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Nut rit ional care and support
for people living with HIV / AIDS
A t rai ni ng course
aci l i t at or s gui de F
Food and Agricult ure Organizat ion
of t he Unit ed Nat ions
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Facilitator's guide
Nutritional care and support
for people living with HIV/AIDS
A training course
WHO Library Cataloguing-in-Publication Data
World Health Organization.
Nutritional care and support for people living with HIV/AIDS: a training course.
4 pts. in 1 v.
Contents: Director's guide -- Facilitator's guide -- Participant's manual -- Overhead
transparencies.
1.HIV infections - therapy 2.Acquired immunodeficiency syndrome - therapy
3.Diet 4.Nutrition therapy 5.Caregivers 6.Teaching materials I.Title.
ISBN 978 92 4 159189 8 (NLM classification: WC 503.2)
World Health Organization 2009
All rights reserved. Publications of the World Health Organization can be obtained from
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Requests for permission to reproduce or translate WHO publications whether for sale or for
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The designations employed and the presentation of the material in this publication do not imply
the expression of any opinion whatsoever on the part of the World Health Organization
concerning the legal status of any country, territory, city or area or of its authorities, or
concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent
approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers products does not imply that
they are endorsed or recommended by the World Health Organization in preference to others
of a similar nature that are not mentioned. Errors and omissions excepted, the names of
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The World Health Organization does not warrant that the information contained in this
publication is complete and correct and shall not be liable for any damages incurred as a result
of its use.
Printed by the WHO Document Production Services, Geneva, Switzerland
Nutritional Care and Support for People Living with HIV: Facilitators Guide
Table of contents
Page
Acknowledgment iii
Introduction 1
OPENING SESSION 14
SESSION 1: HIV AND NUTRITION 21
SESSION 2: INTRODUCTION TO COMMUNICATION SKILLS 30
SESSION 3: EATING WISELY 45
SESSION 4: FOOD SAFETY FOR PEOPLE WITH HIV AND AIDS 68
SESSION 5: IMPROVING FOOD INTAKE 84
SESSION 6: PREVENTING WEIGHT LOSS AND PROMOTING
PHYSICAL ACTIVITY 95
SESSION 7: NUTRITION FOR PEOPLE ON ANTI-RETROVIAL
TREATMEN (ART) 108
SESSION 8: NUTRITION FOR PREGNANT AND BREASTFEEDING
WOMEN WITH HIV 123
SESSION 9: FEEDING OPTIONS FOR INFANTS OF HIV-POSITIVE MOTHERS 135
SESSION 10: FEEDING A CHILD WITH HIV 149
SESSION 11: IMPROVING ACCESS TO FOOD 161
SESSION 12: THE USE OF NUTRITIONAL SUPPLEMENT AND
HERBAL REMEDIES 171
SESSION 13: COURSE REVIEW AND ACTION PLANNING 180
CLOSING SESSION 188
Annex 1: The story of Sam and Suzi 190
Annex 2: Nutritional care and support focus at different stages of HIV and AIDS 196
Annex 3: Nutritional requirements of people living with HIV 197
Annex 4: Sources of further information 199
Annex 5: Course pre- and posts-test 201
Annex 6: Course evaluation sheets 204
Nutritional Care and Support for People Living with HIV: Facilitators Guide
ii
Nutritional Care and Support for People Living with HIV: Facilitators Guide
iii
Acknowledgement Acknowledgement Acknowledgement Acknowledgement
ThisCoursewasdevelopedbytheWorldhealthOrganization'sDepartmentofNutrition
forHealthandDevelopment(NHD)undertheoverallcoordinationandresponsibilityof
Randa Saadeh. Other WHO staff members who have made significant contributions
include Carmen Casanovas from NHD, Ferima Coulibaly Zerbo and Charles Sagoe-
Mosesfrom WHORegionalOfficefortheAfricanRegion,Nana AkuaTameaAttafuah
and Mary Brantuo from WHO Country offices, Micheline Diepart from the HIV/AIDS
Department and Nigel Rollins from the Department of Child and Adolescent Health
(CAH).
Many individuals have contributed to this Course including the consultant in charge of
developing the initial material (Genevieve Becker) and the updated material (Jecinter
Oketch and Noziqhu Tatiana Ndondo) as well as Hareya Fassil who assisted in the
editingandlayout.
We also would like to acknowledge the contribution and input from the participants of
thefirst fieldtest(Swaziland29Januaryto2February2007),secondfieldtest(Ghana-
12 to 16 November 2007) and the delegates from the six countries (Lesotho, Malawi,
Swaziland, Zimbabwe, Mozambique, Zambia) including Primer Ministers, MOH,
scientists and representatives of UN organizations from South Africa meeting on
"Nutritional Care and Support for people living with HIV: Country experiences of
capacitybuilding"heldinJohannesburg21to23July2008.
Itisexpectedthatthematerialwillberevisedby2015.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
iv
Nutritional Care and Support for People Living with HIV: Facilitators Guide
1
Introduction Introduction Introduction Introduction
Nutrition refers to how food is handled, prepared, shared, eaten and ultimately utilized by the body.
Foods contain different nutrients that are essential for various body functions, such as: the Energy
required for breathing; movement, work and temperature control; growth, building, replacement and
repair of the body tissues; protecting and fighting against infection and helping to recover from
illnesses.Goodnutritionisthereforeakeyfactorforthemaintenanceofgoodhealthandqualityoflife
forallpeople.
Malnutrition can result from inadequate or excessive intake of one or more nutrients. Poor nutrition
reduces a persons ability to work and be active. It also weakens the immune system leading to
frequent illnesses, poor growth and development in children, and an inability to replace and repair
body cells and tissues, resulting in severe weight loss. Excessive intake of food leads to excessive
weightgainassociatedwithhighriskofobesity,heartdiseasesandhighbloodpressure.
ForpeoplelivingwithHIV(PLHIV),poornutritionworsenstheeffectsofHIVbyfurtherweakeningthe
immunesystem.Thismayleadtoamorerapidprogressionofthedisease.Moreover,HIVinterferes
withtheabilitytoaccess,handle,prepare,eatandutilizefood,thusincreasingtheriskofmalnutrition
amongpeoplelivingwithHIV.Foodandnutritionalintakecanaffectadherencetoantiretroviraldrugs
(ARVs)aswellastheireffectiveness.Foodinsecurityandinadequateknowledgeofgoodnutritioncan
thus impede management of the disease, particularly in resource-constrained settings where HIV is
prevalentandhealthcareservicesremaininadequate.
Good nutrition, on the other hand, gives strength, helps to maintain and improve performance of the
immunesystemtherebyprotectingthebodyagainstinfectionanddelayingprogressionofthedisease.
Good nutrition cannot cure AIDS or prevent HIV infection; however, people living with HIV who are
well-nourishedarestrongerandbetterabletofightinfections.Goodnutritionwillalsocomplementand
ensureeffectiveantiretroviraltreatment.
Nutritionalcareandsupport,whichincludescounselling,education,information-sharingandprovision
offood,isthereforeafundamentalcomponentofacomprehensivepackageofcareandsupportforall
PLHIV. Ensuring that PLHIV have access to food of adequate quantity and quality at the individual
and household levels is a critical part of their health care. Maintaining a varied and healthy diet can
helpimprovethe bodysutilizationof nutrientstherebycontributingtothe health ofpeoplelivingwith
HIV.Nutritionalcareandsupportmustbestartedattheearlystagesoftheinfectioninordertoprevent
Nutritional Care and Support for People Living with HIV: Facilitators Guide
2
weightlossandmalnutrition.Suchcareandsupportisoftenprovidedbyavarietyofpeopleincluding
family members, nurses, doctors, dieticians, extension workers, volunteers, community support
workersandothers.Inthiscourse,werefertothesepeopleasserviceprovidersandcaregivers.
Effective management of the food and nutrition implications of HIV requires adequate skills and
capacity at the local level. Especially in countries and regions with limited resources, there is a
recognised need to develop the capacity of community-level health service providers and caregivers
in promoting good nutrition as an important component of improving the health and quality of life of
PLHIV.Thistrainingguideprovidespracticalstepsandinformationtohelpstrengthenlocalcapacity
foreffectivenutritioncareandsupportforpeoplelivingwithHIVinlimitedresourcesettings.
Course aims
Thiscourseaimstoimproveknowledgeandskillsonnutritionalcareandsupportamongcommunity-
level health service providers and other extension workers providing services to PLHIV. The
combinationofknowledgeandcommunicationskillscoveredbythecoursewillenableparticipantsto
provide quality nutrition care and support at various service points, thereby contributing to the
improvementofthenutritionalandhealthstatusandtheoverallqualityoflifeofpeoplelivingwithHIV.
Theinformation,ideasandskillsfromthiscoursecanbeusedinmanyways.Examplesinclude:
One-to-onenutritioncounsellingofapersonlivingwithHIV;
Nutritioneducationtoagroupofindividualsataclinicorinacommunitysetting;
Discussingpracticalsuggestionsandskillswithagroupofcaregivers;
Sharinginformationandskillslearnedwithcolleaguestoincreasetheirknowledge;and
Helpingoneselforafamilymember.
This course includes basic information on communication skills. However, it is not designed to train
people to be HIV counsellors. The nutrition information provided is at a basic level. People with
complex nutrition related concerns or co-morbidities such as diabetes, altered lipid levels and other
conditionswouldneedtobereferredtosomeonewithmoreextensivetraininginnutrition.
Target group
The course and the accompanying training guide are intended for use by community level health
service providers and other extension workers whose activities may include providing general
Nutritional Care and Support for People Living with HIV: Facilitators Guide
3
nutrition information, care and support to individuals or groups of people living with HIV and their
householdmembersandcommunities.
Examplesoftheprimarytargetgroupsare:
Communityhealthworkers
Extensionworkers
Socialworkers
Counsellors
Nutritionists
Nursesanddoctors
Courseparticipantsneednothaveanyspecifictraininginnutrition.However,theyareexpectedto:
becomfortableworkingwithpeoplelivingwithHIV;
havemoderateliteracyandbasiccommunicationskills;
havebasicknowledgeaboutHIV,includingitsmodesoftransmission/prevention;and
be familiar with locally available HIV/AIDS services such as counselling and testing,
prevention,treatmentandcare.
For participants with lower levels of literacy or little experience with classroom work, those needing
additional knowledge on HIV in general or more skills in counselling, the course may need to be
extendedoveralongerperiodtoallowmoretimefordiscussionofadditionalinformation.Sourcesof
suchadditionalinformationtocomplementthisguideandcourseareincludedinA AA Annex nnex nnex nnex4 4 4 4.
Course structure
The training sessions can be delivered as a complete course all at one time. This would take about
12-15hours,notincludingmealbreaks.Alternatively,thesessions,whichvaryinlengthfrom30to90
minutes, can be spread out over a number of weeks. The course can therefore be conducted
intensively over two days or spread out over a longer period, as appropriate. If facilitators or
participantscomefromoutsidethearea,itmaybenecessarytoholdanintensivecourse.Iffacilitators
andparticipantsallcomefromwithinthesamedistrictorinstitution,itmaybemorepracticaltodeliver
apart-timecourseoveralongerperiod.Thenumberofcoursefacilitatorsneededwilldependonthe
chosen format of the course and the number of participants. In general, it is recommended that a
maximumof15participantsbeenrolledforeverytwoorthreefacilitators.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
4
Course sessions
The course starts with an opening session, followed by 12 core sessions covering key aspects of
nutrition care and support for people living with HIV. Each of these 12 main sessionsis designed in
thesamewayandcontainsthreeparts:(a)notesofup-todatebasicknowledgeandprinciplesonthe
topic; (b) practical activities and exercises; and (c) a summary of the key points covered in the
session.Thecourseconcludeswithareviewandplanningsession,followedbyaclosingsession.
Thesequenceanddurationofeachsessionisoutlinedbelow.
1
Session Session Session Session Duration Duration Duration Duration
Openingsession 50minutes
1.
LinksbetweennutritionandHIV 30minutes
2.
Introductiontocommunicationskills 105minutes
3.
Eatingwisely 80minutes
4.
Foodsafety 45minutes
5.
Improvingfoodintake 45minutes
6.
Preventingweightlossandpromotingphysicalactivity 60minutes
7.
Nutritionforpeopleonanti-retroviraltherapy(ART) 70minutes
8.
NutritionforHIV-positivepregnantandbreastfeedingwomen 50minutes
9.
FeedingoptionsforinfantsofHIV-positivemothers 35minutes
10.
FeedingachildlivingwithHIV 45minutes
11.
Improvingfoodaccess 55minutes
12.
Useofnutritionalsupplementsandherbalremedies 40minutes
13.
Coursereviewandactionplanning 70minutes
Closingsession 20minutes
The course is classroom-based and involves a variety of facilitation methods, interactive lectures,
role-plays, group discussions, individual reading and group brainstorming exercises to facilitate the
exchange of ideas and encourage participants to apply knowledge and skills acquired during the
varioussessions.
1
Ifthereareadditionalopeningandclosingceremoniesorspeeches,extratimewillbeneeded.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
5
Course design: the story of Sam and Suzi
There is a story about a couple - Sam and Suzi - which runs throughout the course sessions and is
intended to help participants see how the information presented applies to individuals in real life
situations. Included in the course materials, are three pictures of Sam and Suzi, each illustrating
different times in their lives. Facilitators are expected to select, adapt and use versions of the pictures
thataremostappropriatetotheirparticularlocalculturalcontext.ThefullstoryofSamandSuzicanbe
foundinAnnex1. Annex1. Annex1. Annex1.
Course materials
The course materials are packaged in three different guides, related to each other: (a) the Directors
Guide;(b)theFacilitators Guideand(c) theParticipant'sManual.Thecontentsofeacharedescribed
below.
Directors guide
The Directors Guide contains all the information that the course director needs in order to plan and
prepare for a course, and to select facilitators and participants, starting several months before the
actual programme. It contains lists of the materials and equipment needed, as well as samples of
handoutsandformsthatneedtobephotocopiedforparticipantsbeforethecourse.Italsodescribes
theDirectorsroleduringthecourseitself.
Facilitator's guide
This Facilitator's Guide contains information that the facilitator needs in order to lead participants
throughthecourse.Thisincludes:
Instructionsonhowtoconducteachsessionandtheinformationrequiredforeach;
Practicalexercisestobecompletedbyparticipants;
Lecture/discussionguides,alongwithfocusingquestionsandpossibleanswers;and
Role-playsanddemonstrations.
Afollow-upplancancontainatleastthesetwosteps:
Towardstheendofthetrainingcourse,eachparticipantshouldbeaskedtowriteaplanorlist
ofactionsthatheorshewillundertaketoapplytheskillslearnt.
Course Facilitators (with the assistance of the Course Director whenever feasible, can then
visit each participant in his or her workplace severalmonths later, in order to observe his or
herworkanddiscusswhichactionsheorshehasbeenabletoputintopractice.
Using and adapting the manual for the training course
The contents of this manual are presented in a generic format. As such, some of the technical
information will need to be adapted to the particular local context in which the course is being
delivered. Facilitators will need to read the sessions well in advance in order to identify and collect
local information that may need to be added in some sections or omitted in others to suit particular
local conditions. Adapting the information contained in the manual to local circumstances should
thereforebeconsideredasanessentialpartofpreparingforthetrainingcourse.
Whilethiscourseincludesbasicinformationoncommunicationskills,itisnotdesignedtotrainpeople
to be HIV counsellors. The nutrition information provided is at a general level and people with
complex nutrition-related concerns or co-morbidities,such as diabetes, altered lipid levels and other
conditionswouldneedtobereferredtosomeonewithmoreextensivetraininginnutrition.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
8
Using the Facilitator's Guide
SIGNSUSEDINTHEFACILITATORSGUIDE SIGNSUSEDINTHEFACILITATORSGUIDE SIGNSUSEDINTHEFACILITATORSGUIDE SIGNSUSEDINTHEFACILITATORSGUIDE
:Thissymbolandtypefaceindicatesaninstructiontothefacilitator.
: Thissymbolindicateswhatyoushouldsay/explaintoparticipants;questionsyoushouldask questionsyoushouldask questionsyoushouldask questionsyoushouldask
themarehighlightedinboldface. themarehighlightedinboldface. themarehighlightedinboldface. themarehighlightedinboldface.
: This symbol indicates important points, including key points in each session which the
facilitatorshouldemphasize.
Preparing a presentation
It is important that you are thoroughly familiar with the material, and with the order of ideas in
the presentation. This is necessary even if you are an experienced facilitator and/or
knowledgeableaboutthetopic.
Trytoreadthroughallthesessionsratherthanjustfocusingonthoseyouwillpresent.Having
anideaofhowthedifferentsessionsfittogetherwillhelpyoufocusonthe information for each
session without duplicating material that will be presented in later sessions. It also makes it
easier to draw linkages with information from previous sessions or to defer a question if the
topicwillbecoveredlateroninthecourse.
Research and keep abreast of new information of relevance to the topics covered in each
session.
Readthesessionobjectivesfromyourguidetoknowwhatthesessionaimstoachieve.
Outlinetheprogrammeatthebeginningoftheworkshopanddefinetheobjectivesclearly.
Structureyoursessionssothatbothyouandtheparticipantsunderstandtheobjectivesandthe
contenttobecovered.
Read the preparation section, so that you know what to prepare in advance for the session,
namely,trainingaidsandotherkindsofhelpthatyoumayneed.
Read through the text for each session and practise; be clear about the information to be
coveredandhowtopresentit.
Readthenotesthroughcarefully,andstudytheoverheadsthatgowiththem.
In coordination with the course director, consider splitting some session between two or more
facilitators, particularly long sessions that involve different activities such as, role-plays and
othergroupexercises.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
9
Go through the text, and add in your own notes as necessary, e.g., to remind you of points to
emphasize or those of special local importance. Try to think of your own stories and ways to
presenttheinformationnaturallyinyourownway.
Prepare your overheads and/or flipcharts. Have the overheads required for each session
arrangedinthecorrectorder.
KeepyourFacilitatorsGuidewithyouatalltimesandrefertoitthroughoutthe coursepreparation,
deliveryandfollow-upasneeded.
Giving a presentation
Talk in a natural and lively way. It is preferable to present the information in a conversational
mannerinsteadofreadingoutthepresentationnotesexactlyastheyarewritten.
Speakclearlyandslowly,projectingyourvoicesothatallparticipantscanhearandunderstand
whatyouaresaying.Varythetoneandpaceofyourvoiceasnecessary.
Facetheaudienceandmaintaineyecontactwithparticipantswhenspeaking.Becarefulnotto
block participants' view of the screen or board. Move around the room to keep your audience
engaged.Butavoidturningyourbacktotheaudienceformorethanashorttime.
Usenaturalhandgesturesandfacialexpressionsasnecessary.
Explaintoparticipantsexactlywhateachoverheadorflipchartshows,andhighlightclearlythe
mainpointsfromwhichtheyshouldlearn.Asyouexplaintheinformationinthetext,pointtoit
on the overhead or flipchart so that participants can easily keep track of the key points.
Remember, overheads and flipcharts are only visual aids to help your teaching;do not expect
participantstolearnfromthemwithoutyourhelp.
Preparing role-plays
Thesessionsincludeanumberofshortdemonstrationsofcommunicationtechniquesandotherskills.
Read through these role-play exercises carefully so that you understand the points being made in
each.Makesurethatyouhavealltheequipmentthatyouneed.
Taking part in the role-play exercises can be an effective learning experience for participants as it
increasestheirinvolvementandteachesthemcommunicationskills.Askparticipantstohelpwithrole-
playswellinadvanceofthesessionsothattheyhavetimetopreparethemselvesandtodiscussand
understandwellwhattheyareexpectedtodo.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
11
If you feel that participants are not ready to do the role-plays, ask other facilitators to help
demonstrate the exercises first. This can help participants better understand role-playing and
encouragethemtotakepartthemselves.
Practising role-plays
Practise giving the demonstration by yourself, with your assistant or with another facilitator, so that
you know how long it takes, and to ensure that you have all that is needed, including extra tables,
chairsorotherpropstohelpmakethedemonstrationasconvincingaspossible.
Attheendofeachsession,leavetimeforparticipantstoaskquestions.Doyourbesttoanswerthem.
You do not need to know the answer to every question. Other participants may be able to offer
informationoryoucanreferthemtoalocalsourceoffurtherinformation.
Basic requirements of a facilitator and principles of adult learning
This section explains the basic requirements of a facilitator as well as the principles and
methodologies underlying adult learning that should to guide the course. You should read it before
youstartconductingsessions.
Thefacilitatorshould:
Have a warm and welcoming manner and an ability to show approval and acceptance of
participants.
Beabletodevelopagoodrapportwiththegroup.
Beenthusiasticaboutthesubjectandhaveacapacitytodeliveritinaninterestingway.
Be able to create an interactive environment, i.e. by asking questions, moving around the
room,alwaysaddressingthewholegroup,andavoidingfocusingonasmallgrouporindividual.
Alwaysspeakclearlyandinunderstandablelanguage,addressingallparticipants.
Beabletoleadwithoutstiflingparticipation.
Thefacilitatorneedsto:
Ensure that the appropriate visual materials, such as flipcharts or overhead transparencies/
projectorsareavailableandready.
Keepvisualaidssimpleandlegible.
Usetheroomandvisualaidsasrequiredwithoutcreatinginterferenceintheprocess.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
12
Regularly check that participants understand the information being presented and keep them
interestedandengaged.
Useinteractivetechniques,suchasaskingopen-endedquestionswhichrequireparticipantsto
explainandgivedetailedanswersthatdemonstratetheircomprehension.
Ask participants to keep their manuals closed while answering discussion questions so that
theythinkaboutpossibleanswersratherthanreadingtheinformationfromtheirmanuals.
Give participants a genuine chance to arrive at the answers to the questions included in each
sessionthemselves.Questionsareaskedinsuchawaythatparticipantsshouldbeabletofind
theappropriateanswerbylookingattherelevantfiguresdisplayedorbydrawingfromtheirown
experience,orfrommaterialthathasbeencoveredpreviouslyinthecourse.
Sometimes,participantsmayneedadditionalhelpinfindingtheanswer;insuchcases,youmayopt
togivethemahint.Inotherinstances,youmayfindthataskingthequestionagaininadifferentway
canhelp.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
13
REMEMBER REMEMBER REMEMBER REMEMBER! !! !
HIV HIV HIV HIVisaveryemotivetopic.Beawarethatparticipantsmayhavestrongfeelingsaboutthistopic. isaveryemotivetopic.Beawarethatparticipantsmayhavestrongfeelingsaboutthistopic. isaveryemotivetopic.Beawarethatparticipantsmayhavestrongfeelingsaboutthistopic. isaveryemotivetopic.Beawarethatparticipantsmayhavestrongfeelingsaboutthistopic.
It is also likely that some participants are themselves living with HIV or have close family or It is also likely that some participants are themselves living with HIV or have close family or It is also likely that some participants are themselves living with HIV or have close family or It is also likely that some participants are themselves living with HIV or have close family or
frie frie frie friends who are living with the disease. Help participants to understand and accept each others nds who are living with the disease. Help participants to understand and accept each others nds who are living with the disease. Help participants to understand and accept each others nds who are living with the disease. Help participants to understand and accept each others
experiencesandperspectivesandtoshowmutualrespectwithoutpassingjudgement.Avoidand experiencesandperspectivesandtoshowmutualrespectwithoutpassingjudgement.Avoidand experiencesandperspectivesandtoshowmutualrespectwithoutpassingjudgement.Avoidand experiencesandperspectivesandtoshowmutualrespectwithoutpassingjudgement.Avoidand
rectifyanycommentsthatcansoundcriticalofthoseinfectedoraffec rectifyanycommentsthatcansoundcriticalofthoseinfectedoraffec rectifyanycommentsthatcansoundcriticalofthoseinfectedoraffec rectifyanycommentsthatcansoundcriticalofthoseinfectedoraffected. ted. ted. ted.
Checklistoffacilitationskills Checklistoffacilitationskills Checklistoffacilitationskills Checklistoffacilitationskills
Takecentrestage;avoidstandinginacornerorbehindadesk.
Facetheaudience;donotfacetheboardorscreenwhenspeaking.
Avoidblockingtheaudiencesview.
Makeeye-contactwithpeopleinallsectionsoftheaudience.
Movements Movements Movements Movements
Usenaturalgesturesandfacialexpressions.
Move around the room; approach people to get their attention and
encouragetheirparticipation.
Speakclearly,slowlyandloudlyenoughforeveryonetohear;benaturaland
lively;varythetoneofyourvoiceasappropriate.
Speech Speech Speech Speech
Writedifficultnewwordsontheflipchart;pronounceandexplainthem.
Interact with and engage all participants; address them by name as
appropriate.
Ask the questions suggested in the text; ask different participants;
encouragequietparticipantstospeak.
Allow time for participants to answer; do not give the answers too quickly;
drophintsifneeded.
Respondencouraginglyandpositivelytoallanswers;correcterrorswithtact
andsensitivity.
Interaction Interaction Interaction Interaction
Avoid discussions which are off the point or distracting; postpone them if
necessary.Trytogivesatisfactoryanswerstoquestionsfromparticipants.
Have the required aids and equipment ready; check and arrange them
beforethesession.
Makesurethateveryonecanseeclearly;arrangetheroomsotheycan
Point to what you are talking about on the projector or on the screen as
appropriate.
Ifusingaflipchartoraboard,writeinlarge,clearletters.
Visualaids Visualaids Visualaids Visualaids
Cover,turnoff,orremovevisualaidsthatarenotinuseanymore.
Followthesessionplanaccuratelyandcompletely;useyourguide.
Prepare thoroughly; read and obtain any materials that you need
beforehand.
Prepare your helpers (e.g., for role-plays) before the session; practise if
possible.
Useofmaterials Useofmaterials Useofmaterials Useofmaterials
Donotlearnthesessionbyheart;followtheguidebuttalkinyourownway.
Emphasizeimportantpoints;trytoavoidrepetitionunlessreallyuseful.
Dogiveafewlocalexamples;avoidintroducingtoomuchextramaterial.
Ifitisnecessarytoreadfromtheguide,lookattheaudienceregularly.
Timemanagement Timemanagement Timemanagement Timemanagement
Keep to time: pace yourself; gauge the group regularly to ensure that you
arenotmovingtoofastortooslow;donottaketoolongwiththeearlyparts
ofthesession.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
14
Start by introducing yourself then ask other facilitators and participants to take turns introducing
themselves.
AskthemtodescribetheirresponsibilitiesinrelationtonutritionandHIV,wheretheyworkandto
mentiononeexpectationfromtheworkshop.
Ask your co-facilitator to help you write down participants expectation from the course on the
flipchartandpostthecompletelistonthewall.
Giveinformationonadministrativematters(e.g.perdiem,facilitiesinthetrainingsite,etc.)
Askparticipantsiftheyhaveanyquestionsontheaboveandansweranyquestionsraised.
Usethefollowinginformationforfurtherexplanation:
Infection with Human Immunodeficiency Virus (HIV) causes reduction in the bodys natural
defence system against diseases and infections leading to the Acquired Immunodeficiency
Syndrome(AIDS).
As the immune system weakens, the body becomes less able to fight infections. Other germs
takeadvantageofthisopportunityandcausevariousillnessessuchaspneumonia,tuberculosis,
oralthrushandotheropportunisticinfectionsfurtherweakeningthebody.
Whenapersonstartsdevelopingtheseopportunisticinfectionshe/shehasAIDS.Theamountof
timeittakesforthepersontoadvancefromHIVinfectiontoAIDSandhis/heroverallqualityoflife
dependsonthegeneralhealthandnutritionalstatusoftheperson.
Goodnutritionisimportanttoeveryone.Apersonwhoiswell-nourishedmayhaveabetterquality
of life. He/she is stronger and better able to fight infections. This is true for all people but is
especiallyimportantforpeoplewithHIVwhoaremoresusceptibletorecurringinfections.
On the other hand, people living with HIV are at a higher risk of malnutrition as HIV increases
nutritionalneedsevenduringearlystagesofHIVinfection,whennosymptomsareapparent.The
demandincreasessignificantlyduringthecourseof theinfectionposingadditionalchallengesto
peoplelivingwithHIVandtheircareproviders.
People living with HIV and their families need care and support. This care and support may be
provided by nurses, doctors, dieticians, other health workers, lay counsellors, support workers,
familiesandotherpeople.
During this course, we will discuss ways to support people living with HIV to enable them to be
better nourished.Foodisnota magicsolution.ItwillnotstoppeopledyingofAIDS.However,it
canhelppeoplelivelonger,bemorecomfortableandleadlivesthataremoreproductive.
ShowOverhead Overhead Overhead OverheadOpening/ Opening/ Opening/ Opening/1 11 1 andoutlinetheaimsandobjectivesofthecourse.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
17
OVERHEADOPENING/ OVERHEADOPENING/ OVERHEADOPENING/ OVERHEADOPENING/1:COURSEAIMS 1:COURSEAIMS 1:COURSEAIMS 1:COURSEAIMS
The aim of this course is to assist community level health service providers community level health service providers community level health service providers community level health service providers and other other other other
extensionworkers extensionworkers extensionworkers extensionworkersto:
Improve their knowledge and skills on nutrition care and support for people living with
HIV;
Understand the importance of using good communication skills when providing nutrition
careandsupportforpeoplelivingwithHIV;and
BeabletoeffectivelytransferthekeynutritionmessagestopeoplewithHIV,theirfamily
membersandthecommunity.
Course objectives
Bytheendofthetrainingcourseparticipantswillbeableto:
ExplainthelinkbetweennutritionandHIV.
DiscusstheeffectsofHIVonnutrition.
DescribethebenefitsofgoodnutritionforpeoplelivingwithHIV.
Demonstrateappropriatecommunicationskillsfornutritioncounselling.
DescribehowtomanageHIV-relatedsymptomsthatreducefoodintake.
Discussthebasicprinciplesofeatingwisely.
DiscussfoodsafetyforpeoplelivingwithHIVandAIDS.
Outlineguidelinesforpreventingweightlossandpromotingphysicalactivity.
Discussmanagementoffood-druginteractions.
DiscussappropriatenutritionforHIV-positivepregnantandbreastfeedingwomen.
DiscussfeedingoptionsforinfantsofmotherslivingwithHIV.
DiscussfeedingchildrenwithHIV.
Describetheoptionsforimprovingfoodaccess.
Evaluateandprovideadviceabouttheuseofnutritionalsupplementsandherbalremedies.
GiveanoverviewofthetrainingmethodologyandanexplanationaboutSamandSuzisstory.
Methodology
The course will include interactive lectures, role-plays, group discussions, individual reading and
brainstorming to facilitate exchange of ideas and encourage participants to apply knowledge and
skillsfromthesessions.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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The story of Sam and Suzi
The story of Sam and Suzi runs through the course so that you can see how the information
appliestoindividuals.
YouwillfindthefullstoryofSamandSuziinAnnex1. Annex1. Annex1. Annex1.
EachsessioncontainspartsofSamandSuzisstoryrelevanttothatsession.
AlsoincludedarethreepicturesofSamandSuzi,eachillustratingdifferenttimesintheirlives.
Show the three different pictures of Sam and Suzi as overheads or posters; use the versions
appropriatetothelocalarea(seeAnnex Annex Annex Annex1 11 1).
Askparticipantstoturntopage6-7oftheParticipant'sManualwheretheywillfindtheglossaryof
terms.Youmaywishtoaskoneparticipanttoreadthefirstterm,anothertoreadthenextandso
onuntiltheyareallread.Checkforunderstandingofthetermsandclarifywherenecessary.
5. Review the glossary of terms (10 minutes)
Following are definitions of some of the terms that will be used frequently throughout the
course.Askparticipantstotaketurnsreadingthetermsanddefinitionsoutloud.
Caregiver Caregiver Caregiver Caregivers ss s Persons who assume responsibility for providing care to those in need. They
maybehealthworkers,supportworkers,community-basedcareproviders,family
membersandfriends,etc.
Disclosure Disclosure Disclosure Disclosure When a person with HIV reveals his/her status to other persons. There may be
fear of disclosing ones HIV status if the disclosure could result in the person
beingisolatedfromhis/herfamilyorcommunity,stigmatised,oratriskofphysical
orpsychologicalharm.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Energy Energy Energy Energy Can mean the way a person feels, such as when he or she says, I am full of
energyorIhavenoenergy.Theword energy energy energy energyisalsousedtodescribefuelfor
the body. All foods can provide energy (fuel) though some foods provide more
energythanothers.
Food Food Food Food- -- -borneillness borneillness borneillness borneillness Illnesses caused by eating contaminated food containing harmful pathogens or
germs.
HIV HIV HIV HIV Human immunodeficiency virus is one of a family of viruses known as
retroviruses. HIV infects and destroys special white blood cells called CD4+
lymphocytes. These cells are an important part of the bodys immune system,
which is the bodys defence against infection. A person HIV HIV HIV HIV- -- -infected infected infected infected or HIV HIV HIV HIV- -- -
positive positive positive positivemeansthepersonhasbeentestedandthetestresultshowsthattheHIV
virusispresentinhis/herbody.
Immunesystem Immunesystem Immunesystem Immunesystem The processes in the body that help resist or overcome infections. These
processesneednutrientstoworkproperly.
Malabsorption Malabsorption Malabsorption Malabsorption Failure to absorb one or more nutrients from the food eaten into the body. This
mayoccurifthe:
gutwallisdamaged;
foodmovestooquicklythroughthegut(e.g.inthecaseofdiarrhoea);or
bodyprocessesarenotworkingadequately,e.g.ifthedigestionorgansdo
notproduceenoughfluidstobreakdownfoods.
Nutrients Nutrients Nutrients Nutrients Nourishing substances or components of food released during digestion and
absorbedtobeusedtopromotebodyfunctions.Nutrientsmaybedividedinto:
Macronutrients(protein,fatsandcarbohydrates)
Micronutrients(vitaminsandminerals).
Thiscoursefocusesonfoodsthatweeatratherthantheindividualnutrientsthat
makeupthesefoods.
Nutrition Nutrition Nutrition Nutrition Broad term referring to processes involved in eating, digestion and utilization of
food by the body for growth, reproduction and maintenance of health. It also
helpsunderstandtherelationshipbetweenfoodandthebody.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Nutritionalstatus Nutritionalstatus Nutritionalstatus Nutritionalstatus The extent to which the individual needs for nutrients are being met. Weight,
heightandothermeasuresofgrowthareoftenusedtoindicatenutritionalstatus.
Clinicalindicators,suchaslevelsofnutrientsintheblood,urine,boneaswellas
otherareas,aremoredifficulttomeasure.
People living with HIV People living with HIV People living with HIV People living with HIV (PLHIV) (PLHIV) (PLHIV) (PLHIV) A general term used for all people infected with HIV, whether or not
theyareshowinganysignsand/orsymptomsofinfection.
Symptomatic Symptomatic Symptomatic Symptomatic An observable change in the body that indicates the presence of disease. The
opposite of this term is asymptomatic asymptomatic asymptomatic asymptomatic and means that the symptoms of a
conditionarenotpresenteventhoughapersonhasdisease.
Viralload Viralload Viralload Viralload The amount of HIV in the blood of an HIV-positive person. The higher the viral
loadthehighertheriskofdiseaseprogressingintoAIDS.
Foodprovidesnutrientswhichareusedbythebodyto:
Growandreplacecellswhentheyhavebeendamaged.
Produceenergyforwork,movementandwarmth.
Carryoutotherbodyfunctionssuchasdigestionandmetabolism.
Protectagainstandhelptorecoverfromdisease.
Ifthebodydoesnotgetenoughfood,itcannotfunctionproperly.Eventheimmunesystemwhich
isthebodysfightingforceagainstallthedifferentdiseaseswillbeweakened.
In a later session, we will talk more about making food choices in order to provide enough
nutrientstothebody.
Inthissession,wewilldiscussmoreaboutthelinksbetweenHIVandnutrition,specifically:
HowHIVcanaffectnutritionalstatusandqualityoflife;
The benefits of nutrition in the care and support for people living with HIV and their
families.
2. The links between HIV and nutrition (7 minutes)
Explainthefollowing:
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Poor nutrition quickens the progression from HIV to AIDS while good nutrition slows down the
progression from HIV to AIDS. This can be explained with the cyclical link between HIV and
nutrition.
ShowO OO Overhead1/1 verhead1/1 verhead1/1 verhead1/1: :: : The The The The bad bad bad badcycle cycle cycle cycle of of of of p pp poor oor oor oorn nn nutritionandHIV utritionandHIV utritionandHIV utritionandHIV. .. .
OVERHEAD1/1:THE' OVERHEAD1/1:THE' OVERHEAD1/1:THE' OVERHEAD1/1:THE'BAD BAD BAD BADCYCLEOFPOORNU CYCLEOFPOORNU CYCLEOFPOORNU CYCLEOFPOORNUTRITIONANDHIV TRITIONANDHIV TRITIONANDHIV TRITIONANDHIV
W WW Whatdoyouseeinthispicture? hatdoyouseeinthispicture? hatdoyouseeinthispicture? hatdoyouseeinthispicture?
Give participants a few minutes to identify what they see. Write down their responses on a
flipchart(oraskaco-facilitatortowritethemforyou)fordiscussion.Explainthefollowing:
HIV weakens the bodys natural defence system against disease and infection; as a result, the
bodysabilitytofightinfectionisgreatlyreduced.
With weakened ability to fight infections, the body becomes vulnerable to infections which
normally may have not affected the person. Frequent infections and diseases make the body
weakerandacceleratetheprogressionfromHIVtoAIDS.
HIVandfrequentinfectionsincreasethenutritionneedsofpeoplelivingwithHIV.However,they
maynotbeabletotakeenoughfoodtomeettheseneeds.Thisisusuallyduetolossofappetite,
Weakened Immune System
Poor ability to fight HIV
and other Infections
Increased Vulnerability to Infections
e.g. enteric infections, flu, TB, etc.
Increased Nutritional Needs
Inability to meet increased nutritional
needs for fighting infection and viral
reproduction due to:
Loss of appetite;
Inadequate food intake; and
Poor absorption of nutrients.
Poor Nutrition
Weight loss;
Muscle wasting;
Weakness; and
Micronutrient deficiency.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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poor absorption and the changes in the way food is utilized by the body resulting from HIV and
frequentinfections.
The poor intake of food leads to loss of weight, body weakness, and malnutrition, which further
weakensthebodysnaturaldefencemechanism,thusaggravatingthisbadcycle.
In the early stages of infection a person shows no visible signs of illness. But later many of the
signs of AIDS will become apparent, including weight loss, fever, diarrhoea and other
opportunisticinfectionssuchas,sorethroatandtuberculosis(TB).Poornutritionmayaccelerate
theonsetoftheseinfections.
Explain that the discussion in the rest of thissession focuses on how people living with HIV can
avoidorbreakthebadcycleofpoornutritionandHIV.
ShowOverhead1/2: Overhead1/2: Overhead1/2: Overhead1/2:The The The Theg gg good ood ood oodc cc cycleof ycleof ycleof ycleofg gg good ood ood oodn nn nutritionandHIV utritionandHIV utritionandHIV utritionandHIV. .. .
Ifapersoniseatingwell,whateffectcouldthishaveontheHIV Ifapersoniseatingwell,whateffectcouldthishaveontheHIV Ifapersoniseatingwell,whateffectcouldthishaveontheHIV Ifapersoniseatingwell,whateffectcouldthishaveontheHIV- -- -nutrition nutrition nutrition nutritioncycle cycle cycle cycle? ?? ?
Give participants a few minutes to respond by identifying what they see. Write down their
responsesonaflipchart(oraskaco-facilitatortowritethemforyou)fordiscussion.
Discussthefollowingpoints:
The bodys defence system is strengthened against disease and infection and the body has
enough stores of nutrients. The body can therefore easily respond to infection and delay
progressiontoAIDS.
Thebodycanbetterresistinfection.ThishelpspeoplelivingwithHIVtostaystrongerandableto
eatwellandabsorbnutrientsrequiredbythebody.
When people living with HIV are able to meet their bodys food needs, they willnot lose weight;
theywillbeabletostaystrongandwell-nourished.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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OVERHEAD1/2:THE OVERHEAD1/2:THE OVERHEAD1/2:THE OVERHEAD1/2:THEGOODCYCLE GOODCYCLE GOODCYCLE GOODCYCLE OFGOODNUTRITIONANDHIV OFGOODNUTRITIONANDHIV OFGOODNUTRITIONANDHIV OFGOODNUTRITIONANDHIV
Showthekeypointdisplayed.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Awell Awell Awell Awell- -- -nourishedpersonhasastrongerbodytofightinfectionandcopewithHIV nourishedpersonhasastrongerbodytofightinfectionandcopewithHIV nourishedpersonhasastrongerbodytofightinfectionandcopewithHIV nourishedpersonhasastrongerbodytofightinfectionandcopewithHIV. .. .
Readitandreinforceitwiththefollowingexplanation:
The well-nourished body is able to build strength to fight HIV and other infections because the
bodyhasenoughnutrientsstored.Theimmunesystemisstrengthenedevenfurtherandthecycle
continues.
3. The effects of nutrition on HIV (7 minutes)
ThethreewaysinwhichHIVcanaffectthenutritionalstatusofapersonareby:
Reducingfoodintake;
Loweringfoodabsorption;and
Increasingenergyrequirements.
Discussthesethreeeffectsinturn,askingparticipantsaboutthepossiblecausesofeach.
Good Nutritional Status
Weight gain
Muscle size maintained
Strong body
Nutritional Needs Well-met
Adequate food intake/
absorption
Reduced Vulnerability to Infections
Slower progression of HIV to AIDS
Strengthened Ability to Fight
HIV and Other Infections
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Giveparticipantsafewminutestogivetheirsuggestionsandlisttheirresponsesonaflipchartfor
discussion.
Explainthefollowing,focusingonlyonanswersthatmayhavebeenmissed.
Emphasizethefollowingpoints:
For those who are losing weight, add extra quantities of fats and oils such as, butter, margarine
andcookingoiltoincreaseenergyintake.Ifdiarrhoea,vomitingordiscomfortarisesduetothese
increasedintakes,thenreduceintaketoalevelthebodyisabletotolerate.
Refer participants to page 13 of their manual. Ask a participant to read the following statement
andemphasizeitsimportance:
Since the effects of HIV starts even in the early stages of HIV infection, nutrition becomes an
important aspect of care for people living with HIV at all times. It is thus important to find
appropriate ways of encouraging healthy eating as soon as possible so that the person stays
healthy.
4. The benefits of nutrition care and support for PLHIV and their families
(6 minutes)
Good nutrition is particularly important at the initial stages of HIV infection. Nutrition counselling
andeducationatthisearlystagegivesthepersonachancetobuilduphealthyeatinghabitsand
totakeactiontoimproveaccesstofoodandadoptotherhealthypractices.
I II IfapersonhasHIV,whatdifferencew fapersonhasHIV,whatdifferencew fapersonhasHIV,whatdifferencew fapersonhasHIV,whatdifferencewould ould ould oulditmakeifthey itmakeifthey itmakeifthey itmakeiftheywere were were werewell well well well- -- -nourished? nourished? nourished? nourished?
Takeresponsesfromafewparticipants.
Show Overhead 1/3 Overhead 1/3 Overhead 1/3 Overhead 1/3: Impact of good nutrition for people living with HIV. Ask participants to
commentonthisoverhead.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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OVERHEAD1/3:IMPACTOFGOODNUTRITIONFORPEOPLELIVINGWITHHIV OVERHEAD1/3:IMPACTOFGOODNUTRITIONFORPEOPLELIVINGWITHHIV OVERHEAD1/3:IMPACTOFGOODNUTRITIONFORPEOPLELIVINGWITHHIV OVERHEAD1/3:IMPACTOFGOODNUTRITIONFORPEOPLELIVINGWITHHIV
UsethefollowingpointstoemphasizetheimportanceofgoodnutritionforpeoplelivingwithHIV:
PeoplelivingwithHIVwhoarewell-nourishedarelikelyto:
Haveimprovedqualityoflife,beingabletoworkandcontributetothefamilysincome;
Haveprolongedgoodhealth,remainingactiveandabletocareforthemselvesandhelpwith
thecareofchildrenandotherdependants;
Have reduced illnesses and recover more quickly from infections, thereby reducing costs for
healthcare.
Maintainagoodappetiteandstableweight.
ChildrenwithHIVwhoarewell-nourishedcan:
Gotoschoolregularly,resultinginbettereducationanddevelopment;
Havemoreenergytoplayandhavefun.
TheprovisionofnutritioncareandsupporttopeoplelivingwithHIVandtheirfamiliespromotes
well-being,self-esteemandapositiveattitudetowardslife.
GoodnutritionshouldbeoneofthegoalsofcounsellingandcareforPLHIV.
Effectivenutritioncounselling,careandsupportwillimprovethequalityoflifeofpeopleliving
withHIV.
As health workers and caregivers we need to have knowledge and skills that can help
improvethenutritionforpeoplelivingwithHIV.Forexample,counsellorsmayencouragewise
eatingevenonabriefvisit.
Improved
quality of life
Remains active
and productive
Maintains a good appetite
and stable weight
Less illness and ability
to recover more quickly
WELL-NOURISHED
PERSON LIVING WITH HIV
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5. Summary of the session and transition (5 minutes)
Show/reviewthekeypointdisplayedagain.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Awell Awell Awell Awell- -- -nourishedpersonhasastrongerbodytofightinfectionandcopewithHIV nourishedpersonhasastrongerbodytofightinfectionandcopewithHIV nourishedpersonhasastrongerbodytofightinfectionandcopewithHIV nourishedpersonhasastrongerbodytofightinfectionandcopewithHIV. .. .
Food is vital to keep our body working. A well-nourished person has a stronger body for coping
withHIVandfightingadditionalinfections.
MalnutritioninpeoplelivingwithHIVmayresultinweightloss,duetomusclewastingandlossof
bodyfat.Italsoincreasestheriskofinfections,resultingin,e.g.mouthsoresanddiarrhoea,which
inturnfurtherlimitfoodintakeandabsorption.
Good nutrition is veryimportant from the time a person isinfected with HIV. Nutritional care and
supportcanimprovethequalityoflifeofapersonlivingwithHIV.
Askifthereareanyquestions,orifanythingneedsclarifying.
Inthenextsession,wewilldiscusscommunicationskills.
Thenextsessionwillbepresentedby:
Statethenameofthepresenter.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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S SS Session ession ession ession2: 2: 2: 2:Introductiontocommunicationskills Introductiontocommunicationskills Introductiontocommunicationskills Introductiontocommunicationskills
Learning Learning Learning Learningo oo objectives bjectives bjectives bjectives
Bytheendofthissession,participantswillbeableto:
Explaintheimportanceofusingacounsellingapproachwithclients;
Demonstratetheappropriateuseofthesixlisteningandlearningcommunicationskills;and
Demonstratetheappropriateuseofthesixskillsforbuildingconfidenceandgivingsupport.
Session Session Session Sessiono oo outline utline utline utline
Content Content Content Content Time Time Time Time
1 Learningobjectivesandintroductiontothesession 5minutes
2 Introductiontocommunicationskills 15minutes
3 Environmentforcommunication 10minutes
4 Skillsthatfacilitatethecounsellingprocess 50minutes
5 Role-plays 20minutes
6 Summaryofthesessionandtransition 5minutes
Total Total Total Total 105minutes 105minutes 105minutes 105minutes
Preparation for the session
Thissessionshouldbepreparedandconductedbyatleasttwofacilitators.Thisisoneofthe
mostimportantsessions.
Healthandnutritionworkersandothercaregiverswillgainsomecommunicationcompetenciesto
betterconveynutritionmessagestotheirclients.
Writeanddisplaythelearningobjectivesonasheetofflipchartpaper.
Writethekeypointsonaflipchartsheetandkeepitasideuntilneeded:
KEYPOINTS KEYPOINTS KEYPOINTS KEYPOINTS
Whenyouensurephysicalcomfort,listenandtalkaboutfoodandeating, Whenyouensurephysicalcomfort,listenandtalkaboutfoodandeating, Whenyouensurephysicalcomfort,listenandtalkaboutfoodandeating, Whenyouensurephysicalcomfort,listenandtalkaboutfoodandeating,
youshowthatyoucareabouttheperson youshowthatyoucareabouttheperson youshowthatyoucareabouttheperson youshowthatyoucareabouttheperson. .. .
Whenyouassureconfidentialityandgiveclientssupportbypraisingtheirpositiv Whenyouassureconfidentialityandgiveclientssupportbypraisingtheirpositiv Whenyouassureconfidentialityandgiveclientssupportbypraisingtheirpositiv Whenyouassureconfidentialityandgiveclientssupportbypraisingtheirpositive e e e
practicesrelatedtofoodandeating,youhelpbuildtheirself practicesrelatedtofoodandeating,youhelpbuildtheirself practicesrelatedtofoodandeating,youhelpbuildtheirself practicesrelatedtofoodandeating,youhelpbuildtheirself- -- -confidence confidence confidence confidence.
Write each communicationskill on different coloured papers ready to stick on the flipchart when
needed.
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Collect/preparethefollowingtrainingmaterials:
An overhead projector and screen; and/or a flipchart stand, flipchart paper, markers, coloured
paper and means to attach flipchart sheets to the wall or other display surface. If an overhead
projector is not available, the following overheads may be written out/ prepared for display on
flipchartsheets;anenlargedcopyoftheappropriateversionofPicture1canalsobepreparedfor
displayasaposter.
Overhead2/1: Overhead2/1: Overhead2/1: Overhead2/1: Whatg Whatg Whatg Whatgoodcommunication oodcommunication oodcommunication oodcommunicationmeans means means means
Overhead 2/ Overhead 2/ Overhead 2/ Overhead 2/2 22 2: : : : Six l Six l Six l Six listening and learning skills istening and learning skills istening and learning skills istening and learning skills (Alternative: write and display each skill on
differentcolouredcards).
Overhead2/ Overhead2/ Overhead2/ Overhead2/3 33 3: : : : Sixs Sixs Sixs Sixskills kills kills killsforbuilding forbuilding forbuilding forbuildingconfidenceand confidenceand confidenceand confidenceandgiving giving giving givingsupport support support support
Picture1 Picture1 Picture1 Picture1: : : : SamandSuzi SamandSuzi SamandSuzi SamandSuzi (seeA AA Annex1 nnex1 nnex1 nnex1).
Good communication is not just telling or advising a person what they should do. It is a way of
working with people to help them decide for themselves what they think is best to do in their
situation.
Good communication skills can be used in many situations when you are talking to a client. In
nutritionwecouldusegoodcommunicationskillsto:
Gatherinformationonnutritionpracticesandchallengestheclientfaces.
Praisegoodpractices.
Give information on eating wisely or infant and young child feeding practices and suggest
changes,ifneeded.
A discussion may include other family members. However, it is the decision of the persons
themselvesastowhomtoincludeinthediscussion.
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Whatmightinfluenceapersonsdecisiontocarryoutaparticularnutritionpractice? Whatmightinfluenceapersonsdecisiontocarryoutaparticularnutritionpractice? Whatmightinfluenceapersonsdecisiontocarryoutaparticularnutritionpractice? Whatmightinfluenceapersonsdecisiontocarryoutaparticularnutritionpractice?
Allow a few minutes for participants to respond; write down their responses on a flipchart sheet
andthencompletethelistgivenbyparticipants,usingthefollowing:
Many people may not do what they want to do or what you may suggest they do. Clients
decisionsmaydependonanumberofinfluences.
Otherpeoplesbeliefs,opinionsandneeds;
Whocontrolsthehouseholdmoneyandresources;
Localculture,themediaandthepersonssocialstatus;
Thehealthstatusoftheperson;
Whetherthepersonhasdisclosedhis/herHIVstatus;and/or
Whetherthereareanyperceivedriskstotakingtheparticularactioninquestion.
3. Environment for communication (10 minutes)
The story of Sam and Suzi
ShowP PP Picture icture icture icture1 1 1 1:SamandSuzi SamandSuzi SamandSuzi SamandSuzi. .. .
PICTURE1:S PICTURE1:S PICTURE1:S PICTURE1:Sam am am am and and and andS S S Suzi uzi uzi uzi
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Readthestory. .. .
THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI
Sam and Suzi are a young couple expecting their first baby. They have come to the health
centretotalktothecounsellor.
InordertotalkwithSamandSuzi,thecounsellormustcreateacomfortableenvironmentfor
them--onethatputsthemateaseandencouragesthemtotalkopenly.
Askparticipantstoclosetheirmanuals.
Ask one participant to turn to page 17 of the Participants Manual and to read the section on
E EE Environmentforcommunicatio nvironmentforcommunicatio nvironmentforcommunicatio nvironmentforcommunication. n. n. n.
Askotherstodescribehoweachelementcanbeachieved,thenexplainthefollowing:
Thecounsellormustcreateacomfortableenvironmentthatputspeopleateaseandencourages
themtotalkopenly.Anenvironmentthatencouragescommunicationisonethatis:
physicallycomfortable;
private;
psychologicallysafe;thatis,oneinwhichtheclienttruststhehealthworkerorcaregiverand
believesthatwhatisbeingpresentedwillbeconsideredconfidential;and
offerssufficienttimeandattentionforfulldiscussionoftheissues.
A client may feel that the presence of someone such as a family member or friend whom they
trustandsupportshim/her,willcontributepositivelytohis/hercareandsupport.Itisfortheclient
todecidewhoattendshis/hercounsellingsession.
Introducetheskillsthatfacilitatethecounsellingprocess.
Once the session begins, the counsellor must use good communication skills to build a
relationshipthatwillhelpthecounsellortogatherinformationandhelpclientsbuildconfidencein
order to constructively address the issues they face. There are two major categories of
communicationskillsthatcouldbeused:
Listeningandlearningskills;and
Skillsthathelpbuildconfidenceandgivesupport.
Discusseachoftheseskill-setsindetail.
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3.1 Listening and learning skills
Explainthefollowing:
The counsellor needs to listen carefully to what the client is saying in order to gather as much
informationaspossibleabouttheclientsproblem.
The counsellor needs to do less talking than the client because the necessary information is
comingfromtheclient.Thecounsellorcanalsolearnalot abouttheclientsnutritionalstatusby
justobserving,beforeaskinganyquestions.
SometimesthisapproachisreferredtoasTheTripleL(L LL Listen, isten, isten, isten,L LL Lookand ookand ookand ookandL LL Learn earn earn earn ) approach.
There are six six six six listening and learning skills that help the counsellor communicate better and
facilitatethecommunicationprocess.
Usethefollowingpointstoexplaineachofthelisteningandlearningskills
Skill 1: Use helpful non-verbal communication
Non-verbal communication means showing your attitude through your posture, your expressions
andgestureswithoutspeaking.Goodnon-verbalcommunicationskillswillencouragetheclientto
talkmore,focushis/herresponsesandestablishapositiveenvironment.
Followingarefivenon-verbalmeansofcommunication,variousformsofwhichcaneitherhelpor
hindercommunication:
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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H HH Helps elps elps elps H HH Hinders inders inders inders
1 11 1. .. . Posture Posture Posture Posture Sitsothatyourheadislevelwith
theotherpersons
Standwithyourheadhigherthan
theotherpersons.
2 22 2. .. . Eyecontact Eyecontact Eyecontact Eyecontact Lookattheclientandpayattention
ashe/shespeaks
Lookawayatsomethingelseor
down
atyournotes.
3 33 3. .. . Barriers Barriers Barriers Barriers Removethetableorthenotes Sitbehindatable,orwritenotes
whileyoutalk.
4 44 4. .. . Takingtime Takingtime Takingtime Takingtime
Makethepersonfeelthatyouhave
time.Sitdown,greetwithouthurry,
thenjustremainquietsmilingand
waitingforhim/hertorespond.
Beinahurry.Greetquickly,show
signsofimpatience,andlookat
yourwatch.
Open-ended questions are very helpful. This is because to answer such a question a client
mustgivesomeinformation.
Open-endedquestionsstartwithHow?What?When?Where?Why?
Forexample:Howareyoueating?
Closed questions are less helpful. They communicate that the answer that you expect is
either,YesorNo
ClosedquestionsstartwithAreyou?orDidhe?orHashe?orDoesshe?
Forexample:Areyoueatingwell?
Whether the client answers Yes or No, you still will not understand much about his/her
eating habits and will not have sufficient information to identify whether there are any
problemstobeaddressed.
Oneideaatatime:Askingtheclientmorethanonequestionatthesametimeallowshim/her
tochoosewhichquestiontoansweravoidingtheother(s).
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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For example: When will you tell your parents about your status and how do you think they
willreact?Theclientmayavoidsuchaquestionthathe/shedoesnotwanttoanswer.Ifthe
unanswered question is an important one, you must remember to ask it again in a different
way.
No /Why questions often sound psychological and may make the client feel uneasy or
defensive.IfaclientrespondstoaquestionbysayingNo,startthefollow-upquestionwith
Tellme/ExplainthereasonsratherthansimplyaskingWhy?
Skill 3: Use responses and gestures to show interest
In order to encourage the client to continue talking, you must show that you are listening and
interestedinwhathe/sheissaying.
Keywaystoshowyouarelisteninginclude:
Gestures:forexample,maintainingeyecontact,noddingandsmiling
Simpleexpressionsofacknowledgement:forexample,saying:Aha,orMmm.
For example: Avoid questions such as Does the baby sleep well? Instead, ask: How is the
babysleeping?
Showthefirstkeypointofthissessiondisplayed,andaskaparticipanttoreaditoutloud.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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OVERHEAD2/3:SIXSKILLSFORBUILDINGCONFI OVERHEAD2/3:SIXSKILLSFORBUILDINGCONFI OVERHEAD2/3:SIXSKILLSFORBUILDINGCONFI OVERHEAD2/3:SIXSKILLSFORBUILDINGCONFIDENCEANDGIVINGSUPPORT DENCEANDGIVINGSUPPORT DENCEANDGIVINGSUPPORT DENCEANDGIVINGSUPPORT
1. Acceptingwhataclientthinksandfeels;
2. Recognisingandpraisingwhataclientisdoingright;
3. Givingpracticalhelp;
4. Givingalittle,relevantinformationwhichcanbeofimmediateusetotheclient;
5. Usingsimplelanguage;and
6.Makingafewsuggestions,ratherthangivingcommands.
Skill 1: Accept what a client thinks and feels
Acceptingmeansrespondinginaneutralway,withoutagreeingordisagreeing.
Forexample:Theclientmaysay:Idonoteatfish;itisbadforsomeonewithHIVinfection.
Youcouldrespondinaneutralwaybysaying:Isee.
Skill 2: Recognize and praise what a client is doing right
The idea is not just to look for what a client is doing wrong, and try to correct him/her. We must
first recog recog recog recogni ni ni niz zz ze ee e what he/she is doing right right right right and praise him/her or show approval of the good
practices.Praisinggoodpracticeswillhelp:
Buildaclientsconfidence;
Encouragehim/hertocontinuethosegoodpractices;and
Makeiteasierforhim/hertoacceptsuggestionslateron.
Skill 3: Give practical help
Practicalhelpisthemostsupportiveintervention.
When clients have a problem that they need to solve, the counsellor should help them walk
throughthestepsthatwillgivethemtheconfidencetosolvetheprobleminaconstructiveway.
Forexample:
When a client says: I no longer feel comfortable to continue with exclusive breastfeeding
becauseldonotknowiflamproducingenoughbreastmilk,
You could ask: Why do you think that you do not have enough breast milk? or Does the
babycontinuecryingafterfeeding?,and
You could suggest that the mother try breastfeeding the baby more frequently, in order to
havemoremilkforthebaby.
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Skill 4: Give a little relevant information which can be of immediate use to the client
Itisimportanttogiveinformationwhichisrelevanttotheclientssituationnow.Practicalmeasures
thathe/shecantaketoday,ratherthaninafewweekstime.
Trytogiveonlyoneortwopiecesofsuchinformationatatime.
Giveinformationinapositiveway,sothatitdoesnot soundcritical,ormaketheclientthinkthat
he/she has been doing something wrong. This is especially important if you want to correct a
mistakenidea.
You do not need to give new information or correct a mistaken idea immediately. Wait until you
havebuilttheclientsconfidence,byacceptingwhathe/shesays,andpraisingwhathe/shedoes
well.
Skill 5: Use simple language
Itisimportanttousesimplelanguageandfamiliartermstoexplainthingstotheclients.
Avoidusingmedicaltermsortechnicaljargon.
Forexample:Aclientmaynotnecessarilyunderstandthetermexclusivebreastfeeding.Thus,when
informing her about this practice, you could talk about giving a baby breast milk only and not any
othermilkorfood,notevenwater.
Askparticipantstochangethefollowingcommandintoasuggestion:
Youshouldeatmorefruitsthanvegetables
Insteadofsaying:Youshouldeatmorefruitsandvegetables;youcouldsay:Whatabouttrying
somefruitsandvegetablesatmeals?
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Itisalsoimportanttocheckthatthepersonunderstandstheinformationandifshe/hecan,andis
willing to apply the suggestions you are making. Also necessary is some follow-up action to
evaluatehowwelltheclientimplementsthedecision(s)he/shemade.
Showthesecondkeypointdisplayed,andaskaparticipanttoreaditoutloud.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
W WW Whenyou henyou henyou henyouassure assure assure assureconfidential confidential confidential confidentiality ity ity ityand and and andgive give give giveclients clients clients clientssupportbypraising supportbypraising supportbypraising supportbypraisingtheir their their theirpositive positive positive positivepractices practices practices practices
relatedtofoodandeating relatedtofoodandeating relatedtofoodandeating relatedtofoodandeating, , , ,y yy youhelpbuildth ouhelpbuildth ouhelpbuildth ouhelpbuildtheir eir eir eirself self self self- -- -confidence confidence confidence confidence. .. .
5. Role-plays (20 minutes)
Introduce R RR Role ole ole ole- -- -p pp play 2 lay 2 lay 2 lay 2A: A: A: A: The The The The e ee effects of counselling styles on the patterns of interaction between ffects of counselling styles on the patterns of interaction between ffects of counselling styles on the patterns of interaction between ffects of counselling styles on the patterns of interaction between
clientandcounsellor clientandcounsellor clientandcounsellor clientandcounsellor . .. .(H HH Handout andout andout andout2/1 2/1 2/1 2/1 on page26 oftheParticipant'sManual).
Ask two participants to role play (one as the counsellor and the other as the client, i.e. Sam or
Suzi,asappropriate).
Allow them three minutes for preparation, considering that you had already allowed preparation
timebeforethesession.
I II Isthecounselloragreeing sthecounselloragreeing sthecounselloragreeing sthecounselloragreeingor or or ordisagreeing disagreeing disagreeing disagreeingwith, with, with, with,oracceptingwhatSamorSuziis oracceptingwhatSamorSuziis oracceptingwhatSamorSuziis oracceptingwhatSamorSuziissaying? saying? saying? saying?
Introduce R RR Role ole ole ole- -- -play play play play 2B: 2B: 2B: 2B: Demonstration of how to use counselling skills to gather information Demonstration of how to use counselling skills to gather information Demonstration of how to use counselling skills to gather information Demonstration of how to use counselling skills to gather information
(H HH Handout andout andout andout2/2 2/2 2/2 2/2onpage27oftheParticipant'sManual).
Askfortwoparticipantstoroleplay(Aclientandahealthworkertalking)
Allow them three minutes for preparation, considering that you had already allowed preparation
timebeforethesession.
Askparticipantstoobserveandwritedownthetypeofinterventionthehealthworkermakeswhen
respondingtotheclient.
Askthemtoreportwhattheyobservedafterthedemonstration.
6. Summary of the session and transition (5 minutes)
Show/reviewbothkeypoints.
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KEYPOINTS KEYPOINTS KEYPOINTS KEYPOINTS
Whenyouensurephysicalcomfort,listenandtalkaboutfoodandeating, Whenyouensurephysicalcomfort,listenandtalkaboutfoodandeating, Whenyouensurephysicalcomfort,listenandtalkaboutfoodandeating, Whenyouensurephysicalcomfort,listenandtalkaboutfoodandeating,
youshowthatyoucareabouttheperson. youshowthatyoucareabouttheperson. youshowthatyoucareabouttheperson. youshowthatyoucareabouttheperson.
Whenyoua Whenyoua Whenyoua Whenyouassureconfidentialityandgiveclientssupportbypraisingtheir ssureconfidentialityandgiveclientssupportbypraisingtheir ssureconfidentialityandgiveclientssupportbypraisingtheir ssureconfidentialityandgiveclientssupportbypraisingtheir
positivepracticesrelatedtofoodandeating,youhelpbuildtheirself positivepracticesrelatedtofoodandeating,youhelpbuildtheirself positivepracticesrelatedtofoodandeating,youhelpbuildtheirself positivepracticesrelatedtofoodandeating,youhelpbuildtheirself- -- -confidence. confidence. confidence. confidence.
Readandreinforcethekeypoints,addingthefollowingpoints.
Goodcommunicationisnotsimplytellingoradvisingapersonwhattheyshoulddo.Itisawayof
working with people to help them decide for themselves what they think is best to do in their
situation.
Listen, Look and Learn Listen, Look and Learn Listen, Look and Learn Listen, Look and Learn: : : : Do less talking than the client because the necessary information is
comingfromtheclient.
Reviewthevarioustypesofcommunicationskillscoveredinthesession,assummarizedbelow:
Usehelpfulnon-verbalcommunication
Askopenquestions
Useresponsesandgestureswhichshowinterest
Reflectbackwhattheclientsays
Empathize: Show that you understand how the client
feels
Listeningand Listeningand Listeningand Listeningandl ll learning earning earning earning
Avoidwordswhichsoundjudgemental
Acceptwhataclientthinksandfeels
Buildingconfidenceandgivingsupport Buildingconfidenceandgivingsupport Buildingconfidenceandgivingsupport Buildingconfidenceandgivingsupport
Recognizeandpraisewhataclientisdoingright
Givepracticalhelp
Givealittlerelevantinformationwhichcanbeof
immediateusetotheclient
Usesimplelanguage
Makeafewsuggestionsratherthancommands
Inthenextsession,wewilldiscusseatingwisely.
Thenextsessionwillbepresentedby:
Statethenameofthepresenter.
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HANDOUT2/1 HANDOUT2/1 HANDOUT2/1 HANDOUT2/1
ROLE-PLAY 2A: The effects of counselling styles on patterns of interaction between client
and counsellor
The clients are Sam and Suzi who are HIV positive. They will be talking to three different
counsellors who have three different styles of interacting in order to illustrate the effect of
counselling styles on the patterns of interaction between client and the counsellor. Listen to
determine whether the counsellor is agreeing, disagreeing or accepting what Sam or Suzi is
saying.
1. 1. 1. 1.
COUNSELLOR1: Foodsfromanimalscanhelpyoutostayhealthy.
Couldyoueatsomeofthesefoods?
SAM/SUZI: Idonothavethemoneytobuyanimalfoods.
Ibuythespecialtabletsinthemarkettokeepmehealthyand
theyareveryexpensive.
COUNSELLOR1: Ohno,thosetabletsareawasteofyourmoney.
Youshouldnotbuythem.
Disagreeing Disagreeing Disagreeing Disagreeing
Judgemental Judgemental Judgemental Judgemental
2. 2. 2. 2.
COUNSELLOR2: Foodsfromanimalscanhelpyoutostayhealthy.
Couldyoueatsomeofthesefoods?
SAM/SUZI: Idonothavethemoneytobuyanimalfoods.Ibuythespecial
tablets
inthemarkettokeepmehealthyandtheyareveryexpensive.
COUNSELLOR2: Yes,manypeoplebuythosetabletstokeepthemhealthy.
Iamsuretheywillhelpyou.
Agreeingwith Agreeingwith Agreeingwith Agreeingwith
awrongidea awrongidea awrongidea awrongidea
3. 3. 3. 3.
COUNSELLOR3: Foodsfromanimalscanhelpyoutostayhealthy.
Couldyoueatsomeofthesefoods?
SAM/SUZI: Idonothavethemoneytobuyanimalfoods.
Ibuythespecialtabletsinthemarkettokeepmehealthyand
theyareveryexpensive.
COUNSELLOR3: Youfindbuyingthetabletsveryexpensiveandthisleaves
youwithlessmoneyforfood.
PAUSE
HEALTHWORKER I am glad some of the suggestions were useful to
you.Areyouhavinganyproblemseating?
Buildingconfidence Buildingconfidence Buildingconfidence Buildingconfidence
CLIENT Yes,sometimes.
IDENTIFYINGTHEPROBLEM
HEALTHWORKER Describetheproblemsthatyouarehaving? Openquestion Openquestion Openquestion Openquestion
CLIENT Well,mymouthgetssore.
HEALTHWORKER Yourmouthgetssore.Doesitgetsorewhenyoueat
certainfoodsordoesitjustbecomesore?
Reflectingback Reflectingback Reflectingback Reflectingback
Openquestion Openquestion Openquestion Openquestion
PAUSE
CLIENT Justsometimes,itissoreandhardtoeat.
HEALTHWORKER Youfindthatishardtoeatbecauseyourmouthgets
sore. Let me tell you about some things that might
helpyoutoeatmorecomfortably?
Empathy Empathy Empathy Empathy
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Describetheroleoffoodinourbody,forgrowth,repair,energyandprotection;
Outlinetheprinciplesofhealthyeatingoreatingwisely;and
Discusshowfoodchoicesaremade.
Session Session Session Sessiono oo outline utline utline utline
Content Content Content Content Time Time Time Time
1 Learningobjectivesandintroductiontothesession 3minutes
2 Nutrientsandtheirroleinthebody 10minutes
3 Aneatingwiselydemonstrationtalk 30minutes
4 Eatingwisely:summaryanddiscussion
(Role-play3A:Discussing eatingwiselywiththecaregiverofayoung
child)
15minutes
(Total)
(10minutes)
5 Foodchoices
(Exercise3/1:FoodChoicesWorksheet)
20minutes
(Total)
(15minutes)
6 Summaryofthesessionandtransition 2minutes
Total Total Total Total 80minutes 80minutes 80minutes 80minutes
Preparation for the session
Writeanddisplaythelearningobjectivesonasheetofflipchartpaper
Writethekeypointonasheetofflipchartpaperandkeepitasideuntilneeded.
This session may be divided between two facilitators, with one facilitator presenting the theory
sectionsandonefacilitatorgivingthedemonstrationtalk.
Decideonexamplesoffoodsthatareusedintheareaandaddorreplacewiththefoodsonthe
tables.Youmayalsousefoodpostersifavailable.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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The discussion in this session is based on an image of a variety of foods. If you use another
imagethatismorefamiliarinthearea,ensurethatitiseasytounderstand.
Focusonfoodratherthannutrients.Ifyouareusinganothermethodofexplainingeatingwisely,
practisethedemonstrationsoitfitsintotheallocatedtimeof30minutes.
Use locally available pictures and handouts relevant to eating wisely during the talk, if these fit
withtheinformationyouareproviding.
Prepareacollectionoffoodmodelsorflashcardsfordemonstration
Youwillneedeightsheetsofcolouredpapertolistdowntheeighteatingwiselyguidelines,each
onadifferentsheet,inboldletters;keeptheseasideuntilneededduringthedemonstrationtalk.
Ask two participants to assist with the demonstration talk by asking prepared questions. The
questionsareattheendofthetextfortheEatingwiselytalkinthisguide.
Give each of the participants assisting you a question written on a piece of paper and explain
whentoaskthesequestions.
AskparticipantstoformthreegroupsforExercise 3/1: 3/1: 3/1: 3/1: Foodchoices Foodchoices Foodchoices Foodchoicesworksheet worksheet worksheet worksheet (foundonpage
41oftheParticipantsManual).
Collectafewpacketsandtinsoffortifiedfoodsavailablelocallyandbringthemfordemonstration
inthesession.Mentionaregionalbrandoffortifiedfoodproductsifoneexists.
Fordiscussionof H HH Handout3/1: andout3/1: andout3/1: andout3/1: Foodpo Foodpo Foodpo Foodpor rr rtion tion tion tions: s: s: s: sizesofahealthymeal sizesofahealthymeal sizesofahealthymeal sizesofahealthymeal , ,, ,collectafew household
utensils used for serving or measuring food such as, cups, teaspoon, tablespoon, as well as
samplesofafewfruitsfordemonstration.
Collect/preparethefollowingtrainingmaterials.
Anoverheadprojectorandscreen;and/oraflipchartstand,flipchartpaper,markers,sheetsof
coloured paper and means to attach sheets to the wall or other surface. If an overhead
projectorisnotavailable,overheadsmaybewrittenoutonflipchartsheetsorenlargedcopies
canbepreparedfordisplayasposters..
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Overhead3/1: Overhead3/1: Overhead3/1: Overhead3/1: Nutrients Nutrients Nutrients Nutrients
Overhead3/2 Overhead3/2 Overhead3/2 Overhead3/2 Grow,Go,Glow Grow,Go,Glow Grow,Go,Glow Grow,Go,Glow
Overhead3/3 Overhead3/3 Overhead3/3 Overhead3/3 Av Av Av Avarietyoffoods arietyoffoods arietyoffoods arietyoffoods (thiscanbesubstitutedbyalocalillustration)
Overhead3/4 Overhead3/4 Overhead3/4 Overhead3/4: : : : Eatingwiselyguidelines Eatingwiselyguidelines Eatingwiselyguidelines Eatingwiselyguidelines
Overhead3/5 Overhead3/5 Overhead3/5 Overhead3/5; ; ; ;I I I Increasedenergyrequirement ncreasedenergyrequirement ncreasedenergyrequirement ncreasedenergyrequirements ss sforpeoplelivingwithHIV forpeoplelivingwithHIV forpeoplelivingwithHIV forpeoplelivingwithHIV
Overhead3/6 Overhead3/6 Overhead3/6 Overhead3/6: Foodchoices Foodchoices Foodchoices Foodchoices
Table Table Table Table3/ 3/ 3/ 3/1: 1: 1: 1: L LL Legumesandpulses,nutsandoilseeds egumesandpulses,nutsandoilseeds egumesandpulses,nutsandoilseeds egumesandpulses,nutsandoilseeds
Table Table Table Table3/ 3/ 3/ 3/2: 2: 2: 2: M MM Milkandmilkproducts,meats,poultr ilkandmilkproducts,meats,poultr ilkandmilkproducts,meats,poultr ilkandmilkproducts,meats,poultryandfish yandfish yandfish yandfish
Table Table Table Table 3 33 3/3 /3 /3 /3: : : : Starchyfoods Starchyfoods Starchyfoods Starchyfoods
Table Table Table Table3/ 3/ 3/ 3/4: 4: 4: 4: Sugarsandfats Sugarsandfats Sugarsandfats Sugarsandfats
Table Table Table Table3/ 3/ 3/ 3/5: 5: 5: 5: V VV Vegetablesandfruits egetablesandfruits egetablesandfruits egetablesandfruits
Handout3/1 Handout3/1 Handout3/1 Handout3/1: : : : Foodpo Foodpo Foodpo Foodpor rr rtion tion tion tions:s s:s s:s s:sizesofahealthymeal izesofahealthymeal izesofahealthymeal izesofahealthymeal (availableattheendofthissession)
Role Role Role Role- -- -play play play play3A 3A 3A 3A: : : : Discussing Discussing Discussing Discussing eatingwisely eatingwisely eatingwisely eatingwisely withthecaregiver withthecaregiver withthecaregiver withthecaregiverofayoungchild ofayoungchild ofayoungchild ofayoungchild
Exercise3/1: Exercise3/1: Exercise3/1: Exercise3/1:Foodchoicesworksheet Foodchoicesworksheet Foodchoicesworksheet Foodchoicesworksheet(availableattheendofthissession)
Showtheflipchartanddiscussthelearningobjectives.
Bytheendofthissession,participantswillbeableto:
Describetheroleoffoodinourbodyforgrowth,repair,energyandprotection;
Outlinetheprinciplesofhealthyeatingoreatingwisely;and
Discusshowfoodchoicesaremade.
Introduce the session
Sam and Suzi thought about what the HIV counsellor had said to them about how eating wisely
helpspeopletostayhealthylonger.Theydecidedtheywouldgotothetalkatthehealthcentre.
Inthissession,wewillhearatalkasifitwerebeinggiventoagroupinahealthcentre.Thistalk
willdescribetheroleoffoodingrowth,repair,energyandprotectionandoutlinetheprinciplesof
eating wisely. We will discuss how similar information could be used with an individual and how
peoplemakechoicesaboutwhatfoodtheyeat.
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2. Nutrients and their role in the body (10 minutes)
ShowO OO Overhead:3 verhead:3 verhead:3 verhead:3/1: /1: /1: /1: Nutrients Nutrients Nutrients Nutrients andexplainthefollowingpoints
OVERHEAD OVERHEAD OVERHEAD OVERHEAD 3/1: 3/1: 3/1: 3/1:NUTRIENTS NUTRIENTS NUTRIENTS NUTRIENTS
Foodismadeupofnutrientsneededbythebody.Thesenutrientsaredividedintomacro-nutrients
suchas,carbohydrates,proteinandfat, whichareneededinlargeamounts;andmicro-nutrients
suchas,vitaminsandminerals,whichareneededonlyinsmallamounts.
Nutrientsworkasateamandneedeachother.Thebodycannotfunctionproperlyifevenoneof
nutrientsismissing.
A healthy diet provides foods in the right amounts and combinations that are safe and free from
diseaseandharmfulsubstances.
Emphasizethefollowingpoint:
People think of eating food rather than eating nutrients. In this session, we will often talk about
foodandnotnutrients.Thesessionwillalsooutlinedietaryguidelinesdiscussingwhattodowith
everygroupoffood.
3. An eating wisely demonstration talk (30 minutes)
Ensurethatparticipantsunderstandthattheyareexpectedtopretendtobepeopleattendingthe
talkatahealthcentrethroughoutthissession.Remindthemofthisrepeatedlyatthestartofeach
topic(Sections3.1 Sections3.1 Sections3.1 Sections3.1.to3.11. .to3.11. .to3.11. .to3.11.)below.
Introducethepersonwhowillgivethetalkifthesessionissharedbetweenfacilitators.
Presenttheeatingwiselytalk
3.1. Eating wisely: introduction
Welcomethegroupandexplainwhatthetalkisabout.
Goodafternoon/morningandwelcome.
Today,wewilltalkaboutfoodandeating.
Foodisimportanttoallofus.
ShowO OO Overhead3/2 verhead3/2 verhead3/2 verhead3/2: :: :T TT Theroleoffoodinthebody heroleoffoodinthebody heroleoffoodinthebody heroleoffoodinthebodyandexplaintheimportantfunctionsoffood.
Foodisusedbythebodyto:
Grow Grow Grow Grow: : : :Foodisessentialforourbodiestodevelop,replaceandrepaircellsandtissues.
Children need food to grow. For adults, food serves to repair cells and tissues. To illustrate this
processitisusefultothinkofthebodyasawallmadeofmanybricks.Ifabrickisdamaged,itistaken
outandreplacedbyanewone.Thewallmaystayinthesameshapebutitisrepairedorrenewedin
parts.Foodisessentialforthiscontinualrepairprocesstotakeplaceinthehumanbody.
Go Go Go Go: : : :Foodisessentialforourbodiestoproduceenergy,tokeepwarm,tomoveandwork.
Foodprovidesuswithenergyorfueltomoveaboutandbeactive;tokeepthebodyworking,theheart
topumpblood,thelungstobreathe,andtoproducebodyfluidssuchasblood,breastmilk,salivaand
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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digestivefluids.Thebodyalsoneedsfoodtocarryouttheprocessoffooddigestion.Inthesameway
thatacarcannotgowithoutfuel,thebodybecomesweakwithoutfoodandcannotfunction.
Eatingwiselymeanseatingavarietyoffoodsintherightquantity,combinationandfrequencyto
providethebodywiththerequirednutrientsonadailybasis.Thismeansthattostayhealthy,we
needtotrytoeatmanydifferentkindsoffoodateachmeal.
It is essential for all people to understand and follow the principles of eating wisely in order to
ensureadequatefoodformeetingtheirnutritionalneeds.
ShowO OO Overhead3/3 verhead3/3 verhead3/3 verhead3/3: : : : Varietyoffoods Varietyoffoods Varietyoffoods Varietyoffoods andexplaintheguidelinesthatanindividualcanfollowfor
eatingwisely.
OVERHEAD3/3:V OVERHEAD3/3:V OVERHEAD3/3:V OVERHEAD3/3:VARIETYOFFOODS ARIETYOFFOODS ARIETYOFFOODS ARIETYOFFOODS
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3.2. Enjoying a variety of foods
Remind participants that they should still be role-playing as people attending an Eating wisely
talkatahealthcentre.
Showthefirstcolouredpaperenjoyavarietyoffoodandexplainthefollowing:
No single food or group of foods contains all the nutrients that the body needs in the right
quantitiesandcombinations,exceptbreastmilkforinfantsuptosixmonths.
Eating a variety of different foods will provide the nutrients that are essential for our bodies. It is
important to include different food and food groups in ones diet as well as to alter methods of
preparation.
Bytakingcaretochoosefoodsthatareinseasonandlocallyavailable,eatingcanbeenjoyable,
healthyandaffordable.
3.3. Eating wisely: Group activity
Remind participants that they should still be role-playing as people attending an Eating wisely
talkatahealthcentre.
Askthemtogetintogroupsofthree;giveeachgroupastackoffoodflashcards.
Ask each group to single out flash cards with pictures of foods that are easily available in their
regioninonepile.Takebacktheflashcardswithfoodsthatarenotavailable.
Askthemtodiscusshowtheywillusethesefoodsinordertoenjoyavarieddiet.
Askthemtosuggestreasonsthatmightmakeitdifficulttofollowthisguideline.
Usethefollowingpointsfordiscussion:
It might not be possible for all people to enjoy a variety of foods at each meal. However, it is
importantthatatleastthemealsconsumedthroughoutthedayarevaried.
Anexampleofamixedmealofoptimalvarietyisonemadeupofmaize-meal,chicken,pumpkin
andspinach.
Ask participants to provide a similar example of a mixed meal comprising a variety of locally
availablefoods.
Thiscouldbeexchangedwithotherfoodsinothermealsanddays.
Forexample,maize-mealcanbeeatenwithothermeats,animalproductsorlegumes,insteadof
chicken. In addition, try to buy fruits and vegetables that are in season, such as, oranges and
traditional green leafy vegetables, to add variety. Fruits and vegetables can also be grown at
home.
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Inaddition,thesamefoodcouldbecookeddifferently.Forexample,insteadofalwaysfryingfood
infatoroil,youcouldtrysteaming,baking,andgrilling.
Vegetables need not always be cooked but can also be used as salad. It is important to clean
vegetablesthoroughlyiftheyaretobeconsumedraw.
3.4. Make staples or starchy foods the largest part of your meal
Remind participants that they should still be role-playing as people attending an Eating wisely
talkatahealthcentre.
Show the second coloured paper/card: M MM Make staples or starchy foods the larg ake staples or starchy foods the larg ake staples or starchy foods the larg ake staples or starchy foods the largest part of your est part of your est part of your est part of your
meal meal meal meal andexplainthefollowing:
Staple foods should be eaten with every meal. When planning meals, the staple or starchy food
shouldbethecentralormainfood,andtherestofthemealshouldbeplannedaroundthisfood.
Askparticipantstosingleoutandputasidestarchyfoodsfromtheirpileofflashcards.
ClarifyanyconfusionsandshowT TT Table able able able3/ 3/ 3/ 3/1 1 1 1formoreexamples.
Table Table Table Table3/ 3/ 3/ 3/1:Examplesof 1:Examplesof 1:Examplesof 1:Examplesofstaplesor staplesor staplesor staplesorstarchyfoods starchyfoods starchyfoods starchyfoods
Askparticipantstosuggestreasonsthatmightmakeitdifficulttofollowthisguideline.
Usethefollowingpointsfordiscussion:
These foods are relatively cheap and provide mainly energy or fuel to give us G GG Go o o o, as well as
somenutrientstohelpus Grow Grow Grow Grow andGlow Glow Glow Glow .
However,staplesalonearenotenoughtoensureadequatevarietyoffoodandtoprovideallthe
nutrientsthatthebodyneeds.Thus,weneedotherfoodsaswell.
3.5. Eat pulses and legumes, nuts and oil seeds, if possible everyday.
Remind participants that they should still be role-playing as people attending an Eating wisely
talkatahealthcentre.
ShowthethirdcolouredpaperE E E Eat at at atpulsesandlegumes, pulsesandlegumes, pulsesandlegumes, pulsesandlegumes,nutsand nutsand nutsand nutsandoil oil oil oilseeds,ifpos seeds,ifpos seeds,ifpos seeds,ifpossibleeveryday. sibleeveryday. sibleeveryday. sibleeveryday.
andexplainthefollowing:
CerealsandGrains CerealsandGrains CerealsandGrains CerealsandGrains StarchyRootsorTubers StarchyRootsorTubers StarchyRootsorTubers StarchyRootsorTubers StarchyFruits StarchyFruits StarchyFruits StarchyFruits
Maize/CornMeal Cassava(Fresh) Breadfruit
Millet CassavaFlour Plantain
Rice Potato
Sorghum SweetPotato
WheatFlour Yam
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53
Thesefoodsareneededto Grow Grow Grow Grow astheyhelpdevelopandrepairofthebodyandalsotobuildup
strongmuscles.Theyalsocontainsomenutrientstohelp Glow Glow Glow Glow . .. .
Askparticipantstosingleoutandputaside,pulsesandlegumes(e.g.peas,beans,lentils),nuts
andoilseedsfromtheirpileofflashcards.
ClarifyanyconfusionandshowT TT Table able able able3/ 3/ 3/ 3/2 2 2 2formoreexamples.
Table Table Table Table3/ 3/ 3/ 3/2:Exam 2:Exam 2:Exam 2:Examplesof plesof plesof plesofpulsesandlegumes pulsesandlegumes pulsesandlegumes pulsesandlegumes,nuts ,nuts ,nuts ,nutsand and and andoil oil oil oilseeds seeds seeds seeds
Askparticipantstosuggestreasonsthatmightmakeitdifficulttofollowthisguideline.
Usethefollowingpointsfordiscussion:
Thesefoodsarecheapersourcesofproteinthananimalproductssuchas,beefandchicken,and
shouldbeeateneveryday,ifpossible.
However,mostofthemmayrequirethoroughcookingtohelptheirdigestion.
Soakingbeansandpeasinwaterpriortocooking,andusinglocally-made,fuel-efficientcookers
willreducetheamountoffirewoodneededtocookthemwell.
3.6. Eat poultry, meat, fish, eggs, milk and milk products regularly
Remind participants that they should still be role-playing as people attending an Eating Wisely
talkatahealthcentre.
Show the fourth coloured paper Eat Eat Eat Eat poultry poultry poultry poultry, meat, fish, eggs, milk and , meat, fish, eggs, milk and , meat, fish, eggs, milk and , meat, fish, eggs, milk and milk products milk products milk products milk products. . . . and
explainthefollowing:
Thesefoodsareusefulforgrowthandrepair,fortheformationofblood,tostrengthenmuscles
andtheimmunesystemtofightinfections.
Ask participants to single out and put aside, poultry (chicken, turkey, duck and other domestic
birds)meat,fish,eggs,milkandmilkproductsfromtheirpileofflashcards.
ClarifyanyconfusionandshowT TT Table able able able 3 33 3/3 /3 /3 /3formoreexamples.
Pulse Pulse Pulse Pulses ss sandLegumes andLegumes andLegumes andLegumes NutsandOilseeds NutsandOilseeds NutsandOilseeds NutsandOilseeds
Chickpeas GroundNuts
Cowpeas MelonSeeds
KidneyBeans Peanut
Lentils PumpkinSeed
PigeonPeas Sesame
Soybean
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Explainthefollowingpoints:
Liverandotherorganmeatsoroffalareparticularlyvaluablefortheformationofblood.
Fermentedmilkisbeneficialifapersonhasdiarrhoeabecauseitiseasilydigested,mayhelpin
digestionandabsorptionofotherfoodsandisagoodsourceofenergy.Fermentedmilkmaybe
readilyavailableanddoesnotneedtobestoredinarefrigerator.
Breastmilkisagoodfoodforinfantsandyoungchildren.Ithelpsthemto G GG Grow row row row, , , , G GG Go o o o and G GG Glow low low low.
Askparticipantstosuggestreasonsthatmightmakeitdifficulttofollowthisguideline.
Explainthefollowing:
Poultry,meat,fish,eggs,milkandmilkproductsmaybeexpensivebutitisimportanttoinclude
evensmallportionsofsuchfoodsinthemealasoftenaspossible.
3.7. Eat a wide variety of vegetables and fruits everyday
Remind participants that they should still be role-playing as people attending an Eating wisely
talkatahealthcentre.
ShowthefifthcolouredpaperEatawidevarietyofvegetablesandfruitseveryday. Eatawidevarietyofvegetablesandfruitseveryday. Eatawidevarietyofvegetablesandfruitseveryday. Eatawidevarietyofvegetablesandfruitseveryday.andexplain
thefollowing:
Milkand Milkand Milkand Milkandmilk milk milk milkproducts products products products Poultry Poultry Poultry Poultry, , , ,meatandfish meatandfish meatandfish meatandfish
Cowmilk(fresh) Chicken,turkey,duck,geese,etc.
Goatmilk(fresh) Beef(Cow/Bull)
Fermentedmilk Goat
Cheese Lamb(Sheep)
Curd Pork
Yoghurt Rabbit
Deer
Fish
Insects
Organmeats/offal,e.g.liver
Eggs
Nutritional Care and Support for People Living with HIV: Facilitators Guide
55
Vegetablesandfruitsareanimportantpartofahealthydiet.Theysupplyfoodsthatkeepthebody
functioningandtheimmunesystemstrong.
Theyareknownasprotectivefoodsbecausetheyareimportantforpreventingandfighting
infections.
ThesefoodsareespeciallyimportantforpeoplelivingwithHIVtofightinfections.Aimtoeata
widevariety,aseachonehasadifferentwaytohelpus G GG Glow low low lowwithhealth.
Askparticipantstosingleoutandputaside,vegetablesandfruitsfromtheirpileofflashcards.
ClarifyanyconfusionandshowT TT Table able able able3/4 3/4 3/4 3/4formoreexamples.
Askparticipantstosingleoutandputaside,fats,oils,sugarsandsugaryfoodsfromtheirpileof
flashcards.
ClarifyanyconfusionandshowT TT Table able able able3/ 3/ 3/ 3/5 55 5formoreexamples.
Table3/5:Sugars,fatsandoil Table3/5:Sugars,fatsandoil Table3/5:Sugars,fatsandoil Table3/5:Sugars,fatsandoils ss s
SugarandSugaryfoods SugarandSugaryfoods SugarandSugaryfoods SugarandSugaryfoods Fats Fats Fats Fats Oils Oils Oils Oils
Biscuits Butter Coconutoil
Cakes Fatfrommeat Cornoil
Fruitjuices Ghee Groundnutoil
Honey Fatfromfish Palmoil
Jam Margarine Sunfloweroil
Sodas
SugarCane
Table/TeaSugar
Nutritional Care and Support for People Living with HIV: Facilitators Guide
57
Explainthefollowing:
Although fats and sugars are good sources of energy, they are not rich in other nutrients. Thus,
theyshouldbeeateninadditiontootherfoodsandnotinplaceofthem.Closelymonitoringones
weightwillensurethatfats/oilsandsugarsareconsumedinmoderation.
Askparticipantstosuggestreasonsthatmightmakeitdifficulttofollowthisguideline.
Usethefollowingpointsfordiscussion:
Because fats/oils, sugar and sugary products enhance the flavour of food and boost ones
appetite,peopletendtooverusethem.Itcanthenbecomedifficulttoreducetheirintake.
People living with HIV who are not experiencing weight loss should be encouraged to regulate
theirfat/intakeby:
choosingmorefoodswithadequatenaturalfats/oilsandneedlittleornoextraoilforcooking,
and/orusingcookingmethodssuchas,steaming,grillingandboilingasoftenaspossible;and
choosing fewer foods that are rich in sugar, such as fizzy drinks, cakes, sweets, chocolate
andsweetenedfruitjuice.
In case of excess weight gain, sugar and fat intake should be reduced gradually, while closely
monitoringonesweight.Forexample,ifonenormallytakesthreeteaspoonsofsugar,thiscanbe
reducedtotwoandahalfandthengraduallytotwoorless,untiloptimallevelsarereached.
3.9. Drink plenty of clean and safe water
Remind participants that they should still be role-playing as people attending an Eating Wisely
talkatahealthcentre.
Show the seventh coloured paper with Drink plenty of clean and safe water Drink plenty of clean and safe water Drink plenty of clean and safe water Drink plenty of clean and safe water and explain the
following:
Waterisimportantforlifeandisnecessaryeveryday.Apersonneedsabouttwotothreelitresor
eightlargecupsoffluidseachday.
When it is very hot, while working, sweating or suffering from diarrhoea, vomiting or fever, a
personneedstodrinkevenmoretoreplacethewaterthathasbeenlost.Somemedicationsmay
notworkwellifthepersonisdehydrated.Breastfeedingwomenalsoneedextrawater.
Children also need adequate water. However, care should be taken to avoid filling a child with
waterydrinksinplaceoffoods.
Exclusivelybreastfedinfants(<6monthsofage)donotneedextrawater.
Ifdrinkingwateriscollectedfromaprotectedwellorriverthewatershouldbeboiledforatleast10
minutesandstoredincleancontainer(seethediscussioninS SS Session5 ession5 ession5 ession5onFoodSafety).
Inadditiontodrinkingcleanwater,fluidcanalsocomefromjuices,soups,vegetablesandfruitas
wellasmealsthathave gravyorsauces.Thirstisagoodguide;ifyouarefrequentlythirsty,you
needtoincreaseyourfluidintakesignificantly.
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58
However, one should not rely on tea, coffee and alcohol drinks as source of water, as they can
interferewithabsorptionofnutrientsandmayinteractpoorlywithmedicine.
Alcoholicdrinksremovewaterfromthebodyandassucharenotagoodsourceoffluid.
3.10. Use foods that are fortified with essential nutrients, if possible
Remind participants that they should still be role-playing as people attending an Eating wisely
talkatahealthcentre.
Show the eighth coloured paper Use foods that are fortified with essential nutrients, if possible Use foods that are fortified with essential nutrients, if possible Use foods that are fortified with essential nutrients, if possible Use foods that are fortified with essential nutrients, if possible
andexplainthefollowing;
Fortifiedfoodshaveaddednutrientstoimprovethenutritionalvalueofreadilyavailablefoods.
Examples of fortified foods include: salt with iodine, maize meal with vitamins, and oil with
vitaminA.
Where available and affordable, such fortified foods can be used to improve ones nutritional
intake.
It is important to read labels and/or ask for advice regarding the nutrients contained in fortified
foods.Attentionshouldalsobepaidtotheirexpirydates.
Likefruitsandvegetables,fortifiedfoodsshouldnotbeover-cookedasthismayresultintheloss
ofnutrients.
Askthegrouptonamelocallyavailablefortifiedfoods.
Show examples of packets/tins you brought with you and explain how to identify the added
nutrientstheycontain.
3.11. Optimal quantity and frequency of meals
Remind participants that they should still be role-playing as people attending an Eating wisely
talkatahealthcentre.
Explainthefollowing:
People have different needs and so eat different amounts of foods depending on their age,
gender,levelofactivity.
Pregnantandbreastfeedingwomenandpeoplewhoareillalsohavespecialnutritionalneeds.
In particular, because people living with HIV have increased energy needs, they should be
encouragedto:
Increasethefrequencyoftheirmealsandsnacks:
It is easier to eat wisely if you eat three or more times daily, rather than having large meals
once or twice in the day. Having small, frequent meals about three to four hours apart
everydayhelpstoincreaseenergyintake.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
59
Increasetheamountandvarietyoffoodconsumedduringeachmeal.
Thereisoftenuncertaintyregardingtheappropriateamountoffoodtobeeaten.Peopleoften
ask How do I know when I am eating enough? The simplest way of knowing that the
appropriate amount of food is being consumed is by regularly monitoring ones weight and
ensuringthatitiswithinthenormalrangeforonesagegroupandheight.
Measuringportionsoffoodusingcommonutensilssuchas,cupsandspoonscanhelpensure
thatappropriatequantitiesofdifferentfoodtypesareincludedineachmeal.
Ask participants to look at H HH Handout andout andout andout 3 33 3/1 /1 /1 /1: :: : Portion sizes of a health Portion sizes of a health Portion sizes of a health Portion sizes of a healthy y y y meal meal meal meal on page 40 of the
Participant'sManual.
The purpose of this table is to familiarize participants with commonly accepted ways for
measuringportionsofvariousfoodstoensureahealthydiet.Theportionsandexamplesprovided
are intended only as a general reference. The appropriate portions of particular foods to be
included in daily meals will depend on the particular nutritional requirements of individuals and
should be modified as necessary, by following the eating wisely guidelines and closely
monitoringonesbodyweight.
Usingthesampleofutensilsyoubroughtforthesession,discusseachfoodportion;thenexplain
thefollowing:
Increasingnutritionalintakemaymeanconsumingadditionalportionsoffoodsuchas,onetotwo
extraportions(aboutoneortwofistsfull)ofmealymealoronetotwocupsofporridgeduringthe
day.Itcanalsomeananadditionalmealduringtheday.
Makeeveryportioncountbychoosingavarietyoffoodsthatarerichinnutrients.
Ones diet can also be enhanced by adding nutrient-rich foods, including foods fortified with
essential nutrients in each meal. In families with one or more members living with HIV, it is
especiallyimportantfortheentirefamilytoeatwisely.
HIV-positive people need to pay attention to their diet even before they have any symptoms.
Eatingwiselycanhelpthemtostayhealthylonger.
It is essential that people living with HIV understand and follow the eating wisely guidelines to
ensurethattheirfoodintakeisadequateformeetingtheirnutritionalneeds.
3.12. Review of the eating wisely talk: questions and answers
Remind participants that they should still be role-playing as people attending an Eating wisely
talkatahealthcentre.
Askthreeparticipantstorepeatthefollowingpoints:
Themainpointstorememberare:
Eatingwiselyisimportanttoeveryone.
Aimtoeatavarietyoffoods.
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60
Adjusttheamounteatenandhowoftenfoodiseatendependingonindividualneeds.
Askthegrouptoraisequestionsfromthepreparedlistofquestionsanddiscusstheanswers.
Prepared question 1
Allthisfoodseems Allthisfoodseems Allthisfoodseems Allthisfoodseemsveryexpensive.Willeatinglikethiscostalotofmoney? veryexpensive.Willeatinglikethiscostalotofmoney? veryexpensive.Willeatinglikethiscostalotofmoney? veryexpensive.Willeatinglikethiscostalotofmoney?
Answer: Answer: Answer: Answer:
Eatingwiselydoesnotneedtobeexpensive.Vegetablescanbethosethatareavailablelocally.
Giveexamplesoflocallyavailablevegetables.
Some vegetables could be grown in home gardens. Small amounts of animal foods can make a
difference; large amounts are not necessary. Some animal foods such as, tinned fish or chicken
partsmaybeaffordable.
Giveotherlocalexamplesofreadilyavailableanimalfoods,asappropriate.
Prepared question 2
Wh Wh Wh Which ich ich ichsupplementsaregoodforpeoplewithHIV? supplementsaregoodforpeoplewithHIV? supplementsaregoodforpeoplewithHIV? supplementsaregoodforpeoplewithHIV?
Answer: Answer: Answer: Answer:
Supplements do not prevent or cure HIV or AIDS. A variety of good foods will provide adequate
vitaminsandminerals.Itisworthspendingmoneyongoodfoods.
It is rare to have a deficiency of only one vitamin or mineral. It is more common to find a
combination of deficiencies. There is no evidence that taking large doses of a single vitamin or
mineralhelps,unlessthereisanestablisheddeficiencyofthatparticularnutrient.
SomepeoplewithHIVmayneedextravitaminsandmineralsbecausetheyhaveotherconditions
suchasironanaemia.Theymaybeprescribedasupplementthatcontainsawiderangeofvitamins
andminerals,ifavailable.Thisisasupplement,notareplacementforfoods.
It is best to talk individually to your health care provider about using a supplement rather than
choosing a supplement yourself. Nutritional care and support can have a positive impact on
health,evenwithouttheuseofsupplements.
2
Askthegroupforanyadditionalquestionsoftheirown.
After discussing the answers to the questions raised, thank the group for their interest and
attendanceoftheEatingwiselytalk.
End of demonstration talk
Explaintoparticipantsthatthedemonstrationtalkhasnowendedandthattheynolongerneedto
berole-playingaspeopleattendingahealthcentretalk.
Returntotherestofthesession.
2
NewinformationontheroleofvitaminandmineralsupplementsinHIVbecomesavailablefrequently.Keepup-
to-date.
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61
4. Eating wisely: summary and discussion (15 minutes)
Inthiseatingwiselytalkweheardanotherkeypoint:
Showthekeypointdisplayed.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Aimtoeatawidevarietyoffoods,ateachmeal,everyday. Aimtoeatawidevarietyoffoods,ateachmeal,everyday. Aimtoeatawidevarietyoffoods,ateachmeal,everyday. Aimtoeatawidevarietyoffoods,ateachmeal,everyday.
Whatcommunicationskills Whatcommunicationskills Whatcommunicationskills Whatcommunicationskillswereused wereused wereused wereusedint int int inthe he he hee ee eatingwiselytalk atingwiselytalk atingwiselytalk atingwiselytalk? ?? ?
Allowparticipantstodiscussthisandusethefollowingpointstoaddthediscussion.
Communicationskillsusedintheeatingwiselytalkincluded,openquestions,reflecting,offering
smallamountsofrelevantinformationandsuggestions,praiseandcheckingofunderstanding.
Ifthesesimpleapproachesdonothelptoimprovetheclientsdiet,thenhe/shemightneedtobe
referred to a nutritionist or dietician or other specialized caregiver for a more detailed nutritional
assessment.
HEALTHWORKER Yes,thankyouforcomingtoday.Thelasttimewe
spoke,youweregoingtotrytogive(Childsname)afull
bowloffoodthreetimesintheday,plussomething
smallbetweenthemeals.Howdidthatwork?
Openquestion Openquestion Openquestion Openquestion
CAREGIVER Well,itseemsalotoffoodtogiveayoungchild.
Does(he/she)reallyneedthatmuchfood?
HEALTHWORKER Itseemstoyoulikealotoffoodforayoungchild.
(Childname)isgrowingveryfastatthisage.Togrow
well,childrenneedplentyoffood.
Reflect Reflect Reflect Reflect
Giver Giver Giver Giverelevant elevant elevant elevant
i ii inform nform nform nformation ation ation ation
CAREGIVER Butwhatif(he/she)didnteatitall?Idonthaveextra
foodtowaste.
HEALTHWORKER Youareworriedaboutwastingthefoodifitisnoteaten.
Whataboutincreasingtheamountslowlyaddingone
ortwoextraspoonfulseachdayuntilitisafullbowl?
Empathi Empathi Empathi Empathiz zz ze ee e
Suggest Suggest Suggest Suggestion ion ion ion
CAREGIVER Icouldtrythat.ThenIwouldseeif(he/she)eatsit
withoutwastingit.
HEALTHWORKER Thatsagoodidea.
Sowhatwouldyouputinthebowleachtime?
Praise Praise Praise Praise
Check Check Check Check
understanding understanding understanding understanding
CAREGIVER Illputabitmorefoodineachdayuntil(he/she)iseating
afullbowlthreetimesaday.
HEALTHWORKER Exactly.Andyoualreadygiveavarietyoffoods
includingsomeanimalfoodwheneveryoucan,sokeep
doingthis.
Canyoutryitfortwoweeksandthencomebackandtell
mehowitwent?
Praise Praise Praise Praise
Arran Arran Arran Arrange ge ge ge
follow follow follow follow- -- -up up up up
CAREGIVER OK,Illdothat.Thankyou.Good-bye.
HEALTHWORKER Good-bye.
5. Food choices (20 minutes)
SamandSuzinowhavesomeinformationon SamandSuzinowhavesomeinformationon SamandSuzinowhavesomeinformationon SamandSuzinowhavesomeinformationon eatingwisely eatingwisely eatingwisely eatingwisely .Isthisinformationallthatisneeded .Isthisinformationallthatisneeded .Isthisinformationallthatisneeded .Isthisinformationallthatisneeded
forthemtoeatwisely? forthemtoeatwisely? forthemtoeatwisely? forthemtoeatwisely?
Whatcould Whatcould Whatcould WhatcouldaffectSamandSuzisdecisiontoeatwisely? affectSamandSuzisdecisiontoeatwisely? affectSamandSuzisdecisiontoeatwisely? affectSamandSuzisdecisiontoeatwisely?
Wemakechoicesaboutthefoodwewilleatorgivetochildrenorotherswecareforbasedon:
Whatfoodsareavailable/affordable;
Time,energyandequipment;
Knowledge,culture,habit,familypreferencesandbeliefsaboutfood;aswellas
Hungerorappetite.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
64
Knowledge about what foods to eat is not enough. The food a person eats is affected by his/her
access to foods as well as customs and beliefs. Check that any suggestions you give are
acceptableandcanbecarriedout.
When suggesting food to another person, consider their preferences, culture, habits and beliefs.
Foods may be chosen or avoided because of religious beliefs, family tradition, local customs or
personalpreference.
Exercise 3/1: Food choices worksheet (15 minutes)
Askparticipantstoformthreegroups.
Ensurethateachgrouphasacopyofthe Exercise Exercise Exercise Exercise3/1:Foodchoicesworksheet 3/1:Foodchoicesworksheet 3/1:Foodchoicesworksheet 3/1:Foodchoicesworksheetonpage41 of
theParticipant'sManual.
Eachgroupshoulddiscussoneofthethreepointsoutlined(allow5minutesfordiscussion).
Checkthatparticipantsunderstandwhichspecificpointtheyaretodiscuss.
After 5 minutes, bring the three groups back together and ask each to report the main points of
theirdiscussiontothewholegroup.
Attheendofthefeedback,thanktheparticipantsfortheircomments.
Whatkeypointdidwe Whatkeypointdidwe Whatkeypointdidwe Whatkeypointdidwecover cover cover coverinthissession? inthissession? inthissession? inthissession?
Showthekeypointdisplayedonaflipchartsheet
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Aimtoeatawidevarietyoffoods,ateachmeal,everyday. Aimtoeatawidevarietyoffoods,ateachmeal,everyday. Aimtoeatawidevarietyoffoods,ateachmeal,everyday. Aimtoeatawidevarietyoffoods,ateachmeal,everyday.
6. Summary of the session and transition (2 minutes)
Food is needed for energy, to build and repair, to protect and to keep the body functioning. We
needavarietyoffoods.Theamounttoeatandhowoftentoeatdependsonindividualneeds
ShowO OO Overhead verhead verhead verhead3/4 3/4 3/4 3/4: :: : E EE Eatingwiselyguidelines atingwiselyguidelines atingwiselyguidelines atingwiselyguidelines (ortheeightcolouredcardspreparedfordisplaying
theguidelines).
Nutritional Care and Support for People Living with HIV: Facilitators Guide
65
OVERHEAD3/4:Eatingwiselyguidelines OVERHEAD3/4:Eatingwiselyguidelines OVERHEAD3/4:Eatingwiselyguidelines OVERHEAD3/4:Eatingwiselyguidelines
1. Enjoyavarietyoffoods.
2. Makestaplesorstarchyfoodsthelargestpartofyourmeal.
3. Eatpeas,beans,lentils,nutsandseeds,ifpossibleeveryday.
4. Eatanimalandmilkproductsregularly.
5. Eatawidevarietyofvegetablesandfruitseveryday.
6. Usefatsandoilsaswellassugarandsugaryfoodsregularlybutinmoderation.
7. Usefoodsthatarefortifiedwithessentialnutrients,ifpossible.
8. Drinkplentyofsafewater.
Explainthefollowingpoints;
ItisrecommendedthatalleightEatingwiselyguidelinesarefollowed,inordertoensurethatthe
bodygetsallthenutrientsitneedsto Go Go Go Go ,Glow Glow Glow Glow and Grow Grow Grow Grow. . . .
Knowledge about what foods to eat is not enough. Ones diet is affected by the type of foods to
whichonehasaccessaswellasvariouspreferences,customsandbeliefs.
Help clients to deal with the barriers that could hinder them from following the eating wisely
guidelinesandcheckthatanysuggestionsyougiveareacceptableandcanbecarriedout.
Askifthereareanyquestionsandifanythingneedsclarifying.
Inthenextsession,wewilldiscussfoodsafetyforpeoplewithHIV.
Thenextsessionwillbepresentedby:
Statethenameofthepresenter.
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HANDOUT3/1:Foodportions:sizesofahealthymeal HANDOUT3/1:Foodportions:sizesofahealthymeal HANDOUT3/1:Foodportions:sizesofahealthymeal HANDOUT3/1:Foodportions:sizesofahealthymeal
FOODGROUP FOODGROUP FOODGROUP FOODGROUP EXAMPLES EXAMPLES EXAMPLES EXAMPLES 1PORTION 1PORTION 1PORTION 1PORTION PORTIONS PORTIONS PORTIONS PORTIONSFOR FOR FOR FORDAILYMEALS DAILYMEALS DAILYMEALS DAILYMEALS
Bread 1slice
Rice/Pasta cup(measuredafter
cooked)
Maize-meal 1cup(orabout1fistful)
STAPLES&
STARCHY
FOODS
Potatoes 1mediumsizepotato
6PORTIONS 6PORTIONS 6PORTIONS 6PORTIONS- -- - Example:
Breakfast:1cupofporridge
Snack:1sliceofbread
Lunch:1cupofriceduringlunch
Snack:1sliceofbread
Supper:1cupofmaizemeal
Chicken,beef,
lamb,fish
Equivalentsizetoone
chickenthigh
Eggs 1egg
MEAT,FISH,
POULTRY&MILK
Milk(fresh/
fermented)
1cup
3PORTIONS+1PORTIONOF 3PORTIONS+1PORTIONOF 3PORTIONS+1PORTIONOF 3PORTIONS+1PORTIONOF
MILK MILK MILK MILK
Example:
Lunch:1thighofchicken
Snack:2tablespoonsofpeanut
butter
Supper:1cupofcookedbeans
Snack:1glassofmilkforsnacks
PULSES&
LEGUMES/NUTS
&OILSEEDS
Cookedbeans 1cup
Nuts 1cup
Peanutbutter 2tablespoons
Fruits 1mediumsizepieceof
fruit
FRUITS
Fruitjuices 1glass
3PORTIONS 3PORTIONS 3PORTIONS 3PORTIONS- -- - Example:
Breakfast:1glassoforangejuice
Lunch:1pieceoffruit
Snack:1pieceoffruit
Rawchopped
vegetables
1cup VEGETABLES
Cookedvegetables cup
5PORTIONS 5PORTIONS 5PORTIONS 5PORTIONS- -- - Example:
Breakfast:cupofgreenbeans
Lunch:1cupofmixedvegetables
Snack:1cupvegetablesalad
Supper:1cupofgreenleafy
vegetables
FATS&OILS 1teaspoon 5PORTIONS 5PORTIONS 5PORTIONS 5PORTIONS(INCLUDING
NATURALFATSFOUNDIN
MEAT)
Example:1teaspoonofoilfor
everymeal
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EXERCISE3/1:Foodchoicesworksheet EXERCISE3/1:Foodchoicesworksheet EXERCISE3/1:Foodchoicesworksheet EXERCISE3/1:Foodchoicesworksheet
1. 1. 1. 1.Foodavailability Foodavailability Foodavailability Foodavailability
Whataffectstheavailabilityoffoods?
Whatfoodsaregrownorproducedinthearea?
Aretherefoodsthatarecommonlyavailableatonlycertaintimesoftheyear?
Howfardothepeopleyouworkwithneedtogotogettheirfood?
Does the distance differ depending on what the food is? For example, can rice be
obtainednearbybutvegetablesoranimalfoodsarefurtheraway?
Cost is a major factor in availability. Which foods are seen as affordable for many
people?
Which foods mentioned in the Eating wisely talk are considered too expensive for
regularuse?(Wewilldiscussfoodsubsidies,grantsandfoodaidlaterinthecourse.)
2.Time,energyandequipment 2.Time,energyandequipment 2.Time,energyandequipment 2.Time,energyandequipment
How much time is needed everyday to prepare food in order to eat wisely? How does
thisaffectfoodchoices?
Energycanbeoftwokinds.Theenergy orfueltocookthe foodand thehumanenergy
requiredtoprepareit.Howcaneachkindaffectfoodchoices?
Canyouthinkofanyequipmentthatmightnotbeavailabletosomeofthefamiliesyou
careforthatwouldaffecttheirfoodchoices?
Writeanddisplaythelearningobjectivesonaflipchartsheet.
Writethekeypointonasheetofflipchartpaperandkeepitasideuntilneeded:
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Followthef Followthef Followthef Followthefivekeystepstosaferfoods ivekeystepstosaferfoods ivekeystepstosaferfoods ivekeystepstosaferfoodsand and and andstop stop stop stopping ping ping pinggermsfrom germsfrom germsfrom germsfrom
makingyouandthose makingyouandthose makingyouandthose makingyouandthosearoundyou aroundyou aroundyou aroundyouill. ill. ill. ill.
Find out about the local sources and quality of household water supply. Gather information on
local hygiene practices, particularly relating to washing hands and waste/faecal disposal, how
foodisgenerallystoredandpreparedandwhatpeopleknowaboutkeepingfoodandwatersafe.
Findoutinformationfromlocalhealth,water,andfoodsafetyauthoritiesonwhattheyaredoingto
improvethesafetyofthefoodsupplyandpreventionoffood-borneillnesses.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
69
Be familiar with dangerous germs and recent food-borne illness outbreaks if any in the area/
region.
Findouthowagriculturalchemicalsareusedandhowtheyarehandled.
Prioritizetheimportantinformationtobeemphasized.
Writeoutthreesetsofrole-playsforExercise4A.Therole-playsdescribethreecasesinwhichthe
client is not keeping his/her food safe. The health worker will be asked to discuss these cases
withtheclientandhelphim/hermakechangestoimprovefoodsafety.
Writethelearningobjectivesonasheetofflipchartpaperfordisplay.
Collect/preparethefollowingtrainingmaterials:
An overhead projector and screen; and/or flipchart paper, markers and a means to attach
flipchart sheets to the wall or other surface. If an overhead projector is not available the
overheadmaybewrittenoutanddisplayedonaflipchartsheet.
Overhead4/1: Overhead4/1: Overhead4/1: Overhead4/1:Fivekey Fivekey Fivekey Fivekeys ss s to to to tosaferfoods saferfoods saferfoods saferfoods. .. .
Handout Handout Handout Handout 4/1 4/1 4/1 4/1:Observation :Observation :Observation :Observationg gg guide uide uide uide
Handout4/2: Handout4/2: Handout4/2: Handout4/2: Fivekeys Fivekeys Fivekeys Fivekeysto to to tosaferfoods saferfoods saferfoods saferfoods
Handout4/3:Exampleofwatertreatment Handout4/3:Exampleofwatertreatment Handout4/3:Exampleofwatertreatment Handout4/3:Exampleofwatertreatment
1. Learning objectives and introduction to the session (2 minutes)
Review the learning objectives of the session
Bytheendofthissession,participantswillbeableto:
Explaintheimportanceoffoodsafety,especiallyforpeoplelivingwithHIV;
Describehowfoodandwatercanbecomesourcesofinfection;
Discussthefivekeystosaferfoods;and
Developanduseanobservationguidetohelpidentifycommonfoodsafetyproblemsand
theirappropriatesolutions.
Introduce the session
In Session 3 Session 3 Session 3 Session 3, we talked about how important it is to eat enough food, how to choose nutritious
foods and eat wisely. Eating safer food is also an important part of good nutrition. As a part of
goodnutrition,itisimportantthatthefoodweeatandthewaterwedrinkissafe.
Foodcaneasilybecontaminatedbyharmfulgermsorpoisonatanytimebeforeeating,ifitisnot
handled, prepared and stored in a safe way. A person eating these contaminated foods may
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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become ill and experience symptoms such as stomach pains, nausea, vomiting and diarrhoea.
Thisillnessiscalledfood-borneillness.
The consequences of food-borne illness are more severe for people with low immunity such as
peoplelivingwithHIV.
Inthissession,wewilldiscusstheimportanceoffoodsafety,especiallyforPLHIVandsomekey
guidelines for ensuring food safety. It is important that all people follow these food safety
guidelines,whethertheyhaveHIVornot.
Discusswithparticipantssomelocalfoodsthatdoordonotprovideidealconditionsforthegrowth
ofgerms,e.g.drycereals:
3. Other causes of food-borne illness: poisons (3 minutes)
Apartfromgerms,whatareothercausesoffood Apartfromgerms,whatareothercausesoffood Apartfromgerms,whatareothercausesoffood Apartfromgerms,whatareothercausesoffood- -- -borneillness? borneillness? borneillness? borneillness?
Allowparticipantstomakeoneortwosuggestions,beforediscussingthefollowingpoints:
People can also get sick from being poisoned. The sickness can result from chemical
contamination, from exposure to the chemicals on an ongoing basis, for an extended period of
time.
These toxins and chemicals include: natural toxins, metals and environmental pollutants,
chemicals used for treating animals, improperly used pesticides and food additives, as well as
variouschemicalsusedforcleaning.
Discuss with participants local examples of some toxins and dangerous chemicals that could be
sourcesofcontamination.
Some natural toxins, such as aflatoxin aflatoxin aflatoxin aflatoxin, , , , may be caused by moulds growing on food stored in
damp places. Maize and peanuts are some of the foods that can have aflaxtoxin if they are not
storedproperly.Ingestingaflatoxinsmayhaveharmfuleffectsontheliverthatcanleadtocancer.
3
Safemeansthatwaterandfoodarefreefromdangerousgermsandtoxicchemicalsatlevelsthatcouldcause
illnessand/ordisease.
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Some types of cassavas may cause cyanide poisoning when they are not processed well. In
severecases,thismayleadtokidneyfailureanddeath.
Foods grown near highways or roads in areas where most vehicles use leaded fuel may be a
causeofleadtoxicity.
Simple measures, such as, washing and peeling may reduce risk from chemicals found on the
surfaceoffoods.
Appropriatestoragecanhelpavoidorreducetheformationofsomenaturaltoxins.
Discussappropriatecookware.
Usingcookwareandutensilsglazedwithmaterialscontainingheavymetals(e.g.lead,cadmium)
canresultinchemicalpoisoning.
Itisimportanttoreadandunderstandinstructionsonthelabelsofchemicalsusedforcleaning.
Ask participants to get in pairs to design an observation guide, using the outline provided
(Handout 4/1 Handout 4/1 Handout 4/1 Handout 4/1 found on page 48 of the Participants Manual), they should think of a guide that
couldbeusedtoevaluatehowwelltheirclientiskeepingfoodandwatersafe.
Encourageparticipantstothinkaboutobservingtheentirehouse.
Remindthemthat:
Often,whathouseholdmembersdoinonepartofthehousewillaffecthowfoodiskeptinanother
partofthehouse,likethekitchen.
Haveamemberfromeachpairreportthecriteriatothelargegroup.
Posttheitemsreportedupontheflipchart.Askotherstoadditemstothelistthathavenotbeen
mentioned.
Checkthattheparticipantsunderstandandagreethattheitemslistedarerelevanttoassessinga
clientssituation.
Explainthefollowing:
As we discuss more information on food safety you should record any additional items that are
appropriatefortheObservationGuideandaddtheseitemstotheguideattheendofeachsection
ofthepresentation.
6. Keeping food safe (12 minutes)
Introduction to guidelines for keeping food safe
No food is 100 per cent safe at all times. But the risks of illness can be reduce by following five
simplerulesaboutfoodsafetythatcanhelppreventmostfood-borneillnesses.
Doyouknowof/c Doyouknowof/c Doyouknowof/c Doyouknowof/canyousuggestany anyousuggestany anyousuggestany anyousuggestanymeasuresforensuring measuresforensuring measuresforensuring measuresforensuringfo fo fo foodsafety odsafety odsafety odsafety? ?? ?
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Allowparticipantstomakeoneortwosuggestions.
ShowOverhead4/1 Overhead4/1 Overhead4/1 Overhead4/1Fivekeystepstosaferfoods Fivekeystepstosaferfoods Fivekeystepstosaferfoods Fivekeystepstosaferfoodsandexplainthattopreventfood-borneillness
itisessentialthatweunderstandandfollowthefivekeyguidelinestosaferfoods.
E EE Exercise xercise xercise xercise4/2: 4/2: 4/2: 4/2:Adapting Adapting Adapting Adaptingthef thef thef thefive ive ive ivek kk key ey ey eysteps steps steps stepstosaferfoods tosaferfoods tosaferfoods tosaferfoodstothelocalcontext tothelocalcontext tothelocalcontext tothelocalcontext
Ask participants to form three groups. Give each group a role-play and ask them to provide
counselling to a family living with HIV using the observation guide developed in the previous
exerciseandtheFiveKeysforSaferFood:
Ask them to discuss in their groups appropriate ways for following the guidelines within the
particularcontextoftheirlocalarea/region.
Refer them to Handout Handout Handout Handout 4/ 4/ 4/ 4/2 22 2 (found at the end of this session and on pages 49-52 of the
Participant'sManual).
Remind them that the practices they suggest for following each guideline must be feasible and
practicalintheirlocalcontext.
Afterthegroupworkaskeachgrouptopresenttheirsuggestionsandallowtimefordiscussion.
Clarifyanyissuesthatmighthavebeenleftoutusingthefollowingadditionalfacts.
6.1. Keep clean
Dangerous germs are easily carried on hands; wiping cloths and utensils, especially cutting-
boards,andtheslightestcontactcantransferthemtofoodandcausefoodborneillness.
Always wash hands with safe water and soap: advise people and families to always wash their
hands with safe water and soap (or ashes), dry hands by shaking and rubbing them together or
usingacleancloththatiskeptonlyforthispurposeandtokeepfingernailsshortandclean.
Advisepeopleandfamiliesabouthygienearoundthehome.
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Just because something looks clean does not mean that it is. It takes over 2.5 billion germs to
make 250 ml of water look cloudy, but in some cases it takes only 15-20 dangerous bacteria to
causeillness.
6.2. Separate raw and cooked foods to stop germs from spreading
Raw food, especially meat, poultry, seafood and their juices can contain dangerous germs that
may be transferred onto other foods during preparation and storage. This is called c cc cross ross ross ross- -- -
contam contam contam contamination ination ination ination.
Adviseindividualsandfamiliestoalways:
Separate raw and cooked food during cooking and preparation, including the animal
slaughteringprocess.
Keeprawmeat,poultryandseafoodseparatefromotherfoods.
Useseparateequipmentsuchasknivesandcuttingboardsforhandlingrawfoods.
If possible, use one cutting board for meat, chicken and fish and another for vegetables
and bread. Alternatively, clean the board well with soap and hot water after using it for
eachtypeoffood.
Storefoodsincoveredcontainerstoavoidcontactbetweenrawandcookedfoods.
Explainthefollowing:
Cross Cross Cross Cross- -- -contamination contamination contamination contaminationisatermusedtodescribethetransferofgermsfromrawtocookedfood.
Separationmustoccurnotonlywhencooking,butduringallphasesoffoodpreparation,including
theslaughteringprocesses.
6.3. Cook food thoroughly in order to kill germs
Propercookingcankillalmostalldangerousgerms.Foodsthatrequirespecialattentioninclude:
mincedmeats,rolledroasts,largejointsofmeatandwholepoultry.
Adviseindividualsandfamiliestoalways:
Cookfoodthoroughly,especiallymeat,poultry,eggs,fishandseafood.
Bringfoodslikesoupsandstewstoboilingpoint.Formeatandpoultry,makesurejuices
areclear,notpink.
Reheat cooked food thoroughly. Bring to boil or heat until too hot to touch. Stir while re-
heating.
It is not safe to eat raw eggs or foods with raw eggs added. Eggs may carry illness-
causing bacteria that can survive even in cool temperatures but can easily be killed by
heating.
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6.4. Keep food at safe temperatures to slow the growth of germs
Keephotfoodhotandcoldfoodcold.
Itisnotsafetoleavecookedfoodatroomtemperatureformorethantwohours.Germscangrow
andmultiplyveryquicklyiffoodisstoredatroomtemperature.
Adviseindividualsandfamiliestoalways:
Buyfreshfoods,suchasmeatandfishonthedaytheywilleatthem.
Preparefoodinsmallamountstoreduceleftovers.Foodforinfants,childrenandpeople
withlowimmunityshouldbefreshlypreparedandeatenassoonaspossible.
Store fresh foods (especially foods from animals), and cooked food in a cool place, or a
refrigeratorifavailable.
Avoidstoringleftoversformorethanafewhours(unlessrefrigerated).Alwaysstorethem
coveredandreheatthemthoroughlyuntilhotandsteaming(bringliquidfoodstoarolling
boil).
Discuss other practical food storage methods which may be applicable in the local area/region.
Forexample:theuseofcoldwaterforstoringfoodandmilkinsealedcontainers;storingfoodina
special dugout hole in the ground; buying foods which keep well for long periods, such as
potatoesandcassava,etc.
Explainthefollowing:
Foodcanbecooledquicklyby:puttingthefoodontoopentrays;slicinglargepiecesofmeatinto
smallerpieces;placingfoodinacool,cleancontainer;orstirringregularlyforsoups.
6.5. Use safe water/ foods to stop germs and chemicals from entering the home
Raw materials, including water and ice, may be contaminated with dangerous germs and
chemicals. Toxic chemicals may be formed in damaged and mouldy foods. Care in selection of
rawmaterialsandsimplemeasuressuchaswashingandpeelingmayreducetheserisks.
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Safe water
Adviseindividualsandfamiliestoalways:
Use safe water such as, treated piped water or water from a safe source such as, a
protected well. Untreated water from rivers and canals contain germs which can cause
diarrhoea,typhoidordysenteryandarenotsafe!Waterthatisnotsafeshouldbeboiled
beforedrinkingoruseforfoodpreparation.
4
Use clean containers to collect and store water with a lid or covered with a clean cloth.
Rainwater collected in clean tanks is safe as long as the tank is protected from
contamination from birds or other animals. Cool drinks and ice cubes should also be
madewithwaterthatissafe.
Safe food
Adviseindividualsandfamiliestoalways:
Buy fresh foods such as, meat and fish. Look for signs that indicate the poor quality of
food.
Foodswithanysignsofpoorqualityarelikelytohavebeencontaminated.
Wh Wh Wh Which ich ich ichkeypointsdidwe keypointsdidwe keypointsdidwe keypointsdidwediscuss discuss discuss discussinthissession? inthissession? inthissession? inthissession?
Showthekeypointdisplayedandreadit.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Followthef Followthef Followthef Followthefivekeystepstosaferfoodsandstoppingg ivekeystepstosaferfoodsandstoppingg ivekeystepstosaferfoodsandstoppingg ivekeystepstosaferfoodsandstoppinggermsfrom ermsfrom ermsfrom ermsfrom
makingyouandthosearoundyouill. makingyouandthosearoundyouill. makingyouandthosearoundyouill. makingyouandthosearoundyouill.
Eatingsafefoodscanhelpmaintaingoodnutritionalstatus.
Food-borne illness can be life-threatening for PLHIV due to their lower immunity to fight off
infections.
Thefivekeyguidelinestosaferfoodarethekey key key keytopreventingfoodbornillnesses.
Keepyourself,yoursurroundingsandcookingutensilscleantostopgermsfromgrowing
andspreading.
Keeprawandcookedfoodsseparatetostopgermsfromspreading.
Cookfoodthoroughlytokillgerms.
Keepfoodatsafetemperaturestoslowthegrowthofgerms.
4
Findoutabouttheappropriatemethodfortreatingwaterinyourlocalareaorregion.Oneexampleisthebleach
method(seeHandout4/6 Handout4/6 Handout4/6 Handout4/6).
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Use safe water, food and raw materials to stop germs and chemicals from entering the
home.
Askparticipantsiftheyhaveanyquestionsorifanythingneedsclarifying.
Inthenextsession,wewilldiscussimprovingfoodintake.
Thenextsessionwillbepresentedby:
Statethenameofthepresenter.
HANDOUT4/1: HANDOUT4/1: HANDOUT4/1: HANDOUT4/1:Observation Observation Observation Observationg gg guide uide uide uide
Keepclean(includeshandwashing,cleankitchen,dishes,utensils,cleaneatingplaces,separation
ofgarbage,andprotectionfromhumanwaste).
Separaterawandcooked(includesseparationofcuttingandotherutensils).
Cookthoroughly(includesattentionandobservationofcookingequipmentormaterials).
Keepfoodatsafetemperatures(includesobservationofleftovers,foodstorage).
Usesafewaterandrawmaterials(includesobservationofwaterstorage,sourceofdrinkingwater,
watercontainers,watertreatmentandhandling).
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HANDOUT4/2:Fivekeys HANDOUT4/2:Fivekeys HANDOUT4/2:Fivekeys HANDOUT4/2:Fivekeysto to to tosaferfoods saferfoods saferfoods saferfoods
1.Keep 1.Keep 1.Keep 1.Keepc cc clean lean lean lean
Dangerous germs are easily carried on hands, wiping cloths and utensils, especially cutting-boards,
andtheslightestcontactcantransferthemtofoodandcausefood-borneillnesses.
Alwayswashhandswithsafewaterandsoap.
Adviseindividualsandfamiliestoalwayswashtheirhandswithsafewaterandsoap(orashes):
Beforeandafterpreparingfoodandeating;
After being in contact with faeces, e.g., after going to the toilet, cleaning babys bottom or cleaning
cloths,dirtybedlinenorsurfacescontainingfaeces;
Beforefeedingachildorasickperson(makesuretheywashtheirhandstoo);
Dry hands by shaking and rubbing them together or using a clean cloth that is kept only for this
purpose;
Keepfingernailsshortandclean.
Maintainh Maintainh Maintainh Maintainhygienearoundthehome ygienearoundthehome ygienearoundthehome ygienearoundthehome
Adviseindividualsandfamiliestoalways:
Keepkitchen,dishesandutensilsclean.
Washallworksurfaces(tabletops,counters,shelves)anddisheswithsoapandsafewater.
Protectkitchenareasandfoodfrominsects,pestsandotheranimals.
Keeprubbishincoveredbinorrubbishpit.Emptyandwashthebinorburnrubbishregularly.
Wash kitchen cloths, sponges and scourers with soap. Sunlight is an effective way to kill germs
naturally.Dryclothsinthesun.
Keepkitchenwellventilated.Thishelptopreventthegrowthofmouldsandfungus.
Keepfoodpreparationareasingoodcondition(repairwallcracksorholes).
Make composed for the garden with suitable waste food, garden rubbish and animal faeces;
compostingdestroysgermsinfaeces.
Otherwaysofkeepingclean Otherwaysofkeepingclean Otherwaysofkeepingclean Otherwaysofkeepingclean
Adviseindividualsandfamiliestoalways:
Avoidcoughingandsneezingnearthefoodorwater.
Coveranywoundsonhandstopreventcontaminationoffoodduringpreparation.
Usealatrineandkeepitawayfromflies.
Teachchildrentousepotty,anddiscardchildrensfaecesinthetoilet.
Cleanupfaecesfromanimals.
Justbecausesomethinglookscleandoesnotmeanthatitis.Ittakesover2.5billiongermstomake
250mlofwaterlookcloudy,butinsomecasesittakesonly15-20dangerousbacteriatocauseillness.
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Dry cereals and legumes thoroughly and store them in a dry place to avoid moulds from growing.
Mouldycerealsandlegumescontainaflatoxinthatcanmakethemseriouslyill.
Food may also be contaminated from the point of production. Involve extension workers for more
informationongoodagriculturalpractisestoensureproductionofsaferfoods
PeoplewithHIVshouldavoidtastinganyfoodthatmightbespoiled.Theymighthavedonethisinthe
pastandnevergotillbutrememberthingsaredifferentwithHIV.
Some foods are poor value for money because they contain few nutrients. Examples are sodas
(bottled fizzy drink), ice lollies and sweets, which are mainly sugar. These foods should be kept as
treatsnoteatenoften.
Otherinformation Otherinformation Otherinformation Otherinformationonfood onfood onfood onfood- -- -borneillnesses borneillnesses borneillnesses borneillnesses
Food-borneillnesscanalsoleadtolong-termhealthproblemsandsevereillnesses,includingcancer,
arthritis and mental disorders especially among children, people who are sick, pregnant women and
theelderly.
Adviseindividualsandfamiliesto:
Seekmedicaladviceimmediatelywhensymptomsaresevere;forexample,whenbowelmovements
areveryfrequent,verywateryorcontainblood,orlastbeyond3days.
Trynottohandleorpreparefoodwhileilland2daysafterrecoveringespeciallyfromvomitingand/or
diarrhoea.
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HANDOUT4/3:Exampleofwatertreatment HANDOUT4/3:Exampleofwatertreatment HANDOUT4/3:Exampleofwatertreatment HANDOUT4/3:Exampleofwatertreatment
Thebleachmethod Thebleachmethod Thebleachmethod Thebleachmethod
Add1teaspoonoronecapfulifthebottlehasascrewcap(5ml)ofbleachto25litresofwater.
Mixitwellandletitstandfor2hours(orpreferablyovernight)beforeusing.
Storesafewaterincleancontainerwithalidorcoveredwithacloth.
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Session5:Improvingfoodintake Session5:Improvingfoodintake Session5:Improvingfoodintake Session5:Improvingfoodintake
Learning Learning Learning Learningo oo objectives bjectives bjectives bjectives
Bytheendofthissession,participantswillbeableto:
Discuss common eating difficulties that may affect the food intake of people living with HIV;
and
Describe strategies and techniques for improving food intake by overcoming loss of appetite,
sore mouth and throat, nausea and vomiting, change in taste, diarrhoea and other common
difficultiesexperiencedbypeoplelivingwithHIV.
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Collect/preparethefollowingtrainingmaterials:
Anoverheadprojectorandscreen;and/oraflipchartstand,flipchartpaper,markersandameans
toattachflipchartsheetstothewallorothersurface.Ifanoverheadprojectorisnotavailable,the
followingmaybewrittenout/preparedfordisplayonflipchartsheets.
Prepareasheetofflipchartsheetforeacheatingdifficultyusingthefollowingheadings:
Soremouth/throat;
Drymouth/changeintaste;
Diarrhoea;and
Nauseaandvomiting.
Addanyothereatingdifficultiesyouwishtodiscuss.
H HH Handouts5/1 andouts5/1 andouts5/1 andouts5/1to to to to5/ 5/ 5/ 5/4 44 4(availableattheendofthissessionandonpages57-60oftheParticipants
Manual) provide suggestions for addressing the main eating difficulties. Adapt the suggested
measurestolocalfoodsandcircumstancesasappropriate.Encourageparticipantstomaketheir
ownlistsratherthanjustcopyingthese.
H HH Hando ando ando andout5/5 ut5/5 ut5/5 ut5/5: : : : P PP Preparationof reparationof reparationof reparationofano ano ano anoral ral ral ralr rr re ee e- -- -hydration hydration hydration hydration s ss solution olution olution olution (availableattheendofthissessionand
onpage61oftheParticipantsManual). .. .
2. Common eating difficulties that may affect the food intake of people
living with HIV (25 minutes)
Whatarethecommon Whatarethecommon Whatarethecommon Whatarethecommoneating eating eating eatingdifficultiesthataffectthefoodintakeof difficultiesthataffectthefoodintakeof difficultiesthataffectthefoodintakeof difficultiesthataffectthefoodintakeof peoplelivingwith peoplelivingwith peoplelivingwith peoplelivingwithHIV HIV HIV HIV? ?? ?
Allowparticipantstorespondandlisttheirresponsesonasheetofflipchartpaper.
Usethelistbelowtoadditemsthatmayhavebeenmissedbytheparticipants.
Soremouth/throat Soremouth/throat Soremouth/throat Soremouth/throat Thrush, herpes, infections and other conditions may cause sore mouth/throat-
making it difficult to eat. Patients diagnosed with (Candida) oral thrush should
avoideatingsweetfoodssuchas,sugar,honey,sweetfruitanddrinksasthese
can make the condition worse. Mouth hygiene such as rinsing the mouth with
cleanwaterbeforeandaftermealsandcleaningtheteeth,isimportantandcan
helpthepersontofeelbetter.
Dry mouth/change Dry mouth/change Dry mouth/change Dry mouth/change
intaste intaste intaste intaste
A person may find that they have a taste in their mouth; their mouth may feel
dry; or they may be more aware of the texture or feel of food in their mouth.
Somemedicationsmaymakeseasoningssuchas,mint,garlicandgingertaste
lesspleasant.
Diarrhoea Diarrhoea Diarrhoea Diarrhoea When a person passes a loose or watery stool three or more times a day,
he/shehasdiarrhoea.Thereareseveralcausesofdiarrhoeaincludingbacterial
infections,medicationsideeffectsandcontaminationoffoodresultingfromfood
safetyandhygieneproblems.Severediarrhoeamaycausedehydration,lossof
appetite, poor food digestion and absorption, weight loss and malnutrition
resulting in weakness and further illnesses. In young children, diarrhoea can
quicklybecomeseriousandifuntreatedcanleadtodeath.
Nausea/vomiting Nausea/vomiting Nausea/vomiting Nausea/vomiting These symptoms may be caused by infection, stress, certain foods, hunger or
lack of water. Unpleasant smells or a side-effect of some medications or
treatments.Nausea/vomitingmayalsoreducetheappetite.
Inadditiontothesefourmaintypesofeatingdifficulties,peoplelivingwithHIVmayexperiencea
generallossofappetite.Lossofappetitemaybeasignofotherinfectionssuchas,tuberculosis.
It could also be related with pain in the mouth or gut, or be due to depression, anxiety or
tiredness.Thefeelingofhungermaydisappearorthepersonmayfeelsatisfiedandthereforenot
wanttoeat.ItisrecommendedthatpeoplelivingwithHIVexperiencingappetitelossarereferred
totheirdoctor/healthcareproviderfordeterminingandtreatingthecause.
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87
ExplainaboutSamsillhealth,usingthetextbelow.
THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI
Sam was feeling much better for a while. After he talked with the support worker and had
treatmentfortuberculosis,hewaseatingwell,notlosingweightandabletodosomework.
Now,heisnotaswellashewasbefore.Hehasboutsofdiarrhoea,asoremouthandiseating
lessagain.Heislookingforsuggestionsthatmighthelphimwiththesenewproblems.
WhatmightthesupportworkersuggesttoSamtoimprovehisfoodintake? WhatmightthesupportworkersuggesttoSamtoimprovehisfoodintake? WhatmightthesupportworkersuggesttoSamtoimprovehisfoodintake? WhatmightthesupportworkersuggesttoSamtoimprovehisfoodintake?
AllowparticipantstorespondandthenintroduceA AA Activity5/1:Suggestionstoimprovefoodintake ctivity5/1:Suggestionstoimprovefoodintake ctivity5/1:Suggestionstoimprovefoodintake ctivity5/1:Suggestionstoimprovefoodintake. .. .
Explain the importance of giving suggestions that are relevant and realistic to the particular
circumstancesoftheperson.
ACTIVITY5/1:Suggestionstoimprovefoodintake ACTIVITY5/1:Suggestionstoimprovefoodintake ACTIVITY5/1:Suggestionstoimprovefoodintake ACTIVITY5/1:Suggestionstoimprovefoodintake
Ask participants to get into four groups and assign one of the four main types of eating
difficultiestoeachgroupasfollows:
Group1:Soremouth/throat
Group2:Drymouth/changeintaste
Group3:Diarrhoea
Group4:Nauseaandvomiting
Ask the groups to write down their suggestions for dealing with the eating difficulty they are
assigned.
Explaintotheparticipantsthatsomesuggestionsaregiveninthehandoutsforthissessionwhich
canbefoundonpages57-60oftheParticipant'sManual.Encouragegroupstodeveloptheirown
listsratherthansimplycopyingthese.
It is recommended that one facilitator should work with each group to check that participants
understandthetask.
Askeachgroupinturntoreporttheirrespectivesuggestionsfordiscussion;thenwritedownand
displaytheseonsheetsofflipchartpaper.
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3. Eating during recovery from illness (5 minutes)
THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI
Samtriessomeofthesuggestionsandheiseatingbetter.
Hisstrengthimprovesandheisabletotakeregularwalkswithhisfamily.
ButSamsweightremainslowernowthanitwasafewmonthsago.
WhatmightthesupportworkersuggesttoSamabouteat WhatmightthesupportworkersuggesttoSamabouteat WhatmightthesupportworkersuggesttoSamabouteat WhatmightthesupportworkersuggesttoSamabouteatingduringrecovery? ingduringrecovery? ingduringrecovery? ingduringrecovery?
Allowparticipantstogivetheirsuggestionsandexplainthefollowing:
Samtalkstothesupportworkerwhoremindshimthatittakestimetoregainhislostweight.Itcan
takeweeks,notjustdays.Therefore,Samneedstopayspecialattentiontowhatheeatsandto
continuetoeatwisely.
Toregainweightafterrecoveringfromillness,itisimportanttoincreasefoodintakebeyondwhat
onenormallyeats,ratherthanjustgoingbacktoonesnormaldiet.
Emphasizethefollowing;
When recovering from illness, a person has to make sure to eat extra well, by increasing the
quantity and quality of his/her food intake in order to regain weight. The same is recommended
forchildrenrecoveringfromillness,whomustalsobefedmorethanusual,inordertomakeup
formissedmeals.
Remindparticipantsoftheimportanceoffoodsafety(asdiscussedinS SS Session4 ession4 ession4 ession4).
Safefoodpracticesareimportantforeveryone.Infectionsfromwaterandfoodcanmakeaperson
ill or worsen conditions that may cause reduced food intake. Therefore, prevention of infection
fromfoodandwaterisveryimportant.
Discuss, with the people for whom you provide care, ways in which they can keep food safe in
theirhouseholdasdiscussedinS SS Session4 ession4 ession4 ession4.
Discusstheimportanceofreferralfortreatment.
ItisimportanttoencouragepeopleinfectedwithHIVtoseekearlytreatmentwhen:
Diarrhoealastsformorethanthreedays;
An infant or young child is not able to drink or breastfeed, is drinking poorly, becomes
sickerandweak,hasbloodinthestool,developsfever;and/or
Inthecase ofillnessessuchastuberculosis,fever,oralthrushanddepressionthatmay
causelossofappetite.
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4. Preparing an oral re-hydration solution to treat dehydration (5 minutes)
Ask participants to look at Handout Handout Handout Handout 5/5: 5/5: 5/5: 5/5: Preparing Preparing Preparing Preparing an oral re an oral re an oral re an oral re- -- -hydration solution (ORS) hydration solution (ORS) hydration solution (ORS) hydration solution (ORS) to treat to treat to treat to treat
dehydration dehydration dehydration dehydration(foundattheendofthissessionandonpage61oftheParticipant'sManual).
Explainthefollowing:
Dehydrationiscausedbyexcessivelossofwaterandsaltsfromthebodythatoftenoccursdueto
diarrhoeaorvomiting.
NotallpeoplewithdiarrhoeaneedORS,onlythosethataredehydrated.
Inyoungchildren,diarrhoeacanquicklybecomeseriousandifuntreatedcanleadtodeath.Itis
therefore,importanttotreatdehydrationpromptly.
Totreatdehydrationthepersonshouldreceiveanoralre-hydrationsolution(ORS),TheORScan
bepreparedbyusingsafewaterandoneofthefollowing:
apre-preparedORSpacket;
saltandsugar;or
powderedcereal.
RefertoHandout5/5 Handout5/5 Handout5/5 Handout5/5anddiscussthethreedifferentwaysofpreparingORS.
In addition to ORS, it is also recommended that the person experiencing dehydration be given
foodsandfluidswhichhe/shecantolerate.
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HANDOUT 5/5: Preparing an oral re HANDOUT 5/5: Preparing an oral re HANDOUT 5/5: Preparing an oral re HANDOUT 5/5: Preparing an oral re- -- -hydration solution (ORS) for treating dehydration hydration solution (ORS) for treating dehydration hydration solution (ORS) for treating dehydration hydration solution (ORS) for treating dehydration
Usecleanwater,boiledifpossible.
Fromapacket: Fromapacket: Fromapacket: Fromapacket:Followdirectionsonthepacket.
With salt and sugar: With salt and sugar: With salt and sugar: With salt and sugar: To one litre of water, add half a teaspoon of salt and eight teaspoons of
sugar.Stirorshakewell.Thesolutionshouldtastenomoresaltythantears.
Withpowderedcereals: Withpowderedcereals: Withpowderedcereals: Withpowderedcereals:Toonelitreofwater,addhalfateaspoonofsaltandeightteaspoonsof
powderedcereals.Riceisbest,butfinegroundwheatflour,maize,sorghumorcookedmashed
potatoes can also be used. Boil for five to seven minutes to make a liquid soup or watery
porridge.Coolthedrinkquickly.
InadditiontoORS,alsoeatanddrinkfoodsandfluidsthataretolerated.
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Session Session Session Session 6: 6: 6: 6: Preventing weight loss Preventing weight loss Preventing weight loss Preventing weight loss and and and and promoting physical promoting physical promoting physical promoting physical
activity activity activity activity
Learning Learning Learning Learningo oo objectives bjectives bjectives bjectives
Bytheendofthissession,participantswillbeableto:
Explaintheimportanceofmaintainingbodyweight;
Describewaystoincreaseenergyintakeandreduceweightloss;and
OutlinetheimportanceofphysicalactivityforpeoplelivingwithHIV.
Collect/preparethefollowingtrainingmaterials:
Anoverheadprojectorandscreen;and/oraflipchartstand,flipchartpaper,markersandameans
toattachflipchartsheetstothewallorothersurface.Ifanoverheadprojectorisnotavailable,an
enlargedcopyofPicture2canbepreparedfordisplayasaposter.
Role Role Role Role- -- -play6A: play6A: play6A: play6A: Weight Weight Weight Weightc cc concerns oncerns oncerns oncerns
Role Role Role Role- -- -play6B: play6B: play6B: play6B: Physical Physical Physical Physicala aa activity ctivity ctivity ctivity
Picture1:SamandSuzi:Physicalactivity Picture1:SamandSuzi:Physicalactivity Picture1:SamandSuzi:Physicalactivity Picture1:SamandSuzi:Physicalactivity
Picture2:SamandSuzi Picture2:SamandSuzi Picture2:SamandSuzi Picture2:SamandSuzi: : : :W WW Weightloss eightloss eightloss eightloss (seeAnnex1 Annex1 Annex1 Annex1;selectversionsuitableforthelocalarea)
Handout6/1: Handout6/1: Handout6/1: Handout6/1: Suggestions Suggestions Suggestions Suggestionsforadding foradding foradding foraddingextranutritiontoeverydayfood extranutritiontoeverydayfood extranutritiontoeverydayfood extranutritiontoeverydayfood (availableattheendofthis
session)
Handout6/2: Handout6/2: Handout6/2: Handout6/2: Suggestions Suggestions Suggestions Suggestionsforimprovingappetite forimprovingappetite forimprovingappetite forimprovingappetite (availableattheendofthissession)
Bytheendofthissession,participantswillbeableto:
Explaintheimportanceofmaintainingbodyweight;
Describewaystoincreaseenergyintakeandreduceweightloss;and
OutlinetheimportanceofphysicalactivityforpeoplelivingwithHIV.
Introduce the session
AIDSischaracterizedbyprogressiveweightlossandwasting.
Leanbodymusclesmakeupmostofthebodyweightandareresponsibleforvariousfunctionsinthe
body. As damage to the defence system and weight loss increases, the body becomes less able to
performthesefunctions.
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Whenapersondoesnoteatenoughfood,orthefoodeatenispoorlyabsorbedandutilized,thebody
derives energyfromitsownstoresof fat andmuscle. As aresult, thepersonlosesweight because
bodyfatandmusclesarelost.
Increasingthequantityandvarietyofenergy-richfoods:
Eat more staples and starchy foods such as, bananas, bread, maize, millet, potatoes, rice,
sorghum, and wheat and continue to eat more until recovering initial weight. One portion of
such staples is about one fistful (see Handout 3/1 Handout 3/1 Handout 3/1 Handout 3/1 discussed in Session 3 Session 3 Session 3 Session 3). Gradually
increasetheportionsuntilreachingaboutsixormoreportionsaday.
Increase intake of beans, lentils, peas, groundnuts, peanut butter and seeds, such as
sunflowerandsesame.
Include all forms of meat, poultry, fish and eggs as often as possible. Minced meat, chicken
and fish are easier to digest. Offal such, as kidney and liver are also a good source of
nutrientsthatcancontributetoreversingweightloss.
Introduce more diary products such as, full-cream milk, sour milk, buttermilk, yoghurt and
cheeseintothediet.
Graduallyincreaseintakeoffoodscontainingfats/oils,oilseedssuchas,groundnuts,sesame
andavocados.
Addingextranutrientstofoodsormeals:
Howcanweaddextranutrientstofoodormeals? Howcanweaddextranutrientstofoodormeals? Howcanweaddextranutrientstofoodormeals? Howcanweaddextranutrientstofoodormeals?
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Allow participants to respond and write down only the key points raised on a sheet of flipchart
paper;discusstheseaddingthefollowingpoints:
Addingextranutrientstofoods/drinksiscalledenrichingfoods enrichingfoods enrichingfoods enrichingfoods.Food/drinkscanbeenrichedby:
Makingahotdrinkwithmilkinsteadofwater;
Eating more concentrated foods, e.g. eating the solid pieces of a stew/soup before
consumingtheliquidpart;
Increasingthefatcontentoffood,e.g.,byaddingfivetosixteaspoonsoffats/oilstofoodper
day;ifproblemsresultingfromhighfatintakeareexperienced,(especiallydiarrhoea),reduce
theamountoffatinthedietuntilthesymptomspass;thengraduallyincreaseittoalevelthat
canbetolerated;
Includingdairyproductssuch,asfull-creammilk,sourmilk,buttermilk,yoghurtandcheesein
meals; adding milk, or milk powder to foods such as stews, soups, porridge, cereals, and
mashed potatoes. Note that some people may find milk difficult to digest; milk should be
avoided,ifitcausescramps,bloating,orskinrashes.
Addingprotein-richfoodssuchas,beans,lentils,groundnuts,peanutbutteroreggstomaize,
millet,orcassavaporridge;and
Addingonetotwoteaspoonsofextraofsugar,honeyandothersweetproductstofood.
Whileincreasingthefatcontentoffoodscanhelptoregainlostweight,careshouldbetakenthat
sugaryandfattyfoodsarenoteatenassubstitutesformorenutritiousfoods.
Eatingmorefrequentlyandincreasingtheamountsoffood:
Increasingthenumberofmealsandsnackseatendaily;and/oreatinglargeramountsoffood,
especiallyattimeswhenoneisfeelinglikeeating;
Including snacks that are readily available and can be eaten without much preparation in-
between meals. Snacks may include foods such as, nuts, seeds, fruits, yoghurt, carrots,
boiledcassava/sweetpotatoes,chips,andpeanutbuttersandwiches.
Eatingatleastthreemealsadayandsnacksin-betweencanpreventweightlossandreducethe
likelihoodofmalnutrition.
Showthefirstkeypointdisplayed,andaskaparticipanttoreaditoutloud.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Whensymptomsstart,increaseenergyintaketoreduceorpreventweightloss. Whensymptomsstart,increaseenergyintaketoreduceorpreventweightloss. Whensymptomsstart,increaseenergyintaketoreduceorpreventweightloss. Whensymptomsstart,increaseenergyintaketoreduceorpreventweightloss.
10. Physical activity (4 minutes)
Introducethetopicofphysicalactivity
To further build up the body, physical activity should be encouraged during the early stages of
HIVandduringthesymptomaticphase.
Physicalactivityisgenerallygoodforeveryone.
Physical activity may include daily activities such as, household chores and light work in the
gardenorinthefield.Lightactivityeachdayisbetterthanintensiveexerciseonceaweek.
Activitymaybelimitediffoodintakeisverylowandthepersonisveryweak.
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Allow participants to respond and write down only the key points raised on a sheet of flipchart
paper;discussthese,addingthefollowingpoints:
Physical activity uses up energy so it is important to increase ones food intake. It is also
necessarytodrinkextrawaterwhenexercising.
11. Role-play 6B: Physical activity (10 minutes)
Choosetwovolunteerparticipantsandaskthemtopreparefortherole-play.
Introducetherole-play:
The health/nutrition worker talks with Sam to find some physical activity that Sam could do
regularly.ListthecounsellingskillsthesupportworkerisusingaswellasthereactionsofSam.
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ROLE-PLAY 6B: Physical activity
COMMUNICATION COMMUNICATION COMMUNICATION COMMUNICATION
SKILL SKILL SKILL SKILL USED USED USED USED
HEALTHWORKER Goodmorning,Sam.Youarelookingwelltoday.
Howareyoufeeling?
Open Open Open Open- -- -endedquestion endedquestion endedquestion endedquestion
SAM Goodmorning.Iamfeelingbettersincethelasttime
wetalked.
NowIhavemoreenergysoIwasthinkingaboutwhat
yousaidaboutbeingmoreactive.
HEALTHWORKER Yes,activitycanhelptomaintainyourstrength.
Whatphysicalactivitydoyoudoatthemoment?
Reflect Reflect Reflect Reflect
Open Open Open Open- -- -endedquestion endedquestion endedquestion endedquestion
SAM Well,whenIwasillrecently,Istoppeddoingmost
activities.
HEALTHWORKER Wellwhataboutstartinggently?Maybeawalkwithyour
youngsonorplayingballwithhimfor10or15minutes.
Howdoesthatsound?
Suggestion Suggestion Suggestion Suggestion
SAM IcoulddothateasilyImsure.
HEALTHWORKER Maybeyoucouldalsotryweightlifting!Liftyoursonupa
fewtimesandincreasethenumberofliftsasyoucan.
Thiscanstrengthenyourmuscles.Wouldyoubeableto
dosomelifts?
Suggestion Suggestion Suggestion Suggestion
SAM Yes,probably.Whenyouthinkaboutit,thereare
exercisesIcaneasilydoaroundthehouse.
HEALTHWORKER Physicalactivitydoesnotneedtobespecialexercises.
Wecandoalotbyjustincreasingournormalactivity.
Tryitforafewweeksandcomebackagainifyouwantto
talkmore.
Information Information Information Information
Follow Follow Follow Follow- -- -up up up up
SAM Thankyou.IwillseehowIgetonwithincreasingmy
activity.
Takingoneissueatatimeaskparticipantsthefollowing:
How How How HowhelpfulwasthehealthworkersdiscussionwithSam? helpfulwasthehealthworkersdiscussionwithSam? helpfulwasthehealthworkersdiscussionwithSam? helpfulwasthehealthworkersdiscussionwithSam?
Describewhatwashelpfultohim. Describewhatwashelpfultohim. Describewhatwashelpfultohim. Describewhatwashelpfultohim.
How How How Howwell well well welldid did did didthehealthworkerusecommunicationskillsincounsellingSam thehealthworkerusecommunicationskillsincounsellingSam thehealthworkerusecommunicationskillsincounsellingSam thehealthworkerusecommunicationskillsincounsellingSam? ?? ?
Discusstheirresponsesaddingthefollowing:
Samnowfeelswellenoughtoincreasehisphysicalactivitywhichwillfurtherhelphimbuilduphis
body, increase his appetite, boost his immune system and improve his general sense of well-
being.
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ShowPicture Picture Picture Picture1 11 1:SamandSuzi :SamandSuzi :SamandSuzi :SamandSuzi doingsomephysicalactivity doingsomephysicalactivity doingsomephysicalactivity doingsomephysicalactivity (Re-usePicture1 Picture1 Picture1 Picture1; ;; ;emphasizingthat
SamandSuziaregoingforregularwalksaformoflightphysicalactivity)
PICTURE PICTURE PICTURE PICTURE1 11 1:SamandSuzi :SamandSuzi :SamandSuzi :SamandSuzi physicalactivity physicalactivity physicalactivity physicalactivity
Showthesecondkeypointdisplayed,andaskaparticipanttoreaditoutloud.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Physicalactivity Physicalactivity Physicalactivity Physicalactivitycanhel canhel canhel canhelp pp p youtofeelbetter. youtofeelbetter. youtofeelbetter. youtofeelbetter.
Introduce a light physical activity or ask participants to stretch to feel the benefits of physical
activity.
12. Summary of the session and transition (2 minutes)
Show/reviewbothkeypointsdisplayed.
KEYPOINTS KEYPOINTS KEYPOINTS KEYPOINTS
Whens Whens Whens Whensymptomsstart,increaseenergyintaketoreduceorpreventweightloss. ymptomsstart,increaseenergyintaketoreduceorpreventweightloss. ymptomsstart,increaseenergyintaketoreduceorpreventweightloss. ymptomsstart,increaseenergyintaketoreduceorpreventweightloss.
Physicalactivitycanhelpyoufeelbetter. Physicalactivitycanhelpyoufeelbetter. Physicalactivitycanhelpyoufeelbetter. Physicalactivitycanhelpyoufeelbetter.
MaintainingagoodbodyweightcanimprovethequalityoflifeforpeoplewithHIV.Aimtocheck
weightregularlyandtoactpromptlyifweightlossstarts.
Physicalactivitycanhelpimproveappetiteandonesgeneralsenseofwell-being.
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The key points on eating wisely discussed in Session Session Session Session 3 33 3 should continue to apply when
symptomsofweightlossstart.
Askifthereareanyquestions,orifanythingneedsclarifying.
Inthenextsessionwewilldiscussnutritionforpeopleonantiretroviraltherapy(ART).
Thenextsessionwillbepresentedby:
Statethenameofthepresenter.
Explainthefoodandnutritionimplicationsofantiretroviraltreatment(ART);
DiscusstheimportanceofnutritionforpeoplelivingwithHIVonART;and
Identifybestnutritionpracticesanddiscussdrug-mealplansforpeopleondifferent
drugregimens.
Preparation for the session
Writeanddisplaythelearningobjectivesonasheetofflipchartpaper.
Writethekeypointsonasheetofflipchartpaperandkeepitasideuntilneeded.
KEYPOINTS KEYPOINTS KEYPOINTS KEYPOINTS
Understandingmedicationside Understandingmedicationside Understandingmedicationside Understandingmedicationside- -- -effectshelpscarefulselectionoffoodsforprepar effectshelpscarefulselectionoffoodsforprepar effectshelpscarefulselectionoffoodsforprepar effectshelpscarefulselectionoffoodsforpreparing ing ing ing
nutritiousmealsand nutritiousmealsand nutritiousmealsand nutritiousmealsandagoodnutrition agoodnutrition agoodnutrition agoodnutritionp pp plan lan lan lan. .. .
ARTworks ARTworks ARTworks ARTworksbetter better better betterinpeoplewho inpeoplewho inpeoplewho inpeoplewhohavegoodnutr havegoodnutr havegoodnutr havegoodnutritionalpractices itionalpractices itionalpractices itionalpractices. .. .
FindouttheARVdrugcombinationthatiscommonlyusedinyourarea/region.
FindoutwhatlocaldoctorsadviseabouttheinteractionsbetweenART,food,herbs.etc.
Session Session Session Sessiono oo outline utline utline utline
Content Content Content Content Time Time Time Time
1 Learningobjectivesandintroduction 5minutes
2 Interactionsbetweendrugs,foodandnutrition 15minutes
3 Nutritionpracticesformanagingtheside-effectsofantiretroviral
(ARV)drugs
15minutes
4 Makingadrugfoodplan(Exercise) 20minutes
5 Medicationandphysicalactivity(Role-play7) 15minutes
6 Summaryofthesessionandtransition 5minutes
Total Total Total Total 75 75 75 75minutes minutes minutes minutes
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Find out from health facilities about the local/regional selection criteria and procedures for
accessingARVdrugs.
Asktwoparticipantstoassistwiththerole-playfoundonpages77-78oftheParticipant'sManual.
Collect/preparethefollowingtrainingmaterials:
Anoverheadprojectorandscreen;and/oraflipchartstand,flipchartpaper,markersandameans
to attach flipchart sheets to the wall or other surface. If an overhead projector is not available,
overheads may be written out on flipchart sheets or enlarged copies prepared for display as
posters,asappropriate.
Overhead1/1: Overhead1/1: Overhead1/1: Overhead1/1: The The The The bad bad bad badcycle cycle cycle cycle ofpoornutritionand ofpoornutritionand ofpoornutritionand ofpoornutritionandHIV HIV HIV HIV ; ;; ;
Overhead 7/1: Overhead 7/1: Overhead 7/1: Overhead 7/1: Interactionbetween drugs, foodandnutrition Interactionbetween drugs, foodandnutrition Interactionbetween drugs, foodandnutrition Interactionbetween drugs, foodandnutrition (fullversionavailableattheendof
thissession).
Overhead7/2: Overhead7/2: Overhead7/2: Overhead7/2: SupportingmanagementofARV SupportingmanagementofARV SupportingmanagementofARV SupportingmanagementofARVdrugs, drugs, drugs, drugs,foodandnutritioninteractio foodandnutritioninteractio foodandnutritioninteractio foodandnutritioninteractions ns ns ns
Handout Handout Handout Handout 7/1: 7/1: 7/1: 7/1: Recommended nutrition practi Recommended nutrition practi Recommended nutrition practi Recommended nutrition practic cc ces for es for es for es for dealing with the dealing with the dealing with the dealing with the side side side side- -- -effects of AR effects of AR effects of AR effects of ARV VV V
medication medication medication medications s s s(availableattheendofthissession).
Handout7/ Handout7/ Handout7/ Handout7/2 22 2: :: : Daily Daily Daily Dailydrug drug drug drug- -- -foodplanner foodplanner foodplanner foodplanner (availableattheendofthissession).
Role Role Role Role- -- -play7: play7: play7: play7: Discussingeatingw Discussingeatingw Discussingeatingw Discussingeatingwiselywiththecaregiverofayoungchild iselywiththecaregiverofayoungchild iselywiththecaregiverofayoungchild iselywiththecaregiverofayoungchild
Show O OO Overhead 1/1: verhead 1/1: verhead 1/1: verhead 1/1: The The The The bad bad bad bad cycle cycle cycle cycle of of of of poor nutrition and poor nutrition and poor nutrition and poor nutrition and HIV HIV HIV HIV and ask participants to reflect
backonwhatwasdiscussedaboutthebadcycleinSession1. Session1. Session1. Session1.
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OVERHEAD1/1:The OVERHEAD1/1:The OVERHEAD1/1:The OVERHEAD1/1:The' '' 'bad bad bad bad cycle cycle cycle cycleofpoornutritionandHIV ofpoornutritionandHIV ofpoornutritionandHIV ofpoornutritionandHIV
Explainthefollowingpoints:
WhenthecycleofHIVandmalnutritionrepeatsitselfmanytimes overseveralyears,the bodys
naturaldefencesystemisseverelyreducedandtheHIVisabletomultiplyrapidly,thusincreasing
theviralloadandthechancesofotherinfections.
At this stage, ART is recommended to slow down or stop multiplication of HIV. ART work better
when given in combinations of three drugs. ART helps improve the bodys defence system, and
enhancesthepatientssurvivalandqualityoflife.
Asacounsellor,itisimportanttobefamiliarwiththelocal/regionalproceduresforaccessingART
inordertoadvisepeoplelivingwithHIVtoconsiderARTwhentheirbodystartsgettingweaker.
Whydoyouthink Whydoyouthink Whydoyouthink Whydoyouthinkgoodnutritionisimportantfor goodnutritionisimportantfor goodnutritionisimportantfor goodnutritionisimportantforpeopleona peopleona peopleona peopleonantiretroviral ntiretroviral ntiretroviral ntiretroviralt tt treatment reatment reatment reatment? ? ? ?
Give participants a few minutes to respond, and then ask one of them to read the following
points.
Explainthewordshighlightedinboldface.
Weakened Immune System
Poor ability to fight HIV
and other Infections
Increased Vulnerability to
Infections
e.g. enteric infections, flu, TB, etc.
Increased Nutritional Needs
Inability to meet increased nutritional
needs for fighting infection and viral
reproduction due to:
Loss of appetite;
Inadequate food intake; and
Poor absorption of nutrients.
Poor Nutrition
Weight loss;
Muscle wasting;
Weakness; and
Micronutrient deficiency.
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Explainthefollowingpoints:
Starting ART is a life-long commitment to medication. Enduring the initial period of unpleasant
side-effects requires regular food supply, good nutrition plan and continuous support to ensure
healthyeating.
In this session, we will discuss basic information on interactions of ARV drugs interactions of ARV drugs interactions of ARV drugs interactions of ARV drugs with food and
nutritionandwhatactionswecantaketosupporthealthyeatingandadherencetomedication.
2. Interactions between drugs, food and nutrition (15 minutes)
Have you observed any Have you observed any Have you observed any Have you observed any interactions between drugs, food and nutrition among interactions between drugs, food and nutrition among interactions between drugs, food and nutrition among interactions between drugs, food and nutrition among the the the the people people people people with with with with
whom whom whom whomyouworkorlive youworkorlive youworkorlive youworkorlive? ?? ?
Take responses from a few participants and show O OO Overhead 7/1: verhead 7/1: verhead 7/1: verhead 7/1: Interaction between drugs, Interaction between drugs, Interaction between drugs, Interaction between drugs,
food and nutrition food and nutrition food and nutrition food and nutrition (a complete version of which is found at the end of this session). Show one
figureatatimeandexplainthemessageswrittenbeloweachfigure.
OVERHEAD OVERHEAD OVERHEAD OVERHEAD7 77 7/1:Interactionbetweendr /1:Interactionbetweendr /1:Interactionbetweendr /1:Interactionbetweendrugs,foodandnutrition ugs,foodandnutrition ugs,foodandnutrition ugs,foodandnutrition
a) a) a) a)W WW WhentakenwithARVdrugs hentakenwithARVdrugs hentakenwithARVdrugs hentakenwithARVdrugs,certainfoods ,certainfoods ,certainfoods ,certainfoodsmayincreaseorreduceuseofthedrugbythebody mayincreaseorreduceuseofthedrugbythebody mayincreaseorreduceuseofthedrugbythebody mayincreaseorreduceuseofthedrugbythebody. .. .
FOOD
AFFECTS
DRUGABSORPTIONANDUSEINTHEBODY
Example:FattyfoodsandfattymealsmayreduceabsorptionofARVdrugssuchasefavirenz efavirenz efavirenz efavirenz
(orotherbrandsusedlocally).
DRUGS
AFFECT
NUTRITIONABSORPTIONANDUSEINTHEBODY
Example: ARV drugs such as, d4T d4T d4T d4T(or other brands used locally) may change the way the body
usesfatandcarbohydrates.
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DRUG
SIDE-
EFFECTS
AFFECT
FOODINTAKEANDABSORPTION
Examples: Some medications, e.g. 3TC 3TC 3TC 3TC and d4T d4T d4T d4T (or other brands used locally) may lead to
changeintaste;AZTmayalsocausenauseaandvomiting,resultinginreducedfoodintakeand
weightloss.
d)T d)T d)T d)Theinteraction heinteraction heinteraction heinteraction ofcertainARV ofcertainARV ofcertainARV ofcertainARVdrugs drugs drugs drugswithcertainfoodsmaycreateunhealthysideeffects. withcertainfoodsmaycreateunhealthysideeffects. withcertainfoodsmaycreateunhealthysideeffects. withcertainfoodsmaycreateunhealthysideeffects.
MEDICATION + ++ +
CERTAINFOOS
CREATES
UNHEALTHYSIDE-EFFECTS
Examples: Intake of drinks containing alcohol together with ARV drugs may cause liver and
pancreasproblems.Alcoholisalsooftencauseofpooradherencetotreatmentandmayreduce
theappetiteofthepersonlivingwithHIV.
IntakeofsomeherbalremediestogetherwithARVdrugsmayincreasesevere-sideeffects.
CounsellorsneedtomakepeopletakingARVdrugsawareoftheinteractionsofsuchfoodswith
thedrugstheyaretakingsothatthesefoodscanbeavoidedorreduced.
Showthefirstkeypointdisplayed,andaskaparticipanttoreaditoutloud.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Understandingmedicat Understandingmedicat Understandingmedicat Understandingmedicationside ionside ionside ionside- -- -effectshelpscarefulselectionoffoodsforpreparing effectshelpscarefulselectionoffoodsforpreparing effectshelpscarefulselectionoffoodsforpreparing effectshelpscarefulselectionoffoodsforpreparing
nutritiousmealsandagoodnutritionplan. nutritiousmealsandagoodnutritionplan. nutritiousmealsandagoodnutritionplan. nutritiousmealsandagoodnutritionplan.
3. Nutrition practices for managing the side-effects of ARV drugs
(15 minutes)
Introducethissectionbyexplainingthefollowing:
While majority of people who take ARV drugs experience some side-effects, the frequency and
severity of side-effects varies for different ARV drugs and different individuals. A combination of
threedifferentARVdrugsisusuallygiventopatientsandtheinteractionsofeachdrugwithfood
mustbeconsidered.
Gooddietandregularfoodintakehelpstoimproveadherencetotreatmentwhichiscriticalfor
Thewell-beingofpeoplelivingwithHIV
Treatmenteffectiveness
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Preventingdrug-resistance
ThegoalsofnutritioncounsellingforpeopleonARTareto:
Reduce minor side-effects that can result in reduced food intake, e.g., changes in taste,
headache,fever,nauseaandvomiting,upsetstomachanddiarrhoea.
Reduce chronic side-effects such as,increased blood sugar, high fat levelsin the blood and
liverorkidneydamage.
Improvethegeneralwell-beingofpeoplelivingwithHIVwhoareonART.
FailuretomanagetheinteractionsbetweenvariousfoodsandARVdrugs,mayresultinreduced
food intake. The patient may also interrupt or stop taking the medication. Interrupting ART or
takingitincorrectlymayleadto:
Poorhealth,frequentinfectionsandfasterprogressionofthedisease;and
Drug-resistantHIVleadingtofailureoftreatment.
Suggestions for nutrition practices should be based on a clear understanding of the specific
requirementsofthedrugsthatapersonistaking.
Wh Wh Wh Which ich ich ichnutritionpracti nutritionpracti nutritionpracti nutritionpractic cc cesdoyouknowthatmay esdoyouknowthatmay esdoyouknowthatmay esdoyouknowthatmayreduce reduce reduce reducetheside theside theside theside- -- -effectsofAR effectsofAR effectsofAR effectsofARVdrugs Vdrugs Vdrugs Vdrugs? ?? ?
Allow a few participants to respond, then show and discuss O OO Overhead verhead verhead verhead 7/2: 7/2: 7/2: 7/2: Supporting Supporting Supporting Supporting
managementofARV managementofARV managementofARV managementofARV andfoodandnutritioninteractions andfoodandnutritioninteractions andfoodandnutritioninteractions andfoodandnutritioninteractions . .. .
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OVERHEAD OVERHEAD OVERHEAD OVERHEAD7/2:SupportingthemanagementofARVdrugsandfood/nutritioninteractions 7/2:SupportingthemanagementofARVdrugsandfood/nutritioninteractions 7/2:SupportingthemanagementofARVdrugsandfood/nutritioninteractions 7/2:SupportingthemanagementofARVdrugsandfood/nutritioninteractions
Know and understand what medication the client is taking (see Handout 7/1 Handout 7/1 Handout 7/1 Handout 7/1) and make the
clientandothertreatmentsupportersorfamilymembersawareoftheirpotentialside-effects.
Discusshowtoadjustthetimingofdrugandfoodintakeasappropriate.
Discusshowtomanagethepossibleside-effectsanddifficultiesthatmayreducefoodintake.
Identify foods to be increased, decreased or avoided, depending on their effects on drug
absorption.
Supporttheclienttoidentifylocallyavailablefoodsthatwouldhelpinhealthyeatingbasedon:
TheEatingwiselyguidelines;
Drug-foodinteractions;and
Thenutritionalneedsoftheperson.
Support the client to make a drug-meal plan that will guide him/her in choosing appropriate
foodsfordifferentmeals(Exercise7/1 Exercise7/1 Exercise7/1 Exercise7/1).
Followupandassessanydifficultiesandsupportinmakingnecessaryadjustments.
Seekhelpthroughthereferralsystemto otherprogramsandservicesthataddressfoodand
nutrition issues, (e.g., nutritional counselling services, programs focused on promoting
householdaccesstofood)asneeded.
Refer participants to Handout 7/1: Recommended nutrition practices for dealing with the side Handout 7/1: Recommended nutrition practices for dealing with the side Handout 7/1: Recommended nutrition practices for dealing with the side Handout 7/1: Recommended nutrition practices for dealing with the side- -- -
effectsofARVdrugs effectsofARVdrugs effectsofARVdrugs effectsofARVdrugsonpages80-81oftheParticipant'sManual.
Inform participants about the combinations of ARV drugs commonly used in the local area and
askthemtohighlighttheinformationonthoseparticulardrugs.
Explainthefollowing:
Theseareexamplesofdifferentdrugs,their-sideeffectsandtherecommendednutritionpractices
toreducetheseside-effects.
Thisisjustalistofsuggestions,whichshouldbekeptup-to-date.
Thehandoutcouldbeusedasaguideforhelpingclientswhoareexperiencingside-effectsfrom
their medication. However, you should always urge clients to consult with their doctor
immediately.
4. Making a drug-food plan (20 minutes)
AskoneoftheparticipantstovolunteerandreadthestoryofSamandSuzi
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THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI
Sam is feeling weak and his health has generally deteriorated. His doctor recommends
severaltestandsomedrugs.
Based on the test results, the doctor needs to start Sam on ART. Sam is prepared and
enrolledforART.
Histreatmentconsistsofacombinationofthreedrugs:d4T+3TC+EFV.
Explaintheexamplebelowofadrug-foodplanthatthecounsellorcouldusetostartdiscussions
withSam.
4.1. Identifying the medication being taken (10 minutes)
Medication Medication Medication Medicationbeingtaken beingtaken beingtaken beingtaken
Morning d4T+3TC d4T+3TC d4T+3TC d4T+3TC
Night d4T+3TC+EFV d4T+3TC+EFV d4T+3TC+EFV d4T+3TC+EFV
Whatside Whatside Whatside Whatside- -- -e ee effects ffects ffects ffectsis is is isSam Sam Sam Samlikelyto likelyto likelyto likelytoexperienceandhowcouldwemanagetheseside experienceandhowcouldwemanagetheseside experienceandhowcouldwemanagetheseside experienceandhowcouldwemanagetheseside- -- -effects? effects? effects? effects?
Give participants a few minutes to discuss the side-effects related to the drugs as presented in
Handout 7/1 Handout 7/1 Handout 7/1 Handout 7/1 (available on pages 80-81 of the Participant's Manual). and refer them to the
suggestionsprovidedinS SS Session5 ession5 ession5 ession5on Improvingfoodintake Improvingfoodintake Improvingfoodintake Improvingfoodintake . .. .
Explainthehowthevariousside-effectscanbemanagedusingthefollowing:
Mouthulcers(soremouth/sorethroat):Handout5/1 Handout5/1 Handout5/1 Handout5/1
Excessivegasinthestomach,stomachdiscomfortdiarrhoea:Handout5/3 Handout5/3 Handout5/3 Handout5/3
Nausea,vomitingandlossofappetite:H HH Handout5/4 andout5/4 andout5/4 andout5/4
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Fever: drink plenty of fluids and eat energy and nutrient-rich foods, i.e. adding seeds, such as
groundnutorsesamepastesorpeanutbutteroreggstomaize/millet/cassavaporridge.
High fat levels in blood: closely monitor intake of fatty foods and meals; eat plenty of fruits and
vegetablesdaily;increasephysicalactivityaccordingtothecapacityofthepatient.
4.2. Meal planning (10 minutes)
Askparticipantstogetintogroupsoffiveandgiveeachgrouponeofthedailymealstodiscuss
asfollows:
Group1:Morning
Group2:Mid-morning
Group3:Mid-day
Group4:Evening
Group5:Night
Askgroupstodiscusslocallyavailablefoodsthatcouldbetakenateachmealtime.
AskeachgrouptowritedowntheirsuggestionsintheappropriatesectionsofH HH Handout7/2 andout7/2 andout7/2 andout7/2 (found
onpage82oftheParticipantsManual)andtopresentthemfordiscussion.(Thesecanbelater
typedandprintedasareferenceforcareprovidersinthelocalarea).
Showthesecondkeypointdisplayedandaskaparticipanttoreaditoutloud.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
ARTworks ARTworks ARTworks ARTworksbetter better better betterinpeoplewho inpeoplewho inpeoplewho inpeoplewhohavegoodnutritionalpractices havegoodnutritionalpractices havegoodnutritionalpractices havegoodnutritionalpractices. .. .
5. Medication and physical activity: Role-play 7 (10 minutes)
The health/nutrition worker talks with Sam about his medication and physical activity. List the
counsellingskillsthesupportworkerisusingaswellasthereactionsofSam.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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ROLE-PLAY 7: Discussion with Sam about medication and physical activity
COMMUNICATION COMMUNICATION COMMUNICATION COMMUNICATION
SKILL SKILL SKILL SKILL USED USED USED USED
HEALTHWORKER Welcome,Sam.Pleasesitdown.Howareyou
today?
SAM Well,IamOK.Ihavecometotalktoyoumoreabout
themedicationwhichIhavebeentaking.
HEALTHWORKER Yes,Itisgoodthatyoucametotalkaboutyour
medicine.Howareyoudoingwithyourmedication?
Praise Praise Praise Praise
Open Open Open Open- -- -ended ended ended ended
question question question question
SAM Well,IfeelbettersinceIstartedtakingthem.
However,sometimesIreallyhavedifficultiesafter
takingtheminthemorning.Ivomitandsometimesl
justdonotfeellikeeatingatall.
HEALTHWORKER Yes,themedicationsometimesmaymakeyoufeel
likevomitingandcausedifficultiesineating.
Howdoyoutakeyourmedicationinthemorning?
Empathy Empathy Empathy Empathy
Open Open Open Open- -- -ended ended ended ended
question question question question
SAM ItakemymedicationinthemorningassoonasI
wakeup.Thisway,therearelesschancesof
forgettingtotakemymedicine.
HEALTHWORKER Thatsaverygoodidea.
Whatdoyoutakeyourmedicationwith?
Praising Praising Praising Praising
Open Open Open Open- -- -ended ended ended ended
question question question question
SAM Iswallowmymedicinewithlotsofwater.
HEALTHWORKER Doyouthinkthatyoucouldtryeatingordrinking
somethingelsewithyourmedication?
Maybetakingthemedicationonanemptystomach
mightbethereasonforyoufeelinglikevomiting
Checking Checking Checking Checking
understanding understanding understanding understanding
Information Information Information Information
SAM
Itisverydifficultformetoeatanythingearlyinthe
morning.
Ihaveevenstoppedgoingformymorningwalks
becauseIalwaysstartfeelinglikevomitingonmy
wayback.
HEALTHWORKER Awalkinthefreshairisveryuseful.Howabout
startingwiththewalkinthemorningandtryingtotake
yourmedicationwithsomefoodwhenyougetback?
Suggestion Suggestion Suggestion Suggestion
SAM Icouldtrythat.Suzialwaysmakessomethick
porridgetowhichsheaddslemonandsugarwhichI
likeverymuch.
HEALTHWORKER Yes,porridgeisgoodandwillgiveyourbody
strength,addinglemonwillpreventyoufromfeeling
likevomiting.Iamgladthatyoulikeit.
Information Information Information Information
Suggestion Suggestion Suggestion Suggestion
Nutritional Care and Support for People Living with HIV: Facilitators Guide
118
COMMUNICATION COMMUNICATION COMMUNICATION COMMUNICATION
SKILL SKILL SKILL SKILL USED USED USED USED
SAM Thefeelingofvomitingalwayscomesbeforemeal
timesandevenwhenIamhungry,Idonotfeellike
eating.
HEALTHWORKER Well,trynottokeepyourstomachempty.Youdonot
havetowaitonlyformealtimesbeforeyoueat.
Maybeyoucouldalsotrytakingsomethingevery23
hours,evenifitisonlyaglassofmilkapieceoffruit,
vegetables,yoghurtortoastedbreadandpeanut
butter.
Suggestion Suggestion Suggestion Suggestion
SAM Yes,probablyIcouldtrythat.Thereisalwayssome
milk,bananasandorangesinthehouse.
HEALTHWORKER Thatwouldbegreat.Canyoutrythatfortwoweeks?
Andthenyoucancomebackandwecantalkabout
howitwent.
Checking Checking Checking Checking
Follow Follow Follow Follow- -- -up up up up
SAM Thankyou.IwillseehowIgetonwiththeplan.
Good-bye
HEALTHWORKER Good-bye
Takingoneissueatatimeaskparticipantsthefollowing:
HowhelpfulwasthehealthworkersdiscussionwithSam? HowhelpfulwasthehealthworkersdiscussionwithSam? HowhelpfulwasthehealthworkersdiscussionwithSam? HowhelpfulwasthehealthworkersdiscussionwithSam?
Describewhatwashelpfultohim. Describewhatwashelpfultohim. Describewhatwashelpfultohim. Describewhatwashelpfultohim.
Evaluatehowwellthehealth Evaluatehowwellthehealth Evaluatehowwellthehealth EvaluatehowwellthehealthworkerusedcommunicationskillsincounsellingSam. workerusedcommunicationskillsincounsellingSam. workerusedcommunicationskillsincounsellingSam. workerusedcommunicationskillsincounsellingSam.
Show/reviewbothkeypointsdisplayed.
KEYPOINTS KEYPOINTS KEYPOINTS KEYPOINTS
Understandingmedicationside Understandingmedicationside Understandingmedicationside Understandingmedicationside- -- -effectshelpscarefulselectionoffoodsforpreparing effectshelpscarefulselectionoffoodsforpreparing effectshelpscarefulselectionoffoodsforpreparing effectshelpscarefulselectionoffoodsforpreparing
nutriti nutriti nutriti nutritiousmealsandagoodnutritionplan. ousmealsandagoodnutritionplan. ousmealsandagoodnutritionplan. ousmealsandagoodnutritionplan.
ARTworks ARTworks ARTworks ARTworksbetter better better betterinpeoplewho inpeoplewho inpeoplewho inpeoplewhohavegoodnutritionalpractices havegoodnutritionalpractices havegoodnutritionalpractices havegoodnutritionalpractices. .. .
Reviewalltheotherkeypointsdisplayed.
ARTworksbetterinpeoplewhohavegoodnutritionalpractices.BeforeorduringinitiationofART
people with HIV need to be supported to eat wisely. Good nutrition will strengthen their bodys
abilitytoabsorbmedicationandreduceside-effects.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
119
AppropriatedietarychangescanhelptomanageandreducetheimpactofcertainARVdrugside-
effectsonnutrition.
It is important to use drug-specific information when managing the interactions between ARV
drugs,foodandnutrition.
Failuretomanagedrug-food/nutritioninteractionsmayleadtothepersoninterruptingorstopping
taking medication. This can result in poor health and drug-resistant HIV which cannot be
effectivelytreated.
ARTcanimprovethehealthofPLHIV;butitcanalsocreateadditionalfoodandnutritionalneeds.
Always discuss and follow up with clients to assess any difficulties and to provide support in
makingnecessaryadjustments.
Askparticipantsifthereareanyquestionsorifanythingneedsclarifying.
Inthenextsession,wewilldiscussnutritionforpregnantandbreastfeedingwomenwithHIV.
Thenextsessionwillbepresentedby:
Statethenameofthepresenter.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
120
OVERHEAD7/1:Interactionbetweendrugs,foodandnutrition OVERHEAD7/1:Interactionbetweendrugs,foodandnutrition OVERHEAD7/1:Interactionbetweendrugs,foodandnutrition OVERHEAD7/1:Interactionbetweendrugs,foodandnutrition
FOOD
AFFECTS
DRUGABSORPTIONANDUSEINTHEBODY
DRUGS
AFFECT
NUTRITIONABSORPTIONANDUSEINTHEBODY
DRUG
SIDE-
EFFECTS
AFFECT
FOODINTAKEANDABSORPTION
MEDICATION + ++ +
CERTAINFOOS
CREATES
UNHEALTHYSIDE-EFFECTS
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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HANDOUT7/1:Nutritionpracticesforreducingside HANDOUT7/1:Nutritionpracticesforreducingside HANDOUT7/1:Nutritionpracticesforreducingside HANDOUT7/1:Nutritionpracticesforreducingside- -- -effectsofARVdrugs effectsofARVdrugs effectsofARVdrugs effectsofARVdrugs
MEDICATION MEDICATION MEDICATION MEDICATION POTENTIALSIDE POTENTIALSIDE POTENTIALSIDE POTENTIALSIDE- -- -EFFECTS EFFECTS EFFECTS EFFECTS
RECOMMENDEDNUTRITION RECOMMENDEDNUTRITION RECOMMENDEDNUTRITION RECOMMENDEDNUTRITION
PRACTICES PRACTICES PRACTICES PRACTICES
Zidovudine Zidovudine Zidovudine Zidovudine
(AZT) (AZT) (AZT) (AZT)
Fatigue,anaemia,gastrointestinal
intolerance(nausea,vomiting,abdominal
pain,dyspepsia,diarrhoea,flatulence,
constipation),tastedisturbance,headache,
fever,anorexia,somnolence,insomnia;
Takewithfoodtoreduceside
effects.
Lamivudine Lamivudine Lamivudine Lamivudine
(3TC) (3TC) (3TC) (3TC)
.nausea,vomiting,diarrhoea,abdominal
pain,headache,fatigue,insomnia,malaise,
fever,rash,anaemia.
Takewithoutregardtomeals.
Combivi Combivi Combivi Combivi
(3TC/AZT) (3TC/AZT) (3TC/AZT) (3TC/AZT)
SimilartoAZTand3TC. Takewithoutregardtomeals.
Didanosine Didanosine Didanosine Didanosine
ddl ddl ddl ddl
Nausea,;diarrhoea,nausea,vomiting,dry
mouth,headache,hypoglycaemia,liver
failure,insomnia,dizziness,maycause
problemswiththepancreas.
Takeonanemptystomach1
hourbeforeor2hoursaftera
meal.
Donottakewithjuice,antacids
orsupplementsthatcontain
aluminiumormagnesium.
Abacavir Abacavir Abacavir Abacavir
ABC ABC ABC ABC
Hypersensitivity,fever,rash,headache,
Lossofappetite,nausea,vomiting,
diarrhoea,anorexia,fatigue,malaise,sore
throat,cough,shortnessofbreath.Alcohol
increaseslevels.
Rashandgastrointestinaldisturbances
morecommoninchildren.
Takewithoutregardtomeals.
(ABC,3TC, (ABC,3TC, (ABC,3TC, (ABC,3TC, AZT) AZT) AZT) AZT) Seeindividualprofiles. Takewithfoodtoreduceside
effects.
Stavudi Stavudi Stavudi Stavudine ne ne ne
D DD D4T 4T 4T 4T
Nausea,vomiting,diarrhoea,constipation,
anorexia,abdominaldiscomfort,chestpain,
dyspnoea,headache,dizziness,insomnia,
moodchanges,abnormaldreams,
cognitivedysfunction,drowsiness,
depression,anxiety,rash.Maycause
problemswithfatstorageinthebody.
Takewithoutregardtomeals.
Avoidalcohol.
Nevirapine Nevirapine Nevirapine Nevirapine
NVP NVP NVP NVP
Rash,nausea,hepatitis,headache.Less
commonly,vomiting,abdominalpain,
fatigue,fever.Rarelydiarrhoea.
Takewithoutregardtomeals.
Efavirenz Efavirenz Efavirenz Efavirenz
EFV EFV EFV EFV
Rash,abdominalpain,diarrhoea,nausea,
vomiting,anxiety,depression,dizziness,
headache,insomnia,somnolence,
abnormaldreams,fatigue,impaired
concentration.
Takeonanemptystomach.
Indinavir Indinavir Indinavir Indinavir
IDV IDV IDV IDV
Tastechange(metallictaste),
gastrointestinalintolerance(nausea,
diarrhoea,abdominalpain,vomiting,
dyspepsia,flatulence),headache,blurred
vision,dizziness,rash,hyperglycaemia,
maycauseproblemswithfatstorageinthe
body.
Takeonanemptystomach
1hourbeforeor2hoursaftera
meal.
Maytakewithskimmilkorlow-
fat,lightmeal.
Ifgivenwithdidanosineallow2
hourbetweenthedrugs.
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122
MEDICATION MEDICATION MEDICATION MEDICATION POTENTIALSIDE POTENTIALSIDE POTENTIALSIDE POTENTIALSIDE- -- -EFFECTS EFFECTS EFFECTS EFFECTS
RECOMMENDEDNUTRITION RECOMMENDEDNUTRITION RECOMMENDEDNUTRITION RECOMMENDEDNUTRITION
PRACTICES PRACTICES PRACTICES PRACTICES
Ritonavir Ritonavir Ritonavir Ritonavir
RTV RTV RTV RTV
Tastechanges,gastrointestinalintolerance
(nausea,vomiting,diarrhoea,abdominal
pain,dyspepsia,anorexia),throatirritation,
headache,drowsiness,dizziness,sleep
disturbances,fatigue,rash,drymouthand
ulceration,anxiety,fever,weightloss,
sweating,anaemia,hyperlipidemia,
hyperglycaemia,fatmaldistribution.
Takewithfoodtodecreaseside
effects.
Indinavir Indinavir Indinavir Indinavir
Ritonavir Ritonavir Ritonavir Ritonavir
Seeindividualprofiles. Foodhaslittleeffect.Takewith
foodtoreducesideeffects.
Saquinavir Saquinavir Saquinavir Saquinavir
SQV SQV SQV SQV
Gastrointestinalintolerance(nausea,
vomiting,diarrhoea,abdominalpain,buccal
andmucosalulceration),taste
disturbances,headache,chestpain,
dizziness,insomnia,moodchanges,
fatigue,fever,rash.
Maycauseproblemswithfatstorageinthe
body,hyperglycaemia.
.
Takewithin2hoursofameal
whentakenwithRTV.
Administerwithorafterfood.
Avoidgarlic.
Nelfinavir Nelfinavir Nelfinavir Nelfinavir
NFV NFV NFV NFV
Diarrhoea,;nausea,vomiting,flatulence,
abdominalpain,rash,fever,pruritus,
hyperglycaemia,hyperlipidemia,fat
maldistribution.
Takewithorafterfood.
Powdermaybemixedwith
water,milk,pudding.
Itshouldnotbemixedwith
acidicfoodsorjuicesbecause
ofitstaste.
HANDOUT HANDOUT HANDOUT HANDOUT7/2: 7/2: 7/2: 7/2:N NN Nutritionpractic utritionpractic utritionpractic utritionpracticesfor esfor esfor esforreducingthe reducingthe reducingthe reducingtheside side side side- -- -effectsofA effectsofA effectsofA effectsofARV RV RV RVdrugs drugs drugs drugs (Worksheet) (Worksheet) (Worksheet) (Worksheet)
MEAL MEAL MEAL MEAL ART ART ART ART LISTOFFOODSTOBETAKEN LISTOFFOODSTOBETAKEN LISTOFFOODSTOBETAKEN LISTOFFOODSTOBETAKEN
Morning Morning Morning Morning
Mid Mid Mid Mid- -- -morning morning morning morning
Nutritional Care and Support for People Living with HIV: Facilitators Guide
124
Session 8: Nutrition for pregnant and breastfeeding women Session 8: Nutrition for pregnant and breastfeeding women Session 8: Nutrition for pregnant and breastfeeding women Session 8: Nutrition for pregnant and breastfeeding women
withHIV withHIV withHIV withHIV
DiscussthenutritionalconcernsofpregnantorbreastfeedingwomenlivingwithHIV;and
DiscussgoodnutritionpracticesforpregnantandbreastfeedingwomenlivingwithHIV.
Session Session Session Sessiono oo outline utline utline utline
Content Content Content Content Time Time Time Time
1 Learningobjectivesandintroductiontothesession 5minutes
2 NutritionalconcernsofpregnantandbreastfeedingwomenwithHIV 15minutes
3 AnEatingwiselyduringpregnancydemonstrationtalk 15minutes
4 Maternalnutritionduringbreastfeeding 5minutes
5 Foodbeliefsandpractices 15minutes
6 Summaryofthesessionandtransition 5minutes
Total Total Total Total 60 60 60 60minutes minutes minutes minutes
Preparation for the session
Writeanddisplaythelearningobjectivesonaflipchartsheet.
Writethekeypointsonasheetofflipchartpaperandkeepitasideuntilneeded.
KEYPOINTS KEYPOINTS KEYPOINTS KEYPOINTS
Eatingwiselyduringpregnancyhelpsthemotherandthebabytostayhealthy. Eatingwiselyduringpregnancyhelpsthemotherandthebabytostayhealthy. Eatingwiselyduringpregnancyhelpsthemotherandthebabytostayhealthy. Eatingwiselyduringpregnancyhelpsthemotherandthebabytostayhealthy.
Eatingwiselyduringbreastfeedinghelpsthemotherandthebabytostayhealthy. Eatingwiselyduringbreastfeedinghelpsthemotherandthebabytostayhealthy. Eatingwiselyduringbreastfeedinghelpsthemotherandthebabytostayhealthy. Eatingwiselyduringbreastfeedinghelpsthemotherandthebabytostayhealthy.
Collect/preparethefollowingtrainingmaterials:
Anoverheadprojectorandscreen;and/oraflipchartstand,flipchartpaper,markersandameans
to attach flipchart sheets to the wall or other surface. If an overhead projector is not available,
enlargedcopiesoftheoverheadsmaybepreparedfordisplayasposters.
O OO Overhead3/3:Varietyoffoods verhead3/3:Varietyoffoods verhead3/3:Varietyoffoods verhead3/3:Varietyoffoods
Handout Handout Handout Handout8/1 8/1 8/1 8/1: : : :Increasing Increasing Increasing Increasingironabsorption ironabsorption ironabsorption ironabsorption (availableattheendofthissession;oruse
overhead/pictureposterofalocalillustration).
Overhead8/ Overhead8/ Overhead8/ Overhead8/1 11 1: :: : Increasingironabsorption Increasingironabsorption Increasingironabsorption Increasingironabsorption
Worksheet8/1:Foodbeliefsandpractices Worksheet8/1:Foodbeliefsandpractices Worksheet8/1:Foodbeliefsandpractices Worksheet8/1:Foodbeliefsandpractices
1. Learning objectives and introduction to the session (5 minutes)
Review the learning objectives of the session
Showandoutlinethelearningobjectivesdisplayed.
Bytheendofthissessionparticipantsshouldbeableto:
DiscussthenutritionalconcernsofpregnantandbreastfeedingwomenlivingwithHIV;and
DiscussgoodnutritionpracticesforpregnantandbreastfeedingwomenlivingwithHIV.
Introduce the session
Food is important for all of us. Pregnant and breastfeeding women have extra nutritional
requirements due to the changes in their bodies and the needs of the growing baby. This is the
sameforallpregnantwomen,whethertheyareHIV-infected ornot.Pregnantandbreastfeeding
womenwithHIVareatahigherriskofinfection,malnutritionandprematurebirthandwillrequire
extraenergyandothernutrients.
In this session, we will discuss how to provide support to pregnant and breastfeeding mothers
withHIVtoincreasetheirfoodintakeandtomeetenergyandothernutrientneeds.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
126
2. Nutritional concerns of pregnant and breastfeeding women with HIV (15
minutes)
Why Why Why Why do pregnant and breastfeeding HIV do pregnant and breastfeeding HIV do pregnant and breastfeeding HIV do pregnant and breastfeeding HIV- -- -positive positive positive positive women have greater nutri women have greater nutri women have greater nutri women have greater nutritional needs than tional needs than tional needs than tional needs than
thosewhoareHIV thosewhoareHIV thosewhoareHIV thosewhoareHIV- -- -negative negative negative negative? ?? ?
Allow participants to discuss responses and write down the key points raised on a sheet of
flipchartpaper;discusstheseandexplainthefollowing:
PregnantandbreastfeedingwomenwithHIVwillneed:
Extrafoodforbodyfunctions;
Extrafoodforchangesintheirbodyandtheneedsofthegrowingbaby;
ExtrafoodtoreplacenutrientslostduetoHIVinfection;and
Extrafoodforgrowthanddevelopmentifthemotherisadolescent(12-16years).
Motherswhoeatwiselyduringpregnancyandbreastfeedingarelikelyto:
Bemorehealthyandnotbeillsooften;
Gainenoughweightduringpregnancyandbreastfeeding;
ReducechancesofHIVtransmissiontotheirbabies;
Havebabieswithgoodweightandgoodhealth;and
Feedandcarefortheirbabiesproperly.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
127
Encouragemotherstoincludefriendsorfamilymembersinthediscussions,sothattheytoocan
understandthemothersneedforadequatefoodandrestbothbeforeandafterthebabyisborn.
Explainthatthistalkcanbedeliveredtoabroaderaudienceaspartofalonger,moregeneraltalk
onhowtoeatwisely.
Checkthatparticipantsunderstandthattheyshouldberole-playingaspeopleattending thetalk
atanantenatalclinic.
Ifthesessionissharedbetweenfacilitators,introducethepersonwhowillgivethetalk.
Presentthetalk.
3.2. Eating wisely during pregnancy
Welcome/greetthegroup.
Today,wewilltalkabouteatingwiselyduringpregnancy.
Statethekeypointofthetalk(thefirstkeypointofthesession).
Foodisimportantforallofus.Apregnantwomanhasextranutritionalneedsduetothechanges
inherbodyandtheneedsofthegrowingbaby.Thisisthesameforallpregnantwomen,whether
theyareHIV-infectedornot.
Wheneatingwisely,youaimtoeatavarietyoffoodstoensurethatyougetallthenutrientsyou
require.
Animal foods are particularly valuable to eat during pregnancy. They are a good source of iron.
Theironfromanimalfoodsiswellabsorbedbythebody.Ironreducesanaemia,whichiscommon
in women during pregnancy. People who are anaemic get tired easily and are more likely to get
infections.Itistherefore,importanttoincreasedailyintakeofanimalfoods.
Beans, peas, lentils, and dark-green leafy vegetables contain iron but this iron may not be well
absorbed by the body. However, iron absorption can be increased by eating these foods with
vegetablesandfruitsrichinvitaminCsuchas,tomatoesorlemons.
ShowO OO Overhead3/3 verhead3/3 verhead3/3 verhead3/3:V :V :V :Varietyoffoods arietyoffoods arietyoffoods arietyoffoods fromSession3. Session3. Session3. Session3.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
128
OVERHEAD3/3:Varietyoffoods OVERHEAD3/3:Varietyoffoods OVERHEAD3/3:Varietyoffoods OVERHEAD3/3:Varietyoffoods
Show O OO Overhead 8/ verhead 8/ verhead 8/ verhead 8/1 11 1: :: : Increasing iron absorption Increasing iron absorption Increasing iron absorption Increasing iron absorption and distribute H HH Handout 8/ andout 8/ andout 8/ andout 8/1: 1: 1: 1: Increasing Increasing Increasing Increasing iron iron iron iron
absorption absorption absorption absorption (found at the end of this session and on page 89 of the Participant's Manual) or
displayitifyouareusingthehandoutasaposter.
OVERHEAD8/1:Increasingironabsorption OVERHEAD8/1:Increasingironabsorption OVERHEAD8/1:Increasingironabsorption OVERHEAD8/1:Increasingironabsorption
Foodsmayalsohaveironaddedtothem(findoutlocallyavailableandaffordablefoodsthatare
fortifiedwithiron).Increasetheuseofthesefoodsduringpregnancy.
Eating vitamin C-
rich vegetables and
fruits with a meal
helps the body to
use iron
Nutritional Care and Support for People Living with HIV: Facilitators Guide
129
Your doctor or midwife will talk to you if you need vitamin and mineral supplements. If they are
given to you, only take what you are told you need. More is not always better; too much
supplementscanalsocauseproblems.
During pregnancy, you are storing food for your body to use during the pregnancy, at birth and
during the first few months of the babys life. As the baby grows during pregnancy, your weight
should increase. If you are not gaining weight, you may need to eat more food and eat more
often.
Physicalactivityandfreshairaregoodforyouwhenyouarepregnant.Awalkoutsideinsunlight
alsohelpsstrengthenyourbonesandthoseofyourbaby.
Youmayexperienceheartburnandnausea,aswellasachangeintasteandappetitewhenyou
arepregnant.Itmayhelpifyouhavesmallfrequentmeals,drinkmorefluidsandavoidfoodsthat
makeyoufeelill.
Apregnantwomanmayalsosufferfromconstipation.Itmayhelptoeatmorevegetablesandfruit
aswellaswholegraincereals.Drinkingplentyofcleanwaterisalsoimportant.
Let your midwife or doctor know if you are experiencing constipation, heartburn and other
problemsthatmayreducefoodintake.Donotwaituntilafterthebabyisborntoseeifyoureating
orweightimproves.
Safefoodandwaterareveryimportantforallpregnantwomen.Unsafefoodandwatercanlead
todiarrhoeaandvomiting,resultinginweightlossand,inveryseverecasesthelossofthebaby.
Themainpointstorememberfromthistalkare:
Pregnantwomenneedtoeatwiselyfortheirownhealthandthehealthoftheirbaby.
Eatingavarietyoffoodsensuresgettingallthenutrientsneeded;animalfoodsareparticularly
valuable.
Watch your weight; eat larger quantities of food; extra meals and rest more often, if
necessary.
Takevitamins,ironandfolicacidassupplementsifsuggestedbyyourdoctorormidwife.
Visittheclinicregularlyforearlydetectionandtreatmentofinfections.
Askthegroupifthereareanyquestions,orifanythingneedsclarifying.
Remind participants that they should still be role-playing as people attending an Eating wisely
duringpregnancytalkatanantenatalclinic.
Askthegrouptoraisequestionsfromthepreparedlistofquestionsanddiscusstheanswers.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
130
Prepared question 1
Idonotwanttohaveabigbabythatishardto Idonotwanttohaveabigbabythatishardto Idonotwanttohaveabigbabythatishardto Idonotwanttohaveabigbabythatishardtodeliver deliver deliver deliver.IfIeatlesswillmybabybesmall? .IfIeatlesswillmybabybesmall? .IfIeatlesswillmybabybesmall? .IfIeatlesswillmybabybesmall?
Answer Answer Answer Answer: :: :
Somewomeneatlessfoodduringpregnancybecausetheybelievethiswillhelpensurethatthey
haveasmallbabythatiseasilydelivered.Otherseatlesshopingtopreventhavingacaesarean
section.However,foodrestrictiondoesnotmakedeliveryeasy.
Difficult deliveries often occur in cases where the mothers pelvis is small relative to the
circumferenceofthebabyshead.Neitherthesizeofamotherspelvisnorthesizeofthebabys
headisaffectedbytheamountoffoodthemothereatsduringpregnancy.
Also,asmallbabyatbirthismorelikelytohavehealthproblems;soitisbettertoeatwellduring
pregnancytoensureastrong,healthybabyandmother.
Prepared question 2
HowcanIeatenoughtoputonweightifIfeelsickallthetime? HowcanIeatenoughtoputonweightifIfeelsickallthetime? HowcanIeatenoughtoputonweightifIfeelsickallthetime? HowcanIeatenoughtoputonweightifIfeelsickallthetime?
Inthisdemonstrationhealthtalkweheardanotherkeypoint:
Showthesecondkeypointdisplayedandaskaparticipanttoreaditoutloud.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Eatingwiselyduringpregnancyhelpsthemotherandbabystayhealthy. Eatingwiselyduringpregnancyhelpsthemotherandbabystayhealthy. Eatingwiselyduringpregnancyhelpsthemotherandbabystayhealthy. Eatingwiselyduringpregnancyhelpsthemotherandbabystayhealthy.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
131
Watchweightgainduringpregnancy.Asthebabygrows,thewoman'sweightshouldincrease.
5
If
thewomanisnotgainingweightduringthe pregnancy,heown bodyfoodstoresarebeingused
up. If the woman was underweight before the pregnancy, she can be encourage to gain extra
weight.
Somewomenmayneedspecialattentiontotheirweightgainduringpregnancy.
Askthegroupwhichwomenmayneedspecialattentiontotheirweightgainduringpregnancy.
A young woman is still growing herself, so has very high nutrient needs. The mother expecting
twinsorwhostartedthepregnancylowinweightalsohashigherfoodsneeds.
Apregnantwomanwithaheavyworkloadwillusealotofenergy.Alighterworkloadandtimeto
restmayhelptoincreaseweightandimproveherhealth.
Ifapregnantwomanisnotgainingweight,discusswhatsheiseatingandwhatfoodisavailable
toher,totrytoimprovehereatingandweightgain.
In some areas, vitamin and mineral supplements are available to pregnant women. Multivitamin
supplementsduringpregnancymayimprovetheweightgainamongHIV-infectedwomen.
4. Maternal nutrition during breastfeeding (5 minutes)
6
Whataresomeofthe Whataresomeofthe Whataresomeofthe Whataresomeofthe eatingwisely eatingwisely eatingwisely eatingwisely guidelinesyou guidelinesyou guidelinesyou guidelinesyouc cc cangivetomotherswhoarebreastfeeding angivetomotherswhoarebreastfeeding angivetomotherswhoarebreastfeeding angivetomotherswhoarebreastfeeding? ?? ?
Allowtwoorthreeparticipantstogivetheirsuggestionsbeforehighlightingthefollowing:
Itishardworktorecoverfromthebirthofachild,totakecareofababyandperhapsotherfamily
membersaswell.Allmothersneedgoodnutritionandcare,irrespectiveoftheirHIVstatus.
Eating a variety of foods will ensure and adequate supply of all the nutrients a mother needs to
stayhealthy.Extraenergymaymeaneatinganextramealdaily.
During pregnancy, the body retains fluid and lays down fat stores to provide energy when
breastfeeding. Women who breastfeed may lose this fluid and fat over 46 months after birth.
ThisisnormalandisnotthesameaswastingduetoHIVinfection.
Ifthewomansweightafterdeliveryislowerthanherweightbeforepregnancy,evenwhensheis
eating well, her continued weight loss may be a sign of illnesses associated with HIV. Refer
motherswhoarelosingweightandnotfeelingwelltotheclinic.
5
Startingwiththefourthmonth,aweightgainofaround1.5-2kgisnormalandabout10-12kgduringthewhole
pregnancy.
6
TheriskofHIVtransmissionduringbreastfeedingisdiscussedinthenextsession.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
132
Herewehaveanotherkeypoint:
Showthesecondkeypointdisplayed,andaskaparticipanttoreaditoutloud.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Eatingwiselyduringbreastfeedinghelpsthemotherandbabystayhealt Eatingwiselyduringbreastfeedinghelpsthemotherandbabystayhealt Eatingwiselyduringbreastfeedinghelpsthemotherandbabystayhealt Eatingwiselyduringbreastfeedinghelpsthemotherandbabystayhealthy. hy. hy. hy.
Show W WW Worksheet 8/1 orksheet 8/1 orksheet 8/1 orksheet 8/1: :: : F FF Food beliefs and practi ood beliefs and practi ood beliefs and practi ood beliefs and practic cc ces es es es (found at the end of this session and on page
90oftheParticipant'sManual).
This worksheet can also be used as a guideline for discussing food beliefs and practices with
mothers.
6. Summary of the session and transition (5 minutes)
Show/review both key points on display; reinforce them and summarise the session using the
followingpoints.
KEYPOINTS KEYPOINTS KEYPOINTS KEYPOINTS
Eatingwiselyduringpregnancyhelpsthemotherandthebabyto Eatingwiselyduringpregnancyhelpsthemotherandthebabyto Eatingwiselyduringpregnancyhelpsthemotherandthebabyto Eatingwiselyduringpregnancyhelpsthemotherandthebabytostayhealthy. stayhealthy. stayhealthy. stayhealthy.
Eatingwiselyduringbreastfeedinghelpsthemotherandthebabytostayhealthy. Eatingwiselyduringbreastfeedinghelpsthemotherandthebabytostayhealthy. Eatingwiselyduringbreastfeedinghelpsthemotherandthebabytostayhealthy. Eatingwiselyduringbreastfeedinghelpsthemotherandthebabytostayhealthy.
Goodnutritionisimportant forallofus.PoornutritioninawomanwithHIVcanaffectherhealth
andthatofherbaby.PoornutritionmayalsofacilitatetransmissionofHIVtoherbaby.
Encouragepregnant,breastfeedingornewmotherstocareforthemselvesandtheirbabyby:
Eatingwiselyandaincludingavarietyoffoodsintheirdiets;
Nutritional Care and Support for People Living with HIV: Facilitators Guide
133
Eatingfoodwithenoughvitaminandminerals;and
Visitingtheclinicforearlydetection andtreatmentofanyinfectionsandtoobtain guidance on
vitaminandmineralsupplements.
When discussingabout nutritionduringpregnancyandbreastfeedingwitha mother,itisimportant
toknowifthewomanhasdisclosedherHIVstatustoherfamilyandfriends.Somesuggestionsto
improvenutritionmaybedifficulttofollowifthewomanhasnotdisclosedherstatus.
Mothers need to be counselled and informed about local food beliefs and practices that may be
beneficial,neutralorharmful.
Askifthereareanyquestions,orifanythingneedsclarifying.
Inthenextsession,wewilldiscussfeedingoptionsforinfantsofmotherslivingwithHIV.
Thenextsessionwillbepresentedby:
Statethenameofthepresenter.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
134
HANDO HANDO HANDO HANDOUT8/1: UT8/1: UT8/1: UT8/1:Increasingironabsorption Increasingironabsorption Increasingironabsorption Increasingironabsorption
Theamountofironthatapersonabsorbsfromfooddependson:
Theamount amount amount amountofironinthefood;
The type type type type of iron (iron from meat and fish is better absorbed than iron from plants, milk
andeggs);
Thetypesof otherfoods otherfoods otherfoods otherfoods present present present presentinthesamemeal(some increase increase increase increaseironabsorption, e.g.
meatandcitrus,whileothersreduce reduce reduce reduceit,e.g.tea.);and
Whetherthepersonhasanaemia anaemia anaemia anaemia(moreironisabsorbedifthepersonisanaemic).
The amount of iron absorbed from eggs, milk and plant foods such as, low fibre cereals,
pulses, seeds, and vegetables are increased increased increased increased by eating these together with the following in
thesamemeal:
Foods rich in vitamin C, such as, tomato, broccoli, guava, mango, pineapple, paw-paw,
orangeandothercitrusfruits;
Germinatedorfermentedcerealsorpulses,suchas,beansprouts;
Small amounts (about 30 grams) of the flesh or organs/offal of animals, birds, fish and
otherseafood.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
135
WORKSHEET8/1:Findingoutaboutfoodbeliefsandpracticesinthelocalregion WORKSHEET8/1:Findingoutaboutfoodbeliefsandpracticesinthelocalregion WORKSHEET8/1:Findingoutaboutfoodbeliefsandpracticesinthelocalregion WORKSHEET8/1:Findingoutaboutfoodbeliefsandpracticesinthelocalregion
1 11 1. .. . Dopregnantwomeninyourareabelievetherearesomefoodsoreatingpracticesthatare
harmfulduringpregnancy?
2 22 2. .. . Dopregnantwomeninyourareabelievetherearesomefoodsoreatingpracticesthatare
specialorbeneficialduringpregnancy?
3 33 3. .. . Dobreastfeedingwomeninyourareabelievetherearesomefoodsoreatingpracticesthatare
harmfulwhenbreastfeeding?
4 44 4. .. . Dobreastfeedingwomeninyourareabelievetherearesomefoodsoreatingpracticesthatare
specialorbeneficialwhenbreastfeeding?
5 55 5. .. . Canyouidentifythebeneficialandharmfulbeliefsandpractices?Givereasons.
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136
Session Session Session Session9: 9: 9: 9:FeedingoptionsforinfantsofHIVpositivemothers FeedingoptionsforinfantsofHIVpositivemothers FeedingoptionsforinfantsofHIVpositivemothers FeedingoptionsforinfantsofHIVpositivemothers
Learning Learning Learning Learningo oo objectives bjectives bjectives bjectives
Bytheendofthissession,participantswillbeableto:
DiscusstherisksandbenefitsofthedifferentfeedingoptionsforinfantsofHIVpositive
mothers;and
ProvideguidancetoHIVpositivemotherstochoosethemostsuitablefeedingoptions
fortheirsituation.
Session Session Session Sessiono oo outline utline utline utline
Content Content Content Content Time Time Time Time
1 Learningobjectivesandintroductiontothesession 3minutes
2 Infantfeedingoptions 8minutes
3 Risksandbenefitsofdifferentinfantfeedingoptions
Demonstrationtalkforpregnantwomenonfeedingtheirbabies
15minutes
4 Providingongoingsupporttomothers 3minutes
5 Transitionfromexclusivebreastfeedingtocomplementaryfeeding 3minutes
6 Summaryofthesessionandtransition 3minutes
Total Total Total Total 35minutes 35minutes 35minutes 35minutes
Preparation for the session
Writeanddisplaythelearningobjectivesonasheetofflipchartpaper.
Writethekeypointonaflipchartsheetandkeepitasideuntilneeded.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
AllmotherswithHIVshouldreceivecounsellingtoguidethem AllmotherswithHIVshouldreceivecounsellingtoguidethem AllmotherswithHIVshouldreceivecounsellingtoguidethem AllmotherswithHIVshouldreceivecounsellingtoguidetheminchoosing inchoosing inchoosing inchoosinginfantfeeding infantfeeding infantfeeding infantfeeding
optionsmostsuitablefortheirsituation. optionsmostsuitablefortheirsituation. optionsmostsuitablefortheirsituation. optionsmostsuitablefortheirsituation.
Familiarise yourself with the national policies and guidelines on infant feeding in the context of
HIV,iftheyexist.Summarizetheseonasheetofflipchartpaper.
Writethewords:Acceptable,Feasible,Affordable,SustainableandSafe Acceptable,Feasible,Affordable,SustainableandSafe Acceptable,Feasible,Affordable,SustainableandSafe Acceptable,Feasible,Affordable,SustainableandSafeondifferentcolouredA4
sheetsorcardsandkeepthemasideuntilneeded.
FindoutifthereareinfantfeedingcounsellorsavailableinthelocalareaformotherswhoareHIV-
positive.
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137
Asktwoparticipantstoassistwiththedemonstrationtalkbyaskingpreparedquestions.
The prepared questions are found at the end of the text for the demonstration talk (see also
handouts for photocopy in the Directors Guide). Give each of the participants assisting you a
preparedquestionwrittenonapieceofpaperandexplainwhentheyaretoaskthesequestions.
Read more information on the WHO/UNICEF "Infant and Young Child Feeding Counselling: An
integrated course" the job aids on HIV and infant feeding, and WHO/UNICEF Breastfeeding
Counselling:ATrainingCourse.(SourcesoffurtherinformationareprovidedinA AA Annex nnex nnex nnex4 4 4 4). ). ). ).
Collect/preparethefollowingmaterials:
An overhead projector and screen; and/or flipchart paper, markers and a means to attach
flipchartsheetstothewallorothersurface.Ifanoverheadprojectorisnotavailable/used,the
following may be written out on flipchart sheets or enlarged copies prepared for display as
posters,asappropriate.
Overhead9 Overhead9 Overhead9 Overhead9/ // /1: 1: 1: 1: Policyofsupportingbreastfeeding Policyofsupportingbreastfeeding Policyofsupportingbreastfeeding Policyofsupportingbreastfeeding
Overhead Overhead Overhead Overhead9/2: 9/2: 9/2: 9/2: TheUnitedNationsAgencies TheUnitedNationsAgencies TheUnitedNationsAgencies TheUnitedNationsAgencies Recommendation Recommendation Recommendation RecommendationforHIV forHIV forHIV forHIV- -- -positivewomen positivewomen positivewomen positivewomen
Overhead9 Overhead9 Overhead9 Overhead9/ // /3 33 3: : : : Exclusivebreastfee Exclusivebreastfee Exclusivebreastfee Exclusivebreastfeeding ding ding ding
Overhead9 Overhead9 Overhead9 Overhead9/4: /4: /4: /4: R RR Replacementfeeding eplacementfeeding eplacementfeeding eplacementfeeding
Overhead9/5 Overhead9/5 Overhead9/5 Overhead9/5: :: : 20 20 20 20babiesof babiesof babiesof babiesofmotherswithHIV motherswithHIV motherswithHIV motherswithHIV (fordemonstrationtalk)
Handout 9/1: Handout 9/1: Handout 9/1: Handout 9/1: Risks and benefits of different infant feeding options Risks and benefits of different infant feeding options Risks and benefits of different infant feeding options Risks and benefits of different infant feeding options (available at the end of
thissession)
P PP Picture3 icture3 icture3 icture3:SamandSuzi :SamandSuzi :SamandSuzi :SamandSuzi(seeA AA Anne nne nne nnex1 x1 x1 x1; usetheversionmostsuitableforthelocalarea).
1. Learning objectives and introduction to the session (3 minutes)
Review the learning objectives of the session
Showandoutlinethelearningobjectivesdisplayed.
Bytheendofthissessionparticipantsshouldbeableto:
Discuss the risks and benefits of the different feeding options for infants of HIV-positive
mothers;and
ProvideguidancetoHIVpositivemotherstochoosethemostsuitablefeedingoptionsfor
theirsituation.
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138
Introduce the session
Asageneralprinciple,inallpopulations,irrespectiveofHIVinfectionrates,breastfeeding
shouldcontinuetobeprotected,promotedandsupported.
HIVandInfantFeeding:APolicyStatement HIVandInfantFeeding:APolicyStatement HIVandInfantFeeding:APolicyStatement HIVandInfantFeeding:APolicyStatement,developedcollaborativelybyUNAIDS/WHO/UNICEF,1997 ,developedcollaborativelybyUNAIDS/WHO/UNICEF,1997 ,developedcollaborativelybyUNAIDS/WHO/UNICEF,1997 ,developedcollaborativelybyUNAIDS/WHO/UNICEF,1997. .. .
Ask three participants to take turns reading the following (also found on pages 91-92 of the
Participant'sManual):
Participant 1:
Breastmilksuppliesallthenutrientsinfantsbodiesneedforgrowthanddevelopmentduringthefirst
sixmonthsoftheirlives.Inaddition,breastmilkprotectsthemagainstinfectionsandstrengthenstheir
immune system. However, HIV can pass from an infected mother to her baby during breastfeeding
andcaremustbetakentoreducethetransmissionrisk.
Participant 2:
Forthisreason,allpregnantwomenornewmotherswithHIVneedcounsellingwhichincludes:
Informationontherisksandbenefitsoflocallyappropriateinfantfeedingoptions;and
Guidanceinselectingthemostsuitableinfantfeedingoptionfortheirsituation.
Whateveramotherdecides,sheshouldbesupportedinherchoice.
Participant 3:
This session discusses the risks and benefits of different feeding options for infants of mothers who
have been tested for HIV and found to be positive. We will also discusssome of the information the
counsellorneedstofindoutfromthemotherwhenassessinghersituationandhelpinghertochoose
themostsuitablefeedingoptionforhersituation.
For further continued support in carrying out her choice, refer the mother to health workers who
havebeentrainedinbothbreastfeedingandHIVandinfantfeedingcounselling.
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139
Informparticipantsthat,thissessionisonlyabriefoverviewofHIVandinfantfeedingcounselling.
GiveparticipantsmoreinformationontheWHO/UNICEFcourseInfantandYoungChildFeeding
Counselling:Anintegratedcourse,thejobaidsspecificforHIVandinfantfeedingcounsellingand
WHO/UNICEFBreastfeedingCounselling:ATrainingCourse.
2. Infant feeding options (8 minutes)
InformtheparticipantsabouttheUnitedNationsAgenciesRecommendationoninfantfeeding:.
If a woman is HIV-negative or does not know her HIV status, exclusive breastfeeding is
recommendedforthefirst6monthsofthebabyslife.
Show and ask one participant to read O OO Overhead 9/2: verhead 9/2: verhead 9/2: verhead 9/2: The The The The United Nations United Nations United Nations United Nations A AA Agencies gencies gencies gencies
R RR Recommendation ecommendation ecommendation ecommendationforHIV forHIV forHIV forHIV- -- -positivewomen positivewomen positivewomen positivewomen
OVERHEAD 9/2: The United Nations Agencies OVERHEAD 9/2: The United Nations Agencies OVERHEAD 9/2: The United Nations Agencies OVERHEAD 9/2: The United Nations Agencies r rr recom ecom ecom ecommendation mendation mendation mendation for HIV for HIV for HIV for HIV- -- -positive positive positive positive
women women women women
7
The most appropriate infant feeding option for an HIV-infected mother should depend on her
individual circumstances, including her health status and the local situation, but should take
greaterconsiderationofthehealthservicesavailableandthecounsellingandsupportsheislikely
toreceive.
Exclusive breastfeeding Exclusive breastfeeding Exclusive breastfeeding Exclusive breastfeeding is recommended for HIV-infected women for the first 6 months of life
unless replacement feeding is Acceptable, Feasible, Affordable, Sustainable and Saf Acceptable, Feasible, Affordable, Sustainable and Saf Acceptable, Feasible, Affordable, Sustainable and Saf Acceptable, Feasible, Affordable, Sustainable and Safe (AFASS) e (AFASS) e (AFASS) e (AFASS)
forthemandtheirinfantsbeforethattime.
Copy the table below on a flipchart sheet and ask participants to list the benefits and risks of
breastfeedingandthenreplacementfeedingthattheyknow.
Use H HH Handout 9/1: Risks and benefits of different infant feeding options andout 9/1: Risks and benefits of different infant feeding options andout 9/1: Risks and benefits of different infant feeding options andout 9/1: Risks and benefits of different infant feeding options (available at the end of
this session and on page 99 of the Participant's Manual) to clarify or add any points that may
havebeenleftout.
Explain to participants that this handout can also be used to explain the risks and benefits of
differentinfantfeedingoptionsformothersduringcounselling.
3.1. Demonstration talk for pregnant women on feeding their babies
Introduce the demonstration talk
UsethestoryofSamandSuzitointroducethetalk.
THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI
Suzi is pregnant. Suzi and Sam were tested and are HIV-positive. They want to know more
aboutbreastfeedingandHIV.
SamandSuziaretoldattheantenatalclinicthatthereisatalkforpregnantwomen oninfant
feeding.
Theydecidetoattendsotheycandiscussthechoicesandmakeadecisionabouthowtofeed
theirbaby.
Check that participants understand that they should be role-playing as people attending the talk
atanantenatalclinic.
Presentthetalk.
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142
Feeding your baby: a talk for pregnant women
Welcome/greetthegroup.
Today,wewilltalkaboutfeedingyourbaby.Thefirstthingtoknowisthat:
If a woman is HIV-negative or does not know her HIV status, exclusive breastfeeding is
recommendedforthefirst6monthsofthebabyslife.
IfawomanisHIV-positive,theHIVinfectioncanpassfromtheinfectedmothertoherbabyduring
pregnancy,birthandbreastfeeding.Letuslookathowlikelyisthatriskoftransmission.
ShowO OO Overhead9/5: verhead9/5: verhead9/5: verhead9/5: 20 20 20 20babiesof babiesof babiesof babiesofmotherswithHIV motherswithHIV motherswithHIV motherswithHIV andexplainthefollowingpoints:
OVERHEAD 9/5: Twenty babies of mothers with HIV
These are 20 babies of women who have all had a test which showed that they are living with
HIV.TheHIVviruscanpassfromthesewomentotheirbabiesduringpregnancyandbirth.About
fourofthese20babiesarelikelytobeHIV-infectedduringpregnancyandbirth.
8
Now,markfour four four fourbabiesatrandomonthepicturewithamarker.
Ifthemotheristreatedwithantiretrovirals,theriskofpassingtheHIVinfectionfromthemotherto
thebabyisreduced.
9
8
The rate of transmission of HIV during pregnancy and delivery is approximately 2025% without antiretroviral drug
treatment.
9
Transmission of HIV from mother to infant if the mother is taking long term antiretroviral treatment, has a
caesareansectionandavoidsbreastfeedingislessthan2%.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
143
SomebabiesborntomotherswhoareHIV-positivewillbecomeHIV-positiveiftheyarebreastfed,
Up to three babies out of 20 born to women who are HIV-positive may be infected in this way,
dependingonhowandhowlongtheyarebreastfeeding.
10
Mark three three three three additional babies on the picture, with a different colour marker if possible, or a
differenttypeofmark.
Even among women who know they are HIV-positive, only a small number of their infants are
likelytobeinfectedthroughbreastfeeding.
Pointtothe3babiesmarked.
Most babies will not be infected through breastfeeding. However, given the risk, a way must be
foundtominimizetransmissionthroughbreastmilk.
Toreducethetransmission,motherswhoareHIV-positivemaychooseto:
Exclusivelybreastfeed Exclusivelybreastfeed Exclusivelybreastfeed Exclusivelybreastfeed: :: :
Givenothingelseexceptbreastmilk,notevenwater,andthenstopbreastfeedingatsixmonths.
Exclusivebreastfeedingincludes:
ExpressandheattreattheirbreastmilktokilltheHIVvirusbeforegivingittothebaby;or
UsebreastmilkfromawomanwhoisHIV-negative.
Alternatively,HIV-positivemothersmaydecideto:
A AA Avoid breastfeeding altogether void breastfeeding altogether void breastfeeding altogether void breastfeeding altogether: : : : Find a suitable replacement for the breast milk. Replacement
feeding is feasible and acceptable, if the family can afford replacement feeding for a period of
aboutayearormoreandcanpreparethereplacementfoodsafely;
However,ifthebabyisnotbreastfeedandreplacementfeedingischosen,he/sheismorelikelyto
get diarrhoea, chest infections, and other health problems. The family will also need to buy
formulatofeedthebaby,andhavecleanwaterandfueltoboilwater.Also,awomanwhoisnot
breastfeeding may become pregnant again sooner if sexually active. The mother needs to
considertheseissueswhendecidingonthebestoptionforherselfandthebaby.
The risk of HIV transmission is highest when the baby is mixed fed during the first six months,
i.e., when breastfeeding is combined with replacement food (other milk, solid foods or fluids).
Thispracticeshouldbediscouraged.
Mixedfeedingincreasesthechancesofviruspassingtothebaby.
During mixed feeding, the breasts can become engorged and there is an increased risk of
infectionofthebreast.
11
10
Ifthereisnointerventiontopreventmother-to-child-transmissionofHIV,30-45%ofHIV-infectedmotherswill
passonthevirustotheirchild.Uptoabout520%ofthesewillbethroughbreastfeeding.
11
The infectionof thebreast or mastitis may increase the viral load in breast milk,thus increasing the risk of
HIVtransmission.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
144
IfawomanknowssheisHIV-positiveduringherpregnancy,itisagoodtimetothinkandplanon
howshewillfeedherbaby.Shecantalktoherdoctor,nurseorHIVcounsellortohelpherdecide
the best way to feed her baby in her situation and to support her in carrying out the chosen
feedingoption.
Themainpointstorememberare:
If a woman is HIV-negative or does not know her HIV status, exclusive breastfeeding is
recommended for the first six months, continuing thereafter with the addition of complementary
foods.
IfawomanisHIV-positive,sheshouldbecounselledandhelpedtodecidehowtofeedthebaby,
beforethebabyisborn.
If breastfeeding, she should breastfeed exclusively for the first six months and change to
replacementfeedingwhenacceptable,feasible,affordable,sustainableandsafe.
The risk of HIV transmission is higher in those who use mixed feeding (breastfeeding together
withotherfoodsorfluids)anditshouldbeavoided.
Ensure good hygiene and encourage mothers to breastfeed on demand, that is, as often as the
babywantstofeedorwheneverthemotherwantstofeed.Thiswillstimulatemilkproductionand
keepherbreastsfromgettingswollen.
Encourage good breastfeeding technique to prevent sore nipples and breast problems. If these
occur,theyshouldbetreatedpromptly.
Askthegroupiftheyhaveanyquestionsorifanythingneedsclarifying.
Asktheparticipantsselectedatthebeginningofthesession,toraisequestionsfromtheprepared
listofquestionsanddiscusstheanswers.
Prepared question 1
If I breastfeed, I will need to eat more food myself to make good milk. I cant afford this extra food. If I breastfeed, I will need to eat more food myself to make good milk. I cant afford this extra food. If I breastfeed, I will need to eat more food myself to make good milk. I cant afford this extra food. If I breastfeed, I will need to eat more food myself to make good milk. I cant afford this extra food.
Woulditbebettertouseformulaforthebabyinstead? Woulditbebettertouseformulaforthebabyinstead? Woulditbebettertouseformulaforthebabyinstead? Woulditbebettertouseformulaforthebabyinstead?
Askthegroupiftheyhaveanyotherquestionsorifanythingneedsclarifying.
Thankthegroupfortheirinterestandattendance.
End of demonstration talk
Explaintoparticipantsthatthedemonstrationtalkhasnowendedandthattheynolongerneedto
berole-playingaspeopleattendingahealthcentretalk.
Returntotherestofthesession.
----------
Discussthefollowingpointswithparticipants:
Whenamotherdecidesto breastfeed,itisimportantthatshereceivesthesupportsheneedsto
breastfeedexclusivelyandtodiscusswithherhowshecancarryoutherdecisionby:
Gettingmoreinformationonsaferbreastfeedingpractices;and
Eatingwiselytobuildandstorenutrientsneededforherbodyandformilkproduction.
ShowP PP Picture icture icture icture3 33 3: :: :SamandSuzi SamandSuzi SamandSuzi SamandSuzi,thebabyandgrandmother ,thebabyandgrandmother ,thebabyandgrandmother ,thebabyandgrandmother.
AskoneoftheparticipantstovolunteerandreadthestoryofSamandSuzi.
THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI
SuziandSamdecidethatexclusivebreastfeedingisthebestchoiceforthem.Thecounsellor
praisesthemforthinkingaboutthisduringpregnancyandforcomingtodiscusstheirchoice.
Thecounsellorgivesthemsomemoreinformationonsaferbreastfeedingpractices.
SuziandSamsbabyboyisborn.Suziisbreastfeedingexclusively.Everythingisgoingwell.
Suzi is eating wisely, taking some rest and feeding her baby frequently using good
breastfeedingpractices.
However, they do have one problem. Sams mother, Granny, thinks the baby needs water
and tea as well as breast milk. She cannot understand why Suzi and Sam are so insistent
thatthebabyonlyhasbreastmilk.
SuziexplainstoGrannythatexclusivebreastfeedingisbestforbabies.Thebabygetsallhe
needsfrombreastmilk.Hedoesnotneedwaterortea.
Granny keeps asking about giving water and other things to the baby. Sam and Suzi are
afraidGrannywillstartgivingthebabywaterandotherfoodsherself.
SamandSuzidecidetotellGrannythattheyareHIV-positive.Theydothisandexplainwhy
itisveryimportanttobreastfeedexclusivelytoreducetheriskofthebabygettingtheHIV.
Explainthefollowing:
When you discuss infant feeding with a mother who is HIV-positive, also discuss how she will
carry out her decision. If she has not disclosed her status, she will have a hard time getting the
supportsheneedstofeedherbaby.HIVorPMTCTcounsellorscanhelpwomenmakeadecision
aboutdisclosingtheirHIVstatus.
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147
Mothersneedtobesupportedtodevelopaspecificplanthatwillenablethemtominimizeriskand
discomfortduringthetransitionperiod.
ContinuewithSamandSuzisStory.Askoneoftheparticipantstovolunteerandreadtheirstory.
THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI
Suzi breastfeeds exclusively. When little Sam is about five months, she decides she would stop
breastfeeding completely and starts giving other foods and fluids to the baby when he is six
monthsold.
However, if Suzi stops breastfeeding suddenly, she may get engorged breasts and feel ill; her
babywillalsoneedanothersourceoffoodandcomfort.
So she will need to go and discuss her decision to stop breastfeeding with a breastfeeding
counsellortominimizeriskanddiscomfortduringthistransition.
Emphasizethefollowingpoint:
Ifthemotherthinksthatsheisreadytostopbreastfeedingorthechildisoldenoughfordoingso,
refermotherandherbabytoaninfantfeedingcounsellor.
6. Summary of the session and transition (3 minutes)
Show/reviewthekeypointdisplayed.
Askifthereareanyquestionsorifanythingneedsclarifying.
Inthenextsession,wewilldiscussfeedingachildwithHIV.
Thenextsessionwillbepresentedby:
Statethenameofthepresenter.
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149
HANDOUT HANDOUT HANDOUT HANDOUT9/1:Risksandbenefitsofdifferentinfantfeedingoptions 9/1:Risksandbenefitsofdifferentinfantfeedingoptions 9/1:Risksandbenefitsofdifferentinfantfeedingoptions 9/1:Risksandbenefitsofdifferentinfantfeedingoptions
EXCLUSIVEBREASTFEEDING EXCLUSIVEBREASTFEEDING EXCLUSIVEBREASTFEEDING EXCLUSIVEBREASTFEEDING REPLACEMENTFEEDING REPLACEMENTFEEDING REPLACEMENTFEEDING REPLACEMENTFEEDING
Benefits Benefits Benefits Benefits Breastmilkcontainsallthefoodthe
babyneedsforthefirstsixmonths.
Breastmilkiseasytodigest.Doesnot
needwater.
Breastmilkprotectsthebabyfrom
diarrhoea,pneumoniaandother
infections.
Breastmilkisfree,alwaysavailableand
doesnotneedanyspecialpreparation.
Breastfeedingcreatesabondbetweena
motherandherbaby.
Exclusivebreastfeedinghelpsmothers
recoverfromchildbirthandprotectsthem
fromgettingpregnantagaintoosoon.
Exclusivebreastfeedingforfirstfew
monthslowerstheriskoftransmittingHIV
totheinfant.
NoriskoftransmissionofHIVfrom
themothertotheinfant.Mostofthe
nutrientsherbabyneedshave
alreadybeenaddedtotheformula.
Othermembersofherhousehold
canbeinvolvedintheinfants
feeding.
Risks Risks Risks Risks Aslongasthebabyisbreastfed,therisk
ofpassingHIVtothebabyexists.
Otherpeoplemayalsopressurizethe
mothertogivewater,otherliquidsor
foodstothebabywhilesheis
breastfeeding.Thispracticeknownas
mixedfeeding,increasestheriskof
diarrhoeaandotherinfections.
Entailsahigherriskofnon-HIV
infectionssuchas,diarrhoeaand
chestinfectionssincetheinfantwill
nothavetheprotectiveantibodies
obtainedfrombreastmilk.
Theexpenseofobtainingthe
appropriatefoodsforthebaby,as
wellascleanwaterandfuel.
Questionsthatmayberaisedby
othersaboutthemothersHIV
statusbecausesheisnot
breastfeeding.
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Session10:FeedingachildwithHIV Session10:FeedingachildwithHIV Session10:FeedingachildwithHIV Session10:FeedingachildwithHIV
Learning Learning Learning Learningo oo objectives bjectives bjectives bjectives
Bytheendofthissession,participantswillbeableto:
Understandtheimportanceofoptimalinfantfeedingforgrowthanddevelopment;
DiscussthenutritionalconcernsofchildrenwithHIV;and
MakesuggestionsforfeedingachildwithHIVandduringillnessandrecovery.
Writeanddisplaythelearningobjectivesonaflipchartsheet.
Writethekeypointsonaflipchartsheetandkeepitasideuntilneeded.
KEYPOINTS KEYPOINTS KEYPOINTS KEYPOINTS
When When When Whenfeedingachild,respondtohis/hercuesandsignalsand feedingachild,respondtohis/hercuesandsignalsand feedingachild,respondtohis/hercuesandsignalsand feedingachild,respondtohis/hercuesandsignalsand
feedwithcareandpatience. feedwithcareandpatience. feedwithcareandpatience. feedwithcareandpatience.
Feedachildextrafoodduringillnessandrecovery. Feedachildextrafoodduringillnessandrecovery. Feedachildextrafoodduringillnessandrecovery. Feedachildextrafoodduringillnessandrecovery.
Find out about the standard policy regarding vitamin and micronutrient supplementation for
childreninthelocalarea/region.
Familiarize yourself with the national policies and guidelines on infant feeding in the context of
HIVandAIDS,iftheyexist.
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FindoutiftherearechildfeedingcounsellorsformothersandfamilieswithHIV-positivechildren
availableinthelocalarea.
Collect/preparethefollowingmaterials:
An overhead projector and screen; and/or flipchart paper, markers and a means to attach
flipchart sheets to the wall or other surface. If an overhead projector is not used, overheads
maybewrittenoutonflipchartsheetsorenlargedcopiespreparedfordisplayasposters,as
appropriate.
Overhead10/1: Overhead10/1: Overhead10/1: Overhead10/1: Responsivefeeding Responsivefeeding Responsivefeeding Responsivefeeding
Overhead10/2: Overhead10/2: Overhead10/2: Overhead10/2: Feedingthechildwhoisill Feedingthechildwhoisill Feedingthechildwhoisill Feedingthechildwhoisill
Overhead10/3: Overhead10/3: Overhead10/3: Overhead10/3: Feeding Feeding Feeding Feedingachild achild achild achildduringrecovery duringrecovery duringrecovery duringrecovery
Handout10/ Handout10/ Handout10/ Handout10/1: 1: 1: 1: S S S Sample ample ample ampledaily daily daily dailymealp mealp mealp mealplan lan lan lanforchildren forchildren forchildren forchildren (availableattheendofthissession).
W WW Worksheet10/1 orksheet10/1 orksheet10/1 orksheet10/1: : : : Daily Daily Daily Dailymealplanner mealplanner mealplanner mealplannerforchildren forchildren forchildren forchildren (availableattheendofthissession).
Showtheflipchartandoutlinethelearningobjectives.
Bytheendofthesession,participantswillbeableto;
Understandtheimportanceofoptimalinfantfeedingforgrowthanddevelopment;
DiscussthenutritionalconcernsofchildrenwithHIV;and
MakesuggestionsforfeedingachildwithHIVandduringillnessandrecovery.
Introduce the session
WhatmakesitparticularlyimportantforanHIV WhatmakesitparticularlyimportantforanHIV WhatmakesitparticularlyimportantforanHIV WhatmakesitparticularlyimportantforanHIV- -- -infectedchildtogetadequatenutrition? infectedchildtogetadequatenutrition? infectedchildtogetadequatenutrition? infectedchildtogetadequatenutrition?
Allowparticipantstogivetheirsuggestionsandthen,explainthefollowing:
Allchildrenneedadequatenutritionforgrowthanddevelopment.However,HIV-infectedchildren
mayneedspecialattentiontoensurethattheyreceiveadequateamountsoffoodandnutrients.
Mothers with children infected with HIV therefore, need to be given information and support to
ensurethattheirchildrengetextraenergy,aswellasproteinandallthemicronutrientsneededfor
theirgrowthanddevelopment.
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BecauseofthechallengesinassessingtheHIVstatusofyoungchildren,allHIV-positivemothers
needtoensurethattheirchildrenhaveenoughfoodintakeandnutritionalcare.
Inthissession,wewilldiscussnutritionconcernsforchildrenwithHIV.
Thesessionalsoincludessuggestionsforfeedingachildwhoisillorrecoveringfromanillness.
Because of these factors that may reduce food intake in children with HIV, mothers will need
guidanceandsupportforappropriatefeedingpracticesandtoensuretheimprovedfoodintakeof
theirchildrenduringillnessandrecovery.
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3. Feeding a child with HIV (30 minutes)
RefertotheStoryofSamandSuzitoillustratethediscussion.
THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI
SamandSuzisson,littleSamis18monthsoldandgrowingwell.HisHIVstatusisknown:he
hasbeenfoundtobeHIV-negative.
A neighbour of the family has a daughter Leila, who is two years old. Leila has not met her
developmentaltargetsandsheisoftenill.
LeilasfamilyisworriedthatLeilamayhaveHIValthoughshehasnothadatest.
LeilasmotherisillandLeilasfatherdiedayearago.
BecauselittleSamishealthy,LeilasmotherasksSuziforhelpinfeedingLeila.
Explainthefollowing:
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Ask a volunteer participant to read the following possible suggestions Suzi can give to Leilas
mother:
Itisimportanttofeedinfantsdirectlyandtoassistolderchildrentofeedthemselves.
Childrenneedtobehelpedtolearntheskillsassociatedwitheating.
Besensitivetohungerandtosatietycuesorsigns.Theyindicatethatthechildhaseatenallthat
he/shewants.Forexample,thechildmaystopopeninghermouthforfood,turnawayfromfoodor
spititout.
Feedslowlyandpatiently.Encouragethechildtoeatbutdonotforceher.
If a child refuses many foods, it is good to try different food combinations, tastes, textures and
methodsofencouragement.
Minimizedistractionsduringmealsifthechildlosesinteresteasily.
Feedingtimesareperiodsoflearningandlove:talktochildrenduringfeeding,maintainingeye-to-
eyecontact.
Showthefirstkeypointdisplayedandaskaparticipanttoreaditoutloud.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Whenfeedingachild,respondtohis/hercuesandsignalsand Whenfeedingachild,respondtohis/hercuesandsignalsand Whenfeedingachild,respondtohis/hercuesandsignalsand Whenfeedingachild,respondtohis/hercuesandsignalsand
feedwithcareandpatience. feedwithcareandpatience. feedwithcareandpatience. feedwithcareandpatience.
3.2. Foods to suggest for young children
Explainthefollowing:
Like adults, all children need a variety of foods, including a staple food, animal food, vegetables
and fruits and some high-energy or enriched foods, such as those discussed in the previous
sessions.
Relative to their size, children need more food than adults do. However, young children have
smallstomachs,sotheyneedmorefrequentmeals.
DistributetoparticipantsH HH Handout andout andout andout 10/1: 10/1: 10/1: 10/1:S S S Sample ample ample ampledailymealplan dailymealplan dailymealplan dailymealplan f ff forchildren orchildren orchildren orchildren.
Theapproximatequantitiesoffoodsprovidedinthishandoutareonlyintendedasageneralguide
andneednotbeadheredtostrictly.
A flexible approach based on experience, local preferences and the availability of food is
important in ensuring that a wide range of foods are included in planning a variety of daily meal
options.
The meal planning guidance is based on the eight eating wisely guidelines we discussed in
S SS Session3 ession3 ession3 ession3. .. .Theamountoffoodgivenshouldbebasedonresponsivefeedingpractices.
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3.3. Meal planning (20 minutes)
Askparticipantstogetintogroupsoffive.Askeachgrouptowritedownexamplesoffoodchoices
thatcouldbesuggestedforLeilasdailymeals(3mealsand2snacksfortheday).
Ask each group to present their suggestions and write them down on W WW Worksheet 10/1 orksheet 10/1 orksheet 10/1 orksheet 10/1: A daily
mealplanner(foundattheendofthissessionandonpage106oftheParticipant'sManual).
In the last column, groups should write down any special considerations such as, why the
particularfoodandpreparationmethodwaschosen.Thesecanbelatertypedupandprintedas
areferenceforcareprovidersinthelocalarea/region).
Very ill children with HIV are at risk of dying and take a longer time to recover with just normal
foodintake.Theyneedhigherintakesofenergyandnutrientstorecoverrapidly.
However,becauseofillnesstheyfacedifficultiesineatingandmayneedmoreattentioninfeeding
andmanagingthesedifficultiesaswellasintreatingsevereillness.
Show O OO Overhead verhead verhead verhead 10/3: 10/3: 10/3: 10/3: Feeding Feeding Feeding Feeding a child a child a child a child during recovery during recovery during recovery during recovery and use the points below to explain it
further.
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OVERHEAD10/3 OVERHEAD10/3 OVERHEAD10/3 OVERHEAD10/3:Feeding :Feeding :Feeding :Feedinga a a achildduringrecovery childduringrecovery childduringrecovery childduringrecovery
Feedanextra extra extra extrameal.
Giveanextra extra extra extraamount.
Useextra extra extra extrarichfoods.
Feedwithextra extra extra extrapatience.
Giveextra extra extra extrabreastfeedsorfluids.
Feedthechildmorefrequentlythanusualandgiveanextra extra extra extrameal.
Giveextra extra extra extraamountoffoodateachmealifthechildsappetiteisgood.
Givefoodsextra extra extra extrarichinenergyand/ornutrientssuchas,enrichedporridge.
Beextra extra extra extrapatientinencouragingthechildtoeatandmakehim/hercomfortable.
Ifbreastfeeding,giveextra extra extra extrabreastfeeds.
Ifthechildisnolongerbeingbreastfed,giveextra extra extra extrafluidssuchas,water.
Discusswithparticipantsthepossibilitiesforfamiliestopracticetheseguidelines.
Showthesecondkeypointdisplayedandaskaparticipanttoreaditoutloud.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Feedachildextra Feedachildextra Feedachildextra Feedachildextrafoodduringillnessandrecovery. foodduringillnessandrecovery. foodduringillnessandrecovery. foodduringillnessandrecovery.
5. Summary of the session and transition (3 minutes)
Show/reviewbothkeypointsdisplayed.
KEYPOINTS KEYPOINTS KEYPOINTS KEYPOINTS
Whenfeedingachild,respondtohis/hercuesandsignalsand Whenfeedingachild,respondtohis/hercuesandsignalsand Whenfeedingachild,respondtohis/hercuesandsignalsand Whenfeedingachild,respondtohis/hercuesandsignalsand
feedwithcareandpatience. feedwithcareandpatience. feedwithcareandpatience. feedwithcareandpatience.
Feedachildex Feedachildex Feedachildex Feedachildextrafoodduringillnessandrecovery. trafoodduringillnessandrecovery. trafoodduringillnessandrecovery. trafoodduringillnessandrecovery.
Summarizethesessionusingthefollowingpoints:
If a child is ill frequently, he/she may become malnourished and therefore, be at higher risk of
moreillness.Likeadults,childrenneedtobefedwisely,withavarietyofnutritiousfoods.
Childrenrecovermorequicklyfromillnessandloselessweightiftheyarehelpedtoeatwhenthey
areillandrecovering.
Care and attention to eating and extra food should be given to children during illness and
recovery.
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Mothersshouldbeencouragedtotalktotheirhealthworkersforothersupportonfeedingchildren
withHIV.
DistributeHandout10/1totheparticipantsandexplainthefollowing:
This sample meal plan is intended only as a general guide. A flexible approach based on
experience,localpreferencesandtheavailabilityoffoodisimportantinensuringthatawiderange
offoodsareincludedinplanningavarietyofdailymealoptions.Thissampleplanisbasedonthe
eighteatingwiselyguidelinesdiscussedinSession3. Session3. Session3. Session3.Theamountoffoodgivenshouldbebased
onresponsivefeedingpractices
Askparticipantsiftheyhaveanyquestionsorifanythingneedsclarifying.
Inthenextsession,wewilldiscussimprovingaccesstofood.
Thenextsessionwillbepresentedby:
Statethenameofthepresenter.
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HANDOUT10/1:Sampledailymealplanforchildren HANDOUT10/1:Sampledailymealplanforchildren HANDOUT10/1:Sampledailymealplanforchildren HANDOUT10/1:Sampledailymealplanforchildren
12 12 12 12
MEALTIME MEALTIME MEALTIME MEALTIME EXAMPLESOFFOODCHOICES EXAMPLESOFFOODCHOICES EXAMPLESOFFOODCHOICES EXAMPLESOFFOODCHOICES SPECIALCONSIDERATIONS SPECIALCONSIDERATIONS SPECIALCONSIDERATIONS SPECIALCONSIDERATIONS
Breakfast Breakfast Breakfast Breakfast
2tablespoonsfreshorangejuicediluted
withwater
1cupporridgeservedwithwholemilk
added
1smallsliceofbreadspreadwith
margarine
1smallglassofmilk
Freshfruitjuicesalsocontainhighamountsofsugarandshouldbedilutedifnecessary.
Usesafedrinkingwater.
Mid Mid Mid Mid- -- -morning morning morning morning
snack snack snack snack
Selectionof1or2fingerfoods,suchas:
3breadsticks
chunksofapple
6grapes
1smallbanana
3chunksofmelon
1glassofwater
Washedandchoppedvegetablesandfruitsarenutritioussnacksandhelpthechildgain
appetite.
High-fatpotatoproducts(e.g.,chips/crisps)shouldbegivensparinglytochildrenassnacks,
becausetheyoftencontainpoorqualityfat,arehighinsaltandalsosuppresstheappetite.
Usesafedrinkingwater.
Lunch Lunch Lunch Lunch
1sliceofchickenandtomatobread
sandwich
3tablespoonsboiledpeasand1small
choppedboiledcarrot
1smallfruityoghurt
1glassofwater
Ifanimalfoodsarenotavailableorarenottoleratedbythechild,theycanbereplacedby
beansandlentils.
Milkandplain(safe)waterareconsideredappropriatedrinksthroughouttheday.
Freshfruitjuicecanalsobegivenatmealtimes.
12
Note for the facilitator: The menu provided as example was calculated for a requirement of 1200 calories + 10% (for HIV infection) = 1320 calories, distributed in
carbohydrates(59%),proteins(17%)andfat(28%).
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MEALTIME MEALTIME MEALTIME MEALTIME EXAMPLESOFFOODCHOICES EXAMPLESOFFOODCHOICES EXAMPLESOFFOODCHOICES EXAMPLESOFFOODCHOICES SPECIALCONSIDERATIONS SPECIALCONSIDERATIONS SPECIALCONSIDERATIONS SPECIALCONSIDERATIONS
Mid Mid Mid Mid- -- -afternoon afternoon afternoon afternoon
snack snack snack snack
1smallglassofmilk
Selectionof1or2fingerfoods,suchas:
carrotsticks(1smallcarrot)
cucumberslices(1/2acucumber)
2cherrytomatoes
1glassofwater
Washedandchoppedvegetablesandfruitsarenutritioussnacksandhelpthechildgain
appetite.
High-fatpotatoproducts(e.g.,chips/crisps)shouldbegivensparinglytochildrenassnacks,
becausetheyoftencontainpoorqualityfat,arehighinsaltandalsosuppresstheappetite.
Sup Sup Sup Supper per per per
Mincedbeefingravyservedwith2
tablespoonsofmashedpotatoes
mashedspinach/pumpkin
pineappleslice
1glassofwater
Ifanimalfoodsarenotavailableorarenottoleratedbythechild,theycanbereplacedby
beansandlentils.
Freshcookedpotatoesservedindifferentwaysprovideavarietyoftexturesandcanbea
nutritiousadditiontothechildsmeal.
Thiscanreplacedbyothersoftcookedstarchesavailablesuchas,sweetpotatoes,rice,
cassava,yams.
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WORKSHEET10/1:Adailyme WORKSHEET10/1:Adailyme WORKSHEET10/1:Adailyme WORKSHEET10/1:Adailymealplannerforchildren alplannerforchildren alplannerforchildren alplannerforchildren
MEALTIME MEALTIME MEALTIME MEALTIME EXAMPLESOFFOODCHOICES EXAMPLESOFFOODCHOICES EXAMPLESOFFOODCHOICES EXAMPLESOFFOODCHOICES SPECIALCONSIDERATIONS SPECIALCONSIDERATIONS SPECIALCONSIDERATIONS SPECIALCONSIDERATIONS
Breakfast Breakfast Breakfast Breakfast
Mid Mid Mid Mid- -- -morning morning morning morning
snack snack snack snack
Lunch Lunch Lunch Lunch
Mid Mid Mid Mid- -- -afternoon afternoon afternoon afternoon
snack snack snack snack
Supper Supper Supper Supper
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Session11:Improvingaccesstofood Session11:Improvingaccesstofood Session11:Improvingaccesstofood Session11:Improvingaccesstofood
Learning Learning Learning Learningo oo objectives bjectives bjectives bjectives
Bytheendofthissession,participantswillbeableto:
DescribehowHIVcanaffecthouseholdaccesstofood;and
DiscusshowaccesstofoodcanbeimprovedforhouseholdsaffectedbyHIV.
Session Session Session Sessiono oo outline utline utline utline
Content Content Content Content Time Time Time Time
1 Learningobjectivesandintroductiontothesession 5minutes
2 EffectsofHIVandAIDSonaccesstofood 5minutes
3 Improvingaccesstofood 10minutes
4 Supportforimprovingaccesstofood 30minutes
5 Summaryofthesessionandtransition 5minutes
Total Total Total Total 55minutes 55minutes 55minutes 55minutes
Writeanddisplaythelearningobjectivesonaflipchartsheet.
Writethekeypointonaflipchartsheetandkeepitasideuntilneeded.
Find the answers to the following questions about households in your community and make
enoughhandoutsofthesequestionsandtheiranswersforalloftheparticipants,
Whatfoodsarecommonlyeatenandhowaretheseobtained?
Aretheygrown/producedbythehousehold;obtainedfromhunting,fishingorgathering;boughtin
ashop;orbartered/swappedwithotherfamilies?
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Are some foods only available at certain times of the year? How does this affect the variety of
foodseaten?
Do families with high income and low income eat the same foods? If not, how are they different
andwhyaretheydifferent?Whatdothesedifferencesmeanforhealthandwell-being?
What programmes exist in the area that are related to food access? Who benefits from these
programmes? How do they benefit? Which local self-help and other organizations assist poor
householdswithaccesstofood?
Collect/preparethefollowingmaterials:
Anoverheadprojectorandscreen;and/orflipchartpaper,markersandameanstoattachflipchart
sheetstothewallorothersurface.Ifanoverheadprojectorisnotavailable/used,overheadsmay
be written out on flipchart sheets or enlarged copies prepared for display as posters, as
appropriate.
Overhead Overhead Overhead Overhead 11/1: 11/1: 11/1: 11/1: What to do to improve access to food for What to do to improve access to food for What to do to improve access to food for What to do to improve access to food for people livi people livi people livi people living with HIV ng with HIV ng with HIV ng with HIV and their and their and their and their
households households households households
Overhead11/2 Overhead11/2 Overhead11/2 Overhead11/2: : : :Support Support Support Supportfor for for forimprov improv improv improving ing ing ingaccesstofood accesstofood accesstofood accesstofood
Handout11/1: Handout11/1: Handout11/1: Handout11/1:Identifyingcommunitysupportfornutrition Identifyingcommunitysupportfornutrition Identifyingcommunitysupportfornutrition Identifyingcommunitysupportfornutrition (availableattheendofthissession).
Worksheet11/1:Identifyingcommunitysupportfornutrition Worksheet11/1:Identifyingcommunitysupportfornutrition Worksheet11/1:Identifyingcommunitysupportfornutrition Worksheet11/1:Identifyingcommunitysupportfornutrition (availableattheendofthissession).
1. Learning objectives and introduction to the session (5 minutes)
Review the learning objectives of the session
Showtheflipchartandoutlinethelearningobjectives.
Bytheendofthissession,participantswillbeableto:
DescribehowHIVcanaffecthouseholdaccesstofood;and
DiscusshowaccesstofoodcanbeimprovedforhouseholdsaffectedbyHIV.
Introduce the session
Household food security is assured when, at all times, household members have access to
sufficient,safeandnutritiousfoodthatmeetstheirneedsforanactiveandhealthylife.
Whatdoyouunderstandtob Whatdoyouunderstandtob Whatdoyouunderstandtob Whatdoyouunderstandtoby yy y household household household householdfoodsecurity foodsecurity foodsecurity foodsecurity ? ?? ?
Allowparticipantstorespond,andsummarizetheirresponseswithfollowingpoints:
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Householdfoodsecurityisabout:
How members of a household produce produce produce produce or acquire acquire acquire acquire food throughout the year and use
householdresources,includingtimeandmoney,togainaccesstofood;
How households process process process process
13
, preserve preserve preserve preserve
14
or store store store store their food to overcome seasonal
shortagesorimprovethequalityandsafetyoftheirfoodsupply;and
How food is used used used used and shared shared shared shared among the various household members to meet their
specificneeds.
HIVcanaffectaccesstofoodbyreducingahouseholdscapacitytoproduceoracquirefood.This
is because in order to pay for medicalcare, households are often forced to sell their assets and
foodreserves,resultinginthelossoflandandotherproductiveresourcesandincomeneededto
acquirefood.
Stigma can also contribute to uneven allocation of food in the household by favouring healthier
membersofthehouseholdandfurtherreducingtheaccesstofoodofpeoplelivingwithHIV.
Intheprevioussessions,wehavetalkedabouttheappropriateuseoffoodsuchaseatingwisely
and improving food intake. However, it will be difficult for people living with HIV to follow these
guidelines if their access to food is limited. They need additional support to help improve their
accesstofood.
Inthissession,wewilldiscussmoreabout how HIV affectsaccesstofoodforpeoplelivingwith
HIVandtheirhouseholds.Wewillalsodiscussvariouswaysofimprovingaccesstofood.These
measureswillassisthealthworkersandothercaregiverstoofferappropriatesuggestionsonhow
people living with HIV and their households can improve their access to food in different
situations.
AsktheparticipantstothinkabouttheinfluenceofHIVandAIDSonboththequalityandquantity
offoodaccessed.
Allowparticipantstorespondandwritedownthekeypointsraisedonaflipchartsheet;discuss
theseusingthefollowingpointsforadditionalinformation:
13
Foodprocessingisthemethodusedtochangerawfoodintoediblefood.Rawfoodmayneedtopassthrough
different steps of processing before consumption. Processing may also be required to make food last longer
withoutspoilage.
14
Food preservation is the method of handling food in such a way as to stop or slow down spoilage and to
prevent food-borne illness while maintaining nutritional quality, textureand flavour. Methods for preserving food
include: drying, smoking, salting, fermentation, heating, bottling, canning, refrigeration and addition of chemical
preservatives.
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2.2. Effect of HIV on how households process, preserve and store food
Oncefoodhasbeenplantedandharvested,householdsneedtodecidehowtoutilizethefoodfor
immediateconsumptionandtostorefoodforfutureconsumption.
Many of the methods of food processing and preservation used at home such as, grinding and
poundingaretime-consumingandlabour-intensive.Thesetasksmaynotbeeasilyperformedby
veryillpersonsorchildrenwhohavelosttheirparents/caregivers.
2.3. Effect of HIV on how households use and share the food within the family
Whenmembersofahouseholdeattogether,themannerofservingthemealandthedistribution
ofdifferentfooditemsmayaffectthefoodintakeofdifferentfamilymembers.Somepracticesmay
resultinwomenandchildrenreceivinglessfood,despitetheirhighnutritionalneeds.
Adultswhoareill,orchildren,maynotbevaluediftheyarenotproductive.Therefore,theymay
notbegiventheamountandqualityoffoodtheyneed.
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In order to provide people living with HIV with appropriate suggestions for meeting their specific
nutritional needs by improving food access and intake, it is important to know how food is
preparedandsharedamongvarioushouseholdmembers.
3. Improving access to food (10 minutes)
Explainthefollowing:
EarlydiagnosisofHIVwillenableimprovementstofoodaccessthatcanprolonglifeandkeepthe
personhealthyandproductiveforalongerperiodoftime.
Health workers and other support workers need to discuss with people living with HIV and their
familymembersaboutaccesstofoodandeatingconcernssoonafterdiagnosiswithHIV.
Health/supportworkersneedtoworkwiththeindividualorhouseholdtoassesstheirfoodaccess
situation and recommend improvements that are feasible or refer them to other support
programmesasappropriate.
ShowO OO Overhead verhead verhead verhead11/ 11/ 11/ 11/1: 1: 1: 1: I I I Improvingaccesstofoodfor mprovingaccesstofoodfor mprovingaccesstofoodfor mprovingaccesstofoodforpeoplelivingwith peoplelivingwith peoplelivingwith peoplelivingwithHIV HIV HIV HIVandtheirhousehold andtheirhousehold andtheirhousehold andtheirhouseholds s s s
Askparticipantstoturntopage110oftheParticipant'sManualandaskthreeparticipantstoread
thefollowing:
Awareness-raising
aboutthelinks
betweenHIVand
nutrition
Continuous
discussiontoidentify
foodaccess
problemsand
solutions
Referraltoother
support
programmes
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Participant 2: Continuous discussions
Continuous discussions offer an opportunity to share experiences and talk about factors affecting
access to food and suggestions to reduce or overcome the problems. All family members, including
childrenneedtobeinvolvedindiscussionsaboutaccesstofood.
Participant 3: Referral for more support
NotonlynutritionistanddieticiansplayaroleinsupportingpeoplelivingwithHIVandtheirhouseholds
to improve access to food and nutrition. Health workers, agricultural extension workers, community
development agents, teachers, religious leaders, self-help groups and other organisations can also
contribute and help the household have improved access to food. There may be also government
agencies and local organisations providing care and support to people living with HIV and their
familiestoimprovetheiraccesstofood.
For referral, a good starting point would be to make a list of local organisations, institutions, groups
and important persons in the community and the support they provide that could contribute to
improvingaccesstofood.
4. Support for improving access to food (30 minutes)
4.1. Types of support/services for improving food access
ConstructOverhead11/2 Overhead11/2 Overhead11/2 Overhead11/2withparticipantsasfollows:
Drawacircleinthemiddleofaflipchartsheetandwriteaccesstofood accesstofood accesstofood accesstofood insideit..
Draw another circle next to it, and as an example write psycho psycho psycho psychological and emotional logical and emotional logical and emotional logical and emotional
support support support support ; connect this circle to the middle circle with an arrow to show that it is among the
typesofsupportthatcanhelpimprovefoodaccess.
Askparticipantstoaddandfillinothercirclesinasimilarway.
Refer to Overhead 1 Overhead 1 Overhead 1 Overhead 11/2 1/2 1/2 1/2 and add other key factors that were not raised by participants to
completethechart.
Show O OO Overhead 11/2: Support to improve access to food verhead 11/2: Support to improve access to food verhead 11/2: Support to improve access to food verhead 11/2: Support to improve access to food and use the points below to
discusstoexplainit.
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OVERHEAD11/2:Supporttoimproveaccesstofood OVERHEAD11/2:Supporttoimproveaccesstofood OVERHEAD11/2:Supporttoimproveaccesstofood OVERHEAD11/2:Supporttoimproveaccesstofood
Supportandservicesforimprovingfoodaccessmayinclude:
Psychological and emotional support for PLHIV in making decisions regarding the
disclosure of their HIV status and generally helping them cope with living with the
disease.
Householdorcommunitygardenstoensureaccesstoplentyofaffordablefreshfoods.
Food assistance, as a temporary measure to support adults, pregnant and lactating
womenandchildrenwhomaybemalnourished.
Home-based care, hospices or day-care for ill members of the household or children, if
theparentsareill.
Incomegeneratingactivities,credit,insuranceschemesandgrantstoincreasetheability
topurchasefood,improveinputsordiversifyincomesources.
Support with policies and regulations to ensure that the most vulnerable, including
widows,orphansandtheelderlyhaveaccesstoland,productiveresourcesand/orother
resources/income for meeting their nutritional needs, e.g. instituting fair and equitable
inheritancerights,andassetprotectionmeasuresforwidows/orphans.
Other financial support which could include, meeting the direct costs of school fees and
healthcarecosts.
Simpleandeasyfoodpreservationandstoragemethodstomaintainthequalityoffoodin
storeandextendfoodstocks,inordertominimizetheneedforadditionalfoodpurchases.
Home-based
care,hospices
orday-care
Food
assistance Household/
community
gardens
Income-
generating
activities
Lifeskillsand
vocational
training
Credit,
insurance
schemes
andgrants
Improvingfood
production,
preservation
andstorage
Psychological
andemotional
support
Accessto Accessto Accessto Accessto
food food food food
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Life skills and vocational training for children and youth to expand their employment
opportunities.
4.1. Types of support/services for improving food access
Ask participants to turn to page 113 of the Participant's Manual and read H HH Handout 11/1 andout 11/1 andout 11/1 andout 11/1: : : :
Identifying community support for nutrition Identifying community support for nutrition Identifying community support for nutrition Identifying community support for nutrition. .. . This handout can also be used to identify available
supportandimportantpersonstobecontactedfornutritioncareandsupport.
Askparticipantstonowturntopage114oftheParticipant'sManualanddiscussWorksheet11/1: Worksheet11/1: Worksheet11/1: Worksheet11/1:
Identifying community support for nutrition with participants Identifying community support for nutrition with participants Identifying community support for nutrition with participants Identifying community support for nutrition with participants; allow them to fill in the answers
appropriatetotheirlocalarea,asyouproceed.
5. Summary of the session and transition (5 minutes)
Showthekeypointdisplayedandaskaparticipanttoreaditoutloud.
Askparticipantsiftheyhaveanyquestionsorifanythingneedstobemadeclearer.
Inthenextsession,wewilldiscusstheuseofnutritionalsupplementsandherbalremedies
Thenextsessionwillbepresentedby:
Statethenameofthepresenter.
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HANDOUT11/1:Identifyingcommunitynutritionalsupport HANDOUT11/1:Identifyingcommunitynutritionalsupport HANDOUT11/1:Identifyingcommunitynutritionalsupport HANDOUT11/1:Identifyingcommunitynutritionalsupport
TYPESOFFOOD TYPESOFFOOD TYPESOFFOOD TYPESOFFOOD- -- -SECURITY/NUTRITIONAND SECURITY/NUTRITIONAND SECURITY/NUTRITIONAND SECURITY/NUTRITIONAND
LIVELIHOODSUPPORT LIVELIHOODSUPPORT LIVELIHOODSUPPORT LIVELIHOODSUPPORT
WHOCOULDHELP? WHOCOULDHELP? WHOCOULDHELP? WHOCOULDHELP?
Informationoneatingwisely,includingfooddiversity,
improvingfoodintakeandkeepingfoodsafe.
Nutritionists/dieticians;healthworkers
Informationonfoodproductioninasmallplacethatdoes
notrequirealotoflabour.Forexample,home/communal
gardeningandrearingsmallanimals,aregoodwaysof
makingaffordablefreshfoodsavailabletoahousehold.
Agriculturalextensionworkers
Informationonhowtopreserveandstorefood,including
informationonhowtochooseprocessedfoods,incase
householdsdonothavefoodtopreserve.
Agriculturalextensionworkers
Informationonappropriatewaysofpreparingandsharing
mealswithinthefamilytoensurefairshareoffood,
especially,forpeoplelivingwithHIV,children,pregnant
andlactatingwomen.
Nutritionists,dieticians;health
workers
Income-generatingactivitiesthatcanimprovea
householdsabilitytobuyfoodandcareforafamily
memberwhoisill.
Micro-financeorganisations
Socialsupportmechanism,including,socialgrants,self-
help,andwelfareschemes.
Communitydevelopmentworkers;
communityleaders;self-help/support
groups;faith-basedgroups;social
developmentandwelfareagencies
Caringforandeducating,vulnerablechildreninthe
household,providingthemwithshelter,food,schoolfees,
lifeskillandvocationaltraining.
Communitydevelopmentworkers,
self-help/supportgroups,faith-based
groups,socialgrant/welfareagencies
Raisingawarenessaboutthespecialneedsandconcerns
ofHIV-affectedhouseholdsinordertoreducestigmaand
discriminationsothatpeoplewithHIVarenotexcluded
fromthecommunityandcommunitymembersknowhow
tohelp.
Socialandcommunitydevelopment
workers
PreventingnewHIVinfectionsandhelpingpeopleliving
withHIVandthosewhoareaffectedbythediseasetolive
longer,betterqualityandproductivelives.
Healthworkers
Providingpsychologicalandemotionalsupport,for
example,byrecognizingpeoplelivingwithHIVandtheir
familiesaspartofthecommunity;supportingthosewho
disclosetheirstatusandgenerallyhelpingthemcopewith
thedisease.
Support/caregroups;faith-based
groups
Helpingwiththecareofanillperson,orwiththechildren
inthefamilyiftheparentsareill.
Healthworkers;support/caregroups
Providingfoodtotheveryillandorphanedchildren.
Communitydevelopmentworkers;
communityleaders,support/care
groups,socialgrant/welfareagencies
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WORKSHEET11/1:Identifyingcommunitysupportfornutritionwithparticipants WORKSHEET11/1:Identifyingcommunitysupportfornutritionwithparticipants WORKSHEET11/1:Identifyingcommunitysupportfornutritionwithparticipants WORKSHEET11/1:Identifyingcommunitysupportfornutritionwithparticipants
1.WhatkindsofsupportmaybeneededbyindividualsorfamiliesaffectedbyHIVandAIDS?
2.Whichservices,organisations,groups,andimportantpersonsworkwiththecommunitytohelp
householdsgrowfoodand/orearnmoney?
3. What services, organizations, groups, and important persons help people who are too ill to
work?
4.Arethereparticulargroupsorpeoplethatareexcludedfromjoiningorreceivingservicesfrom
some of these sources? (for example, if services are only for men, women, or for families with
short-termneeds.)Whichonesandwhy?
5. What might prevent a person or family from obtaining assistance from such people,
organisationsorservices?
6. In what ways could these local services and organisations work together to help families
acquireadequatefoodfortomeetthenutritionalneedsoftheirhouseholdmembers.
7. Is there a need for services or assistance from organisations outside the local community? If
so,whattypesofexternalservicescouldmakealong-termdifferencetothecommunity?
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Session Session Session Session 12: 12: 12: 12: Use of nutritional supplements and herbal Use of nutritional supplements and herbal Use of nutritional supplements and herbal Use of nutritional supplements and herbal
remedies remedies remedies remedies
Learni Learni Learni Learningobjectives ngobjectives ngobjectives ngobjectives
Bytheendofthissession,participantswillbeableto:
Discusstheuseofnutritionalsupplementsandherbalremedies;and
Evaluate alternative practices and products commonly recommended for/ used by people
livingwithHIV.
Sessionoutl Sessionoutl Sessionoutl Sessionoutline ine ine ine
Content Content Content Content Time Time Time Time
1 Learningobjectivesandintroductiontothesession 5minutes
2 Categoriesofproductsandherbalremedies 10minutes
3 EvaluatingproductsclaimforHIV 15minutes
4 Warningflags 5minutes
5 Summaryofthesessionandtransition 5minutes
Total Total Total Total 40minutes 40minutes 40minutes 40minutes
Preparation for the session
Writeanddisplaythelearningobjectivesonaflipchartsheet.
Writethekeypointsonaflipchartsheetandkeepitasideuntilneeded.
KEYPOINTS KEYPOINTS KEYPOINTS KEYPOINTS
Nothingcanreplaceeatin Nothingcanreplaceeatin Nothingcanreplaceeatin Nothingcanreplaceeatingwisely. gwisely. gwisely. gwisely.
Donotbelieveeverythingyouhear. Donotbelieveeverythingyouhear. Donotbelieveeverythingyouhear. Donotbelieveeverythingyouhear.
Discussthebenefitsandrisksofall Discussthebenefitsandrisksofall Discussthebenefitsandrisksofall Discussthebenefitsandrisksofallalternative alternative alternative alternativepracticesandproducts. practicesandproducts. practicesandproducts. practicesandproducts.
Findoutwhichsupplementsandtraditionalremediesarecommonlyusedinthelocalarea,ifany,
andwhattheycost.
If possible, collect some containers, leaflets or labels with information on these products for
demonstration.
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Draw a table with four columns on a flipchart sheet with the following headings: Helpful Helpful Helpful Helpful , , , ,
Neutral Neutral Neutral Neutral , , , , Harmful Harmful Harmful Harmful , , , ,Donotknow Donotknow Donotknow Donotknow. .. .Discusswiththecoursedirectorandco-facilitatorsandchoose
some examples of local products that you agree fit into each category, and write them down in
theappropriatecolumn.YouwillusethistableduringtheExercise12 Exercise12 Exercise12 Exercise12/1. /1. /1. /1.
Thepurposeofthegroupactivitythissessionistohelpparticipantslearntoevaluatetreatments
ratherthancometoagroupconclusionaboutwhatistoberecommended.
Collect/preparethefollowingmaterials:
Anoverheadprojectorandscreen;and/orflipchartpaper,markersandameanstoattachflipchart
sheetstothewallorothersurface.Ifanoverheadprojectorisnotavailable/used,overheadsmay
bewrittenoutanddisplayedonflipchartsheets.
Overhead Overhead Overhead Overhead12/1: 12/1: 12/1: 12/1: Evalua Evalua Evalua Evaluatingproductsclaimsfor tingproductsclaimsfor tingproductsclaimsfor tingproductsclaimsforHIVand HIVand HIVand HIVandAIDS AIDS AIDS AIDS
Overhead Overhead Overhead Overhead12/2: 12/2: 12/2: 12/2: Warningflags Warningflags Warningflags Warningflags
Handout 12 Handout 12 Handout 12 Handout 12/1: Questions that may help in evaluating herbal remedies and other products /1: Questions that may help in evaluating herbal remedies and other products /1: Questions that may help in evaluating herbal remedies and other products /1: Questions that may help in evaluating herbal remedies and other products
(availableattheendofthissession).
Showtheflipchartandoutlinethelearningobjectives.
Bytheendofthissession,participantswillbeableto:
Discusstheuseofnutritionalsupplementsandherbalremedies;and
Evaluate alternative practices and products commonly recommended for/used by people
livingwithHIV.
Introduce the session
ManypeoplewithHIVusedifferentproducts,remediesandtreatmentsforHIV.Atpresentthereis
no evidence of herbal remedies that can cure or treat HIV. However, service providers need to
understandandbesensitivetobeliefsandthekindsofalternativeproductsusedbypeopleliving
withHIV.
Someofthesenutritionalsupplementsandherbalremediesmaybebeneficialandsomemaybe
harmfultopeoplewithHIV.Itisimportanttofindoutmoreabouttheproducts,notethosethatare
harmful and discuss with people living with HIV, traditional healers or those who promote those
productswhytheuseofsuchproductsshouldbediscouraged.
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There are many information materials listing supplements and herbal remedies reported to be
beneficial.Eventhoughforsomepeoplesuchproductscouldbetheonlyoptiontheyhave,before
using herbal remedies, individuals need to evaluate products and identify those that can be
harmfulandthosethatcanbeofbenefit.PeoplelivingwithHIVshouldbesupportedindeciding
whetheraproductortreatmentmightbeusefulforthemaswellascost-effective.
Thepurposeofthissessionistodiscussthedifferentwaysofevaluatingtheseproductswiththe
aimofidentifyingthosethatcouldbeharmfulandshouldbediscouraged,whilepromotingthose
thatareeffectiveandlow-costalternativetreatments.
ThiswillenableserviceproviderstocounselpeoplelivingwithHIVaboutnutritionalsupplements
andherbalremediesthatmaybeharmful.
NutritionalsupplementsmaybeneededtohelpmeetthenutrientneedsofpeoplelivingwithHIVwho
have lost their appetite/whose food intake has decreased or who are not tolerating their usual diet.
Nutritionalsupplementscanhelppreventmalnutritionincluding,micronutrientdeficiencies.However,
suchsupplementsareonlyadditionstothedietandshouldnotbeusedasasubstituteforfood.There
aretwotypesofnutritionalsupplements,namely:
15
Give examples of nutritional supplements that are used locally. Often, these are powders added to milk or
otherdrinksandusedanytimepeoplearenoteatingwell.
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Example: Replacing solid food with fluids for persons who are unable to eat but able to drink and/or
for those with limited food access. (Contact your local Ministry of Health or nutritionist for more
information).
Suchfood-basednutritionalsupplementscouldalsobemadeathomeandareusuallyconvenientto
prepare.However,especiallyiftheyareintendedasthetotalfoodintakeofapatientformorethana
fewdays,theiruseshouldbediscussedwithadietician,nurseordoctor.
Nutrient supplements:
Nutrient supplements are vitamin and mineral products in the form of tablets, pills or liquids. Such
productscancontainasinglevitaminormineraloracombinationoftwoormorenutrients,commonly
knownasm mm multi ulti ulti ulti- -- -vitamin vitamin vitamin vitamins ss sorm mm multi ulti ulti ulti- -- -mineral mineral mineral minerals ss s.
Nutrient supplements are often not easily available; they are expensive and leave less money for
food.Amixeddietshouldprovideenoughofthesevitaminsandminerals.Itwouldtherefore,bebetter
to provide a good mixed diet including, animal products, fruits and vegetables whenever possible,
ratherthanbuyingsupplements.
In cases where the food intake of people living with HIV is very low, multi-vitamin and multi-mineral
supplements can help to meet their increased nutritional requirements. The following guidelines
shouldbeadheredto:
Seek advice from a dietician, nurse or doctor before recommending supplements to people with
HIV,inordertogetthebestvalueformoney.
Alwaystakevitaminpillsonafullstomach.Beconsistentandtakethemregularly.
It is often more practical and cheaper to take a combined product (multivitamin and mineral
supplements) rather than several pills containing different vitamins and minerals, as people
usuallyhavemorethanonedeficiency.
However, iron supplements may be a problem for people with HIV, as they can increase the
activityofsomebacteria.Supplementsthatdonotcontainironmaythereforebetter.
Take supplementation according to the advice on the label. More is not better. Taking a high
dose is a waste, can cause nausea, vomiting, decreased appetite, liver and kidney problems; it
mayalsointerferewiththeimmunedefencesystem.
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2.2. Herbal treatments and remedies (Participant 2)
Traditional and herbal remedies promoted as treatment
Herbal remedies present alternatives to formal biomedical practices, and are among the treatments
oftenofferedbytraditionalhealers.PeoplelivingwithHIVshouldbeadvisedtoalwaysdiscussother
treatmentssuchastheuseofherbalremedieswithhealthworkers,doctorsornutritionists.
PeoplelivingwithHIVshouldbemadeawareofherbalremediesthatcouldbeharmfultotheirhealth.
Health workers should explain to people living with HIV, traditional healers and others offering such
treatments,whytheuseofsuchremediesshouldbediscouraged.
Herbs and spices
Herbs and spices used in food during preparation should be differentiated from traditional herbal
remedies.Someofthebenefitsofherbsandspiceswhichinclude,improveddigestion improveddigestion improveddigestion improveddigestion,stimulationof stimulationof stimulationof stimulationof
appetite appetite appetite appetiteandfoodpreservation foodpreservation foodpreservation foodpreservationaregeneralandnotspecifictoHIV.
As the effects of such herbs and spices may not be the same for all people, they should be used in
moderate amounts. Excessiveusemaycauseproblemsand have atoxiceffect.Moreover,itshould
beemphasisedthefunctionofsuchherbsandspiceswillnotbeincreasedbytakingtheminexcess.
More evidence is needed because very littleisknown about the interactions between herbs and the
medication people living with HIV might be taking. Supplements, herbs and spices are not an
alternativetoeatingwisely.Theyshouldbeusedasadditionstofoodeaten.
Showthefirstkeypointdisplayed,,andaskaparticipanttoreaditoutloud.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Nothingcanreplaceeatingwisely. Nothingcanreplaceeatingwisely. Nothingcanreplaceeatingwisely. Nothingcanreplaceeatingwisely.
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3. Evaluating products claims for HIV (15 minutes)
On what basis would youevaluate whether a product does what the person selling On what basis would youevaluate whether a product does what the person selling On what basis would youevaluate whether a product does what the person selling On what basis would youevaluate whether a product does what the person selling/promoting /promoting /promoting /promotingit it it it
saysitcando? saysitcando? saysitcando? saysitcando?
Allowafewparticipantstorespond,andwritetheirresponsesdownonaflipchartsheet.
Addpointsthatmayhavebeenmissedfromthefollowing:
No secret cures or therapies for HIV exist. To help people living with HIV make decisions,
consideranddeterminewhethertheherbalremedyis:
Helpfulorbeneficial:ifthereisindependentscientificevidencetosupportit;
16
Neutral:ifthereisastrongbeliefthatitisneitherhelpfulnorharmful;or
Harmfulordangerous.
Youmayaskforopinionsfromdifferentpeoplewhohavenothingtogain.
Exercise 12/1: Evaluating practices and herbal remedies
Guiding questions that may help in evaluating the safety of herbal remedies and products are
providedinH HH Handout12/1 andout12/1 andout12/1 andout12/1attheendofthissessionandonpage120oftheParticipant'sManual.
Divide the participants into small groups and give the samples of some of the supplements or
remediesthatyouhadbroughtforthesession
Askthegroupstousethechecklistinoverhead12/1toevaluatetheproduct
Leteachgrouppresenttheirfindingsfordiscussion.
Communicating with the people with HIV about nutritional supplements and herbal remedies is
essential. The uses of questions like: What else are you using to take care of your health? is
recommended to help find out the nutritional supplements and herbal remedies that the person
maybetaking.
16
Independentscientificevidenceontheeffectivenessofaproductisyieldedbyindependentstudiesdonebysomeoneother
thanthecompanyproducing/promotingtheproduct.
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4. Warning flags (5 minutes)
ShowO OO Overhead12/2: verhead12/2: verhead12/2: verhead12/2: Warningflags Warningflags Warningflags Warningflags andaskoneparticipanttoreadoutthepoints.
OVERHEAD12/2:Warningflags OVERHEAD12/2:Warningflags OVERHEAD12/2:Warningflags OVERHEAD12/2:Warningflags
Thisisthecure;itgivesmiracleresults.
Donotuseanyothertreatments.
Thisdoctor(product/treatment)istheonlyonewhichcanhelpyou.
Itcostsalotofmoney.
Personalaccountsarethemain/mostreliablesourceofinformationonresults.
Theingredientsareasecret.
Askparticipantstoidentifythosestatementsthattheyhaveheardbeingcommonlyused.
Showthesecondkeypointdisplayed,andaskaparticipanttoreaditoutloud.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Donotbelieveeverythingyouhear. Donotbelieveeverythingyouhear. Donotbelieveeverythingyouhear. Donotbelieveeverythingyouhear.
Discussthebenefitsandrisksofall Discussthebenefitsandrisksofall Discussthebenefitsandrisksofall Discussthebenefitsandrisksofallalternative alternative alternative alternativepracticesandproducts. practicesandproducts. practicesandproducts. practicesandproducts.
Atpresent,thereisnoevidencethatherbalremediescancureortreatHIV.
CommunicatingwithpeoplelivingwithHIVaboutnutritionalsupplementsandherbalremediesis
essentialtoensurethattheyareawareofherbalremediesthatcouldbeharmfultotheirhealth.
You can use your communication skills to ask open ended-questions, reflect and clarify, accept
whatthepersonissaying,givesomeinformationand/oroffersuggestions.
PeoplelivingwithHIVshouldbesupportedinevaluatingwhetheraproductortreatmentmaybe
h hh helpful elpful elpful elpful/beneficial beneficial beneficial beneficial,whetherthereisastrongbeliefthatitisneutral neutral neutral neutral, ,, , orh hh harmfu armfu armfu armful ll l/dangerous /dangerous /dangerous /dangerousforthem.
Seek advice from a dietician, nurse or doctor before recommending supplements, so as to
ensurethebestvalueformoney.
Traditional healers and religious leaders are esteemed and trusted in most communities; work
withthemtofindthebestwaytoshareinformationonherbalremediesandproductsthatcouldbe
harmfulforpeoplewithHIV.
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5. Summary of the session and transition (5 minutes)
Show/reviewbothkeypointsdisplayed.
KEYPOIN KEYPOIN KEYPOIN KEYPOINTS TS TS TS
Nothingcanreplaceeatingwisely. Nothingcanreplaceeatingwisely. Nothingcanreplaceeatingwisely. Nothingcanreplaceeatingwisely.
Donotbelieveeverythingyouhear. Donotbelieveeverythingyouhear. Donotbelieveeverythingyouhear. Donotbelieveeverythingyouhear.
Discussthebenefitsandrisksofallalternativepracticesandproducts. Discussthebenefitsandrisksofallalternativepracticesandproducts. Discussthebenefitsandrisksofallalternativepracticesandproducts. Discussthebenefitsandrisksofallalternativepracticesandproducts.
Askparticipantsiftheyhaveanyquestionsandifanythingneedstobemadeclearer.
In the next session, we will review the course and talk about ways in which we can use the
knowledgeandskillsacquiredfromthiscourseinourwork.
Thenextsessionwillbepresentedby:
Statethenameofthepresenter.
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QUESTIONS QUESTIONS QUESTIONS QUESTIONS YES YES YES YES NO NO NO NO DO DO DO DONOT NOT NOT NOTKNOW KNOW KNOW KNOW
Does the product or herb contain substances in amounts that
couldbeharmful? (asknutritionisttohelpyoureadthelabels)
Does the product or herb have harmful interactions with other
foodsandanyothermedicationthatyouaretaking?
Does the product or therapy replace or delay seeking health
careandtreatmentthatisgenerallyregardedaseffective?
Doestheproductortherapypromoteoremphasizeaparticular
productornutrient?
Does the product provide enough energy and protein along
with a variety of other nutrients? (ask nutritionist to help you
readthelabels)
Doyouhavetopayalotofmoneyfortheproductortherapy?
Does buying this product reduce money available for buying
food?
Doesuseoftheremedyreduceyourfoodintake?
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Session13:Courserevi Session13:Courserevi Session13:Courserevi Session13:Coursereviewandactionplanning ewandactionplanning ewandactionplanning ewandactionplanning
Listkeypointsaboutnutrition,careandsupporttosharewithpeoplelivingwithHIV;
Discusstheimportanceofcaringforthecaregiver;
Outlinewaysinwhichthecourseinformationcanbeputintopractice;and
Discussanyquestionsregardingnutrition,careandsupportforpeoplelivingwithHIV.
Session Session Session Sessiono oo outline utline utline utline
Content Content Content Content Time Time Time Time
1 Learningobjectivesandintroductiontothesession 5minutes
2 Reviewofcommunicationskills 10minutes
3 Reviewofkeypoints 10minutes
4 Actionplanning 30minutes
5 Caringforcaregivers 10minutes
6 Summaryofthesessionandtransition 5minutes
Total Total Total Total 70minutes 70minutes 70minutes 70minutes
Thissessionshouldbefacilitatedbyallthefacilitatorsthathaveparticipatedinthecourse.
Theactivitiesforthissessionaredividedintotwomainparts:
Reviewactivitiesthatwillbedoneinplenary;and
Actionplanningactivitiesthatwillbedoneingroups.
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Decidewithparticipantsatthestarthowbesttodividethegroups(byparticipantsregion/local
area,orthehealthfacility/typeoffacilityorservicewheretheywork).
Collect/preparethefollowingtrainingmaterials:
An overhead projector and screen; and/or flipchart paper, markers and a means to attach
flipchart sheets to the wall or other surface. If an overhead projector is not available/used,
overheadsmaybewrittenoutonflipchartsheetsorenlargedcopiespreparedfordisplayas
posters,asappropriate.
Haveallthekeypointsdiscussedthroughoutthecourseavailablefordisplay(butkeepthem
covereduntilthestartofthesession).
Overhead Overhead Overhead Overhead 2/ 2/ 2/ 2/2 22 2: : : : Sixlisteningandl Sixlisteningandl Sixlisteningandl Sixlisteningandlearning earning earning earnings ss skills kills kills kills
Overhead Overhead Overhead Overhead 2/ 2/ 2/ 2/3 33 3; ; ; ; S SS Sixs ixs ixs ixskills kills kills killsforbuildingconfidenceandgivingsupport forbuildingconfidenceandgivingsupport forbuildingconfidenceandgivingsupport forbuildingconfidenceandgivingsupport
Overhead13/1: Overhead13/1: Overhead13/1: Overhead13/1: Plac Plac Plac Placestopromotenutritionfor estopromotenutritionfor estopromotenutritionfor estopromotenutritionforpeoplelivingwith peoplelivingwith peoplelivingwith peoplelivingwithHIV HIV HIV HIV
Post Post Post Post- -- -test: test: test: test:prepareenoughcopiesforallparticipants(seeAnnex Annex Annex Annex7 77 7).
Course Course Course Coursee ee evaluation valuation valuation valuations ss sheet heet heet heet: : : :prepareextracopiesforparticipantswhomayhavemisplacedtheir
copysincetheopeningsession.
WehavefollowedSamandSuzithroughafewyearsoftheirlives.Sincetheyfoundoutthatthey
wereHIV-positive,theyhavefacedmanychallenges.Eatingwiselyhashelpedthemtokeepwell
forlonger.
Suzi has had a lot of contact over the last few years with support services for people living with
HIV. One of these service providers asks Suzi if she would like to work with them as a support
worker.
In this session, we will look at how Suzi learns to be a support worker. In doing so we will also
revisethekeypointsyouhavelearntthroughoutthecourse.
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AllowparticipantstogiveresponsesthenshowO OO Overhead2/ verhead2/ verhead2/ verhead2/2 22 2: : : : Sixl Sixl Sixl Sixlistening istening istening istening and and and andl ll learning earning earning earnings ss skills kills kills kills
andaskoneparticipanttoreadouttheskills.
Suzicannowusethelearningandlistening;andbuildingconfidenceandsupportskills.
Askifanyonehasanyquestionontheseskillsandhowtousethem.
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4. Action planning (30 minutes)
ACTIVITY 13/1: How are we going to use this information?
Askparticipantstogetintothegroupsforthisactivityasagreedduringthepreparationfor
thissession.
Explainthefollowing:
The focus of this activityis on working together to discuss and commit to a plan of action
thatwecanallputintopracticeinordertoaddressthenutritioncareandsupportneedsof
peoplelivingwithHIVdiscussedthroughoutthecourse.
Askthevariousgroupsto:
Identifyandwritedownthecurrentnutritioncareandsupportsituationintheirareaofwork;
Askthemtospecifywhattheywouldwanttoimproveinthecurrentsituationbasedonthe
knowledgeandskillstheyhaveacquiredthroughthiscourse;
Ask them also how they are going to use the information from this course to improve
nutritioncareandsupportforPLHIVandtheirhouseholdsandthecommunity.
Askeachgrouptowritetheirideasonaflipchartsheet.Allowparticipants20minutesto
completethisactivity.Thenaskeachgrouptotaketurnspresentingtheirideasfor
discussion.
Encourageparticipantstowritedownsomeofthekeyactivitiesthattheyhavediscussedin
thespaceprovidedintheirParticipant'sManuals(page125)forfuturereference.
The organisation that Suzi works with is aware that people who are providing care and support
need to be cared for themselves. Caregivers include, nurses, doctors, peer support workers,
dieticians,counsellors,aswellasfamiliesandneighbours.
Showthekeypointforthissessionandaskaparticipanttoreaditoutloud.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Caregiversneedcaretoo. Caregiversneedcaretoo. Caregiversneedcaretoo. Caregiversneedcaretoo.
Askparticipantstodiscusswaysthatcareandsupportcouldbegiventocaregiversbythe
organisation,institutionorotherbodywithwhichthecaregiverswork.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Whenthecaregiverisafamilymemberorneighbour,howcantherestofthecommunityprovide Whenthecaregiverisafamilymemberorneighbour,howcantherestofthecommunityprovide Whenthecaregiverisafamilymemberorneighbour,howcantherestofthecommunityprovide Whenthecaregiverisafamilymemberorneighbour,howcantherestofthecommunityprovide
careforthecaregiver? careforthecaregiver? careforthecaregiver? careforthecaregiver?
Askparticipantstofocusonthecaregiverratherthanthoseforwhomtheyprovidecare.
Writedowntheirresponsesonaflipchartsheet.
Followingaresomeexamplestosuggest,ifparticipantsfinditdifficulttothinkof waysofcaring
forthecaregiver:
Itcanbedifficultforsupportworkerstotalktoothersabouteatingwiselyiftheyareshortoffood
themselves.Someorganisationsprovidefoodparcelsfortheirworkers.
Support from other caregivers in the same situation and being able to discuss their feelings can
alsohelp.
Shared care, respite services and ensuring that caregivers have some time for themselves can
givecaregiversachancetorest.
Concludethediscussionwiththefollowingpoint.
Knowledgeandskillscanhelpacaregivertofeelmoreconfident.Theinformationprovidedinthis
course can enhance the care and support caregivers offer to people living with HIV and their
families. Many people are able to do something about the foods they eat. Caregivers can thus
alsobemotivatedbythepositiveresultsthatcanbeattainedbyputtingtheknowledgeandskills
acquiredthroughthiscourseintopractice.
6. Summary of the session and transition (5 minutes)
NutritionalcareandsupportcanmakeadifferencetothelivesofpeoplelivingwithHIVandtheir
families.Thefoodtheyeatmaybeoneareathatpeoplearelikelytohavesomecontrolover.
Nutrition care and support are not just short-term actions; they are ongoing ongoing ongoing ongoing activities, requiring
continuous reflection, dialogue and reinforcement, depending on the needs of those with whom
youareworking.
People living with HIV need the support of their families, communities and those who care for
themtocarryoutsomeoftherecommendedpractices.
ShowO OO Overhead13/1:Placestopromotenutrition verhead13/1:Placestopromotenutrition verhead13/1:Placestopromotenutrition verhead13/1:Placestopromotenutritionfor for for forpeoplelivingwith peoplelivingwith peoplelivingwith peoplelivingwithHIV HIV HIV HIV,andread/explainit.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
188
OVERHEAD13/1:PlacestopromotenutritionforPLHIV OVERHEAD13/1:PlacestopromotenutritionforPLHIV OVERHEAD13/1:PlacestopromotenutritionforPLHIV OVERHEAD13/1:PlacestopromotenutritionforPLHIV
Places to
promote
nutrition for
PLHIV
Part of VCT
programmes
During counselling
for clinical problems
With self-help
and support
groups
Home care visits
During
inpatient
care
Nutrition
education
You can use the information from this course in many areas. You can use the knowledge and
skills you have acquired with those you assist, to share with colleagues, your own families and
communities.
I(We)hopethatthiscoursehasgivenyousomeusefulknowledgeandskillsforprovidingsupport
andcaretopeoplelivingwithHIV.
Askparticipantsiftheyhaveanycommentsorquestions.
InformparticipantsthattheyarenowgoingtocompletethecourseP PP Post ost ost ost- -- -test test test testandthattheyhave
20minutestodoso.DistributecopiesofthePost-test.
OncetheyhavecompletedthePost-test,informparticipantsthattheyarenowreadytoproceed
totheclosingsessionofthecourse.
RemindparticipantstoalsohandintheircompletedCourse Course Course Coursee ee evaluation valuation valuation valuations ss sheets heets heets heetswhichwere
distributedduringtheopeningsession.
Introducetheperson(s)whowillclosethecourse.
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Closingsession Closingsession Closingsession Closingsession
The duration of this closing session will vary depending on whether an external guest speech/
closing ceremony for presenting certificates of attendance is planned. If no such ceremony is
plannedtheclosingsessionwilltakeabout15minutes.
Preparation for the session
Collect/preparethefollowingmaterials:
Ifcertificatesofattendancearetobegiven,ensurethattheyarepreparedinadvance.
Makealistofallthepeoplewhoneedtobethankedfortheircontributionstothecourse.
Overhead Overhead Overhead Overheado oo opening pening pening pening/ // /1 11 1: :: :Courseaims(seeOpeningSession OpeningSession OpeningSession OpeningSession).
RemindparticipantsbeforethestartofthissessiontocompletetheCourseevaluationsheets.
Closing remarks
Usethefollowingaspartofyourclosingremarks:
Nutrition is an essential part of the care for people living with HIV. As soon as a person knows
he/sheisHIV-positive,he/sheneedstopayattentiontotheirdietandensurethattheyareeating
Nutritional Care and Support for People Living with HIV: Facilitators Guide
190
wisely.
Briefly review some of the action plans discussed forfollowing up on the course and continuing
activities.
Thank you for participating and sharing your experiences, your thoughts and your ideas during
thiscourse.
Thankotherpeoplewhohavecontributedsuchas,theorganizers.
Presentcertificatesifneeded.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
191
A AA Annex nnex nnex nnex 1: 1: 1: 1:T TT The he he hestoryofSamandSuzi storyofSamandSuzi storyofSamandSuzi storyofSamandSuzi
Sam and Suzi, a young couple, recently diagnosed to be both HIV-positive who are expecting their
firstbaby.
PICTURE1/1:SamandSuzi PICTURE1/1:SamandSuzi PICTURE1/1:SamandSuzi PICTURE1/1:SamandSuziexpectingtheirfirstbaby expectingtheirfirstbaby expectingtheirfirstbaby expectingtheirfirstbaby
PICTURE1 PICTURE1 PICTURE1 PICTURE1/2 /2 /2 /2:SamandSuzi :SamandSuzi :SamandSuzi :SamandSuziexpectingtheirfirstbaby expectingtheirfirstbaby expectingtheirfirstbaby expectingtheirfirstbaby
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WefirstmeetSamandSuziinS SS Session2: ession2: ession2: ession2:Introductiontoc Introductiontoc Introductiontoc Introductiontocommunicationskills ommunicationskills ommunicationskills ommunicationskills, ,, ,whentheyhavecome
forbasicnutritioncounsellingfollowingthediagnosis.ThestoryofSamandSuziisusedtointroduce
ustothreedifferentstylesofinteractingastheymeetwiththreedifferentcounsellorstodiscussabout
nutrition.Thishelpstoillustratetheeffectofcounsellingstylesonthepatternsofinteractionbetween
clientandthecounsellor.Wethenmeet Samand Suziagainin S SS Session3:Eatingwisely ession3:Eatingwisely ession3:Eatingwisely ession3:Eatingwisely, , , , whenthey
attendtheE E E Eatingwisely atingwisely atingwisely atingwisely talk.
Later in the course, the story of Sam and Suzi is used to introduce nutrition care and support for
patientsatdifferentstagesofthedisease,indifferentphysiologicalstates(pregnancy,breastfeeding),
andatdifferentages(infants,children).InS SS Session5:Improvingfoodintake, ession5:Improvingfoodintake, ession5:Improvingfoodintake, ession5:Improvingfoodintake,Samstartstoexperience
some opportunistic infections. He first had tuberculosis that was treated, followed by bouts of
diarrhoeaandsoremouthwhichaffecthisfoodintake.Samseeksformorenutritioncounsellingand
support.Helooksforsuggestionsthatmighthelphimwithhisnewproblems.Thestoryintroducesus
to circumstances when you will need to give suggestions for improving food intake during a
counselling session. In the story, Sam tries some of the suggestions he is given. He starts eating
betterandhisstrengthalsoimproves.Heisnowabletotakeregularwalkswithhisfamily.
In S SS Session 6: ession 6: ession 6: ession 6: P PP Preventing weight loss and promoting physical activities reventing weight loss and promoting physical activities reventing weight loss and promoting physical activities reventing weight loss and promoting physical activities, the story of Sam and Suzi is
usedtointroducethemanagementofweightconcerns,specifically,weightlossasaconsequenceof
frequentopportunisticinfections.Becauseoftheseboutsoftheopportunisticinfections,Samsweight
islowerthanitwasafewmonthsago,asillustratedinPicture2 Picture2 Picture2 Picture2.Arole-playofSamandcounselloris
usedtoillustratecounsellingskillsthatcanbeusedatthisstage,aswellasthepossiblereactionsofa
client. Sam and the support worker talk more about Sams weight loss and how he can monitor his
weight at home where there is no weighing scale (e.g., by checking whether his clothes are getting
loose and paying closer attention to the comments of people around him about his weight). The
counsellorremindsSamthatitisessentialtovisitstheclinicregularlyandtoconsultwiththesupport
workerwhenhenoticessignsofweightloss.Thehealth/nutritionworkerinformsSamaboutdifferent
ways of preventing weight loss, regaining lost weight and the importance of physical activity. They
alsotalkaboutsimplephysicalactivitiesthatSamcoulddoregularly.
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PICTURE2 PICTURE2 PICTURE2 PICTURE2/1 /1 /1 /1:SamandSuzi :SamandSuzi :SamandSuzi :SamandSuzi:weightloss :weightloss :weightloss :weightloss
PICTURE2: PICTURE2: PICTURE2: PICTURE2:/2 /2 /2 /2SamandSuzi SamandSuzi SamandSuzi SamandSuzi:weightloss :weightloss :weightloss :weightloss
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In session 7: Nutrition care and support for people on ART session 7: Nutrition care and support for people on ART session 7: Nutrition care and support for people on ART session 7: Nutrition care and support for people on ART, the story of Sam and Suzi is used to
illustrate nutrition counselling at the advanced stages of HIV infection (AIDS) and particularly, when
AIDS patients start antiretroviral treatment. We meet Sam at the stage where he has become very
weak and his health has generally deteriorated. His doctor recommends several tests and some
drugs.Basedonthetestresults,thedoctorneedstostartSamonART.Samispreparedandenrolled
for ART (a combination of three drugs: d4T + 3TC + EFV). A role-play between the health/ nutrition
worker and Sam is used to illustrate nutrition counselling skills needed to interact with a person
initiatingARTtreatment.Therole-playemphasisestheinteractionbetweenfoodandmedication.
InSession8:Nutritioncareandsupportduringpregnancyandbreastfeeding, Session8:Nutritioncareandsupportduringpregnancyandbreastfeeding, Session8:Nutritioncareandsupportduringpregnancyandbreastfeeding, Session8:Nutritioncareandsupportduringpregnancyandbreastfeeding,wemeetSamandSuzi
during the E E E Eating wisely during pregnancy ating wisely during pregnancy ating wisely during pregnancy ating wisely during pregnancy demonstration talk. We meet them again in S SS Session 9: ession 9: ession 9: ession 9:
InfantfeedingoptionsforHIVpositivemothers InfantfeedingoptionsforHIVpositivemothers InfantfeedingoptionsforHIVpositivemothers InfantfeedingoptionsforHIVpositivemotherswhentheyattendanothertalkforpregnantwomenon
infantfeedingaimedathelpingthemmakeadecisionabouthowtofeedtheirbaby.Afterthetalk,they
decide that exclusive breastfeeding is the best choice for them. The counsellor praises them for
thinkingaboutinfantfeedingoptionsduringpregnancyandforcomingtodiscussit(demonstratingthe
communication skill of praising good practice). The counsellor then refers them to a lactation
counsellor,formoreinformationonsaferbreastfeedingpractices.
In S SS Session ession ession ession 9 9 9 9 we also use the story of Sam and Suzi to introduce some of the common barriers that
HIV-positive women are faced with when they choose exclusive breastfeeding for their infants. The
importanceofdisclosingonesHIVstatusatthisstageandduringthetransitionperiodwhenmothers
needtostopbreastfeedingisemphasisedasfollows.
Suzicontinuestobreastfeedexclusively.Everythinggoeswell;sheiseatingwisely,takingsomerest
and feeding her baby frequently using good breastfeeding practices. However, the couple do have
oneproblem.Samsmother,Granny,thinksthebabyneedswaterandteaaswellasbreastmilk,as
illustratedinP PP Picture icture icture icture 3 33 3ofSamandSuzi.
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PI PI PI PICTURE3 CTURE3 CTURE3 CTURE3/1 /1 /1 /1:SamandSuzi :SamandSuzi :SamandSuzi :SamandSuzi,thebabyandgrandmother ,thebabyandgrandmother ,thebabyandgrandmother ,thebabyandgrandmother
PICTURE3 PICTURE3 PICTURE3 PICTURE3/2 /2 /2 /2:SamandSuzi :SamandSuzi :SamandSuzi :SamandSuzi,thebabyandgrandmother ,thebabyandgrandmother ,thebabyandgrandmother ,thebabyandgrandmother
ThegrandmothercannotunderstandwhySuziandSamaresoinsistentthatthebabyonlyhasbreast
milk. Suzi explains to Granny that exclusive breastfeeding is best for babies. The baby gets all he
needsfrombreastmilk.Hedoesnotneedwaterortea. Grannykeepsaskingaboutgivingwaterand
other things to the baby. Sam and Suzi are afraid Granny will start giving the baby water and other
Nutritional Care and Support for People Living with HIV: Facilitators Guide
196
foodsherself. SamandSuzidecidetotellGrannythattheyareHIV-positiveandexplainwhyitisvery
importanttobreastfeedexclusivelytoreducetheriskofthebabygettingtheHIV.Grannyisupsetthat
theydidnottellhersoonerthattheyhadHIV,butsheisverysupportive.
Suzi breastfeeds exclusively little Sam and wants to stop breastfeeding completely and start giving
other foods and fluids to the baby when he is six months. However, if Suzi stops breastfeeding
suddenly; she may get engorged breasts, feel ill and her baby will need another source of food and
comfort.Suziwillneedtodiscussherdecisiontostopbreastfeedingwithabreastfeedingcounsellorto
minimiseanyhealthrisksanddiscomfortduringthistransition.
In S SS Session ession ession ession 11: 11: 11: 11: F FF Fee ee ee eeding a child with HIV ding a child with HIV ding a child with HIV ding a child with HIV, we use the story of Sam and Suzi to illustrate nutritional
management during illness and recovery, especially for children who have frequent infections that
may be due to HIV. Since Sam and Suzi took good care of themselves and the baby, Little Sam is
growingwellandisfoundtobeHIV-negativewhenheistestedat18months.Wethereforeintroduce
a new family, Sam and Suzis neighbours. The family have a daughter Leila, who is two years old.
Leilahasnotmetherdevelopmentaltargetsandsheisoftenill.LeilasfamilyisworriedthatLeilamay
have HIV although she has not been tested. Leilas mother is ill and Leilas father died a year ago.
BecauseLittleSamishealthy,LeilasmotherasksSuziforhelpinfeedingLeila.Suzi,recallssomeof
thelessonsshelearntfromthecounsellorssuchas,responsivefeedingandsharesthisinformation
andsomemealplanningpracticessheusesforLittleSamwithLeilasmother.
Finally, in Session 13 Session 13 Session 13 Session 13: :: : Review of the course Review of the course Review of the course Review of the course, we use the story of Sam and Suzi to introduce the
concept of nutrition care and support for caregivers. Since Suzi now has good knowledge and
experience about nutrition and HIV, a community-based organisation employs her as a support
worker. The organisation that Suzi works with is aware that people who are providing care and
supportneedtobecaredforthemselves.Caregiversmaybenurses,peersupportworkers,doctors,
dieticians, counsellors, families or neighbours. Course participants can use this story to try and
identifythevarioustypesofsupport/servicesthatcanbegiventosupportworkers/caregivers.
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Annex 2: Nutritional care and support focus at different stages Annex 2: Nutritional care and support focus at different stages Annex 2: Nutritional care and support focus at different stages Annex 2: Nutritional care and support focus at different stages
ofHIVandAIDS ofHIVandAIDS ofHIVandAIDS ofHIVandAIDS
STAGES STAGES STAGES STAGES SIGNS SIGNS SIGNS SIGNS NUTRITONCAREAND NUTRITONCAREAND NUTRITONCAREAND NUTRITONCAREAND
SUPPORT SUPPORT SUPPORT SUPPORT
Asymptomatic Asymptomatic Asymptomatic Asymptomatic Nophysicalsignorsymptoms Educationaboutthe
importanceofnutritionfor
peoplelivingwithHIV.
Eatingavarietyoffoods.
Storingandpreparingfoods
safely.
Symptomatic(acute) Symptomatic(acute) Symptomatic(acute) Symptomatic(acute) Acuteinfections;fever;night
sweats;fatigue;headache;loss
ofappetite;lossof<10%of
bodyweight
Continuingwithearlier
activities.
Addressingfoodand
eating-relatedsymptoms.
Preventingweightloss.
Ensuringsufficientaccess
tofood.
Symptomatic(chronic)/AIDS Symptomatic(chronic)/AIDS Symptomatic(chronic)/AIDS Symptomatic(chronic)/AIDS Chronicinfections;prolonged
fever;diarrhoea;TB;
pneumonia;lossof>10%of
bodyweight
Continuingwithearlier
activities.
Providingadequateenergy
toreduceeffectsof
malnutrition
Managementofdrug-
nutrientinteractions.
Palliativecare Palliativecare Palliativecare Palliativecare Severewastingsyndrome Alleviatingsymptomsand
providingsupporttothe
clientandcaregiver.
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ThenutritionalrequirementsofpeoplelivingwithHIVareinfluencedbyseveralfactors,includingage,
physiologicalchanges(pregnant,breastfeeding),physicalactivity,clinicalstagesofhealth,
metabolismandviralloadcount.
DAILY DAILY DAILY DAILYENERGY ENERGY ENERGY ENERGY
REQUIREMENTS REQUIREMENTS REQUIREMENTS REQUIREMENTS
TRANSLATIONINTOFOOD TRANSLATIONINTOFOOD TRANSLATIONINTOFOOD TRANSLATIONINTOFOOD
INTAKE INTAKE INTAKE INTAKE
Adults:HIV Adults:HIV Adults:HIV Adults:HIV- -- -negative/healthy negative/healthy negative/healthy negative/healthy 1999to2580kilocalories. Educationaboutthe
importanceofnutrition
forPLHIV.
Eatingavarietyoffoods.
Storingandpreparing
foodssafely.
Adults:HIV Adults:HIV Adults:HIV Adults:HIV- -- -positive positive positive positive
(early/asymptomaticstage) (early/asymptomaticstage) (early/asymptomaticstage) (early/asymptomaticstage)
10%moreenergy(anadditional
210kilocalories).
1additionalfistfulof
maizemealor1cupof
porridgetakenduring
thecourseofthedaily.
Adults:HIV Adults:HIV Adults:HIV Adults:HIV- -- -positive positive positive positive
(late (late (late (late/symptomaticstage) /symptomaticstage) /symptomaticstage) /symptomaticstage)
20-30%moreenergy(an
additional420to630
kilocalories).
2to3additionalfistfuls
ofmaizemealor2to3
cupsofporridgetaken
duringthecourseofthe
day.
Children:HIV Children:HIV Children:HIV Children:HIV- -- -positive positive positive positive Moreenergy,if
asymptomatic.
20-30%moreenergyif
symptomatic,withpoor
weightgain.
50-100%forthoseseverely
malnourished.
Alleviatingsymptoms
andprovidingsupportto
theclientandcaregiver.
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200
1. WhatisthedifferencebetweenHIVandAIDS?(writetheanswerbelow)
1)
2)
3)
1)
2)
3)
4. Name THREE THREE THREE THREE common things that may cause eating difficulties for PLWHIV. (write the
answersbelow)
1)
2)
3)
5. Name THREE THREE THREE THREE suggestions on what to do when there is no enough food for PLWHIV. (write
theanswersbelow)
1)
2)
3)
Nutritional Care and Support for People Living with HIV: Facilitators Guide
203
Formultiplechoice questionsbelow,circlethecorrect answer. Somequestionshave morethanone Formultiplechoice questionsbelow,circlethecorrect answer. Somequestionshave morethanone Formultiplechoice questionsbelow,circlethecorrect answer. Somequestionshave morethanone Formultiplechoice questionsbelow,circlethecorrect answer. Somequestionshave morethanone
correctanswer correctanswer correctanswer correctanswer
a) Immediatelytelltheclientoffifshe/heisdoingsomethingwrong
b) Creatingcomfortableenvironment,whichputthemateaseandencouragethemtotalk?
c) Makeoneortwosuggestionsnotcommands
a) Weightlossorwasting
b) Severediarrhoealastingmorethanonemonth
c) Troubleseeing
a) Eatsmallfrequentmealsthroughouttheday;eatsomething2-3hours
b) Increaseintakeoffattyfoods
c) Preparetheirownfood,sincetheyaretheoneswhoknowhowtheyliketheirfood
d) Trytoeatdryfoodssuchasdrybreadorplaintoast
9.WhichisthecorrectwaytomakeOralRehydrationSolution(ORS)
a) 8tablespoonsofsugar,teaspoonofsaltandboiledwater
b) 12tablespoonsofsugar,18teaspoonsofsaltandwater
c) 8tablespoonsofsugar,12teaspoonsofcerealsandboiledwater
a) GivingARVstothemotherduringlabourandthebabyshortlyafterbirth
b) Mixedfeeding(givingthebabybreastmilkandotherfoodsorliquids)
c) Exclusivebreastfeedingorexclusiveformulafeeding
11.Whataresomeofthewaysofpreparingsaferfood?
a) Cookfoodthoroughly.Formeatandpoultry,makesurejuicesareclear,notpink.
b) Washyourhandsbeforetouchingfoodandbetweentouchingrawandcookedfoodduring
foodpreparation
c) Wash all raw fruits and vegetables thoroughly with safe water before use or, peel them
beforeeating.
d) Alloftheabove
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Read the following s Read the following s Read the following s Read the following statements tatements tatements tatements; check whether the statements are true or false ; check whether the statements are true or false ; check whether the statements are true or false ; check whether the statements are true or false ( ( ( (mark the appropriate mark the appropriate mark the appropriate mark the appropriate
boxwitha boxwitha boxwitha boxwitha) )) )
Statements Statements Statements Statements True True True True False False False False
12
GoodnutritionwillcureHIV
13
Awell-nourishedpersonisstrongerandabletofightinfections
14
PLWHIVshouldavoideatinganimalandmilkproducts
15
Fermentedmilkisbeneficialforpeoplewithdiarrhoea
16
GoodnutritionwillimprovetheeffectofARThelpingthepersonrecovertheir
bodysimmunityandimprovingtheoverallwell-being
17
AllbreastfeedingbabiesborntoHIVpositivemothersgetHIV
18
HIVandAIDSaffectthewaythebodyusedfood/nutrients
19
Food that gives as energy (such as rice, maize) should make the largest
partofourmeals
20
Physicalactivitysuchashouseholdchoresandlightworkinthegarden/field
areofbenefitstoPLWHIV
21
Drinking tea or coffee with meals increases absorption of iron that we get
fromthefoodweeat
22
Whensuggestingfoodstoaperson,considerhis/herpersonlikesandhabits
23
Giveextrafoodtochildrenduringillnessandwhenrecoveringfromillness
24
Excessiveintakeofsomemicronutrientscanbetoxic
25
TherearesomeherbalremediesthatcancureandtreatHIVandAIDS
Nutritional Care and Support for People Living with HIV: Facilitators Guide
205
Annex6:Courseevaluationsheet Annex6:Courseevaluationsheet Annex6:Courseevaluationsheet Annex6:Courseevaluationsheets ss s
Part1:Evaluationoftheparticipantslearning Part1:Evaluationoftheparticipantslearning Part1:Evaluationoftheparticipantslearning Part1:Evaluationoftheparticipantslearning
You have just completed the Nutritionalcare and support for people living with HIVcourse. Please
answer the following questions thoughtfully and completely. Your answers will help us improve this
course.Thankyou.
1.AftercompletingthecourseIratemyselfas(pleasetickinthechosencolumn)
Able to Partially
able to
Not able to I was able
to do this
before the
course
Listtwowaysinwhichnutrition
affectsHIV
Gatherinformationoncurrent
feedingandnutritionpractices
andconcernsofanindividual
Offersuggestionsonwaysof
improvingcurrentfeedingand
nutritionpracticesofan
individual
Participateinlocaldiscussions
onpracticalnutritionand
feedingpoliciesandpractices
forpeoplelivingwithHIV
2. Overall,Iwouldratethiscourseas(circleone):ExcellentGood ExcellentGood ExcellentGood ExcellentGood Poor Poor Poor Poor
3. Ilearntfromthiscourse(circleone):
Verymuch Verymuch Verymuch Verymuch Moderate Moderate Moderate Moderateamount amount amount amount Verylittle Verylittle Verylittle Verylittle
Nutritional Care and Support for People Living with HIV: Facilitators Guide
206
4.What have you learnt from this course that would be most useful in your work with people living
withHIVandtheircaregivers?
__________________________________________________________________________
__________________________________________________________________________
Comments:
Pleaseusethefollowinggradingscaleandcommentconstructivelyasappropriate
1verylow 1verylow 1verylow 1verylow------------------------------------------------------- ------------------------------------------------------- ------------------------------------------------------- -------------------------------------------------------5veryhigh 5veryhigh 5veryhigh 5veryhigh
Programme: Programme: Programme: Programme:
Towhatextentwasthefollowinguseful?
1.Openingremarksandgeneralpresentationofthework
2.Presentationoftheexpectedoutcomes
3.Wayforwardlistofactions
4.Closingremarks
Comments
Nutritional Care and Support for People Living with HIV: Facilitators Guide
207
Process Process Process Process
Pleasegradethefollowing
Session1 Session1 Session1 Session1 NutritionandHIV NutritionandHIV NutritionandHIV NutritionandHIV
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.Howfeasibleisittoadapttothecontextinyourcounty'swork
Comments:
Session2 Session2 Session2 Session2 Introductiontocommunicationskills Introductiontocommunicationskills Introductiontocommunicationskills Introductiontocommunicationskills
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.HowfeasibleisittoadapttothecontextinSwazilandwork
Comments:
Session3 Session3 Session3 Session3 Eatingwisely Eatingwisely Eatingwisely Eatingwisely
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.HowfeasibleisittoadapttothecontextinSwazilandwork
Comments:
Nutritional Care and Support for People Living with HIV: Facilitators Guide
208
Session4 Session4 Session4 Session4 FoodsafetyforpeoplewithHIVandAIDS FoodsafetyforpeoplewithHIVandAIDS FoodsafetyforpeoplewithHIVandAIDS FoodsafetyforpeoplewithHIVandAIDS
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.HowfeasibleisittoadapttothecontextinSwazilandwork
Comments:
Session5 Session5 Session5 Session5 Improvingfoodintake Improvingfoodintake Improvingfoodintake Improvingfoodintake
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.HowfeasibleisittoadapttothecontextinSwazilandwork
Comments:
Session6 Session6 Session6 Session6 P PP Preventing reventing reventing reventingweightlossandpromotingphysicalactivity weightlossandpromotingphysicalactivity weightlossandpromotingphysicalactivity weightlossandpromotingphysicalactivity
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.HowfeasibleisittoadapttothecontextinSwazilandwork
Comments:
Nutritional Care and Support for People Living with HIV: Facilitators Guide
209
Session7 Session7 Session7 Session7 NutritionforpeopleonAntiretroviralTherapy NutritionforpeopleonAntiretroviralTherapy NutritionforpeopleonAntiretroviralTherapy NutritionforpeopleonAntiretroviralTherapy
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.HowfeasibleisittoadapttothecontextinSwazilandwork
Comments:
Session8 Session8 Session8 Session8 Nutritionforpregnantandbreastfeeding Nutritionforpregnantandbreastfeeding Nutritionforpregnantandbreastfeeding NutritionforpregnantandbreastfeedingwomenwithHIV womenwithHIV womenwithHIV womenwithHIV
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.HowfeasibleisittoadapttothecontextinSwazilandwork
Comments:
Session9 Session9 Session9 Session9 Feedingopt Feedingopt Feedingopt FeedingoptionsforinfantofHIVpositivemothers ionsforinfantofHIVpositivemothers ionsforinfantofHIVpositivemothers ionsforinfantofHIVpositivemothers
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.HowfeasibleisittoadapttothecontextinSwazilandwork
Comments:
Nutritional Care and Support for People Living with HIV: Facilitators Guide
210
Session10 Session10 Session10 Session10 FeedingachildwithHIV FeedingachildwithHIV FeedingachildwithHIV FeedingachildwithHIV
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.HowfeasibleisittoadapttothecontextinSwazilandwork
Comments:
S SS Session11 ession11 ession11 ession11 Improvingaccesstofood Improvingaccesstofood Improvingaccesstofood Improvingaccesstofood
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.HowfeasibleisittoadapttothecontextinSwazilandwork
Comments:
Ses Ses Ses Session12 sion12 sion12 sion12 Theuseofnutritionalsupplementsandherbalremedies Theuseofnutritionalsupplementsandherbalremedies Theuseofnutritionalsupplementsandherbalremedies Theuseofnutritionalsupplementsandherbalremedies
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.HowfeasibleisittoadapttothecontextinSwazilandwork
Comments:
Your comments are very important to us. Please write on the back of this sheet any additional
commentsorobservationsthatyouhaveaboutthecourse,includingsuggestionsforimprovements.
Thankyou.
Nutritional Care and Support for People Living with HIV: Facilitators Guide
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