Malawi PMTCT Participant Manual

Malawi PMTCT Participant Manual

Acknowledgements

The Malawi National PMTCT Training Package represents more than five years of programme experience, technical expertise from local and international partners and many months of hard work by Ministry of Health and National AIDS Commission staff. This package is aharmonization of the Government of Malawi’s original PMTCT Training Manual, the PMTCT Guidelines for Implementers, the Handbook for Health Workers and the WHO/CDC PMTCT Generic Training Package. It also includes the most recent national policies in all areas relevant to PMTCT.

This Training Package was prepared by the National PMTCT Technical Working Group (TWG)with technical assistance from the François-Xavier Bagnoud (FXB) Center at the University of Medicine and Dentistry of New Jersey and funding from the US Centers for Disease Control and Prevention. The TWG is grateful to both organizations for their valuable assistance and unwavering support.

The Ministry of Health would like to thank the members of the PMTCT Technical Working Group, including the following people: Peggy Chibuye, Mwate K. Chintu, Dennis Chiombeza, Miriam Chipimo, Paul Dielemans, Michael Eliya, Janet Guta, George Kafulafula, Ursula K. Kafulafula, Esmie Kamanga, Florence Kayambo, Buhendwa Leopold, Wellington Limbe, Julius Malewezi, Daniel Maseko, Kondwani Mkandawire, Catherine Mkangama, Martha Mondiwa, F.M. Munthali, Theresa Gloria Mwale, Jane Namasasu, Lucius S.C. Ng’omang’oma, Humphreys K. Nsona, J. Odoyo-June, Eric Schouten, Victoria Shaba.

Thanks also go to the Observers during the pilot test, all of whom are mentioned above as well as to the Trainers; Sharon Bisika, Belinda Gombachika, Felina Kaliati, Paul Kaseka, Maggie Mhango, Dalitso Midiani, Jacinta Mtengezo, and Susan Sundu. The Ministry of Health would also like to thank all the Participants who attended the pilot test.

Thanks to theFXBCenter staff (Virginia Allread, Sahai Burrowes,Melody Corry, Karen Forgash, Rebecca Fry, Magaly Garcia,Deborah Hunte, Natalia Rivera, Monica Reiss, and Bhavani Sathya) for their tireless effort in the writing of this Training Package.

There are many individuals whose countless contributions enhanced the development of this Training Package; gratitude is expressed to them all.

The Malawi Prevention of Mother-to-Child Transmission of HIV (PMTCT) Training Package is a comprehensive approach to the training of healthcare workers. The components in this package are:

Trainer Manual
Participant Manual
Presentation Booklet

Table of Contents

Foreword...... Introduction-4

Abbreviations and Acronyms...... Introduction-6

Course Overview...... Course Overview-2

Ice Breaker and Ground Rules...... Course Overview-6

Module 1:Introduction to HIV and AIDS

Unit 1: Magnitude, Impact and Response to HIV and AIDS...... 1-2

Unit 2: Basic Facts about HIV and AIDS...... 1-10

Module 2: Overview of HIV Prevention in Mothers, Infants, and Young Children

Unit 1: HIV in Malawi...... 2-2

Unit 2: Mother-to-Child Transmission of HIV Infection...... 2-5

Unit 3: Comprehensive Approach to Prevention of HIV Infection in Infants and Young Children 2-8

Unit 4: Role of Maternal and Child Health Services in the Prevention of HIV Infection in Infants and Young Children 2-15

Module 3: Specific Interventions to Prevent MTCT

Unit 1: Implementation of Comprehensive ANC Services...... 3-2

Unit 2: Antiretroviral Prophylaxis and Treatment for the Prevention of MTCT 3-8

Unit 3: Optimal Management of Women During Labour and Delivery.....3-11

Unit 4: Postpartum Management of Women and Infants...... 3-16

Module 4: Infant Feeding in the Context of HIV Infection

Unit 1: Overview of Global Infant Feeding Recommendations...... 4-2

Unit 2: Infant-Feeding Options...... 4-11

Unit 3: Supportive Counselling for Safer Infant Feeding Choices...... 4-20

Module 5: Stigma and Discrimination Associated with HIV

Unit 1: Introduction to the Concepts of Stigma and Discrimination and International Human Rights 5-3

Unit 2: Social Context and Impact of Stigma and Discrimination...... 5-6

Unit 3: Dealing with Stigma and Discrimination in Healthcare Settings and Communities 5-10

Module 6: Testing and Counselling

Unit 1: Basic Principles of HIV Testing and Counselling (TC) for Prevention of Mother-to-Child Transmission of HIV (PMTCT) 6-2

Unit 2: Counselling Skills...... 6-11

Unit 3: HIV Testing...... 6-18

Unit 4: HIV Pre-Test and Post-Test Counselling…………………………….. 6-23

Module 7: Comprehensive Care and Support for Mothers and Families with HIV Infection

Unit 1: Treatment, Care and Support of the Mother with HIV Infection.....7-2

Unit 2:Prevention and Treatment of HIV-Related Conditions ...... 7-6

Unit 3: Identification and Management of Sexually Transmitted Infections (STIs) 7-14

Unit 4:Adult HIV Staging and ARV Therapy ...... 7-18

Unit 5: Treatment, Care and Support of the Infant and Young Child Exposed to HIV 7-25

Module 8: Referral for treatment, care and support services

Unit 1: Linkages and Referrals Supporting PMTCT Services...... 8-2

Unit 2:Community Education, Outreach and Mobilization...... 8-8

Module 9: Safety and Supportive Care in the Work Setting

Unit 1: Universal Precautions...... 9-2

Unit 2: Handling and Decontamination of Equipment and Materials...... 9-4

Unit 3: Managing Occupational Exposure to HIV...... 9-15

Unit 4: Supportive Care for the Carer...... 9-19

Module 10: Management of PMTCT services

Unit 1:Introduction to Management of PMTCT Services...... 10-2

Unit 2: Monitoring and Evaluation of PMTCT Services...... 10-6

Unit 3: Practical Attachment...... 10-13

FAQs...... FAQs-1

Glossary...... Glossary-1

Foreword

The transmission of HIV from a pregnant mother to her infant during pregnancy, labour, delivery, or breastfeeding is the most significant source of HIV infection in infants and young children. The administration of antiretroviral prophylaxis, therapy, and quality care during the antenatal and intrapartum periods—including counselling and support for safer infant feeding—can significantly reduce rates of mother-to-child transmission of HIV (MTCT). Postpartum and follow-up care are essential components of a comprehensive care package for mothers and families affected by HIV. The Ministry of Health is committed to the development of effective and comprehensive prevention of mother-to-child transmission (PMTCT) services, fully integrated into maternal-child health services.

There are many staff involved indelivery of comprehensive PMTCT services. The list includes nurses, nurse midwives, clinical officers, doctors, nutritionists, medical assistants, laboratory technicians, pharmacists, counsellors, community-based distributors, and home-based care volunteers. The information provided in this Manual targets healthcare workers at all levels of the PMTCT healthcare delivery system.

You as a healthcare worker will find a role to play in PMTCT service delivery. Some of the defined roles and responsibilities are specific to certain healthcare worker cadres. Healthcare workers will be expected to undergo training programmes that are relevant to PMTCT service delivery. The roles and responsibilities of healthcare workers will include the following:

Carry out PMTCT IEC activities.
Conduct group education and counselling sessions with clients.
Perform HIV tests or refer clients to testing centres.
Provide safer infant feeding counselling and support.
Provide ARV prophylaxis or refer for ARV treatment; support ARV adherence
Practice safe delivery techniques
Provide for refer for care, treatment and support services.
Manage Reproductive Health clinics into which PMTCT services are integrated.
Coordinate the components of the PMTCT services.
Participate in PMTCT monitoring and evaluation.

The doctors, nurses, nurse midwives, and clinical officers are expected to participate in virtually all of the above activities. They will play a critical role in the planning, provision, monitoring, and evaluation of the comprehensive PMTCT services. They will also be expected to participate in communication, advocacy, and social mobilization.

The medical assistants, pharmacists, laboratory technicians, nutritionists, and counsellors will be expected to focus more on the provision of support services for the PMTCT program. Depending on their areas of expertise, this may include activities such as carrying out IEC for PMTCT or providing counselling and support for selecting a safe infant feeding option. They will also be actively involved in the monitoring and evaluation of PMTCT activities.

The community-based resource persons such as distributors (CBDs) and home-based care (HBC) volunteers will be expected to play the key role of carrying out IEC for PMTCT. They will also be involved in providing counselling and support for mothers who are selecting an infant feeding option.

To facilitate the rapid scale-up of high quality PMTCT programmes, the Ministry of Health has developed this Malawi National PMTCT Training Package 2006 to train healthcare workers on carrying out a successful PMTCT program. The National PMTCT Training Package is comprised of ten interactive, skill-building modules:

Module 1:Introduction to HIV and AIDS
Module 2:Overview of HIV Prevention in Mothers, Infants, and Young Children
Module 3:Specific Interventions to Prevent Mother-to-Child Transmission of HIV (PMTCT)
Module 4:Infant Feeding in the Context of HIV Infection
Module 5:Stigma and Discrimination Associated with HIV/AIDS
Module 6:Testing and Counselling
Module 7:Comprehensive Care and Support for Mothers and Families with HIV Infection
Module 8:Referral for Treatment, Care and Support Services
Module 9Safety and Supportive Care in the Work Setting
Module 10:Management of PMTCT Services

The National PMTCT Training Package represents a collaborative effort between the government and non-governmental partners in both pre-service and in-service settings working to improve the quality of care for women and their families. This Training Package was adapted based on the following resources:

Malawi PMTCT Training Manual
Prevention of Mother-to-Child Transmission of HIV in Malawi, Guidelines for Implementers, 2003
Prevention of Mother-to-Child Transmission of HIV in Malawi, Handbook for Health Workers, 2003
Zanzibar National PMTCT Trainer Manual, 2005
WHO/CDC PMTCT Generic Training Package, 2004

Using advanced training strategies, this course presents the basic knowledge for PMTCT programme implementation. It serves as a comprehensive resource for healthcare workers, managers, and trainers, and should be supplemented with additional hands-on training for complex clinical topics such as infant feeding and HIV testing and counselling. Training healthcare workers is an essential component of effective PMTCT programmes. The Ministry of Health presents this national training package as part of its overall strategy to:

Achieve the goal of the national PMTCT programme to reduce mother to child transmission of HIV in Malawi by 50% by the end of the year 2010. This goal was set in conformity with the UNGASS target (June 2001) and in line with the goals set by governments, including Malawi, in the Abuja Declaration (December 2000).
Improve the health status of all women of child-bearing age and children in the country by facilitating utilization of PMTCT services by at least 75% of the women attending antenatal clinics by the end of 2010.

Dr. W.OO. Sangala

SECRETARY FOR HEALTH

Abbreviations and Acronyms

ABCAbacavir; also Abstinence, Be Faithful, Use Condoms (HIV/AIDS prevention message)

ADFAfrica Development Fund

AIDSAcquired immunodeficiency syndrome

ANCAntenatal care

ARVAntiretroviral

ARSAntiretroviral syndrome

ARTAntiretroviral therapy

BCGBacille of Calmette-Guerin

BCIBehaviour change interventions

CBDCommunity Based Distributor

CBOCommunity based organization

CDCCenters for Disease Control and Prevention

CHAMChristian Health Association of Malawi

CMVCytomegalovirus

CNSCentral nervous system

CPTCotrimoxazole preventive therapy

CSTCounselling skills and technique

CTXCotrimoxazole

D4T/3TCCombination of stavudine and lamivudine, known as “Duovir”

DNA PCRHIV DNA polymerase chain reaction (PCR)

EHEthambutol

ELISAEnzyme-linked immunosorbent assay

FAOUnited Nations Food and Agricultural Organization

FAQFrequently asked question

FBOFaith Based Organization

FPFamily planning

HAARTHighly active antiretroviral therapy

HBCHome based care

HCWHealthcare worker

HIVHuman immunodeficiency virus

HMIS Health management information systems

HSVHerpes simplex virus

HTCHIV testing and counselling

IECInformation, education and communication

IGAIncome generating activity

IMCIIntegrated management of childhood illness

IPTIntermittent presumptive treatment for malaria

ITNInsecticide-treated bednet

IUCDIntrauterine contraceptive device

LBWLow birth weight

LIPLymphoid interstitial pneumonitis

MACMycobacterium Avium Complex

MACROMalawi AIDS Counselling & Resource Organisation

MCHMaternal and Child Health

MOH / MOHPMinistry of Health (and Population)

MTCTMother-to-child transmission of HIV

NGONon-governmental organization

NGUnon-gonococcal urethritis/cervicitis

NVPNevirapine

OIOpportunistic infection (now more commonly referred to as “HIV-related condition”)

OPDOut-patient department

PCPPneumocystis jirovecipneumonia (formerly referred to as Pneumocystis carinii pneumonia)

PCRPolymerase chain reaction

PEPPost-exposure prophylaxis

PGLPersistent generalized lymphadenopathy

PIDPelvic inflammatory disease

PLHIVPerson living with HIV/AIDS

PMTCTPrevention of mother-to-child transmission of HIV

RHReproductive Health

RNA PCRRNA polymerase chain reaction (PCR)

SPSulfadoxine pyrimethamine

SRHSexual and Reproductive Health

STISexually transmitted infection

TBTuberculosis

TCTesting and counselling

TBATraditional birth attendant

UNAIDSJoint United Nations Programme on HIV/AIDS

UNFPAUnited National Population Fund

UNGASSUnited Nations General Assembly Special Session

UNICEFUnited Nations Children's Fund

USAIDU.S. Agency for International Development

WHOWorld Health Organization

VCTVoluntary counselling and testing (now more commonly referred to as HTC, HIV testing and counselling)

ZDVZidovudine, the generic name for azidothymidine (AZT)

Introduction-