0551-2506064
189
Uttar Pradesh
Umang CCC
Society for
Welfare &
Advancement of
Rural
Generations
(SWARG)
Allahabad
21 Shivpur,
P.O. Dhoomanganj,
Allahabad 211010
Mr. Manoj Kumar
0532-232845
190
Uttar Pradesh
Umang CCC
Kanpur
191
Uttar Pradesh
Umang CCC
Agra
192
Rajasthan
SAMBAL CCC
Bal Sansar
Ajmer
Swasti B-88, Sarswati

Marg, Bajaj Nagar,
Jaipur
Mr. Bhanwer Govind

Singh
0145-2600415,
09461478052
193
Rajasthan
Jeevan Prakash
CCC Gramin
Vikas Evam
Paryavaran
Sanstha
Bikaner
Basadi-Boroda,
Post Udawala,
via Sainthal,
District Dausa,
Rajasthan
Ms. Nisha Seezo
0151-2110285
194
Rajasthan
Seva Mandir
CCC Seva
Mandir
Udaipur
Old Fatehpura,
Udaipur- 313004,
Rajasthan
Ms. Ratan Paliwal
0294-2451041,
2450960
195
Rajasthan
Jeevan Asha
Jaipur
196
Rajasthan
Jeevan Anand
CCC St. William
Educational and
Social Welfare
Society
Jodhpur
Nurses Manual
Page 242
Address
Contact
Person
776/17 E, Housing Board Mr. Kuldeep Chaudhary

Chopashni, Jodhpur
Phone No.
0291 2707498

S.
No.
State
Name of
the CCC
District
197
Gujarat
Karuna Shakti
CCC Kaira
Social Service
Society
Ahmerdabad
198
Gujarat
Navjeevan Trust
CCC
199
Gujarat
200
Address
Contact
Person
Phone No.
Karuna Shakti CCC,

Matikhan Talawadi,
Ramol Gatrad Road,
Nr. Toll-tax Bridge,
Ring Road, Ahmedabad
ksss@gmail.com,
Karunasccc@gmail.com
Sr. Elizabeth
079-22861216/49 &
079-65442593
Rajkot
Jamnagar Road,
Opp. Morbi House,
Post Box No. 36,
Rajkot, Gujarat
Fr. C.C. Jose CMI
0281-2490916
Navjeevan CCC
Navjeevan
Welfare Society
Bhavnagar
Our Lady Pillar

Disceinsary, Plot No.
428/F, Prabhudas Talav,
Ruvapari Road,
Bhavnagar
Sr. Dr. Scholastica

Macwan
(0278) 2573559
Gujarat
Sphoorti
Sabarmati
Samruddhi
Seva Sangh
Mehsana
Sabarmati Sammrudhi
Seva Sangh,
C/o Catholic Ashram,
Post Box No.3,
Ramosana Road,
Mehshana - 384002
Ms. Hemlata
(079) 23227856
201
Gujarat
Jeevan Jyoti
Kripa Foundation
Vadodara
Jeevan Jyot CCC,

Ms. Susan
C/O Kripa Rehabilitation
Centre,At & Post Amodar,
Taluka-Vaghodiya,
Vadoara - 390019
(0265) 5596970
202
Gujarat
Santwana CCC
Jamnagar
203
Gujarat
Sarvjanik CCC
Surat
Sarvjanik Medical
Trust
Pastagia Street,
Nr. Rampura Petrol
Pump, Rampura,
Surat - 395003 (Gujarat)
M. M. Amla
0261-2492678
204
Chattisgarh
Lifeline CCC
Model Bastar
Integrated Rural
Development
Society (BIRDS)
Bastar
C/o MPM Hospital,

Aghanpur, Jagdalpur,
Bastar DT.,
Chhattisgarh - 494005
Fr. K.T. Thomas
07782 229030,
229032
205
Chattisgarh
Holy Cross
Pavitra Cruz
Sisters Society
Sarguja
Holy Cross CCC,

Holy Cross Hospital,
Ambikapur,
DistrictSarguja,
Chattisgarh - 497001
Sr. Juliet Jacob
(+91-79363660)
(+91-9425255922)
206
Chattisgarh
Karuna CCC
Durg
Karuna CCC, Karuna

Hospital, Nandini Road,
Khurispar, Bhillai,
Durg - 490002
Sr. Sushila
0788 - 2296486;
9752898960
207
Chattisgarh
Maria Sahay
CCC
Bilaspur
Maria Sahaya CCC,

Sipat Road, Sarkanda,
Bilaspur - 495006
Sr. Kusum
0775 -22733673;
98983396495

District
Category
Nurses Manual
Page 243
S.
No.
State
Name of
the CCC
Address
Contact
Person
Phone No.
208
Chattisgarh
Jeevodaya CCC Raipur

Jeevodaya Social
& Leprosy
Rehabilitation
Center
Jeevodaya CCC, Social

& Leprosy Rehabilitation
Center, P.O. Abhanpur,
Dt. Raipur,
Chattisgarh - 493661
Fr. Abraham
Thylammanal SAC
0771 2120131
209
Madhya Pradesh
Saathi CCC
Kripa Social
Welfare Society
Ujjain
MIG A 5/16 Mahakal

Vanijyik Kendra,
Ujjain - 456010
210
Madhya Pradesh
Asha Kiran
Jabalpur
Diocesan for
Social Service
Society
Jabalpur
M-54, 7th Lane,

Behind Gupta Hotel,
Sharda Colony,
Shakti Nagar, Jabalpur
Avinash Pillai
9425873616
211
Madhya Pradesh
Maitri Asha
Niketan
Bhopal
Gandhi Bhavan,
Shyamla Hills
Mr. Shaji Chacko
0755-4273848
212
Madhya Pradesh
Vishwas CCC
Pavitra Atma
Sevika Sangh
Indore
R-847, Near Poineer

Convent, Mahalaxmi
Nagar, Indore
Sr. Geeta
0731-2556372
213
West Bengal
Arunima CNI
Calcutta
Diocesan
Central Fund
Kolkatta
81, Diamond Harbour

Road, Barisha,
Kolkata - 700 008
Mr. Suvobrata Das
(033) 6450 8840
214
West Bengal
Snehalaya
Gandhi Mission
Trust
Midnapur
Vill - Dihibaliharpur,
Mr. Badal Maharana
Post - Daspur,
Dist - Paschim Medinipur,
West Bengal - 721211,
India
03225-254217
215
West Bengal
Sparsha
SPARSHA
Howrah
Vill. - Majerati, Banitabla,

P.O. Jadurberi,
P.S. Uluberia, Howrah
Mr. Surja Kanta Ghosh
33 2661 1815
216
West Bengal
Jeshu Ashram
Jesu Ashram
Siliguri
Vill Matigara,
P.O. Matigara,
Dist Darjeeling,
West Bengal
Mr. Ratan Lama
3536453470
217
West Bengal
Chetna CCC
Bardwan
Asansol Burdwan
Seva Kendra
Jhinguti, P.O.- Phagupur,

Burdwan
Mr. Rahul Sonkar
9832713315
218
West Bengal
Sewa Kendra
Sewa Kendra
Kolkotta
Kolkatta
Seva Kendra, Community Mukul Haldar

Care Centre, Seva
Kendra, Calcutta
Extension, Dum Sum,
93, P.K. Guha Road,
Kumarpara,
Dum Dum Cantonment,
Kolkata 700 028
(033) 30239384
219
West Bengal
ASHAAR ALO
CCC Social
Welfare Institute
Malda
P.O. - Phulbari,
Manaskamana Road,
Dist. Malda - 732101,
West Bengal
03512-340900
Nurses Manual
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District
District
Category
0734-2533246
Mr. Selestion Minz

S.
No.
State
Name of
the CCC
District
220
West Bengal
Bhalobasha,
Bhoruka
Jalpaiguri
Bhoruka Bhalobasha,
Tamali Dutta
C/o Mr. Sushil Chandra,
Farm More, Mohit Nagar,
Post - Jalpaiguri-735101
9733263805
221
West Bengal
Anugalaya CCC
Anugyalaya
DDSSS
Darjeeling Hills
4, Mall Villa.,
C.R. Das Road,
Darjeeling - 734101
Mr. Albert Rai
9749091420
222
Bihar
Nai Asha
Nazareth CCC,
Mokama
Nazareth
Hospital Society
Mokama
Nazareth Hospital,
Mokama P.O.,
Patna Dist., Bihar
Sr. Nirmala Mulackal
06132232367 /
233014
223
Bihar
Holy Family,
Bhagalpur
Bhagalpur Holy
Family, Bhagalpur
The Poreyahat Holy

Family Society,
Holy Family Convent,
Tilakmanjhi, Bhagalpur,
Bihar - 812001
Sr. Grace
224
Bihar
Sanjeevani
Sanjeevani
Darbhanga
Darbhanga
Sanjeevini Community
Care Centre,
Hospital Road, Beta,
P.O. Leheriasaria,
Dist. - Darbanga, Bihar
Er. Kaushendra Sanjay

Kumar
225
Bihar
Jeevan Sagar
Fakirana Sisters
Society
Muzaffarpur
Fakirana Sisters Society, Sr. Mary Elise

Sacred Heart Convent,
Bettiah, District West
Champaran, Bihar
0621-2280196
226
Bihar
Navjeevan Kurji
Holy Family
Hospital
Patna
Kurji Holy Family

Hospital, Bihar - 800010
Sr. Francina
0612-2262156
227
Orissa
Ashray LEPRA
Society
Koraput
Behind Collectorate,
Hati Line, Koraput,
Orissa
Mr. Rajendra Chowdhury
06658-252352
228
Orissa
SATHI TSRDS
Ganjam
At/Po- Bahadurpeta,
Dr. P.C. Mahapatra
(On the way to
Gopalpur-on-Sea)
Via- Bhanjabihar, Ganjam
0657-2425999
229
Orissa
Astha CCC
The Medics
Khurda
Near Kalinga Vihar

Phandi, Kalinga Vihar
Phase II, Plot No.
HIG-358, Patrapada,
Bhubaneswar-19
Dr. Dilip Kumar Pradhan
06764-234075;
09437018075
230
Orissa
Kiran CCC Utkal

Sevak Samaj
Cuttack
Plot No. 191, Mahanadi

Vihar, Nayabazar,
Cuttack, Orissa-753004
0671-2444984
ussngo@sify.com
Mr. Amiya Bhusan Biswal 0671-2444984
231
Orissa
Jyothi CCC
Balasore
NA
Jyoti CCC,
Post - Kuruda,
Balasore - 756054
Pretheep Jose/ Fr. Paul

District
Category
Address
Contact
Person
Phone No.
(+91-9308004404)
06782 - 256173
Nurses Manual
Page 245
S.
No.
State
Name of
the CCC
District
232
Tripura
Hepititis
Foundation of
Tripura, Agartala
Agartala,
West Tripura
233
Tripura
Udaipur Bignan
O Sanskriti
Mancha, Udaipur
234
Pondicherry
Shanti Bhavan
Nurses Manual
Page 246
District
Category
Address
Contact
Person
Phone No.
Anandlok, Indra Nagar,

Agartala, Tripura West
Shri Snehangshu
Sekhar Dutta,
9436463337
3812321166
South Tripura
Aaswas,
Nehru Supermarket,
House No. 47/48,
Udaipur, South Tripura
Shri Jaglul Ahsan,

9436521882
0381-223117,
09856140969
Pondicherry

Annexure 34: Ice Breakers & Energizers

Remember these are more fun when the trainers join in!
1. SHAKE ALL HANDS:
Everyone in the room shakes everyone elses hand within a strict time limit of one minute. This gets energy
up, and obliges each participant to acknowledge everyone else.
2. SPACE ON MY RIGHT:
Participants are seated in a circle. The facilitator arranges for the space on their right to remain empty. They
then ask a member of the group to come and sit in the empty space; for example, I would like Lili to come
and sit on my right. Lili moves and there is now a space on the right of another participant. The participant
who is sitting next to the empty space calls the name of someone different to sit on his or her right. Continue
until the entire group has moved once.
3. WHAT WE HAVE COMMON:
The facilitator calls out a characteristic of people in the group, such as having children. All those who have
children should move to one corner of the room. As the facilitator calls out more characteristics, such as
likes football, people with the characteristic move to the indicated space.
4. THE SUN SHNES ON:
Participants sit or stand in a tight circle with one person in the middle. The person in the middle shouts
out the sun shines on... and names a colour or articles of clothing that some in the group possess. For
example, the sun shines on all those wearing blue or the sun shines on all those wearing socks or the
sun shines on all those with brown eyes. All the participants who have that attribute must change places
with one another. The person in the middle tries to take one of their places as they move, so that there
is another person left in the middle without a place. The new person in the middle shouts out the sun
shines on... and names a different colour or type of clothing.
5. BODY WRITIING:
15 Body writing Ask participants to write their name in the air with a part of their body. They may choose
to use an elbow, for example, or a leg. Continue in this way, until everyone has written his or her name
with several body parts.
6. TIDES IN / TIDES OUT:
Draw a line representing the seashore and ask participants to stand behind the line. When the facilitator
shouts Tides out!, everyone jumps forwards over the line. When the leader shouts Tides in!, everyone
jumps backwards over the line. If the facilitator shouts Tides out! twice in a row, participants who move
have to drop out of the game.
7. SIMON SAYS :
The facilitator tells the group that they should follow instructions when the facilitator starts the instruction
by saying Simon says... If the facilitator does not begin the instructions with the words Simon says, then
the group should not follow the instructions! The facilitator begins by saying something like Simon says
clap your hands while clapping their hands. The participants follow. The facilitator speeds up the actions,
always saying Simon says first. After a short while, the Simon says is omitted.

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8. WHAT SOUND IS THIS?

Someone makes a sound and everyone else tries to identify it the person who guesses right makes
another sound. Sounds could include animal and bird noises, machines, vehicles or food preparation.
9. WHERE WERE YOU?
Ask each participant to pull a coin out of their purse and look at the year on the coin. Give them one minute
to think about where they were and what significant event took place during that year. Ask few or all
participants (depending on time) to share their memories in one or two sentences.
10. REFLECTING ON THE DAY:
To help people to reflect on the activities of the day, make a ball out of paper and ask the group to throw
the ball to each other in turn. When they have the ball, participants can say one thing they thought about
the day.
11. WRITING ON BACKS:
At the end of a workshop, ask participants to stick a piece of paper on their backs. Each participant then
writes something they like, admire or appreciate about that person on the paper on their backs. When they
have all finished, participants can take their papers home with them as a reminder
12. TREASURE HUNT
Material Needed: Any object eg Book/ Hand bag/Vase etc. (Treasure)
A thin dupatta to blind fold
Steps:
Ask for a participant to volunteer, without telling the purpose of the game ( Volunteer should trust the
Trainer).
Take her out of the room and blindfold her.
In the meantime, come back and ask the other participants to rearrange the furniture in the room to
create enough space and to make the game more interesting.
Bring the volunteer back in the room, make her feel the treasure and put it at some accessible location
in the room.
Instruct her to hunt for it in the room.
Do not give any explicit instructions to the volunteer or the group on whether she can seek the help
from the group or whether the group can guide her.
Make sure that the volunteer does not hurt herself while hunting for the treasure; If you observe that
the volunteer is finding it difficult to locate the treasure ,keep it at a more convenient location.
Observe the group behavior ie whether they remain silent or assist the volunteer in locating the treasure
(by providing her appropriate directions) - both while you are present in the room or when you move
out; do they wait for instructions from you to guide the volunteer or do they themselves take the
initiative.
Ultimately, when the volunteer is able to successfully hunt for treasure, congratulate her on her efforts
and remove the blindfold.
13. PAPER DANCE (Achieving Maximum with Minimum resources)

Resources Needed: Double page or half page same size old news papers, (depending upon the number
of participants examples for 30 participants take 15 papers).
Process:
Make the group count 1,2,1,2

Divide all the 1s and 2s in two groups and pair them
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Page 248

Distribute one paper to each pair and make them stand comfortably and dance on the paper. Instruct
them to make sure that their feet remain inside the paper only.
After few minutes, ask them to fold the paper in half and dance, with their feet remaining inside the
paper.
Ask the participants to repeat the process, as many times as they can, by folding the paper half every
time (some would be able to do it by folding the paper 5 or 6 times, where as some would stop at 3
or 4 times only)
In the end, ask the participants:
Q 1 qualities needed to do this exercise
Q 2 their feelings during the excercise, and write them on the flip chart
Q 3 What made some of the pairs carried on with the exercise for long?
Write their responses on a flip chart.
SAMPLE ENERGIZERS:
The following can be carried out to music, with brief stops in the music to signal that the movement/role
should change.
Divide the participants into pairs, one person in the front and the other person behind. Get the person
at the back to rub the shoulders of the person in front. The pair turns around and exchange roles.
Get participants of the same size and preferably same gender, to stand back to back. Each person
drops her/his head on the other persons shoulder and relaxes.
Participants can form a semi-circle with the person at the far end bending forwards from the waist,
hands forward and inhaling, and exhaling while coming up, everyone follows suit.
Everyone does spot jogging while facing her/his partner.
Get a small group to stand on either side of a person. The person in the middle gets gently pushed
from one group to another. The person in the middle should not resist or move voluntarily, but just relax
and let others take care of her/him.

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Page 249
Annexure 35 : Role of Nurse at ART and CCCs

Roles and Responsibilities of Nurses at ART Centres
One or two nurses (depending upon the volume of patients) should be deputed to the ART center by the
hospital (or institution). There should be one contractual nurse, in addition, supported by NACO (qualification
being same as far appointment of nurses in the hospital).
Nurses play a very important role at the ART center and their responsibilities include the following:
Dispensing of ARV drugs (till a pharmacist is added to the team)

Counselling of patient
Assisting in record keeping and maintenanceof patient documents
Streamlining and guiding patients at theART center and helping the center to run efficiently and in an
orderly fashion
Coordinating and tracking the referrals made within the hospital by establishing linkage with various
departments and in-patient wards
Nursing care and follow-up of patients admitted in the hospital
Roles and Responsibilities of Nurses at CCCs

The candidate should be a Diploma in nursing from a recognized nursing school/college with experience
of providing nursing care for preferable two years in a public or private health institution.
Nursing Care
Nursing care required for inpatients

Take the vital signs and follow-up readings of the patients as per requirement
Maintaining follow-up charts
Provide medicine intake to the patients as per doctors prescription
Watch out for any changes in condition and report to the doctor
Assist the doctor in OP clinic as well as during ward rounds
Counsel patients on different aspects such as treatment adherence, drug intake as per regimen prescribed,
nutrition and safe sexual behaviour, positive prevention and positive living, reproductive health choices
Provide Anti-natal and Post-natal care
Provide nutritional supplements as required
Maintenance of patient records and case sheets
Administrative Responsibilities
Coordinate and track the referrals from and to other medical facilities
Report on the referred cases from other facilities
Report on stocks of medicines and other consumables
Provide data on the formats required for monitoring
Maintain the drug dispensed register and the stock of drugs received
Function as case manager for overview of the referrals and linkages including integrated care of the
PLHIV case.
In-charge of coordinating the outreach workers to follow the treatment and follow up plan as has been
decided for the PLHIV by the clinical team
Other Responsibilities
Practice Universal precaution principles

Participate in the staff meetings and provide feed back
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SECTION FIVE
Glossary of Terms
amd
References
Nurses Manual
Page 252

Section Five: Glossary of Terms and References
Glossary of Terms
The definitions in this glossary were taken from the Glossary of HIV/AIDS-related Terms compiled
by UNAIDS and available at:
http://www.unaids.org/Unaids/EN/Resources/Terminology/glossary+of+hiv_aids-related+terms.asp.
Terms not found in this UNAIDS database were defined by I-TECH trainers for a training held in
Namibia. These are indicated with an asterisk (*).
Abacavir (ABC)
A nucleoside reverse transcriptase inhibitor antiretroviral medicine used

in HIV infection with at least two other antiretroviral medicines.
Aciclovir
Antiviral medicine used to treat the symptoms of herpes simplex virus

infection, herpes zoster virus (shingles), and disseminated varicella
zoster virus (chicken pox) in immunocompromised patients.
Adherence
The process in which a patient follows a prescription and

recommendations for a regimen of care. The patient participates and
understands plan of care and treatment.
AIDS
Acquired Immune Deficiency Syndrome. The most severe manifestation

of infection with the human immunodeficiency virus (HIV).
AIDS Defining Conditions
Numerous opportunistic infections and neoplasms (cancers) that, in

the presence of HIV infection, constitute an AIDS diagnosis. Persons
living with AIDS often have infections of the lungs, brain, eyes and
other organs, and frequently suffer debilitating weight loss, diarrhoea,
and a type of cancer called Kaposis sarcoma.
ARV
Antiretroviral. Drug used to fight infection by retroviruses, such as HIV

infection.
ART or ARVT
Antiretroviral Therapy. A treatment that uses antiretroviral medicines

to suppress viral replication and improve symptoms.
Asymptomatic
Without symptoms. Usually used in the HIV/AIDS literature to describe

a person who has a positive reaction to one of several tests for HIV
antibodies but who shows no clinical symptoms of the disease.
Bloating
Any abnormal general swelling, or increase in diameter of the abdominal

area.
CD4 Cells
1. A type of T cell involved in protecting against viral, fungal and

protozoal infections. These cells normally orchestrate the immune
response, signalling other cells in the immune system to perform
their special functions. Also known as T helper cells.
2. HIVs preferred targets are cells with a docking molecule called
cluster designation 4 (CD4) on their surfaces. Cells with this
molecule are known as CD4-positive (or CD4+) cells. Destruction
of CD4+ lymphocytes is themajor cause of the immunodeficiency
observed in AIDS, and decreasing CD4+ lymphocyte levels appear
to be the best indicator for developing OIs
CD4 Receptors
The chemical on the surface of a CD4 lymphocyte to which HIV

attaches.*
CD4 Count
A way of measuring ehavi-competency by counting the lymphocytes

that carry the CD4 molecule. Normal is well over 1000/ml of blood. A
count lower than 200 ml is an indicator of AIDS.*

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Compliance
The degree of constancy and accuracy with which a patient follows a

prescribed regimen
Child Custody
. The care, control, and maintenance of a child, which a court may

award to one of the parents following a Divorce or separation
proceeding.
Chronic
The term chronic means lasting a long period of time. In medicine, an

illness may be considered chronic if it has lasted six months or more,
or if there is no expectation of improvement.
Client Initiated Counselling A HIV-prevention intervention initiated by the client at his or her free
will
Code of Ethics
A code of ethics is a set of principles of conduct within an organization

that guide decision making and behaviour. The purpose of the code
is to provide members and other interested persons with guidelines
for making ethical choices in the conduct of their work.
Colostrum
Also known as beestings or first milk,is a form of milk produced by the

mammary glands in late pregnancy and the few days after giving
birth.In humans, it has high concentrations of nutrients and antibodies,
but it is small in quantity. Colostrum is high in carbohydrates, high in
protein, high in antibodies, and low in fat (as human newborns may
find fat difficult to digest).
Combination Therapy
(For HIV infection or AIDS.) Two or more drugs or treatments used

together to achieve optimum results against infection or disease. For
treatment of HIV, a minimum of three antiretrovirals is recommended.
Combination therapy may offer advantages over single-drug therapies
by being more effective in decreasing viral load. An example of
combination therapy would be the use of two nucleoside analogue
drugs (such as lamivudine and zidovudine) plus either a protease
inhibitor or a non-nucleoside reverse transcription inhibitor.
Combivir
A combined pill containing zidovudine and lamivudine that was USFDAapproved in 1997 for the treatment of HIV infection in adults and
adolescents 12 years of age or older.
Cough Hygiene
Procedures to contain infectious respiratory secretions in people

showing symptoms of disease, beginning at initial point of
encounter.Usual respiratory hygiene includes covering the mouth/nose
when sneezing or coughing; using tissues and disposing of them in
no-touch containers; and careful hand washing.
Didanosine (ddI)

DNA
Deoxyribonucleic acid. Except for a few viruses, all living cells carry
genetic information as DNA.*
DOTS
Directly Observed Treatment-Short Course
DOTS PLUS
Directly Observed Treatment-Short Course For Multi Drug Resistant

TB
Drug Resistance
The ability of bacteria and other microorganisms to withstand a drug

to which they were once sensitive and were once slowed in growth or
killed outright.
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Drug Toxicity
The systemic effects of a drug that are related to the overall level of
the medication in the bloodstream. Drug toxicity may occur with
overdosage of a medication, accumulation of the drug in the body
over time or the inability of the patients body to eliminate the drug.
Efavirenz (EFV or EFZ)
A non-nucleoside reverse transcriptase inhibitor for combination use

with at least two other antiretroviral drugs for adults and children with
HIV. Contraindicated in pregnancy; substitute nevirapine for efavirenz
in pregnant women or women for whom effective contraception cannot
be assured.
Efficacy
(Of a drug or treatment). The maximum ability to produce a result,

regardless of dosage. A drug passes efficacy trials if it is effective at
the dose tested and against the illness for which it is prescribed.
ELISA Test
Acronym for enzyme-linked immunosorbent assay. A type of enzyme

immunoassay (EIA) to determine the presence of antibodies to HIV in
the blood or oral fluids. Repeatedly reactive (i.e. two or more), ELISA
test results should be validated with an independent supplemental test
of high specificity, such as the Western blot test.
Epidemiology
The branch of medical science that deals with the study of incidence,
distribution and control of a disease in a population.
Fusion
The stage of the HIV lifecycle in which the virus binds to the CD4
receptor, activates other proteins on the surface of the cell, then fuses
with the T helper or macrophage cell.*
Fusion Inhibitor (FI)
A category of ARV drugs that are designed to attack the fusion stage
of the HIV lifecycle. Drugs in this category are not available in India.*
Generics
All drugs carry a generic namean INN (International Non-proprietary

Name)which is the official name given to the molecule/medicine.
GFATM
Global Fund For AIDS, TB & Malaria
HAART
Highly Active AntiRetroviral Therapy. The name given to treatment

regimens recommended by leading HIV experts to aggressively
suppress viral replication and progress of HIV disease. The usual
HAART regimen combines three or more different drugs such as two
nucleoside reverse transcriptase inhibitors and a protease inhibitor,
two NRTIs and a non-nucleoside reverse transcriptase inhibitor or
other combinations.
HIV
Human Immunodeficiency Virus. The virus that weakens the immune

system, ultimately leading to AIDS.
HIV-1
Human Immunodeficiency Virus Type 1. The retrovirus isolated and

recognized as the etiologic (i.e. causing or contributing to the cause
of a disease) agent of AIDS. HIV-1 is classified as a lentivirus in a
subgroup of retroviruses. Most viruses and all bacteria, plants, and
animals have genetic codes made up of DNA, which uses RNA to
build specific proteins. The genetic material of a retrovirus such as
HIV is the RNA itself. HIV inserts its own RNA into the host cells
DNA, preventing the host cell from carrying out its natural functions
and turning it into an HIV factory.

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HIV-2
Human Immunodeficiency Virus Type 2. A virus closely related to HIV1 that has also been found to cause AIDS. It was first isolated in West
Africa. Although HIV-1 and HIV-2 are similar in their viral structure,
modes of transmission, and resulting opportunistic infections, they have
differed in their geographical patterns of infection.
HIV Antibody Test
If positive, the results of this test indicate that the person has been
exposed to HIV and has developed antibodies to the virus after the
window period of up to 12 weeks has passed.
ICTC
Integrated Counselling & Testing Centre-An ICTC is a place where a

person is counselled and tested for HIV, of his own free will or as
advised by a medical provider
Immunodeficiency
Breakdown in immunocompetence (i.e. the ability of the immune system

to resist or fight off infections or tumors) when certain parts of the
immune system no longer function. This condition makes a person
more susceptible to certain diseases.
Immune Reconstitution
Syndrome
As the number of CD4 cells increases in a patient on HAART, these

cells recognize antigens to which the patient has been previously
exposed, leading to symptoms of the diseases these antigens represent,
e.g. TB. Actual infection may or may not be present.*
Immunology
The study of the immune system.*
Incidence
The number of new cases within a specific period of time.*
Integrase
An enzyme used to integrate HIV DNA into the host cells own DNA.*
Interferon
A protein that can inhibit the development of a virus in a cell.
Interrogation
To ask someone a lot of questions for a long time in order to get

information, sometimes using threats or violence
Lamivudine (3TC)

Lopinavir
A protease inhibitor antiretroviral drug used in combination with two

other antiretroviral medicines.
Mandatory
Required or commanded by authority; obligatory
Maternal Antibodies
Antibodies passed from mother to fetus during pregnancy. Diagnosis

of HIV through antibody testing for infants under 18 months is
complicated by maternal antibodies.
NACO
National AIDS Control Organization-Nodal organisation for formulation

of policy and implementation of programs for prevention and control of
HIV/AIDS
NACP
National AIDS Control Program-Nationwide programme to steer the

HIV/AIDS prevention and treatment programme.
Nelfinavir (NFV)
A protease inhibitor antiretroviral medicine used for the treatment of

HIV infection in combination with two other antiretroviral medicines.
Nevirapine (NVP)
A non-nucleoside reverse transcriptase inhibitor used in HIV infection

in combination with at least two other antiretroviral drugs; used in
prevention of mother-to-child transmission in HIV-infected patients.
Notifiable Diseases
Notifiable diseases are infectious diseases that must be reported to

government officials by law. These diseases can be caused by bacteria,
viruses, parasites, fungi and protozoa
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NNRTI
Non-Nucleoside Reverse Transcriptase Inhibitors. A class of drugs

that inhibit an enzyme used by HIV called reverse transcriptase. The
non-nucleoside reverse transcriptase inhibitors include efavirenz and
nevirapine. They interact with a number of drugs metabolised in the
liver; the dose of protease inhibitors may need to be increase when
they are given with efavirenz or nevirapine. Nevirapine is associated
with a high incidence of rash and occasionally fatal hepatitis. Rash is
also associated with efavirenz but is usually milder. Efavirenz treatment
has also been associated with an increased plasma cholesterol
concentration.
NRTI
Nucleoside Reverse Transcriptase Inhibitors. A category of ARV drugs

that binds to the active site of the HIV reverse transcriptase stopping
the production of HIV DNA. Drugs in this category include zidovudine
(AZT), didanosine (ddl), zalcitabine (ddC), stavudine (D4T), lamivudine
(3TC), and abacavir, zalctabine, tenofovir.*
Occupational Exposure
Occupational exposure refers to exposure to potential blood-borne

infections (HIV, HBV and HCV) that occurs during performance of job
duties.
Opportunistic Infections
(Ois)
Illnesses caused by various organisms, some of which usually do not

cause disease in persons with healthy immune systems. Opportunistic
infections common in persons diagnosed with AIDS include
Pneumocystis carinii pneumonia; Kaposis sarcoma; cryptosporidiosis;
histoplasmosis; other parasitic, viral and fungal infections; and some
types of cancers.
PCR
Polymerase chain reaction. A laboratory method to find and measure

very small amounts of RNA or DNA. It is used as the viral load test
to diagnose HIV in infants and to measure the level of HIV RNA in the
blood of infected persons.*
PEP
Post-Exposure Prophylaxis. The use of ARV therapy just after a

possible exposure to HIV has occurred. Recommended after rape, an
occupational exposure to HIV (e.g. needlestick injury) or just after
birth for infants who are born to HIV infected mothers.*
Personal Protective
Equipments
A part of standard precautions, personal protective clothing or

equipment worn by a health worker, for protection against a hazard,
in particular blood-borne pathogens
PLHIV
Acronym for person/people living with HIV/AIDS.
PMTCT
Acronym for prevention of mother-to-child transmission.
PPTCT
Prevention Of Parent To Child Transmission
Prevalence
The number of cases at any time during the study period, divided by
the population at risk.*
Protease
An enzyme used by HIV to process new copies of the virus after it has
reproduced; drugs specifically aimed at this enzyme are called protease
inhibitors (see below). Human cells also use protease enzymes, but
they are different from the HIV protease.

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Protease Inhibitor (PI)
Antiviral drugs that act by inhibiting the virus protease enzyme, thereby
preventing viral replication. Specifically, these drugs block the protease
enzyme from breaking apart long strands of viral proteins to make the
smaller, active HIV proteins that comprise the virion. If the larger HIV
proteins are not broken apart, they cannot assemble themselves into
new functional HIV particles. The protease inhibitors include
amprenavir, indinavir, lopinavir, nelfinavir, ritonavir, and saquinavir.
Provider Initiated
Counselling
Routine, confidential, HIV testing offered to patients visiting health

institutions
RNA
Ribonucleic acid*
Rapid Test
HIV blood, saliva, urine, or vaginal secretions test that yields same
day results. Only rapid blood (finger stick) tests are currently available
in India.*
Resistance
The ability of an organism, such as HIV, to overcome the inhibitory

effect of a drug, such as AZT or a protease inhibitor.
Retrovirus
A type of virus that, when not infecting a cell, stores its genetic
information on a single-stranded RNA molecule instead of the more
usual double-stranded DNA. HIV is an example of a retrovirus. After
a retrovirus penetrates a cell, it constructs a DNA version of its genes
using a special enzyme called Reverse Transcriptase. This DNA then
becomes part of the cells genetic material.
Reverse Transcriptase
This enzyme of HIV (and other retroviruses) converts the singlestranded viral RNA into DNA, the form in which the cell carries its
genes. Some antiviral drugs approved by the FDA for the treatment of
HIV infection (e.g. AZT, ddI, 3TC, d4T, and ABC) work by interfering
with this stage of the viral life cycle. They are also referred to as
reverse transcriptase inhibitors (RTIs).
Ritonovir
A protease inhibitor antiretroviral medicine used in HIV-infection, as a

booster to increase effect of indinavir, lopinavir or saquinavir and in
combination with two other antiretroviral medicines.
Saquinavir (SQV)
A protease inhibitor antiretroviral medicine used in HIV infection in

combination with two other antiretroviral medicines and usually with
low-dose ritonavir booster.
Sentinel Surveys
This form of surveillance relates to a particular group (such as men

who have sex with men) or activity (such as sex work) that acts as an
indicator of the presence of a disease.
Seroconversion
The development of antibodies to a particular antigen. When people

develop antibodies to HIV, they seroconvert from antibody-negative
to antibody-positive. It may take from as little as one week to several
months or more after infection with HIV for antibodies to the virus to
develop. After antibodies to HIV appear in the blood, a person should
test positive on antibody tests. See Window Period.
Side Effects
Medical problems that result from ARV rug toxicities. Common side
effects include: peripheral neuropathy, lipodystrophy, hepatitis,
pancreatitis, and lactic acidosis.*
STI
Also called venereal disease (VD), an older public health term, or

sexually transmitted disease (STD). Sexually transmitted infections
are spread by the transfer of organisms from person to person during
sexual contact.
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Surveillance
The ongoing and systematic collection, analysis, and interpretation of

data about a disease or health condition. Collecting blood samples for
the purpose of surveillance is called serosurveillance.
Symptomatic
Having evident signs of disease: weight loss, fever, diarrhea, enlarged

glands, oral candida, herpes, skin problems.*
Syndromic Case
Management
The diagnosis and treatment of selected STIs based on the identification

of a syndrome through a clinical flowchart.
Transcription
The process of duplication or copying information from DNA.*
Translation
The synthesis of proteins under the direction of RNA.*
Viral Load
In relation to HIV: The quantity of HIV RNA in the blood. Research

indicates that viral load is a better predictor of the risk of HIV disease
progression than the CD4 count. The lower the viral load the longer
the time to AIDS diagnosis and the longer the survival time.
WHO Staging System
A classification of the clinical stages of HIV disease developed by the

World Health Organization on the basis of clinical manifestations that
can be recognized and treated by clinicians in diverse settings, including
resource-constrained settings, and by clinicians with varying levels of
HIV expertise and training
Window Period
Time from infection with HIV until detectable Seroconversion. During

this time HIV antibody tests will be negative, even though the person
is infected. 90% of infected individuals will test positive within 3 months
of exposure and 10% will test positive within 3 to 6 months of exposure.*
Zidovudine (ZVD or AZT)
A nucleoside reverse transcriptase inhibitor antiretroviral medicine,

zidovudine was the first antiretroviral drug to be introduced. Used in
HIV infection in combination with at least two other antiretroviral drugs,
and in monotherapy of maternal-fetal HIV transmission.

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References
Antiretroviral Therapy of HIV Infection in Infants and Children in Resource Limited Settings: Towards
Universal Access. Recommendations for A Public Health Approach (2006) WHO
Antiretroviral Therapy for HIV Infection in Adolescents and Adults in Resource Limited Settings: Towards
Universal Access. Recommendations for a Public Health Approach (2006) WHO
Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants in Resource
Limited Settings: Towards Universal Access. Recommendations for a Public Health Approach ART
(2006) WHO
Chronic HIV Care with ARV Therapy Including IDU Management: Integrated Management Of HIV/
AIDS At District And Community Level (2004) WHO
Clinical HIV/AIDS Care for Resource Poor Settings (2006) Medicin Sans Frontieres
Clinical Management of Sexually Transmitted Infections in Resource Poor Settings: A Comprehensive
Guide for Clinicians (2004) Vol II Alliance in India.
Estimated Risk and Timing of MTCT in the Absence of Interventions (NACO & IAP, 2006)
Family Health International (2003), HIV/AIDS Care & Treatment: A Clinical Course for People Caring
for Persons Living with AIDS; Arlington: USA
Guidelines for Antiretroviral Therapy for HIV-infected Adults and Adolescents; March 2007; NACO
Guidelines on the Management of Occupational and Non-Occupational Exposure to HIV and PostExposure Prophylaxis; February 2007; NACO
Guidelines for Prevention and Management of Common Opportunistic Infections/Malignancies among
Adult/Adolescents PLWHAs; Final draft November 2006; National AIDS Control Organisation,
Ministry of Health & Family Welfare, Government of India
Guidelines for HIV Care and Treatment in Infants and Children; Nov 2006; NACO, Indian Academy
of Paediatrics, with support from Clinton Foundation, UNICEF, WHO
Holmes KK, Levine R, Weaver M, PhD. Effectiveness of condoms in preventing STIs
IAP Workshop of Safe Injection Practices: Recommendations and Safe IAP plan. (2005). Indian
Paediatrics Vol 42 (Feb 17): 155-161
Magnitude of Paediatric HIV - (Source: AIDS epidemic update 2006, UNAIDS)
McGilvray, M., & Willis, N., All about Antiretrovirals: A Nurse Training Programme, Trainers Manual,
Africaid, 2004, pp. 35-36.
NACO Specialist Training Reference Module, 2005
National AIDS Control Programme, Phase III 2006-2011 Strategy and Implementation Plan Draft, pg
18, 27, 60-85; Jul 19th, 2006; NACO, Ministry of Health and Family Welfare, GOI
Pain Management at the End of Life: A Physicians Self-Study Packet (2006) Maine Hospice Council.
Inc
Palliative Care: Symptom Management and End of Life Care: Integrated Management of Adolescent
and Adult Illness. (2007) Draft WHO
Prevention Strategies for People with HIV/AIDS; International HIV/AIDS Alliance, 2003.
Prevention for Positives, King-Spooner 1999; Vernazza et al. 1999
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Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health
Care Settings. Department of Health and Human Services. Center for Disease Control and
Prevention. [Title]. MMWR 2006;55 (No. RR-14):
Sexually Transmitted Diseases: Policies and Principles for Prevention and Care, UNAIDS/WHO 1999.)
Sexually Transmitted Infections: Treatment Guidelines.(2006) NACO
The Emergence of Palliative Care. (2001) Cancer Control Editorial vol8 (No1):3-5
Training Module for Counsellors on TB and HIV Coordination. (2005). Central TB division and NACO.
Update -Prevention and control of Sexually Transmitted Infections: Draft WHO Global Strategy May
2006; and 1999 WHO data
Understanding and Challenging HIV Stigma Toolkit for Action, Trainers Guide, Developed by Ross
Kidd (Botswana) and Sue Clay (Zambia) September, 2003
Wald A, Link K. Risk of Human Immunodeficiency Virus Infection in Herpes Simplex Virus Type 2Seropositive Persons: A Meta-Analysis. Journal of Infectious Diseases. 2002; 185:45-520)
WHO Training Modules for the Syndromic Management of Sexually Transmitted Infections, 2nd Edition
WHO Case Definition of HIV Surveillance and Revised Clinical Staging and Immunological Classification
of HIV Related Disease in Adults and Children. (2006) WHO
WHO HIV and Infant Feeding Technical Consultation Held on behalf of the Inter-agency Task Team
(IATT) on Prevention of HIV Infections in Pregnant Women, Mothers and their Infants Geneva,
October 25-27, 2006
Website References
http://www.cdc.gov/hiv/resources/factsheets/transmission.htm)
www.undp.org.in/NEWS/UNDP%20August%20Newsletter.pdf
http://www.ccghe.jhmi.edu/assets/CCGHE/Documents/Module4-Confidentiality.pdf
http://www.nacoonline.org/policy.htm
www.fhi.org.
www.mohfw.org
www.unaids.org
www.who.org
www.unicef.org
www.indiannursingcouncil.org

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NURSES MANUAL

HIV/AIDS AND ART TRAINING FOR NURSES

National AIDS Control Organisation

Copyright 2009 by Indian Nursing Council.

First Edition 2009

HIV/AIDS and ART Training for Nurses

Baseline Assessment .......................................................................................................... 162

HIV/AIDS and ART Training for Nurses

SECTION FIVE: Glossary of Terms and References. ...................................................................... 251

HIV/AIDS and ART Training for Nurses

(K. Sujatha Rao)

HIV/AIDS and ART Training for Nurses

HIV/AIDS and ART Training for Nurses

Mr. T. Dileep Kumar

HIV/AIDS and ART Training for Nurses

HIV/AIDS and ART Training for Nurses

Acquired Immune Deficiency Syndrome

Ante Natal Care

Anti Retroviral Therapy

Behaviour Change Communication

Community Based Organisation

Community care centres

Commercial Sex Worker

Deoxy ribo Nucleic Acid Polymerase Chain Reaction

Directly Observed Therapy Short Term

Enzyme-Linked Immunoflourescent Assay

Human Immunodeficiency Virus

Health Care Professionals

Integrated Counselling and Testing Centre

Injecting Drug User

Information Education Communication

Men who have Sex with Men

National AIDS Control Organization

Out Patient Department

Post Exposure Prophylaxis

People Living with HIV/AIDS

Progressive Multifocal Leukoencephalopathy

Personal Protective equipment

Prevention of Parent To Child Transmission

Revised National Tuberculosis Control Programme

State AIDS Control Societies

Syndromic case management

Sexually Transmitted Infection

Targeted intervention programme

White Blood Cell

World Health Organization

HIV/AIDS and ART Training for Nurses

Mr. T. Dileep Kumar

Dr. Asha Sharma

Dr. Manju Vatsa

Ms. Harinder Jeet Goyal,

Dr. Sandhya Gupta,

Dr. Juliana Linnette DSa

Mrs. Sunita Miglani,

Mrs. K.S. Bharati

10. Dr. S.N. Misra

Ms. Deepika C Khakha,

Dr. Dilip Vaswani

12. Ms. Poornima Sharma

HIV/AIDS and ART Training for Nurses

HIV/AIDS and ART Training for Nurses

Section One: About this Course

Goals of the Training

Demonstrate knowledge of HIV prevention, comprehensive care, and antiretroviral treatment