INSTITUTE FOR OPEN

LEARNING

STUDY MANUAL

HEALTH EDUCATION III

CODE: HED-3426

COPYRIGHT
Published by the International University of Management
Windhoek, Namibia
International University of Management 2009
No part of this publication may be reproduced, stored in retrieval system or transmitted in
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without prior permission of the publishers.

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Contents

Page

Overview. 3
Foreword.4
Unit One: The Dynamics of HIV an Advanced Study.................................................5
Unit Two: The effects of HIV on the Immune System and Disease Progression.11
Unit Three: HIV and Opportunistic Infections19
Unit Four: Study of Anti-Retroviral Therapy...26
Unit Five: Monitoring of Anti-Retroviral Therapy36
Unit Six: Adherence in Anti-Retroviral Therapy .. .41
Unit Seven: Nutrition and HIV..46
Unit Eight: Living Positively with HIV ..56
Unit Nine: Study of the National Health Policy and Health Care System in Namibia....67
Unit Ten: Post-Exposure Prophylaxis (PEP) .. 77
Assignments: ..85
References: 87

Overview
This manual has been designed and written to assist students and increase their
understanding of the Viral cycle through an advanced study which also helps them
understanding how medicine works on inhibiting the cycle and thus improving the life of the
infected individual. The unit on opportunistic infections discusses the effects of the virus on
the immune system, the relationship between the immune system and progression of
disease. The study of Antiretrovirals focuses particularly on the different classes available in
the world, but in particular in Namibia and how it works and further develops the
understanding of the importance of monitoring ARV therapy towards successful outcomes
and improved adherence. The critical aspects of Nutrition and its role in successful
treatment and managing of side effects are discussed. The manual also examines the
National Health policy and Post Exposure Prophylaxis guidelines in Namibia.
Module Assessment
Assignment(s)
You will be required to complete and submit eight (8) assignments. These assignments are
assessed as part of the coursework, it is therefore very important that you complete them.
Examination
An examination will be written at the end of manual, presently a year. The assessment
strategy will focus on application of theory to practice.
General
At fourth year of study, students are expected to read widely and show the marker that they
have the ability to analyze a variety of viewpoints and to hold a specific position of their own
(backed by theoretical justification)
4

Resource List
If it is at all possible, try to access the websites, journals and other sources of pertinent
information such as newspapers, newsletters, etc. A resource list is attached at the back of
the Manual.
Foreword
Having dealt with different aspects in terms of HIV and its effects on the individual, student
are now beginning to analyze different medical and biomedical situations related to ART,
Opportunistic infections, Disease progression, the role of Nutrition and Adherence in more
detail. Students should now begin to develop working knowledge and skills in HIV/AIDS
studies. Furthermore, students are encouraged to continuously consult libraries and the
internet, in their quest to gather recent information on HIV/AIDS. This manual contains the
most current information, yet it is important to remember that HIV and AIDS and its
treatment are an ongoing matter and are being researched.

Unit One: The Dynamics of HIV- An Advanced Study

1. Introduction
Antiretroviral therapy (ART) works towards stopping the natural evolution of HIV infection
from contamination, to the appearance of opportunistic diseases = AIDS, normally after 8 to
10 years in adults less than this in children. It is important to have a thorough understanding
of the structure of Human Immune-deficiency Virus (HIV), and its relationship with our
immune system through Patho-physiology studies. Furthermore, epidemiological studies are
also necessary towards this quest, as they present the depth of damage caused by
HIV/AIDS in the individual and in the world at large.
2. The Structure of HIV
The HI-virus has a unique structure, which is identified by the following characteristics:
The virus size: The virus is 80-100 nanometers in diameter, equivalent to 1/10.000
of a millimeter and it's is shape is spherical
Outer part: It has spikes gp120 a double lipid layer derived from the host cell
membrane, as well as trans-membrane gp41 which mediate the entrance of virus
into the host cell. (gp stands for glycoprotein)
The core, centre or capsid: The core consists of important proteins such as p24
which is the main protein, as well as p17, p9, p7. Within the core there exists twosingle strand ribonucleic acid (RNA) genetic material and these consist of enzymes
namely:
1. Reverse Transcriptase enzyme
2. Protease enzyme
3. Integrase enzyme

Figure 1: Structure of the Human Immunodeficiency Virus (HIV)

This is part of a larger HIV and AIDS picture gallery. For more HIV and AIDS photos visit
www.avert.org/historyi.htm.
The Human Immune Deficiency Virus (HIV) belongs to the Genus Lenti virus, in the
Retroviridae family. It exists in 2 types HIV 1 and HIV 2. It is HIV 1 that is responsible for the
global pandemic due to its high capacity of changing (mutation).
3. Groups and subtypes of the HI Virus
There are three groups of HIV1, namely:
Group M (Major): This group has 10 subtypes or clades from A-J. These are
unevenly distributed A, C, D are common in Africa. The subtype C is the most
virulent; with highest capacity of mutation and recombination to give mosaic
7

genomes. It has a high passage in mother to child infection and forms easily
resistant types, and is suspected to be the leading cause of up to 90% of Southern
Africa pandemic. The Subtype B is found in Europe and Northern America and has
been highly studied. Numerous Circulating Recombination Forms (CRF) have been
identified e.g. CRF 01, A E means a mixture of subtype A and E, or CRF 02, A G
means a mixture of subtype A and G. Group 0 (outliner) of HIV 1 is found to be
restricted mainly to central Africa region.
Group N (Non M, Non O) virus is rare and has been isolated in a few cases in
Cameroon only. HIV 1 is a rapidly evolving virus because of its errorprone nature of
its reverse transcription, which has a high turnover and the ability to adapt itself
rapidly and diversify. This nature of the virus has serious implications on rapid
development of drug resistance as it can escape the detection capacity of the
immune system. It affects the creation of an effective vaccine, as well as accurate
diagnosis.
There are 5 subtypes of HIV 2 and is reported to be less infectious and virulent
compared to HIV 1, subtypes A-E. The structures of HIV 1 and 2 are almost the
same but HIV 1 has been studied much more.
4. HIV life Cycle/Viral Replication Cycle
The HIV virus has a determined cycle during the process of infection; generally it consists of
7 steps, but some, such as the illustration suggests 13 steps. The steps are
illustrated in figure 2 and fully explained in the text following the illustration.

4.1 Figure 2: Graphic Illustration of the cycle of HIV www.avert.org/historyi.htm.

4.2 The Steps of viral replication

Step 1: Binding:
HIV attaches itself through the interaction of HIV envelope glycoprotein and host cell
receptors (CD4 molecules) and co-receptors. Receptors are CD4 antigens located on
some cells like lymphocytes macrophages, monocytes, glial cells of the brain and
Langerhans cells. The co-receptors are known as CCR5 and CX R4. The receptors and
co-receptors determine which cells can be infected by HIV.
Step 2: Fusion:
9

The envelope protein gp120 binds itself to host cell receptors and co-receptors. This is
followed by the insertion of gp14 into the cell membrane of the host cell and there is
fusion of the 2 membranes.

Step 3: Entry:
The virus leaves its membrane (unloading) and the core is released into the cytoplasm
of the host cell. There is interaction between the core and the host cell enzymes, which
release the viral enzymes.
Step 4: Reverse Transcription:
HIV is made up of a single-strand genetic material and for it multiply it must convert itself
into double-strand that is RNA (Ribonucleic acid) becoming DNA (Deoxyribonucleic).
The viral enzyme responsible for this conversion is called reverse transcriptase. This
process is very inefficient and it gives rise to mistakes in duplication, which is called
mutations and some may be resistant to anti retroviral treatment.
Step 5: Integration and Replication:
The viral DNA enters into the host cell nucleus with the help of the viral enzyme,
integrase. It inserts the viral DNA into the host cells DNA. This process is called
integration. This is the real infection of the cell. Once this is done the cell stays infected
for the rest of its life, and it referred to as molecular infection. The viral genetic
material is integrated into host genetic materials DNA. Then the host cell is used as a
machine to produce HI-virus under the command of viral DNA. This is called replication.
Step 6: Budding:
The viral DNA particles [Provirus] gather at the membrane of the CD4 + Cell. These push
10

through the cell membrane by budding and the double lipid layer of the host cell form the
lipid layer and the outer layer of the virus which is now ready to infect a new cell.
Step 7: Maturation:
The gp160 embedded in the cell membrane, is cleaved by the viral enzymes protease
which produce functional gp41 and gp120 forming a mature virus which can infect other
hosts cells, the CD4+ cells. One of the most important natural defense against HIV
infection lies on the CD4 cell. The normal CD4 + cells number is 600 1200 cells/mm 3. If
these are infected they decrease in number which causes the deterioration of the
immune system and the appearance of infections called opportunistic diseases or
infections evolving into AIDS.
Conclusion
The dynamics of HIV and its replication cycle and subsequent infection of the individual is
complex. It requires understanding to comprehend the complexities of the viral cycle and
why specific medicines are developed to effectively contain the infection for a period of
years and thus increase the longevity of infected individuals. It furthermore highlights the
difficulties science is faced with in their quest to continue with the development of more
effective antiretroviral medicine, towards the ultimate goal of finding a cure.

11

Unit Two: The effects of HIV on the Immune System and Disease Progression
1. Introduction
HIV infects the Immune System, mainly the CD4 cells and causes the body to weaken over
time. The risk of having opportunistic infections and progressing to AIDS becomes higher as
the CD4+ count decreases and the risk is highest when the CD4 + cell count is 200 cells/mm 3
and below , the level at which most countries recommend the commencement of AR
Therapy.
2. Monitoring the Immune System
2.1 CD4 cell count (usually done in Adults)
CD4 count monitoring is done at diagnosis and ever six months to monitor the effectiveness
of treatment. The CD4+ cell count or the total lymphocytes count (normal range is between
600 -1200) is a useful parameter for judging the recovery of the immune system as well as
the effectiveness of the treatment and the good adherence to treatment of the patient.
If CD 4 cells are damaged, the immune system is seriously affected, because it depletes
the number of cells and creates dysfunction of the immune system, including destruction of
B cells, thymus dysfunction and autoimmune abnormalities.
For more effective outcome on ARV therapy, it is often recommended to start treatment
when the CD4+ cell count is around 200/mm 3 or when a patient is at stage 3 or 4 of the
World Health Organization clinical staging system, the stages will be discussed later in this
unit

12

2.2 CD4 Percentage (usually done in children)

The CD4+ cell count in children varies with age (or even according to regions) and reaches
the aspect of adult at the age of 5 to 6 years. A child is suspected to be exposed and to
have HIV infection and acquired opportunistic infection when the CD4 cell count is less than
15%, which is equivalent to 200cells/mm 3 in adults. The percentage of CD4 can be scaled
as 25% normal, and 15% as severe immune suppression.
Table 1: CD4+ Percentage Chart for Children
Classification of HIV Age related CD4 Values
associated
Percentage
Percentage
immunodeficiency

Percentage

Cells /mm

11 months
12.35 months
36-59 months
5 years
Not significant
35
>30
>25
>500
Mild
30-35
25-30
20-25
350-499
Advanced
25-29
20-24
15-19
200-349
Severe
<25
<20
<15
<200 or<15
Source: Guidelines for Antiretroviral Therapy .page 38, Best measured when patients are clinically stable.

3. Monitoring viral replication

Viral Load is the amount of HIV in the blood (Plasma). It is the count of the number of HIV
or RNA copies/ml of blood (plasma). When the viral load is high it means there is a fast
destruction of CD4+ cells, when it is low it reflects a stronger immune system and less
destruction of CD4+ cells.

13

A viral load below 400 copies /ml indicates a good sign. It means the treatment is effective,
the patient is getting better and the immune system usually shows signs of
recovery by a rise of CD4+ cell count. It should be noted that undetectable
levels do not mean the patient is healed, but the patient still remains
infectious and can still transmit the disease.
If treatment is stopped it will lead to destruction of CD4 + cells and an increase in viral load.
The plasma (HIV-RNA Levels) viral load is a useful indicator of a good response
to ARV usually obtained in 70-80% with a viral load of 50 copies or less after 4-6
months of treatment. This test has the disadvantaged of being very expensive
and is thus done after six months of treatment initiation to gage initial response
to treatment to identify patients with suboptimal response so as to strengthen
adherence counseling to prevent treatment failure and prevent emergence of
ART resistance. Subsequent tests are done only when clinically required to
measure treatment response when no real improvement is observed.
Viral load are also done in cases of immunological failure 4 months after changing
treatment.
4. Clinical Monitoring of the stages of disease progression of HIV infection
The World Health Organization (WHO) has developed a disease staging system for HIV
infection which assists health care workers all over the world to make clinical decisions. It is
of critical importance and very useful in resource limited poor countries, where a health
worker may have to make decisions in the absence of a test result. This does however not
exclude the process of counseling and testing and laboratory diagnosis where guidelines
and support structures are in place.

14

4.1

Stages of disease progression in Adults and Adolescents

Clinical stage I: Asymptomatic

Generalized Lymphadenopathy (which may include some general swelling

around neck, under armpit etc with no real threat);
o Performance scale I - The client is asymptomatic(show no signs and

symptoms of disease) and can do/ have normal activity

Clinical Stage II
Signs and symptoms
Unexplained Weight loss (< 10% of presumed or measured body weight)
Minor mucocutaneous manifestations
Seborrheic dermatitis, prurigo, fungal nail infections, recurrent oral ulcerations,
e.g. angular cheilits)
Herpes zoster within the last 5 years
Recurrent upper respiratory tract infections (e.g. bacterial sinusitis)
o Performance scale 2 The client experience some of these

symptoms, if given treatment, can continue with normal

activity.
Clinical Stage III:
Signs and symptoms
Weight loss (> 10%of presumed or measured body weight)
Unexplained persistent diarrhea > 1 month
Unexplained persistent fever (intermittent or constant) > 1 month

15

 Oral hairy leucoplakia

Pulmonary Tuberculosis,
Unexplained anemia (below 8g/dl), neutropenia (below 0.5x10L and or chronic
thrombocytopenia (below 50x10/L))
Severe bacterial infection (i.e. Pneumonia, pyomyositis)
o Performance scale 3 The client is bedridden less than 50 %

of the time.
Clinical Stage IV:
Signs and symptoms
Pneumocystis carinni pneumonia (PCP),
Toxoplasmosis with diarrhea > 1 month
Cryptosporidiosis
Cytomegalovirus disease of liver, spleen,
Herpes simplex virus infection, mucocutaneous > 1 month or visceral
Progressive multifocal Leucoencephalopathy
Any disseminated endemic mycosis
Candidiasis of esophagus trachea, bronchi, anogenital areas
A typical mycobacteriosis disseminated of the lung
Non-typhoid salmonella septicemia
Extra pulmonary tuberculosis(EPTB)
Lymphoma
Kaposi sarcoma
HIV encephalopathy
16

 HIV wasting syndrome/cachexia

o Performance scale 4 The client is bed-ridden more
than 50% of the time

4.2 Stages of disease progression in infants and children

Table 2: WHO stages of HIV infection are also known as stages of HIV infection
WHO
Asymptomatic
Pediatric Stage I
Persistent generalized lymphadenopathy (PGL) Hepatosplenomegaly
WHO
Pediatric Stage 2
Mild

WHO
Pediatric Stage 3
Advanced

WHO
Pediatric Stage 4
(Severe)

Unexplained persistent Hepatosplenomegaly, Papular Pruritic eruptions

Seborrheic dermatitis, extensive wart virus infection
Fungal nail infections, Angular cheilits, herpes Zoster, recurrent chronic
upper respiratory infections, unexplained persistent parotid
enlargement, or moluscum contagiosum infection , recurrent oral
ulcerations,
Unexplained moderate malnutrition, unexplained Persistent diarrhea (>
14 days), unexplained persistent fever above 37c, intermittent or
constant for longer than one month, Oral hairy leucoplakia,
Unexplained Anemia < 8g/dl, neutropenia < 0.5x10/L, Thrompbopenia <
0.5x 10/L, HIV related Neuropathy, Acute necrotizing ulcerative
gingivitis/peritonitis, Lymph node TB, Pulmonary TB, Severe recurrent
bacterial pneumonia, symptomatic lymphoid interstitial pneumonia,
chronic HIV associated lung disease including bronchietasis.
ADD THE LITTLE 9
Unexplained severe wasting syndrome, stunting or severe malnutrition
not responding to standard therapy, Pneumocystis Pneumonia
Recurrent severe bacterial infection excluding Pneumonia, Chronic or
labial or cutaneous HSV lasting > 1 month, Extra pulmonary
tuberculosis, Kaposis sarcoma. Esophageal Candidiasis, Cryptococcal
meningitis, Any disseminated endemic mycosis, Cryptosporidiosis or
Isosporiasis (diarrhea > 1 month), CMV infection: liver, spleen
17

Lympnodes, Disseminated Mycobacterium Tuberculosis, candidate of

Trachea bronchi or lungs, Acquired Recto-vesicle fistula, cerebral of B
cell , Non-hodgkin Lymphoma,
Progressive multifocal
Leucoencephalopathy(MPL), HIV encephalopathy

4.3 Evolution of HIV infection in Children

The progression in children of the clinical stages is a bit different from that of adults.
There are those with a rapid decline of CD4 + percentage with an early onset of
disease in the first year. The mortality is very high from recurrent severe infections
such as pneumonia, bacterial infections and diarrhea. At birth usually they have
hepatomegaly, higher viral load and low CD4 cell count. There is rapid evolution
towards AIDS, in most cases up to 75% of patients die before the age of 5 years.
Long-term non-progression. These patients live up to 8 years. They have a higher
CD4+ percentage (>15%) and a lower viral load ( 15,000 copies/ml) at the age of 30
months.
4.4 Early suggestive signs/symptoms of HIV infection in children
In the absence of HIV testing of the mother and thus the child/children, it is important to
know the early signs suggestive of HIV infection and these may include:
Recurrent pneumonia, Oral thrush, Persistent or pus ear discharge
Persistent diarrhea, Very low weight, Enlargement of lymph nodes and

Parotide

Enlargement
These symptoms have a low sensitivity that is why it is important to counsel the mother/
parents and or guardian on the importance of knowing their status and testing for their
child/ren. Table 3 gives clarity on distinguishing between signs and symptoms of HIV
infection in children at an early stage to ensure earlier intervention for treatment, care and
support services.
18

Table 3: Clinical signs or conditions in children that may suggest HIV infection
Specificity for HIV infection
Signs/Conditions
Signs/conditions very specific to Pneumocystis, Pneumonia,
HIV infection
Esophageal Candidiasis, extra-pulmonary
Cryptococcosis, invasive salmonella infection,
lymphoid interstitial pneumonia, herpes zoster with multi-dermatome
involvement,
Kaposi Sarcoma, Lymphoma, progressive
multifocal histology
Signs/conditions
Severe bacterial infection if recurrent, persistent or recurrent oral
Common in HIV-infected
thrush, Bilateral painless parotid enlargement, generalized persistent
Children and uncommon
non-inguinal
Uninfected children
lymphadenopathy, hepatomegaly splenomegaly
Not related to malaria
Persistant/ recurrent Fever,
Neurologic Dysfunction,
Herpes zoster (shingles) single dermatome.
Persistent generalized dermatitis
Unresponsive to treatment.
Signs/conditions common in HIV- Chronic recurrent otitis and ear discharge, Persistent or recurrent
infected children but also diarrhea, severe pneumonia, tuberculosis, bronchietasis, failure to
common in ill uninfected children thrive, marasmus

Source: (Handbook on Pediatric AIDS in Africa)

Conclusion
It is most important to understand the effects the virus has on the immune system and how
disease progress as it influences the care provided to the individual.

19

Unit Three: HIV and Opportunistic Infections (OIs)

1. Introduction
HIV infection weakens the immune system of the body, during the first years, the immune
system, although weakened functions quiet well. The infected may have no symptoms or
signs of disease, or may have minor symptoms like skin disease, a little weight loss and
repeated sinus infections.
As years goes on, the body becomes weaker and the individual becomes easily infected
with diseases he/she would normally fight off. These diseases are called Opportunistic
infections, because they take advantages of the weakened immune system to cause
disease. (The killing of a springbuck by a lion, devouring much of its kill and the hyena
waiting in the bushes to finish off the leftovers is a useful analogue to explain)
2. The relationship between Immune system and viral infection (Risk of Opportunistic
Infections)
People with a good immune system have CD4 counts between 600-1200. As the CD4 level
decreases the risk of getting opportunistic infections increases.
20

Figure1: Relationship of CD4 Count & Viral Loads without Treatment

HIV infection progresses over time, when infected the body (immune) may take up to 3-6
weeks to react in developing antibodies to HIV (this one of the reasons why a recent
infection does not show in an antibody test as is referred to as the window period) there is
a peak in the viral load also referred to as primary infection and during this time the person
may have signs and symptoms similar to flu and malaise.
During primary infection the viral load is very high and thus the risk of transmitting or
acquiring HIV infection during unprotected sexual intercourse. While the viral load peak, the
CD4 decreases in its attempt to fight the infection and this period of internal infection and
reaction is referred to as seroconversion.
An extended period of between 1 -10 years may follow (also referred to as the latent period)
where the person have no signs and symptoms of disease and this vary from person to
person and depends on their exposure to TB and other infections and their nutritional
status. Some or most people may develop symptoms of disease earlier than that.
Without interventions such as prophylaxis against TB and other opportunistic infections, the
21

person develops these illnesses and can easily die from it. Therefore it is better to know
your HIV status early, to receive preventative treatment and start ARVs if the CD4 is below
200 which prolong life and survival dramatically.
Due to the difficulty in treating HIV infection, PREVENTION is KEY in controlling the
epidemic through the promotion of SAFE SEX in an attempt to slow the spread of the
virus and treating Opportunistic infections to improve the quality of life of infected
individuals.
The symptoms of AIDS are primarily the result of conditions that do not normally develop in
individuals with a healthy immune system. Most of these conditions are caused by bacteria,
viruses, fungi and parasites that are normally controlled by the immune system. People with
AIDS have increased risk of developing certain cancers such as Kaposi sarcoma, cervical
and lymphomas. The specific opportunistic infections that people develop depend on the
geographical area where they live, but these infections nearly infect every organ in the
system.

3. Common Opportunistic Infections

There are various opportunistic infections but this unit will only discuss some of the
most common ones.
Figure 1: Adopted from: www.avert.org/historyi.htm.

22

3.1 Tuberculosis (TB) is the most common infections amongst HIV infected individuals,
especially in countries with a high HIV prevalence rate. TB progresses rapidly in infected
persons and accelerates the spread of HIV. TB MAKES HIV WORSE and HIV MAKES TB
WORSE. TB transmits easily to infected HIV individuals due to their immunocompromized
system. It may occur in the early stages of HIV and can be potentially fatal, but is treatable.
In Namibia about 70% of HIV infected individuals have TB due to the high burden of TB
disease in the country. The risk of acquiring TB increases from 10% life time risk in
uninfected individuals to 50% life time risk in HIV infected individuals. HIV and TB is a lethal
combination (also referred to as dual infection/dually infected) as both destroys the immune
system and renders the individual to earlier succumb to death if not treated early enough.
TB makes use of the opportunity of a weakened immune system to develop from latent to
active disease and in most cases HIV individuals develops TB at the onset of exposure.
TB is difficult to diagnose in HIV individuals because of the similarity of symptoms, it
progresses faster and if untreated is in most if not all cases fatal. Treating TB and HIV at the
same time (also referred to as dual treatment) is even harder due to drug interactions and
other side effects and makes it harder for individuals to adhere successfully.

23

TB usually presents with symptoms of coughing more than 3 weeks, eventually becoming
productive, night sweats, fever, anorexia and general malaise, weight loss and it may also
involve pleuretic pain and hemoptysis and dyspnoea. In the later stages of HIV disease, TB
present as extra pulmonary (TB outside the lungs in bone, liver, lymph nodes and is
mostly systemic.)
The importance of integrated TB and HIV service provision is very critical and HIV infected
individuals should be protected against TB at all cost by ensuring that health care providers
conduct TB screening at each and every visit by asking the standard questions of (1) early
detection: coughing. night sweats, fever. Losing weight and in contact with TB (2) in case of
no signs and symptoms to provide prophylaxis and explain the importance of adherence
which include INH for 6 months to treat latent TB and protect the individual against
developing active TB.
TB Treatment for active TB disease includes a regimen of medicine according to first line or
second line treatment. Daily observed therapy is very useful to promote and ensure
adherence as interruption of TB treatment can lead to resistance. (More will be discussed in
the fourth year of study)

3.2 Pneumocystis Pneumonia (PCP) originally known as Pneumocystis carinni

pneumonia
Pneumocystis pneumonia is relatively rare in immunocompetent people, but common
amongst HIV infected people. Generally occurs when CD4 is less than 200 and is one of the
first indications of AIDS in untested individuals.
It presents with respiratory systems such as dry cough and chest pain and persistent fever.
Prevention includes prophylactic treatment with Cotrimoxazole when CD4is below 300 to
24

protect the individual. Adherence to treatment is crucial.

3.3 Cryptococcal Meningitis is another mot common life threatening fungal infection when
CD4 is below 100. Early non specific symptoms include fever and headache without signs
of meningeal irritation.
With progression, patients have an altered mental state, neck stiffness and some may have
cutaneous involvement such as moluscum contagiosum. Patients can also develop
pulmonary Cryptococcal disease with or without central nervous system involvement.
Prevention not really possible as it source of environmental transmission remains unclear.
Treatment involves antibiotics for an initial 14 days followed by maintenance therapy of 10
weeks.

3.4 Candidiasis (oral thrush) is a fungal infection very common and is some of the first
clinical signs of HIV infection. It presents as a thick white layer in the mouth, throat and gut
or genital lining.
It causes difficulty in swallowing of food and has a negative impact with nutrition. Treatment
include antibiotics for extended period of time and persons should maintain good mouth
hygiene and be encourage to eat even though it may be painful to maintain nutritional
status.
3.5 Kaposi Sarcoma (KS) is characterized as a tumor of the blood vessel or lymphatic
vessels, either raised or flat, appears dark blue (initial stage of disease) or pink lesions in
the skin, mucus membranes, gastrointestinal tract and lungs. Treatment involves antibiotics
and is symptomatic.

25

3.6 Cytomegalovirus Infection (CMV) normally presents in l the glands and scatter
throughout the body as infection progresses. It is associated with herpes and can cause
blindness. Treatment includes the provision of antibiotics.

3.7 Herpes Simplex (HSV) and Herpes Zoster, they are not life threatening, but painful.
HSV causes sores around the mouth and genitals. Treatment includes the provision of
antibiotics, good general and personal hygiene.
3.8 Unexplained Diarrhoea that is persistent for weeks due many possible causes
including common bacterial infections such as salmonella, Shigella and other. This also has
an extremely negative impact on the nutritional status as the person becomes malnourish
and the ability to eat is decreased due to loss of appetite and can result in drastic weight
loss. Prevention includes maintenance of good general hygiene with food and all other
environmental aspects, eating well balanced food, drinking fluids to replace lost nutrients. In
serious cases individuals are admitted to be rehydrated.
3.9 Sever Weight Loss, most HIV infected persons loose metabolic active tissue which is
linked wit increase mortality, quickens disease progression. The loss of muscle and body
mass leads to the destruction of functional status and strength. If a person loose more than
10% of body mass, it is called wasting Syndrome. Prevention involves maintenance of
good nutrition and treatment involves admission for rehydration.
Note that there is a lot more Opportunistic infections caused by HIV, these are but some of
the most common ones.
Conclusion
Understanding HIV and the diseases related to its progression is of vital importance, not
26

only for the infected individual, but also important for those caring for them.

Unit Four: The Study on Antiretrovirals (ARVs)

1. Introduction
HIV and AIDS has NO CURE The widespread use of ARVs since the mid 1990s has
reduced AIDS related mortality dramatically and improved and extended life for persons
living with HIV (PLWHA). Persons infected with HIV are starting antiretroviral treatment in
Namibia according to the National Guidelines for ARVs. Antiretroviral treatment demands
lifelong commitment once started, and requires support and guidance to clients on an
ongoing basis.

27

Research on a vaccine as treatment is still ongoing after 30 years, but HIV 1 remains a
difficult target for developing a vaccine, thus the treatment of HIV is currently by providing
ARVs, including prevention.
2. Definition of Terms used in HIV Treatment
ART- AntiRetroviral Treatment/Therapy
ARVs- AntiRetroVirals
HAART- Highly Active AntiRetroviral Treatment
Triple Therapy- Three Antiretrovirals
These terms basically means the same.
3. Classes of Current ARVs
Antiretroviral medicines are classified according to their effectiveness in the intervention
/inhibition of the HIV cycle and their names usually refer to the specific step in the HIV cycle.
The ARVs use in the clinical Management of HIV and are categorized into one of five
classes namely:
o 3.1 Nucleoside and nucleotide reverse transcriptase inhibitors (NRTIs and
NtRTIs), (examples include Lamivudine, Stavudine, Zidovudine, and Tenofivir)
o 3.2 Non-nucleoside reverse transcriptase inhibitors (NNRTIs), (examples
include Nevirapine and Efavirenz)
o 3.3

Protease

Inhibitors

(PIs),

(examples

include

Indinavir,

Lopinavir-

retonavir/Keletra)
o 3.4 Entry Inhibitors (Maraviroc (Selzentry) is the only approved entry inhibitor to
use, and Enfuvirtide as fusion inhibitor and these medicines are not available yet in
Namibia) and

28

o 3.5 Integrase Inhibitors (Raltegravir (Isentress) is the only approved integrase

inhibitor and is not yet available in Namibia)

4. The Goal of Antiretroviral Therapy

Standard goals include the improvement of clients life, reduction in complications and
reducing HIV to undetectable levels. It does not cure and does not prevent the return of high
levels of HIV and resistance to treatment, once treatment is stopped. Without ARVs, the
progression for HIV to AIDS vary between 9- 10 years and the median survival time after a
diagnosis of AIDS is 9 months. ARVs increases survival time from between 4 and 12 years.
5. The Benefits of ARVs
ARVs have many benefits to the individual, the family, community and the country at large.
Some of these benefits include:
Decrease in opportunistic infections and hospitalizations
Increase in survival
Decrease in perinatal transmission
Restoration of hope and the opportunity to live long and well with HIV
Maximal suppression of the level of HIV virus in the blood, or viral load
Restoring the function of the bodys immune system
Improvement of quality of life
Reduction of HIV-related morbidity and mortality

6. Typical ARV Regimens

Typical regimens for treatment consist of a combination, also referred to as a cocktail of
two nucleoside reverse transcriptase inhibitors (NRTIs) plus a Protease Inhibitor (PI) or a
29

non-nucleoside reverse transcriptase inhibitor (NNRTI). Medicines are classed such that it
works as effectively as possible in the combination. It is important to note that some
medicines can also not be used in combination due to the risk of drug interaction as in the
case of (Zidovudine and Stavudine). These regimens are normally prescribed for adults.
Table 1: Common ARVs
Nucleoside
Reverse
Transcriptase
Inhibitors
(NRTI s)

Nucleotide ReverseNon-Nucleotide
Transcriptase
Reverse
Inhibitors
Transcriptase
(NtRTIs s)
Inhibitors
(NNRTI s)

Protease Inhibitors
( PI s)

ZIDOVUDINE
(AZT)
STAVUDINE (D4T)
LAMIVUDINE
(3TC)
ABACAVIR (ABC)*
DIDANOSINE
(DDI)
*ABC available in
private sector

TENOFOVIR (TNF)* NEVIRAPINE

*Used for patients with(NVP)
Hepatitis
B
Co-EFFAVIRENZ
Infection
(EFV)

RITONAVIR (RTV) = Booster

INDINAVIR (IDV)
LOPINAVIR/RITONAVIR (LPV)
NELFINAVIR (NFV)*
SAQUINAVIR (SQV)*
*Available in private sector

In children (particularly young infants) HIV disease can progress very rapidly, thus treatment
recommendations are more aggressive. An important aspect of ARV regimens is that it
should never be offered as Mono therapy (one medicine only) and should never be partially
interrupted due to the risks of developing resistance.
7. Namibian ART Regimens
7.1 Table 2: Regimens for Adults
Designation
First Line

Regimen
AZT+3TC+NVP

Alternatives to D4T+3TC+NVP
First line
AZT+3TC+EFV

Comments
Major Toxicities
Preferred first line for adult and AZT- associated anemia and neutropenia
adolescents and safe in NVP Associated hepatotoxicity and sever
pregnancy
rash
NRTI associated metabolic side-effects
Used if patients cannot tolerate D4T Neuropathy and Lipodystrophy
first line, EFV contra-indicated in EFV associated CNS(mood and sleep

30

D4T+3TC+EFV

Second
Options

Salvage
Therapies

first trimester of pregnancy, thus disorders), teratogenicity in pregnancy

effective contraceptive
AZT- associated anemia and neutropenia
NRTI associated metabolic side-effects
Line TDF+AZT+3TC+LPV/r Only used in documented ddl- associated pancreatitis and peripheral
AZT+3TC+ddl+LPV/r clinical , immunological or neuropathy
ABC+ddl+LPV/r
biological failure
AZT- associated anemia and neutropenia
ABC only used on LPV/r available as fixed dose PI- associated lipid and glucose
consultation
with combination, heat stable tablets abnormalities
specialist
with LPV 200mg+RTV 50 mg.
TDF associated proteinuria
NRTI associated metabolic side-effects
Ddl+3tc+IDV+LPV/r
TDF+3TC+IDV+LPV/r

Dual PI regimens to be used in IDV associated nephrolithiasis and skin

extreme cases only. Expert changes
consultation with specialist is NRTI associated metabolic side-effects
required.

Source: Guidelines for Anti retroviral therapy, page 7

7.2 Table 3: Regimens for children
First line Regimen
D4T+3TC+NVP

Second line Regimen

ABC+ddl+LPV/r

7.3 Eligibility for ART in Adults

Medical criteria:
WHO Clinical stage 3 or 4, irrespective of CD4 count or
CD4 cell counts, 200 cells/mm in general population and, 250 cell/mm in pregnant women
irrespective of clinical stage and
Social criteria:
Having a fixed address for past three months
Ready access to a designated treatment centre
Not abusing alcohol, no untreated underlying psychiatric conditions. Be committed to
lifelong treatment, strict adherence, practicing safe sex and allow for home visits if indicated.

31

7.4 Eligibility for children

Childrens immunological response is better than that of adults, they restore CD4 counts
much better and more rapidly. It is important to know that when a child gets better he/she
gains weight; there is a need to adjust the dosages which are calculated by body surface
area.
o Medical criteria: in < 18 months of age and proven HIV infection

WHO Pediatric stage 3 or 4 regardless of CD4%,

WHO Pediatric stage 1 or 2 only if CD4 is < 25%
o Medical criteria: in > 18 months of age and proven HIV infection
WHO Pediatric stage 3 or 4 regardless of CD4 %,
WHO Pediatric stage 1 or 2 only if CD4 is < 20%
8. HOW does ARVs work?
ARVs reduce the ability of the HIV to replicate
In turn, this increases the ability of the body to fight disease
As HIV decreases replication
The immune response increases
The importance of adherence is vital to suppress viral loads (inhibiting the viral cycle) to
undetectable levels for absolute effectiveness of ARVs. Unit seven provides more
details on adherence.
Figure 1: The Classes of ARVs and the intervention on the cycle of HIV (Refer to
arrows)

32

NRTIs
Zidovudine
(AZT)
Stavudine
(D4T)

NtRTIs/ NNRTIs
Tenofivir (TNF)
Nevirapine (NVP)
Efavirenz (EFV)

Adopted from training information developed by MOHSS, 2008.

Figure 2: Targets of Antiretroviral Drugs

33

PIs
Ritonavir (RTV)
Indinavir (IDV)
Lopinavir/Ritonavir
LPV

Source: www.avert.org/historyi.htm.

9. The economic issues related to ARVs in developing countries

ARVs are expensive and the majority of people do not have access to medicine
and treatment for HIV and AIDS.
The cost of medicine is not only the medicine itself, but includes the additional
services provided such as testing, counseling, clinical review and other. Donor
support may become less as years go by, so self sufficiency of the country is an
aspect of concern.

34

 Though the current combination of ARVs for Namibian clients are effective and
adequate, developing countries cannot afford ALL ARVs available on the
market, such as Entry and Fusion inhibitors or integrase inhibitors due to the cost
associated with these medicines.
Though medicine maybe available in country, it may not be accessible to all: (lack
of transport, lack of trained staff and or medicines at nearest facility, clients not
meeting social criteria).
Lack of sufficient nutrition to adhere to treatment is another serious concern for
PLWHA, agricultural and self help programmes needs to be implemented.

10. The use of alternative medicine has little effect on the mortality and morbidity of HIV,
but may improve the quality of life of individuals. Acupuncture has been used for peripheral
neuropathy, but it cannot cure AIDS. Test of herbal medicines has proven no added benefit,
but may rather produce serious side effects. Vitamins and minerals may reduce disease
progression, whereas Selenium can be used as additional treatment as it is associated with
improvement in CD4, but cannot in itself reduce mortality and morbidity.
Conclusion
The provision of ARVs is life saving and improve the quality of life, reduce mortality and
morbidity. It is important to understand the different regimens chosen by Namibia, the
eligibility criteria and how ARVs work in inhibiting the viral cycle.

35

Unit Five: Monitoring of Anti-retroviral Therapy

1. Introduction
Monitoring for effectiveness of anti retroviral therapy involves different important activities
and these include:
2. Baseline Diagnosis and ongoing Clinical Monitoring
This is based on clinical assessment and medical history including past medical history
(illnesses, for example tuberculosis), hospitalizations and surgical interventions, time past
since diagnosis of HIV infection. In addition, current medical signs (symptoms) are also
taken into consideration. Women are provided with information on dual contraception and
can plan safe pregnancies. Vital signs include the monitoring of weight, any abnormalities of
eyes (fundi) oropharyns lymph nodes, lungs, heart, abdomen, extremities, nervous system
and genital organs, including examining for STIs.
First follow up visit should be after the first 2-4 weeks after initiation of therapy, which is
useful for evaluation and reinforcing adherence to anti retroviral therapy. Monthly visits
should be scheduled for clinical review, reinforcing adherence, encouraging disclosure and
partner referral and testing of children, and identifying problems which may require referral
to the next level. These visits should also identify any side effects of the treatment, and
providing information on how to cope with these to promote adherence. As the time of
treatment and associated adherence levels and success improves visits can be scheduled
on a 3 monthly to 6 monthly basis.
3. Clinical monitoring for toxicity and effectiveness of ART
The patient should know about side-effects and potential toxicity, in order to be aware and
seek care and assistance when necessary. The clinical evaluation of effectiveness of ART is
36

important with the basic parameters examined as follows:

The perception of the patient on how he/she is doing on therapy;
Any changes of weight;
Any changes in the frequency or severity of symptoms (e.g. fever, diarrhea, etc)
Any physical findings signs e.g. immune reconstitution (lymph nodes swelling),
disease progression (e.g. or pharyngeal, vulvo-vaginal candidiasis, Lipodystrophy,
etc.)
4. Laboratory Monitoring
The basic laboratory monitoring includes 3 categories of tests for a patient having HIV
infection. These are:
HIV diagnosis to confirm the existence of the infection. This is prior to initiation of
therapy.

Monitoring the therapy effectiveness viral Load (V.L.) and CD4 + cell count.
(discussed in unit four)

Monitoring of drug related toxicities by chemistry and hematology assay. (This

aspect of ARVs will be discussed in more detail in the fourth year of study.)

The recommended initial laboratory tests before ART are:

An HIV antibody test to confirm HIV infection,
A hemoglobin or haemotocrit level,
A white blood cell count and its different types,
Serum alanine or aspartate aminotransferase level to see the possibility of hepatitis
(monitoring hepatoxicity) ,
Serum creatinine to see renal function,
37

 Hepatitis B surface antigen,

Amylase to see the pancreatic function and ,
Pregnancy test for women.
4. Monitoring of side-effects
Though ARVs has a lot of benefits, it has, like any other medicine also some side effects.
Only about 5% of clients on treatment experience serious clinical side effects, whereas up
to 50% of clients may have less than optimal results on ARVs. The issues involved is many
fold and can include medicine intolerance, ineffective prior treatment, infection with drug
resistant strain of HIV, non-adherence and non-persistence.
This can be a worry for clients and they need reassurance and information on how to handle
side effects effectively.
All Antiretrovirals have medicine specific side effects and these are summarized in unit four
in the table 2, however the three categories of side effects are briefly discussed in this unit.
(More elaborate discussions of medicine related side effects are dealt with in the fourth year
of study). This does not prevent students from reading about it in the guidelines.

4.1 Side effects can be put into three different categories.

Common side effects (uncomfortable for client but not dangerous) and include
symptoms like nausea, headaches, dizziness, diarrhea, feeling tired and muscle
pain. It usually occurs when treatment begins, but gets better within two weeks.

Potentially serious side effects, these may include pallor, yellow eyes, severe
abdominal pain, and rash. These symptoms can be life threatening and the clients
should seek medical care urgently.
38

Side effects later during treatment can occur when on treatment for months or
even years. The most common is abnormal fat distribution (fat gain on abdomen,
breast, shoulders, neck and sometimes fat lumps under the skin) and (fat loss from
arms, legs, buttocks and face)

4.2 Managing side effects

General information
Health care workers should discuss the very common side effects with clients before
starting treatment and give advice on how to manage it.
Clinical review with follow up should always involve discussion on side effects even
when client does not mention any.
Clients should be warned of potential side effects and when to seek medical care.
Side effects should be given immediate attention.
It should be noted that the management of side effects has a direct relation to
nutrition and this will be discussed in more detail in unit seven.

4.2.1 Managing some specific side-effects: What clients can do:

Nausea and Vomiting
Take medication with food if possible, take frequent small meals, avoid greasy, spicy and
fatty food, and take small sips of clean boiled water to maintain hydration
Headache

39

Take some rest in dark room, put cold cloth over eyes and forehead, if symptoms persist,
see nurse
Diarrhoea
Eats small meals more times a day, soft easy to digest food, avoid greasy spicy and fatty
foods, drink lots of fluid / clean boiled water to maintain hydration
Rash
Keep skin clean and dry, Use mild soaps, plenty of water to keep skin hydrated, if rash
persist, see nurse immediately
CNS symptoms (Nightmares, Sleeplessness, Sadness or Worry)
Avoid heavy meals before sleeping, avoid alcohol or drugs, and talk about feelings with
friends or family.
Fatigue
Rest as must as possible, have a routine, avoid alcohol and drug use, do light physical
exercises as it may help, eat diet that includes fruits and vegetables
Numbness, tingling or burning of feet
Wear loose fitting socks and shoes to protect feet, keep feet uncovered in bed, soak feet in
lukewarm water, and dont walk too much at a time
Lipoatrophy/ Lipodystrophy- fat redistribution
Refer to the Nurse/ Doctor for management

5. Monitoring of Resistance in ARVs

Resistance results from changes in genetic information of the virus; these changes are
called mutations. Whenever HIV is replicating or growing, these mutations can occur.

40

Some mutations in the virus allows it to resist the effects of one or another
antiretroviral medicine which leads to medicine resistance which basically
means that those specific medications will no longer be effective in controlling
the multiplication HIV.

Resistance occurs with therapy that is not potent and the patient with HIV will
develop medicine resistance if treated with only 1-2 medicines.

Resistance also occurs with missed doses, if the patient misses 3-4 doses
per week can develop medicine resistance

5.1. Effects of Resistance

Medicine resistance limits activity of current medicine regimen and limits future options. As
ART combinations fail which results in HIV progression and damaging of the CD4 cells,
leading Opportunistic Infections and other illness.
5.2 Preventing Resistance
Using HAART (Triple therapy), pperfect (100%) patient adherence to ART
Excellent patient education and preparation before starting ART
Support from the HCW and family to help the patients have perfect adherence
Identify the barriers to adherence and ways of overcoming them
Managing side effects
Regular patient follow-up and monitoring of viral loads and CD4 according to
protocol/guidelines
Note that resistance is discussed in more detail in the fourth year of study.

6. Other issues of concern in ARV management

Cross-Resistance resistance to one in class of drugs influence on the rest in class
41

 Infection with Drug-Resistant HIV limits options for treatment

Adverse Reactions adjust or change treatment, in cases stop all together

Drug failure-slow in reducing viral load (VL), side effects may be severe, intolerable
and life threatening requiring a change in treatment.

6.1 Changing Treatment

Monitoring of VL is important.
Early change in treatment, though this may increases the risk of running short of
(options) combination.
Late change in treatment may be recommended, but this also has the danger of
developing induced resistance to certain drugs and may limit future options.

6.2 Salvage Therapy

Salvage therapy is the combination of ARVs used other than those used in 1 st and 2nd
treatment. This is also called also 2nd line, 3rd line or Rescue Therapy
With higher level of viral load (VL), it puts great pressure on it to succeed to get
lesser VL, but there are chances to develop drug resistance.
Examine the choice of new treatment depending on the causes of the failure and
consult a consultant physician.
Conclusion
The management of ARVs is critical in effectiveness not only for individual clients but for the
family and community as a whole. The many issues and aspects that have an influence on
its success and effectiveness are interrelated. Carefully considerations should be employed
at all times.

42

Unit Six: Adherence in Anti-Retroviral Therapy

1. Introduction
To understand Adherence in the context of ARVs, the term Compliance has to be
understood. Traditionally in the world of medicine, patients have to comply with medical
instructions as it forms the patient-provider relationship where the doctor/nurse tell the client
what to do and the instructions are followed without question.
Adherence in ARV treatment is not compliance; it indicates that everybody (the clinical tem
and the client and in cases the family) is working together, and that the client is willing to
make behavior changes to improve their health. It engages the participation of the client in
the plan of care. Adherence involves adherence to care and treatment and works with the
understanding of the client, his/her consent and in partnership towards achieving the best
outcome for the client. It is not merely to comply with what the health care system wants.
Studies have shown that to be effective, adherence to ART which is greater than 95% is
needed.
ARVs brings about improvements in a clients life by reducing mortality and morbidity. Very
high levels of adherence, 95% are required to achieve sustained suppression of HIV levels
over time Guidelines for ARVs Namibia which can be seen in table 1 as adopted from the
guidelines. However, there are some cases of unsuccessful adherence due to mainly
medication intolerance, infection with drug resistant strain of HIV and non persistence. It has
43

been shown that increasing rates of adherence to HAART leads to successful reduction of
viral load increase in immunity, and thus increased quality of life and prolonged lifespan.

Table 1. Correlation between adherence and virologic response to HAART

ADHERENCE TO HAART
VIRAL
LOAD
<
400c/ml
>95 adherence
78%
90% to 95% adherence
45%
80% to 90 % adherence
33%
70% to 80% adherence
29%
<70% adherence
18%
Note adherence percentages
are calculated as the number
of doses taken over number
prescribed
2. Factors that may have implications on Adherence.

Patient-Provider Relations:
Provider/ Patient relationship (trust /satisfaction/ confidence),
Attitudes of health care providers and confidentiality,
Patient education and understanding of the multiple issues involved,
Adequate preparing through adherence counseling,
Accessibility of appointments, medication.
Clinical Setting
A friendly, supportive and non-judgmental setting ,
Convenient appointment schedules according to ability of client to attend,
44

 Confidentiality/privacy,
Health care providers level of understanding of ART,
Provider variables culture, attitudes, bias

Patient Variables
Understanding of the regimen and the associated side effects and how to manage it
and persist under difficult circumstances,
Substance abuse and depression,
Disclosure and partner(s) referral, issues of safe sex and condom use,
Appointment keeping and the feasibility thereof , missing it due to aspects beyond
control,
Health beliefs and attitudes/ competing beliefs (traditional, religious),
Perception of self -control over illness and situation,
Preparedness in general with family and at work,
Social support from health care providers, family and work,
Stigma and discrimination associated with illness
Treatment Regimen
Complexity of the regimen, including multiple doses and the possibility of forgetting
and missing doses,
pill burden leading to pill fatigue, (i.e. many pills to take at various times),
Specific food and fluid requirements and if ignored may result in less absorption of
medicine and thus resistance,
Side effects leading to the client stopping to take medicine or taking it irregularly
45

leading to resistance.
Disease Characteristics
Treatment adherence for conditions that are not symptomatic tends to be poorer than
for those that affect the patients quality of life , this problem is typically worsened by
the emergence of side effects
Patients on ART who have experienced an OI are more likely to adhere to treatment

3. Benefits of adherence
Adherence is the most important factor for successful ARV treatment and improved health
status. Poor adherence is the most frequent cause of treatment failure and the development
of resistance.Excellent adherence results in maximum and lasting suppression of viral
replication slows mutation and thereby viral resistance. Excellent adherence reduces
development of resistance to medication and has public implications.

4. Managing and supporting Adherence

4.1 Measuring Adherence
There are various ways to measure adherence to treatment and these includes:
Self-reporting by the client on his/her visit on how treatment is taken which should
involve asking questions and verifying the different pills (pill identification test) and
how and when they are taken,
Pill counts that should be performed by the health care provider to calculate if all
doses was taken accordingly and thus determine adherence percentage,
Pharmacy records and the client card can provide useful data on adherence over
46

time
Biological markers such as CD4 count and viral load testing can also indicate if client
adheres to treatment.

4.2 Preparing for adherence

Clients need sufficient preparation for successful adherence and different sessions are
conducted before actual treatment commence. (More information on these aspects are
discussed in Psychological Counseling III)
Provide the recommended pre-adherence counseling sessions as per guideline to
prepare client for the road ahead, using the protocols available,
Identify the potentially poor adhering patient (look at records of Cotrimoxazole and
INH adherence, can be a good indicator))and address the barriers to adherence
during counseling before first ARV prescription,
Identify a treatment supporter (adherence partner or buddy),
Provide Initiation counseling to clarify all outstanding matters and prepare client for
his/her specific regimen of treatment, include supporter if possible,
Generate daily-due review and refill list and flag absent patients,
Provide on-going counseling per protocol at each visit to existing and identify
potential problems that may interfere with successful adherence,
Refer to community-based health care workers and NGOs,
Use DAART or modified DOT (practiced at health centers, CBOs, or at patients
home),
Use incentives and enablers (e.g., having income-generating projects for caregivers
or providing transport on clinic days or food)

47

Conclusion
Excellent adherence to ART is essential for successful ARV treatment and improved health.
Poor adherence is the most frequent cause of treatment failure and the development of
resistant strains of HIV and the consequences of poor adherence are poor health outcomes
and increased health care costs. Though adherence is difficult there are effective strategies
that can significantly maximize adherence by identifying the issues of concern, regular
follow up and support.
Unit Seven: Nutrition and HIV
1. Introduction
Nutrition is the provision of food to the body to support life. Food provides carbohydrates
(the building blocks), proteins and fats (the macronutrients), vitamins and minerals (the
micronutrients) to the body in adequate and a balanced quantity, from there the term
Balanced Diet. Nutrition is also called nourishment or aliment. A Balanced or Healthy Diet
can prevent many of the most common health problems. Food is the foundation of
nutritional health. We cannot replace food, we can only supplement, adjust, increase or
decrease the amount of food intake.
Good or adequate nutrition in HIV can mean different things at various stages of the HIV
disease. In the early stages of disease, eating a relatively balanced diet may be adequate,
however as the disease progresses, minor health problems may occur which may influence
the appetite (fever and nausea) or ability to eat (mouth sores or thrush) and will require
adjustments to eating habits and types of food to maintain a healthy diet.
2. The four main food groups
2.1Carbohydrates

48

These are the most affordable food and form the backbone of the diet. They are the foods
that give energy and include starch such as bread and rice; they are digested easily and
provide energy fast. Other carbohydrates include whole grains, beans and peas and provide
more fibre and slowly raise the sugar and energy levels. Carbohydrates should be taken
with each meal as they are affordable, nutritious and satisfying. PLWHA needs extra
carbohydrates to get more energy and calories to fight infections and prevent weight loss.

2.2 Proteins
The main sources of proteins include meats, fish and shellfish, poultry and eggs, legumes
(dried beans and peas) and soy products, nuts and seeds, milk and dairy products
Proteins have many important functions; they are used to make cell structures, hormones,
enzymes and components of the immune system, which protects the body from infections,
like the CD4 cells. They are very important and critical in the diet of PLWHA and should be
taken in higher amounts to help them maintain lean body mass and fight off opportunistic
infections by providing building blocks for the immune system. When there are infections,
there should be a higher protein intake with high calorie intake to improve recovery. Proteins
should be taken at least three times a day.

2.3 Fats
Fats and oils are the concentrated source of energy in food supply and are needed in small
amounts only. Some fats are necessary in the diet as it provide building blockscalled
essential fatty acids, which the body cant make. Fats are required to provide energy, the
building of cells and it helps with the absorption of vitamins such as A, D, E and K. PLWHA
does not necessarily need too much fat as it may have a negative outcome for some of the
49

medications, however small amounts are needed to help them gain weight. Healthy fats
include monounsaturated fats and omega-3 fatty acids. Other healthy fats include olive oil,
canola oil, flax oil, nut oils, nuts, avocados.

2.4 Vitamins and Minerals

These are needed to regulate chemical processes and protect against diseases. Many
vitamins (17) and minerals (14) are required in the body to function properly and these can
be maintained by eating a variety of food such as fruits and vegetables, cereals and milk
products. Because most foods only have a small amount of vitamins and minerals it is
important to eat a variety of food every day.
2.5 Water (Essential for life!)
Water and fluids are required to keep the bodys cells working smoothly. Because we lose
fluid through urine, stool and sweat, it needs to be replaced each day. An easy-to-remember
rule of thumb is to drink 8 glasses of water a day. However, the amount of fluid needed
depends on body size and how much water is lost. Water also plays a vital role in the
building of cells and it regulates the body processes.
A well hydrated body helps to process medication more effectively. It is important for
PLWHA to always ensure that they have safe drinking water and if not, water should always
be boiled. Boiling should take at least five minutes and water can then be cooled before
drinking. Juices and cool drinks, tea and coffee also contain water, however coffee is not
good because the caffeine it contains dehydrate (dries out) the body.

3. Nutrition and your immune system

50

3.1 The immune system needs good nutrition to function well. Nutrition plays a major
role in immunity and the ability of the immune system to respond to infection. The nutrients
from food, keep the immune system strong in many ways. For example, the skin and linings
of the lungs and intestines provide the first line of defense by acting as physical barriers to
infections/invaders such as viruses and bacteria. These barriers are very sensitive to
nutrition, especially vitamin A, and deteriorate when people dont get proper nutrition. When
this happens, viruses and bacteria have easier access into the body.
Another example is that the body defends against infections/invaders by using different
types of immune cells. To protect the body, the immune system (cells) requires energy,
proteins, vitamins and minerals. If people do not eat healthy, they lack the key nutrients and
this weakens the bodys ability to fight infection.
3.2 How HIV affects nutrition
Nutritional issues are common in HIV disease. Problems can be related to HIV infection
itself and to the effects of the medications. For example, the virus infects some of the
immune cells in the intestines which cause local inflammation and reduce efficient
absorption of nutrients and medicines. This can result in weight loss or deficiencies in
vitamin and minerals.
The nutritional needs of people with HIV are more and greater because the body has to
work overtime to deal with a chronic viral infection and to fight off opportunistic infections.
Other critical aspects involve poor appetite, fatigue, nausea and other side effects of
medications that make it hard to eat well.
HIV affects nutrition in three sometimes overlapping ways:
Causes decrease intake of food
Interfering with the digestion and absorption of nutrients and it
51

 Changes the bodys metabolism, (absorption and use of food and nutrients)
Decreased food consumption
Decreased food consumption may result from the following factors:
Inability to eat or swallow (painful sores in the mouth and throat)
Loss of appetite (fatigue, depression, and other changes in the mental state)
Side effects of medications (nausea, loss of appetite, a metallic taste in the mouth,
diarrhea, vomiting, and abdominal cramps)
Reduced quantity and quality of food in the household (inability to work, reduced
income, lack of family awareness and or support)
Nutrient and food absorption
Poor absorption is caused by the following:
HIV infects the intestinal cells, that damages the gut, even in people with no other
symptoms of infection
Increased incidence of opportunistic infections such as diarrhea, which is a
common cause of weight loss in people living with HIV
Poor absorption of fat reduces the absorption and use of fat-soluble vitamins such as
vitamins A and E. This can further compromise nutrition and the immune status.
Changes in metabolism
Changes in metabolism in HIV-infected people occur as a result of the immune systems
response to HIV infection.
When the body reacts to the HIV infection, it releases pro-oxidant cytokines and
other oxygen-reactive species. These results amongst others in anorexia
(causing lower intake of food) and fever (increasing energy requirements),
52

 If the infection is prolonged, muscle wasting occurs because muscle tissue is

broken down to provide the amino acids with the immune protein and enzymes
they need which increases energy requirements of people living with HIV/AIDS
during the asymptomatic phase by 10 percent over the level of energy intake
recommended,
The body also responds to this release of pro-oxidant cytokines by increasing the
demand for antioxidant vitamins and minerals, such as vitamins E and C, zinc,
and selenium. These vitamins and minerals are used to form antioxidant
enzymes. Oxidative stress occurs in an imbalance between the pro-oxidants and
antioxidants, when there are not enough antioxidants to meet the demands of the
pro-oxidant cytokines. This stress is believed to increase HIV replication and
transcription, leading to higher viral loads and disease progression. For this
reason, many studies have examined the impact of antioxidant vitamin
supplementation on HIV transmission and disease progression.
More information on this is available from local pharmacists and the web, important is to
note that these supplements should NEVER replace the intake of food which at times
occurs where clients use the only available money to buy these products in the hope that it
will improve their nutritional status.
HIV/AIDS-associated wasting syndrome
Wasting syndrome is a multifaceted complication of HIV that is well known to increase
morbidity and mortality. Studies have found a relationship between body cell mass changes
and the progression of HIV disease:
A progressive depletion of body cell mass in the late stages of HIV disease and
Significant prolonged survival in patients with body cell mass of > 30 percent of body
weight or serum albumin levels exceeding 3.0g/dl
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 There may be many other causes of AIDS-wasting syndrome and these include
reduced energy intake, gastrointestinal disorders including diarrhea and
malabsorption and other metabolic issues.

Changes in body composition

In general severe illness reduce the ability of an individual to maintain normal food intake
due to many varied reasons, which in turn causes reduced absorption of nutrients to meet
energy needs. The result is usually weight (fat mass) is lost during this period of time, but
when health is restored, the individual regain weight and body mass soon as normal eating
habits return. In normal people not infected with HIV, fats are stored in adipose tissues and
are catabolized to fuel the body energy needs, thus sparing amino acids needed to build or
preserve lean body mass.
However, with HIV/AIDS, the opposite occurs. The amino acids are used to fuel energy
needs, while fat continues to accrue. The patient may consume adequate nutrient levels
but utilizes and stores them inadequately. The patient has excess adipose tissue in
proportion to lean tissue as the body converts the digested nutrients into fat instead of lean
tissue. With high triglyceride levels in the blood, resting energy expenditure is increased.
The underlying causes of an HIV-infected persons inability to preserve or regain lean tissue
remain unknown.
4. Malnutrition and HIV
The impact of HIV disease on the Nutritional status of the infected individual varies over the
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period of disease progression. However it is important to start early on managing nutrition

so as to avoid some of these deficiencies which at times can be fatal. Malnutrition and HIV
negatively affect each other. HIV infection usually results in poor nutrition as a result of
insufficient intake of food, malabsorption due to infections and altered metabolism. This
cycle presents the following results:
Weight loss, the most common and often disturbing symptom of HIV, reported in 95
percent to 100 percent of all patients with advanced disease due to loss of muscle
tissue and body fat,
Deficiency in Vitamin and minerals,
Reduced immune function and competence and thus increased susceptibility to
secondary infections and
Increased nutritional needs because of reduced food intake and increased loss of
nutrients leading to rapid HIV disease progression
5. Managing Optimum Nutrition in HIV.
This refers to managing HIV related symptoms with food and other nutritional practices to
improve on food uptake and nutrient uptake to prevent malnutrition and thus improve the
overall health and nutritional status of the individual. Overall much of these symptoms
relates to food intake and makes it thus uncomfortable for clients and in the process they
loose much needed nutrition and the diseases progresses faster as the body becomes
weak.
Managing nutrition involves and has as its goal to alleviate the symptoms, reduce
discomfort and improve nutrition and the best way would be to use locally available food.
Management will have to be innovative by adding more flavour to food to encourage client
to have the urge to eat, present it more appetizing and in smaller, digestible portions at
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times more helpful and perhaps eating with the person to stimulate appetite so as to provide
more comfort, lessen pain associated with mouth sores, prevents dehydration,
complements medical treatment and the immune system.
Important to note that there is no magic approach to managing nutrition in HIV, but rather
being aware of what food are available at home, giving appropriate guidance on how to
improve intake of food and how food actually reduce these symptoms and at all times
ensures that clients have access to food and to refer for nutritional support if required.
Nutritional advice is of no substance if given in an environment where none is available,
therefore the need to know the situation of clients to relate advice accordingly. Refer to the
National Guideline on Nutritional Management for People living with HIV/AIDS.

Conclusion
HIV affects nutrition by decreasing food consumption, impairing nutrient absorption, and
causing changes in metabolism and HIV wasting syndrome. The overall nutritional status
also affects HIV disease progression and mortality. It is thus of utmost importance to
improve and maintain good nutrition to prolong health and delay HIV disease progression.
Counseling and other interventions to prevent or reverse weight loss are likely to have the
greatest impact early in the course of HIV infection.

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Unit Eight: Living Positively

1.Introduction
Living positively is a phrase commonly used to refer to the interrelated issues and
circumstances with which individuals have to deal with following an HIV positive test
result. A booklet /note book developed for community workers in Southern Africa
called: Antiretroviral Treatment Skills and Knowledge (ASK) describes it as a
journey to a future full of possibilities.
Living with HIV involves a complexity of issues and circumstances which needs
careful understanding and comprehension to fully appreciate the implications it has
on individuals, the family, community and the world at large.
BEGINNING TO ACCEPT
Acceptance/Denial
Counseling
Support groups

Resigning/difficulty thinking about future

Think that it is possible to go on living

LEARN ABOUT
HIV + STATUS
Shock, denial,
frustration, anger,
guilt, suicidal, pain

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Access to ART, Counseling,

support from support
groups/family/others

HOPE AND
POSITIVE
LIVING
Laugh again
Plan life
Work well
Love again
Contribute to
community
development

Feel like its end of

life

Neutral zone looking for

something /someone to hold on

New beginning

Adopted from: Antiretroviral Treatment Skills and Knowledge (ASK), page 26

2. The components of Positive Living
2.1Acceptance of status
No person can continue with a normal live without accepting the diagnosis of HIV, including
understanding the various issues involved towards improving their life. Some people are
better prepared to receive an HIV Positive test result than others and it may have various
psychological effects a person, which is not a onetime situation, thus not a case of a once
off discussion, but rather a long term process of the client being willing to be assisted to
work through the issues in counseling and ongoing counseling and in cases may involve
referral to other professionals who are more competent in dealing with specific aspects.
People always experience grief upon learning that they or their partners or a friend is HIVpositive. Grief is multidimensional; it can be experienced on all levels of the person in
the heart (feelings and emotions), the mind (thoughts), the spirit (meaning of life), and the
body (physical manifestations). It is a time of transition from the time of diagnosis, through
the process of being ill every so often, through times of good health to the days of serious
illness and preparing for impending death.
People living with HIV may mourn the loss of good health and these may include:
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 Denial It cant be true

Anger- Why me?
Bargaining- Maybe if ..
Depression Its all over (past losses)
Acceptancea resignation, letting go, but memories still remain. Not always
pleasant/happy
The stages are fluid, and an individual may move in and out of them in their unique
individual manner and tempo. The importance of counseling should be explained to the
individual to help the person deal with spoken and unspoken feelings, overcome difficulties
of readjustment and set goals for a new beginning to take on the illness with its issues and
prepare strategies to cope as effectively as possible.
2.2 Disclosure
To disclose HIV status can be very difficult to do, but needs to be done when ready so as to
get the required support from those closest to the individual. However, it should be done
with the necessary caution and careful planning which should include identifying who to
disclose to first (most understanding and supportive), finding a private, quiet place and time
for the discussion and request that the discussion be kept confidential, developing a list on
what to say and how to say it and practice to do it and anticipating both supportive and nonsupportive responses and how the responses may make the individual feel. Disclosure
makes it easier to cope, especially when partner and family are understanding, they can
provide much needed support.
A treatment supporter is of vital importance with whom client can discuss the test result
and who can offer support in the immediate term, but also on a long term basis and who
may help in disclosure and future planning and with other coping mechanisms.
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Support groups can be of vital importance as it help the individual to share experiences on
the challenges with the disease and get some helpful advice on issues of concern, however
people should be aware when joining support groups they should have had worked through
self acceptance and be willing to be known as being infected by a wider group of people.
Support groups can also be of help in religious issues to assist in dealing with the grieving
process and the issues related to Why me? And help building a relationship with GOD
towards spiritual healing.
Disclosing to children should be considered carefully as it can be stressful for children
as they are highly perceptive, (especially older ones) who often know something is wrong
even if the parent has not disclosed. It can relieve the stress of uncertainty and help with
communication and building trust and openness by talking about their status. Its best for to
learn about it from the parents themselves, so they can address the fears children may
have. Disclosure to children and family can actually lower the levels of depression of the
parents. The decision to tell a child that a parent or parents are HIV-infected should be
individualized to the childs age, maturity, family dynamics, social circumstances, and health
status of the parent. The reaction of children depends on their relationship with parents.
Disclosure may initially cause stress and tension and parents should be aware of this and
handle it appropriately. Parent should also consider disclosing to other adults close to the
children to help them share this burden and develop a network of support. Before
disclosing, parent should have made peace with their status (not to disclose when having
feelings of anger, frustration and depression).
2.3 Prevention of transmission to others
The risk of sexual intercourse without condoms is very high even though on treatment and
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even though partner is also infected. The use of condoms also prevents other sexually
transmitted infections and protects against unplanned pregnancies. Sexual desires will
return after treatment works well, thus the options to abstain, delay continuation of sexual
activity and consistent and correct use of condoms should be considered. Sexual activity
includes a second individual, to whom disclosure should be done. The myths associated of
having sex with a virgin and other should be discussed and clarified. Client should build
confidence in condom use negotiation and the correct use of condoms as well as initiating a
risk reduction plan to protect self and others from HIV and other STIs.

2.4 Nutrition
Nutrition is the provision of food to the body to support life. Food provides carbohydrates
(the building blocks), proteins and fats (the macronutrients), vitamins and minerals (the
micronutrients) to the body in adequate and a balanced quantity, from there the term
Balanced Diet.Food is the foundation of nutritional health. We cannot replace food, we can
only supplement, adjust, increase or decrease the amount of food intake.
Good or adequate nutrition in HIV can mean different things at various stages of the HIV
disease. In the early stages of disease, eating a relatively balanced diet may be adequate,
however as the disease progresses, minor health problems may occur which may influence
the appetite (fever and nausea) or ability to eat (mouth sores or thrush) and will require
adjustments to eating habits and types of food to maintain a healthy diet. The nutritional
needs of people with HIV are more and greater because the body has to work overtime to
deal with a chronic viral infection and to fight off opportunistic infections.
Advice the client to avoid refined sugar and sweets as it increases the risk to develop oral
and dental problems and slows the healing of ulcers and sores/thrush. Locally available
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food should be encouraged, small meals throughout the day to help with digestion and
sprinkling of orange juice over fatty food to help with digestion. Advice should include to
encourage client to start own garden, to eat locally available food such as mahangu, ground
nuts, Mopani worms, seek food assistance early enough and advice/refer clients to
appropriate support groups or organizations who need social assistance.
Optimum Nutrition in HIV is required to prevent malnutrition and wasting syndrome, help the
body to fight disease and infections and delay disease progression, get and maintain a good
body weight and overall strength and help with effective medicine absorption and generally
improve the quality of life and productivity of PLWHA.
A well hydrated body helps to process medication more effectively. It is important for
PLWHA to always ensure that they have safe drinking water and if not, water should
always be boiled. Boiling should take at least five minutes and water can then be cooled
before drinking. Juices and cool drinks, tea and coffee also contain water, however coffee is
not good because the caffeine it contains dehydrate (dries out) the body.
Safe storage of drinking water is important for PLWHA as their immune systems are
compromised and the drinking of unsafe water can cause unnecessary diarhoeal disease
that can be detrimental to their health. Studies have also shown that safe drinking water
reduces diarhoeal disease by over 30%. Having access to safe water increases and
improves time spent to care for PLWHA, time that would have been spent collecting water.
It is therefore important to ensure safe water at the point of use by, storing water in clean,
close containers and use water purifying tablets or use chlorination in cases of flood
situations.

2.5 Planning for the future, including Family Planning

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Pregnancy status in the case of female clients is assessed and if pregnant advice on
PMTCT. Family planning in HIV infected persons is vital in that planning for a pregnancy
involves the risk of HIV transmission and STIs because of having unprotected sex. Dual
protection (contraception, usually injectable to prevent unintended pregnancy and
condoms to protect against STI, including HIV) should be discussed and provided. Safe
family planning education can be considered for individuals who have no children and
would like to have (unprotected sexual intercourse during ovulation period) and for this the
doctor can be involved. If no more children are planned, the client can consider tubal
ligation (sterilization) and discussed the dangers of pregnancy termination in unsafe
situations.
Disclosure will also enhance planning for the future of children and other members of the
family as it will now involve them and better decisions can be taken.
The drawing up of a will can be considered to ensure all aspects of the family are taken
care of, especially where children are involved.

2.6 Treatment and Adherence

The provision of information on referral for opportunistic infections, including TB prevention
though prophylaxis and ARV treatment options is discussed to clarify early on when ARVs
is available and the importance of prophylaxis.
The realities of side effects and its management should be known by client to effectively
managed his/her treatment and know when to report to the health care provider.
Adherence is the most important factor for successful ARV treatment and improved health
status. Poor adherence is the most frequent cause of treatment failure and the development
of resistance.Excellent adherence results in maximum and lasting suppression of viral
replication slows mutation and thereby viral resistance. Excellent adherence reduces
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development of resistance to medication and has public implications.

2.7 Healthy lifestyle
Body Cleanliness
Health problems that emanate from failing to keep the body clean which can include
scabies, bad body smells. Wash body with clean water and soap daily and take a bath at
least once a weak (based on the weather condition and nature of work). Washed or clean
clothes should be dressed after washing the body.
Teeth and gum (mouth) hygiene
The teeth and gum can be easily attacked by diseases from failing to keep oral hygiene.
Health problems that emanate from failing to keep mouth hygiene include bad mouth
smells, teeth decay, tooth ache and ulcers/sores of the gum. Wash mouth with clean water
in the morning and before going to bed, wash /rinse mouth with clean water after meals.
Regularly brush or clean the teeth with chop sticks or tooth cleaner. (Each person should
have their own tooth brush or tooth cleaner) and avoid sweets and sweet food.
Hygiene of the hands and fingers (optimal hand washing)
Hands become easily contaminated since it is used to touch different surfaces. Keeping
hands clean and fingernails cut is important. Fingernails that are long or not cut properly can
harbour germs. Always ensure that hands are protected against accidental injury and if
injured, clean and cover cuts and bruises. Always apply lotion to hands to keep it moist and
prevent dryness which can cause cracks in the skin. Disease that come from failing to keep
the hygiene of the hands and finger nails can include diarrhea.
Hand washing prevents diarrhoea effectively and can reduce the risk of contracting
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diarrhoea by up to 44%, provided it is properly done. Since Diarhoeal disease is chronic in

PLWHA and becomes more severe with time, it is important to protect family members and
caregivers from contracting diarhoea through the promotion of proper hand washing and
clearing of feaces immediately with water and a cleaning agent.
Proper hand washing involves using soap or ash and rubbing hands together at
least three times and drying them properly with a clean cloth or by air.
Before and after handling food and before eating,
After using the toilet or changing the nappies of a child or cleaning a
person who has diarrhoea, the feaces should be wiped away immediately,
using hand protection, water and a cleaning agent,
When completing any other activities that involves dirt and contaminate
hands, even if no dirt or contamination is visible,
Before giving breastfeeding or preparing replacement feeding,
Foot hygiene
Our foot is exposed to different health problems unless it is properly kept clean. Health
problems that occur as a result of poor foot hygiene and walking bare foot include hook
worm (penetrates through the bare foot), tetanus, bad smell, piercing and cutting by sharp
ends, wounds, bites by insects and others, fungus etc. Wash feet with clean water and soap
on daily basis, wear shoes that fit properly, if washable, wash feet wear on a regular basis,
Cut toe nails on time and if accidental injury to feet, clean and cover bruises and cuts.
Hygiene of clothing
Clothes protect our body from cold and other conditions and help to maintain warmth and
human dignity. It is important for a healthy lifestyle to change day and night clothes every
65

day. The sweat of the body, cigarette smoke and dust attaches to clothes and accumulates
to produce a bad smell. Dirty clothes not only cause bad smells, but can also cause body
itching and ulceration over time.
Wash clothes regularly, after one wearing,
Outdoor drying in the sun and ironing of clothes is very good to destroy
any germs left by inadequate washing,
Store clean close in a dust free and clean area.

Safe Sanitation Practices are important as PLWHA are susceptible to diarhoeal

disease; therefore feacal matter (in cases of soiling of linen and in cases of using
alternatives other than a fixed toilet) should be dispose properly by household
members and caregivers. Family members should use universal precaution by
protecting themselves in wearing gloves or covering hands with plastic to avoid
contact with feacal matter. Encouraging and maintaining safe sanitation practices
include:
The use of a hygienic latrine/toilet at all times if available, and to wash
hands immediately after use,
Assisting small children to use the toilet or potty or fixed place for
defecating safely,
Placing a plastic underneath bedding to contain spills and use of easy
washable bedding material,
The use of a bedside pot for weak and sick individuals and appropriate
cleaning and disinfection after use.
Soak wet linen in cold water and wash separately, hang out in sunlight to
dry properly,
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 Cleaning up of spills of diarhoea should be done by throwing diluted

bleach such as JIK on the spill and wiping it with toilet paper. Used
papers should be thrown in the toilet or burned.
Managing Stress
If we have stress, it negatively impact health as it weakens the immune system. Exercise
increase fitness and boost the immune system. Others include relaxation techniques such
as meditation. We can also manage stress by improving skills to build confidence at work,
with our children and in general in society.
We can reduce anxiety and uncertainty about issues of concern by increasing our
knowledge on what is going on. Learn more about HIV to understand it better. Facing the
object of fear or stress may also reduce the fight or flight response (example to face the
subject of disclosing status to partner or family or children) instead of ignoring it or hoping it
will go away or resolve itself)
Exercises
Exercise is the performance of movements to develop and maintain physical fitness and
overall health. The more frequent we exercise, the more fit we become and the more
effectively we can prevent some diseases such as cancer, heart disease, obesity and back
pain. The mind should be exercised by reading and discussing important subjects.
Exercises can be grouped into three types, namely
Flexibility exercises such as stretching to improve the motion of muscles
and joints.
Aerobic exercises such as walking and running to increase cardiovascular
endurance and muscle density.

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 Anaerobic exercises such as weight training or sprinting to increase

muscle mass and strength.
Physical exercise is important to maintain physical features of healthy weight, healthy
bones, joints and muscles and promote physiological well-being and strengthening the
immune system. It also improves and stimulates the appetite, reduces nausea, improves the
digestive system and thus preventing weight loss.
Avoidance of alcohol , tobacco and other drugs
Alcohol use depletes cell formation and dehydrates it due to its toxicity and destroys cells of
the central nervous system, the brain and liver, especially the liver and causes liver cancer
or liver cirrhosis. Alcohol also irritates the stomach lining which causes diarrhoea and
vomiting. In the long term it impairs the ability to think clearly and thus affect general
reasoning, which may put people at risk of HIV re-infection and forgetting to adhere to
treatment or go foe follow up appointments. Tobacco has a negative effect on the smokers
appetite, depleting their nutritional status and thus the ability of the immune system to fight
off disease and infection, which is not good for the HIV infected individual who needs good
nutrition to keep infections away.

Conclusion
Living with HIV involves a complexity of issues and circumstances which needs careful
understanding and comprehension to fully appreciate the implications it has on individuals,
the family, community and the world at large.

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Unit Nine: Study of the National Health Policy and Health Care System
1. Introduction
Health is regarded as a fundamental human right and was defined by in 1948 the
World Health Assembly as a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity.In 1986, the WHO stipulated that
health is a resource for everyday life, not the object of living, health is a positive concept
emphasizing social and personal resources as well as physical capabilities, everyone has
the right to a standard of living adequate for health and well being of himself and family

Namibia inherited a fragmented health service mostly curative oriented from various ethnic
69

administration at independence. Independence brought about changes including the

restructuring of health service delivery to ensure equitable access to basic social welfare
and health care which formed part of the top four priorities of the government of Namibia.
Taking into consideration of the health needs at the time of independence, the MOHSS
embarked upon formulation of a policy which was first issued at independence in 1990,
revised in 1997 which resulted in a policy framework guided by the principles of Primary
Health Care (PHC).

Developing the policy TOWARDS ACHIEVING HEALTH AND SOCIAL WELL BEING
FOR ALL NAMIBIANS: A POLICY FRAMEWORK had as its goal the ultimate attainment
of health and social well being of all Namibians to lad economically and socially productive
lives.
2. The overall objectives included:
To improve and maintain the physical and mental health status of all Namibians,
To improve and maintain the social wellbeing, self-reliance and coping capabilities of
individuals, families and communities.
2.1 Specific objectives included:
The provision of efficient, cost effective, appropriate and comprehensive quality
health and social welfare services at different levels of care,
Prevent disability and provide relevant rehabilitation services,
Maintain and support the health and social wellbeing of the population through
preventative, promotive and disease control efforts in collaboration with all relevant
partners in particular the communities concerned,
Ensure availability and efficient utilization of the necessary resources required to
70

maintain agreed upon health care and social welfare standards.

Formulate, implement, monitor, evaluate and review policies required for optimal
service delivery/performance
Provide and promote public health services and advise local and regional authorities
on public health matters,
Ensure quality assurance, continuous availability, proper storage and rational use of
essential drugs at all levels,
Ensure availability and utilization of effective regulations on health and social welfare
services through appropriate legislation,
Promote, regulate, support and conduct , in particular operational research to
improve overall service delivery,
Ensure development, strengthening and utilization of efficient management systems
as effective tools for management,
Ensure the availability of appropriately trained human resources at various levels in
order to strengthen and maintain professional standards, and
Promote self-reliance and coping strategies of individuals, families and communities
in collaboration with relevant health and social welfare service partners.
3. The Guiding Principles for Health and Social Services in Namibia
3.1 Equity
In accordance with the constitution all Namibians should have equal access and attention
should be given to correcting disparities.
3.2 Availability and Accessibility
Involves progressive extension of services especially to disadvantages regions and
71

underserved communities, including vulnerable gruops

3.3 Affordability
Preventive and promotive services are free of charge and fee structures should be made
available for all other services. Exploring health care financing for optimal care should be
pursued.
3.4 Community Involvement
High premium placed on community involvement including consultation, cooperation and
communication at all levels and makes them masters of sustainable health care in their own
environments
3.5 Sustainability
All new programmes should be subjected to sustainability assessment before
implementation
3.6 Intersectoral Collaboration
All other government and non-governments sectors to be consulted and involved in health
care planning, implementation, monitoring and evaluation of health and social welfare
programmes.
3.7 Quality of Care
National norms, guidelines and standards of care shall be reviewed, formulated and applied
to ensure quality services.

4. Approaches and strategies

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4.1 Development and strengthening

By determining priorities and formulation of strategies and detailed plans of action for
smooth running of health and social services
4.2 Service Provision
4.2.1Primary Health Care services shall be provided at all levels of service provision
and will include:
Promotion of proper nutrition and adequate supply and utilization of safe water,
Reproductive health including maternal, child care and family planning,
Immunization against the major infectious diseases,
Promotion of basic housing and sanitation,
Prevention and control of locally endemic diseases,
Appropriate treatment of common diseases and conditions,
Education and training concerning prevailing health and social problems in the
communities and methods of preventing and controlling them,
Community based services, empowerment and self-reliance,
Promotion and maintenance of oral and mental health and
Development and implementation of appropriate district health packages and
management support teams.
4.2.2 Secondary and tertiary level services
These shall be rationalized and appropriately strengthened to provide integrated systems of
referral and supervisory support for PHC. Tertiary and secondary levels will also be used for
73

training of health workers and social workers and for research.

4.2.3 Provision of social welfare and rehabilitative services
MOHSS shall contribute to social and economic development by designing and
implementing a developmental community centered and participatory social welfare policy
which will promote the social , mental, spiritual and physical well being of all Namibians,
In collaboration with other sectors make available social allowances and relief to those most
in need, including he protection and empowerment of women, children, the elderly and
people with disability by providing counseling, rehabilitation, pensions and allowances.
4.2.4 Other additional services
These will include prevention of social problems through advocacy towards equal
opportunities, promotion of human security, community development, poverty reduction and
responsible lifestyles,
Provision of remedial and psycho-social rehabilitation with counseling, cognitive and
behavoiural therapies, motivational interviews, group therapies and life skills training,

The provision of institutional care as the last resort for vulnerable people and groups.

5. Health and Social Services Reform (Integrated Health Care Delivery: The Challenge
of Implementation - a situation analysis and practical implementation guide.
This document has been developed in 1995 to address the management levels and
processes at the time. Much has changed since 1995 in terms of political reallocation of
regional and district structures and the management structures has been adopted and
updated accordingly. Students are advised to read the document for additional information
to this specific section of this unit.
Local level PHC and outreach services strengthened and expanded to
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disadvantaged and underserved communities,

District level services at hospitals, health centres and clinics managed by district
coordinating committee to identify health and social needs in collaboration with
communities an participate in the planning of the overall health service provision in
the country. This level will have functional management responsibilities as well as
budgetary responsibilities,
Regional management teams will be phased in to replace the current regional
directorates in accordance with the local authorities line ministries and shall have the
responsibility of planning, supervision and monitoring of services in collaboration with
local authorities and district management under their jurisdiction and provide
management and technical support to district management,
The national level will have the responsibility to formulate policies and guidelines to
guide service provision and by managing through

technical support in the

implementation and operationalization of such through conducting administrative

auditing of service provision, resource mobilization, international relations, regulation
and standard setting. Specific management structures will exist at national level and
these will include the Executive Committee, the Ministerial Management Committee
and the Policy Management Development and Review Committee. The Ministerial
Steering Committee will be the highest policy making body in the MOHSS.

A National ADIS Committee shall be reconstituted and be the highest policy making
body on matters related to HIV/AIDS in the country.

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A Statutory National Social Welfare Council shall be an advisory body on social

services policy, social allowances, relief and other matters relate to social welfare
services.
6. Legislation and Regulation
This will be enacted to appropriately address Namibias legal needs in respect of health and
social welfare institutions and professions; umbrella legislation shall be enacted providing
for establishment of various councils governing professional bodies such as blood
transfusion, medical laboratories, catering and others.
7. Rational use of Drugs
By ensuring compliance of all pharmaceutical organizations, including health care providers
with the national essential drug list and adherence to standard treatment guidelines.
Legislation is enacted to ensure conformance with international standards.
8. Financing Health and Social Welfare Services
MOHSS shall mobilize resources through appropriate and sustainable means and ensure
efficient use of such resources to guarantee equity of quality service
Promotive and preventive service be free of charge, district/tertiary and secondary services
packages developed and adequately financed,
Special attention to accelerate services in the disadvantaged and underserved
communities,
Financial responsibility and accountability be decentralized to allow for more appropriate
and flexible responses at local level of service provision
9. Human Resource Development
Development of a long term human resource strategy be given priority, including pre-service
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training, in-service training, retraining to address priority needs of the population. Standards
of professional practices and conduct shall be maintained and improved,
Special consideration shall be given to staff serving in remote areas nd re deployment of
staff shall be done in accordance with need.
10. Partnership in Health and Social Welfare

The MOHSS acknowledges the valuable contribution of church health service

providers and shall endevour to strengthen their efforts in terms of capital costs and
operational costs in accordance with agreements.

Private and public health and social welfare services shall co-exist in accordance
with the mixed economy with close cooperation and collaboration,
Private health service shall be required to register with the MOHSS to comply with
service and building standards as set by government.
Limited private practice can be pursued by full time medical specialists under strict
control, not compromising their state responsibilities.
Namibia will maintain its membership with the WHO and other UN agencies as well
as NGOS and other countries and these will be developed progressively.
11. Health and Social Welfare Research
The MOHSS recognize the importance of research in decision making process and
emphasis will be put on such towards the priority needs of the country.
A National policy on research and health system research will be developed and capacity
building of staff at all levels.

13. Traditional Medicine

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Traditional hrealth systems remain an integral part of the majority of Namibians cultural
value and beliefs.

Fostering of good working relationships will be pursued between

conventional and traditional medical practices, by encouraging regulation and establishing a

traditional practitioners association.
Research into traditional herbal medicine and other modes of treatment will be encouraged
and supported.
14. Strategy Formulation and Review
The MOHSS had developed a number of strategies and policies since independence on TB,
Malaria, PHC, CBHC, IEC, Essential drugs, FP, Nutrition and food security, protection and
empowerment of women, however much are still outstanding such as,
Social welfare, refining social welfare allowances ad relief, decentralization, support
services and others. Since much time has passed most policies has been developed and is
continuing. The process also include adjusting programmes based on research and meeting
new challenges identified over time, thus an ever evolving process, including the aspects of
HIV/AIDS, Malaria, Cholera and other emerging health and social problems/challenges.

Conclusion
This policy framework provides a comprehensive guidance to the provision of health care in
Namibia at the time in 1998, some aspects remains current, important though is to realize
that most of these aspects and health problems such as HIV and AIDS evolves over time
due to its social and economic nature and are updated over time, not necessarily within this
specific policy framework but in various other policy documents that expands on the specific
aspects in more details. Students are also advised that a new policy statement has been
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developed, but are yet to be gazette for implementation.

Unit Ten: Post Exposure Prophylaxis (PEP)

1. Introduction
HIV/AIDS is a major public health problem in Namibia. It affects different sectors of he
society and poses risk to health care workers who care for HIV infected individuals. In the
majority of work settings, there is no risk of acquiring or transmitting HIV inflection, implying
that it is limited to occupations where employees come into direct contact with blood or body
fluids or other persons, which is mainly in the health care setting. Health care workers are at
low, but measurable risk of HIV infection after accidental exposure, conversely situations
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may exist where the health care worker is a potential source of HIV infection to clients.
Based on international studies, nosocomial transmission of HIV (transmission of infection in
health care settings) are estimated at 0.09-0.3%, however the risk of transmission of
Hepatitis B and C (HBV and HCV)is significantly greater and ranges from 1-31% and 1.8%
respectively. Based on these studies universal precautions/guidelines have been developed
by the Centers of Disease Control (CDC). Compliance to infection control measures and
universal precautions is therefore of utmost importance in the health care setting, which now
also include the additional strategy of PEP.
The objective of the PEP guidelines are to offer legislation and regulations regarding
employer/employee responsibilities, guidance on prevention of exposure, evaluation of
exposure and management in cases of accidental exposure, including counseling, treatment
and follow up.
2. The Legal Framework of PEP
A Presidential proclamation in 1997 compelled different ministries under the
Labour act (Act 6 of 1992) to ensure health and safety of employees at work, which
was spearheaded by the MOHSS to monitor its implementation and control through
the relevant legislation. The Labour Act stipulates the general duties of the employer
and employee in recognition of the importance of health and safety at work and
these include:
Role of employer includes providing safety equipment and facilities including
protective clothing free of charge and clear and accurate information about HIV and
how to minimize hazards and risks.
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 The role of the employee includes prevention and avoidance of risks and the use of
universal precautions at all times.
Confidentiality of exposed Health care provider includes that information be kept
confidential and only be accessible to responsible individuals with significant regard
for the employees health such as occupational health and safety personnel.
Training to be provided to all employees including all aspects of health and safety to
enable employees to take responsibility for their own health and safety. Major
aspects to include, avoidance of occupational exposure, adhering to safety practices
and universal precautions, action to take following an exposure, importance of
reporting and general monitoring of exposure.

3. Factors associated with HIV, Hepatitis B and Hepatitis C Transmission

Table 1 Factors after Percutaneous exposure to HIV infected Blood
RISK FACTOR

Adjusted
Ratio
Deep injury
16.1
Visible blood on device
5.2
Procedure involving needle placed 5.1
directly in vein or artery
Terminal illness in source patient
6.4
Post-exposure use of Zidovudine
0.2
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odds 95% Confidence Interval

(6.1-44.6)
(1.8-17.7)
(1.9-14.8)
(2.2-18.9)
(0.1-0.6)

Note: Odds ratio odds of exposure in those exposed to the disease to those not exposed
95% confidence interval represents the rang within which the true magnitude of effect lies
with a 95 % degree of assurance
Source: National guidelines on PEP at the workplace, page 9

Factors associated with Hepatitis B

Is a viral blood borne agent and the risk after exposure ranges from 1-31%. It maily involves
or put at risk health care workers in casualty, assisting with transplants and heamodialysis,
post mortems pathologists/assistants, clinical technicians in laboratories, first aid and
emergency personnel, cleaning and laundry staff in contact with blood and blood
derivatives.

Factors associated with Hepatitis C

A viral agent and exposure risk ranges from 0-7% and persons most at risk are those
handling blood and blood derivatives.

Table 2 .Summary if risks of transmission of blood borne agents

VIRUS
Risk Range
HIV
0.09-0.3%
Hepatitis B- e Ag negative
1-6%
Hepatitis B e Ag positive
22-31%
Hepatitis C
0-7%
Source: National guidelines on PEP at the workplace, page 10

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4. Universal Precautions
4.1 Barrier protection such as personal protective equipment or clothing to act as a shield
between the health care worker and the source of exposure or contamination such as
gloves (hand and skin contact), face protection such as masks (mucous membranes) of
eyes, mouth, nose, protective clothing against splashing body fluids (gowns, aprons coats)

4.2 Hand washing or other skin surfaces thoroughly and immediately when contaminated
and at regular intervals between clients and other activities.

4.3 Avoid accidental injuries by needles, scalpels, blades and other instruments when
performing procedures and dispose of it appropriately in puncture resistant containers. This
includes not bending or recapping needles.

5. The Rationale for PEP

HIV:
PEP is to maximize the suppression of viral replication that might occur to prevent or
abort early infection, thus the early intervention for all significant exposure. Biological
inference suggests that initial virus uptake and antigen processing after inoculation may
take several or even days.
Hepatitis B:
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All health care workers should receive prophylactic HBV vaccine on commencement of
employment and a booster dose after 5 years.
Hepatitis C:
There is no effective vaccine or PEP against HCV that will prevent infection.

6. Recording and Reporting Occupational Exposure

An incident report is completed detailing the date, place, time and details of
exposure, details of procedure performed, details o exposed health care providers
and details about counseling and testing. This is kept confidential and for references
purposes.
Employers report is completed by immediate supervisor or designated person.
Attending doctor complete first medical report and PEP is accessed according to the
level of service provision within the prescribed timeframe of 72 hours.
A final medical report after 6 months of follow up is done.
7. General Management considerations
7.1 Immediate post exposure activities:
Wash site of exposure with water without scrubbing the area,
Exposed mucus membranes rinse with water,
Do not use caustic agents, encourage free bleeding of site, remove all contaminated
clothing.
7.2 Assess and determine need for PEP

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Step 1: Assess type and severity of exposure: (EC)

Exposure to mucus membrane or broken skin

Determine Volume

o Few drops, short duration=SMALL EC 1

o Several large drops/long duration/major blood splash=LARGE EC 2
(Take into consideration the type of body fluid such as blood, fluids containing blood, tissues
infectious for blood borne viruses, potentially infectious fluids of tissue such as
semen, vaginal secretions, pleural, amniotic fluids etc)
Exposure to intact skin

NO PEP

(Nothing to consider, just ensure skin is intact)

Percutaneous exposure

Determine Severity

o Solid needle, superficial scratch LESS SEVERE=EC2,

o Hollow needle, deep puncture MORE SEVERE= EC3
(Take into consideration the three types of exposure with significant risk, percutaneous from
needles, instruments, bone fragments, significant bites with breaks in skin, exposure to
mucous membranes including the eye, exposure to broken skin such as abrasions, cuts,
and eczema)
Step 2: Determine HIV Status Code of Source (HIVSC)

HIV Negative
NO PEP
o HIV Positive, asymptomatic/high CD4, LOW TITRE=HIVSC1,
o Advanced disease, Primary infection or low CD4 count, HIGH
TITRE=HIVSC2
o HIV status unknown or source unknown= HIVSC UNKNOWN

(Take into consideration the presence of HIV antibody, presence of HBs Ag and Presence of
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HCV antibody) Remember to take into consideration the window period in an HIV negative
result. Important is to valuate the ARV resistance of the source patient and the HIV
serostatus, immune status to HBV and HCV and also HBV vaccine status of the exposed
person)
Step 3: determine PEP Recommendation from EC and HIVSC
Table 3: Recommended PEP Regimens
HIV SC
EC
PEP Recommendation
1
1
PEP may not be warranted
2
1
Consider Basic Regimen
1
2
Recommended Basic Regimen
2
2
Expanded Regimen Recommended
1 or 2
3
Expanded Regimen Recommended
Source: National guidelines on PEP at the workplace, page 44

8. Recommended Post Exposure Prophylaxis Regimens

8.1 Important Aspects:
Should be initiated within 24-72 hours, the earlier the better
Should be continued for the full 28 days despite associated side effects
PEP can be discontinued if source patient is proven HIV negative or the Health
worker is HIV positive.
Pregnant health care workers should be handled carefully
If side effects become unbearable, expert advices from a consultant physician should
be sought.
Health care worker should be counseled and followed up according to protocol.(see
age 25 of guideline)The monitoring for PEP toxicity should be done according
recommended protocols and the health care workers should be informed
accordingly.
Table 4: PEP Regimen in Namibia
Regimen

Recommended Combinations
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Basic Regimen

Expanded Regimen
Basic regimen plus one of the following:

AZT(Zidovudine;Retrovir 300mg)+3TC(Lamivudine; EPIVIR

150mg)
Available as Combivir 1 tablet twice a day after meals for 28
days
Lopinavir 400mg /Ritonavir 100mg (LPV/r (Keletra) after meals
for 28 days
0R
Indinavir400mg/Ritonavir400mg ()IDV/r after meals for 28 days
Indinavir800mg/Ritonavir100mg ()IDV/r after meals for 28 days
(Note: 2 regimens for Ritonavir enhanced Indinavir)
OR
Efavirenz(EFV;Stocrin) 600mg daily for 28 days
OR
Nelfinavir (NFV;Viracept) 1250mg twice daily or 750mg three
times daily after meals for 28 days

Side-effects of combinations
These should be handled symptomatically.
AZT anemia, nausea, neutropenia, Continued counseling o adhere should be done and support
headache, insomnia, muscle pain and provided where and when required.
weakness
3TC abdominal pain, nausea, diarhoea,
skin rashes and pancreatitis
LPV/r diarhoea, fatigue, skin rashes,
increased cholesterol
IDV/r- rash, insomnia, somnolence, dizziness,
trouble concentrating and abnormal dreams.

Conclusion
Provision of Post Exposure Prophylaxis in the health care setting is important to prevent
transmission of HIV infection and the appropriate protocols should be followed at all times.
Provision of PEP outside the health care setting are determined on a case to case basis
and adequate records should be kept for ongoing surveillance for future guideline
development and modification.
Assignments for this Manual:
Assignment 1
Question 1
Describe the HIV life Cycle in full, from attachment to the host cell to the maturation of the
HIV virus. (Use your own words to show understanding)
[10 marks]
Question 2
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Draw a schematic of the HIV virus and the host cell (CD4) to highlight the cycle you
described in Question 1. How would you explain the cycle of HIV to an individual with no
medical background?
[15 marks]
Assignment 2
Question 1
Discuss the goal of ARV Therapy and the benefits for HIV infected individuals, their families
and the community at large.
[10 marks]
Question 2
Starting ART is a lifelong commitment, discuss the side effects associated with the
medication and in each explain how you would assist/ advise a client to cope with it. Be sure
to include in your discussion the issues related to adherence and nutrition.
[15 marks]
Assignment 3
Question 1
Describe the relationship between the CD4 count, viral load and Opportunistic Infections.
Draw a sketch to illustrate your answer.
[5 marks]
Question 2
HIV and TB is a lethal combination. Discuss

[20 marks]

Assignment 4
Individual Project
Conduct a review of the Antenatal Sentinel Survey Report of 2008, (MOHSS) Outline and
Analyze ALL the KEY FINDINGS and RECOMMENDATIONS in the report. Your analysis
should include your own view on the key issues.
[25 marks]
Assignment 5
Question
Conduct a review and analysis of the National Health Policy of the MOHSS. Discuss the
current management structures in relation to the policy and challenge of implementation
[25 marks]
Assignment 6
Question
Living Positively with HIV is a phrase commonly used when referring to self management
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For PLWHA. Elaborate

[25 marks]
Assignment 7
Group Assignment
You should work as a group in the planning, gathering and presentation of the information
on the assignment.
Adherence to ARVs is vital to the success of therapy for individuals as well as at community
level. Conduct a small study on adherence to ARVs at three different ART sites in the city
of Windhoek (full and part time students). Distance students can do it for one ART site.
For all students: Include in your study challenges and recommendations and compare it to
one other study in Africa.
Assignment 8
Question
Adequate Nutrition for PLWHA is extremely important. Discuss
[25 marks]
Note:
Assignments are part of continuous assessment of students and contribute to the
overall assessment to qualify for examinations. (40%)
Assignments should be submitted on the due date, failing will result in a penalty.
(distance education students should get information from the office)
Students should complete assignments as individuals, unless it is a group
Assignment.
Each question carries 25 marks as indicated.

References:
1. MOHSS. National Guidelines on POST-EXPOSURE PROPHYLAXIS at the
Workplace, July 2004, Windhoek, Namibia
2. Republic of Namibia. National Policy on HIV/AIDS, March 2007, Windhoek, Namibia.
3. MOHSS. Towards Achieving Health and Social Well being for ALL NAMIBIANS: A
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Policy Framework, July 1998, Windhoek, Namibia

4. MOHSS. Integrated Health Care Delivery: The challenge of Implementation A
situation analysis and Practical Implementation Guide, January 1995, Windhoek,
Namibia.
5. MOHSS. Antiretroviral Treatment Guidelines, 2007, Windhoek, Namibia
6. MOHSS. Integrated Management of Adolescent and Adult Illness (IMAI) ,
Comprehensive HIV Care with ART, 2007,Windhoek, Namibia
7. Antiretroviral Treatment Skills and Knowledge (ASK) Notebook for Community
Workers in Southern Africa, 2007, Edition 2
8. MOHSS. Guidelines for voluntary Counseling and Testing, First Edition, 2006
Windhoek, Namibia.
9. MOHSS, Namibia. Nutrition Management for People living with HIV/AIDS, A resource
guide for Clinical Health Workers, 2007
10. USAID. Programming Guidance for Integrating Water, Sanitation and Hygiene
improvement into HIV/AIDS Programmes. The Hygiene Improvement Project

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