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Nut rit ional care and support
for people living with HIV / AIDS
A t rai ni ng course
aci l i t at or s gui de F
Food and Agricult ure Organizat ion
of t he Unit ed Nat ions
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Facilitator's guide


Nutritional care and support
for people living with HIV/AIDS
A training course



















WHO Library Cataloguing-in-Publication Data

World Health Organization.
Nutritional care and support for people living with HIV/AIDS: a training course.

4 pts. in 1 v.

Contents: Director's guide -- Facilitator's guide -- Participant's manual -- Overhead
transparencies.

1.HIV infections - therapy 2.Acquired immunodeficiency syndrome - therapy
3.Diet 4.Nutrition therapy 5.Caregivers 6.Teaching materials I.Title.

ISBN 978 92 4 159189 8 (NLM classification: WC 503.2)

World Health Organization 2009
All rights reserved. Publications of the World Health Organization can be obtained from
Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27,
Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who.int).
Requests for permission to reproduce or translate WHO publications whether for sale or for
noncommercial distribution should be addressed to Publications, at the above address (fax:
+41 22 791 4806; email: permissions@who.int).
The designations employed and the presentation of the material in this publication do not imply
the expression of any opinion whatsoever on the part of the World Health Organization
concerning the legal status of any country, territory, city or area or of its authorities, or
concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent
approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers products does not imply that
they are endorsed or recommended by the World Health Organization in preference to others
of a similar nature that are not mentioned. Errors and omissions excepted, the names of
proprietary products are distinguished by initial capital letters.
The World Health Organization does not warrant that the information contained in this
publication is complete and correct and shall not be liable for any damages incurred as a result
of its use.

Printed by the WHO Document Production Services, Geneva, Switzerland





Nutritional Care and Support for People Living with HIV: Facilitators Guide
Table of contents
Page
Acknowledgment iii
Introduction 1
OPENING SESSION 14
SESSION 1: HIV AND NUTRITION 21
SESSION 2: INTRODUCTION TO COMMUNICATION SKILLS 30
SESSION 3: EATING WISELY 45
SESSION 4: FOOD SAFETY FOR PEOPLE WITH HIV AND AIDS 68
SESSION 5: IMPROVING FOOD INTAKE 84
SESSION 6: PREVENTING WEIGHT LOSS AND PROMOTING
PHYSICAL ACTIVITY 95
SESSION 7: NUTRITION FOR PEOPLE ON ANTI-RETROVIAL
TREATMEN (ART) 108
SESSION 8: NUTRITION FOR PREGNANT AND BREASTFEEDING
WOMEN WITH HIV 123
SESSION 9: FEEDING OPTIONS FOR INFANTS OF HIV-POSITIVE MOTHERS 135
SESSION 10: FEEDING A CHILD WITH HIV 149
SESSION 11: IMPROVING ACCESS TO FOOD 161
SESSION 12: THE USE OF NUTRITIONAL SUPPLEMENT AND
HERBAL REMEDIES 171
SESSION 13: COURSE REVIEW AND ACTION PLANNING 180
CLOSING SESSION 188
Annex 1: The story of Sam and Suzi 190
Annex 2: Nutritional care and support focus at different stages of HIV and AIDS 196
Annex 3: Nutritional requirements of people living with HIV 197
Annex 4: Sources of further information 199
Annex 5: Course pre- and posts-test 201
Annex 6: Course evaluation sheets 204





Nutritional Care and Support for People Living with HIV: Facilitators Guide
ii





Nutritional Care and Support for People Living with HIV: Facilitators Guide
iii

Acknowledgement Acknowledgement Acknowledgement Acknowledgement

ThisCoursewasdevelopedbytheWorldhealthOrganization'sDepartmentofNutrition
forHealthandDevelopment(NHD)undertheoverallcoordinationandresponsibilityof
Randa Saadeh. Other WHO staff members who have made significant contributions
include Carmen Casanovas from NHD, Ferima Coulibaly Zerbo and Charles Sagoe-
Mosesfrom WHORegionalOfficefortheAfricanRegion,Nana AkuaTameaAttafuah
and Mary Brantuo from WHO Country offices, Micheline Diepart from the HIV/AIDS
Department and Nigel Rollins from the Department of Child and Adolescent Health
(CAH).

Special thanks go to Food and Agriculture Organization (FAO) in Rome (Brian


Thompson) and South Africa (Margaret McEwan and Mercy Chikoko) and FAO
Regional office (Cheikh Ndiaye) for their close collaboration and support. FAO has in
addition made financial contribution to the development and finalization of the revised
version.

Many individuals have contributed to this Course including the consultant in charge of
developing the initial material (Genevieve Becker) and the updated material (Jecinter
Oketch and Noziqhu Tatiana Ndondo) as well as Hareya Fassil who assisted in the
editingandlayout.

We also would like to acknowledge the contribution and input from the participants of
thefirst fieldtest(Swaziland29Januaryto2February2007),secondfieldtest(Ghana-
12 to 16 November 2007) and the delegates from the six countries (Lesotho, Malawi,
Swaziland, Zimbabwe, Mozambique, Zambia) including Primer Ministers, MOH,
scientists and representatives of UN organizations from South Africa meeting on
"Nutritional Care and Support for people living with HIV: Country experiences of
capacitybuilding"heldinJohannesburg21to23July2008.

Itisexpectedthatthematerialwillberevisedby2015.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
iv





Nutritional Care and Support for People Living with HIV: Facilitators Guide
1

Introduction Introduction Introduction Introduction

Nutrition refers to how food is handled, prepared, shared, eaten and ultimately utilized by the body.
Foods contain different nutrients that are essential for various body functions, such as: the Energy
required for breathing; movement, work and temperature control; growth, building, replacement and
repair of the body tissues; protecting and fighting against infection and helping to recover from
illnesses.Goodnutritionisthereforeakeyfactorforthemaintenanceofgoodhealthandqualityoflife
forallpeople.

Malnutrition can result from inadequate or excessive intake of one or more nutrients. Poor nutrition
reduces a persons ability to work and be active. It also weakens the immune system leading to
frequent illnesses, poor growth and development in children, and an inability to replace and repair
body cells and tissues, resulting in severe weight loss. Excessive intake of food leads to excessive
weightgainassociatedwithhighriskofobesity,heartdiseasesandhighbloodpressure.

ForpeoplelivingwithHIV(PLHIV),poornutritionworsenstheeffectsofHIVbyfurtherweakeningthe
immunesystem.Thismayleadtoamorerapidprogressionofthedisease.Moreover,HIVinterferes
withtheabilitytoaccess,handle,prepare,eatandutilizefood,thusincreasingtheriskofmalnutrition
amongpeoplelivingwithHIV.Foodandnutritionalintakecanaffectadherencetoantiretroviraldrugs
(ARVs)aswellastheireffectiveness.Foodinsecurityandinadequateknowledgeofgoodnutritioncan
thus impede management of the disease, particularly in resource-constrained settings where HIV is
prevalentandhealthcareservicesremaininadequate.

Good nutrition, on the other hand, gives strength, helps to maintain and improve performance of the
immunesystemtherebyprotectingthebodyagainstinfectionanddelayingprogressionofthedisease.
Good nutrition cannot cure AIDS or prevent HIV infection; however, people living with HIV who are
well-nourishedarestrongerandbetterabletofightinfections.Goodnutritionwillalsocomplementand
ensureeffectiveantiretroviraltreatment.

Nutritionalcareandsupport,whichincludescounselling,education,information-sharingandprovision
offood,isthereforeafundamentalcomponentofacomprehensivepackageofcareandsupportforall
PLHIV. Ensuring that PLHIV have access to food of adequate quantity and quality at the individual
and household levels is a critical part of their health care. Maintaining a varied and healthy diet can
helpimprovethe bodysutilizationof nutrientstherebycontributingtothe health ofpeoplelivingwith
HIV.Nutritionalcareandsupportmustbestartedattheearlystagesoftheinfectioninordertoprevent




Nutritional Care and Support for People Living with HIV: Facilitators Guide
2
weightlossandmalnutrition.Suchcareandsupportisoftenprovidedbyavarietyofpeopleincluding
family members, nurses, doctors, dieticians, extension workers, volunteers, community support
workersandothers.Inthiscourse,werefertothesepeopleasserviceprovidersandcaregivers.

Why is this course needed?

Effective management of the food and nutrition implications of HIV requires adequate skills and
capacity at the local level. Especially in countries and regions with limited resources, there is a
recognised need to develop the capacity of community-level health service providers and caregivers
in promoting good nutrition as an important component of improving the health and quality of life of
PLHIV.Thistrainingguideprovidespracticalstepsandinformationtohelpstrengthenlocalcapacity
foreffectivenutritioncareandsupportforpeoplelivingwithHIVinlimitedresourcesettings.

Course aims

Thiscourseaimstoimproveknowledgeandskillsonnutritionalcareandsupportamongcommunity-
level health service providers and other extension workers providing services to PLHIV. The
combinationofknowledgeandcommunicationskillscoveredbythecoursewillenableparticipantsto
provide quality nutrition care and support at various service points, thereby contributing to the
improvementofthenutritionalandhealthstatusandtheoverallqualityoflifeofpeoplelivingwithHIV.

Theinformation,ideasandskillsfromthiscoursecanbeusedinmanyways.Examplesinclude:
One-to-onenutritioncounsellingofapersonlivingwithHIV;
Nutritioneducationtoagroupofindividualsataclinicorinacommunitysetting;
Discussingpracticalsuggestionsandskillswithagroupofcaregivers;
Sharinginformationandskillslearnedwithcolleaguestoincreasetheirknowledge;and
Helpingoneselforafamilymember.

This course includes basic information on communication skills. However, it is not designed to train
people to be HIV counsellors. The nutrition information provided is at a basic level. People with
complex nutrition related concerns or co-morbidities such as diabetes, altered lipid levels and other
conditionswouldneedtobereferredtosomeonewithmoreextensivetraininginnutrition.

Target group

The course and the accompanying training guide are intended for use by community level health
service providers and other extension workers whose activities may include providing general




Nutritional Care and Support for People Living with HIV: Facilitators Guide
3
nutrition information, care and support to individuals or groups of people living with HIV and their
householdmembersandcommunities.

Examplesoftheprimarytargetgroupsare:
Communityhealthworkers
Extensionworkers
Socialworkers
Counsellors
Nutritionists
Nursesanddoctors

Courseparticipantsneednothaveanyspecifictraininginnutrition.However,theyareexpectedto:
becomfortableworkingwithpeoplelivingwithHIV;
havemoderateliteracyandbasiccommunicationskills;
havebasicknowledgeaboutHIV,includingitsmodesoftransmission/prevention;and
be familiar with locally available HIV/AIDS services such as counselling and testing,
prevention,treatmentandcare.

For participants with lower levels of literacy or little experience with classroom work, those needing
additional knowledge on HIV in general or more skills in counselling, the course may need to be
extendedoveralongerperiodtoallowmoretimefordiscussionofadditionalinformation.Sourcesof
suchadditionalinformationtocomplementthisguideandcourseareincludedinA AA Annex nnex nnex nnex4 4 4 4.

Course structure

The training sessions can be delivered as a complete course all at one time. This would take about
12-15hours,notincludingmealbreaks.Alternatively,thesessions,whichvaryinlengthfrom30to90
minutes, can be spread out over a number of weeks. The course can therefore be conducted
intensively over two days or spread out over a longer period, as appropriate. If facilitators or
participantscomefromoutsidethearea,itmaybenecessarytoholdanintensivecourse.Iffacilitators
andparticipantsallcomefromwithinthesamedistrictorinstitution,itmaybemorepracticaltodeliver
apart-timecourseoveralongerperiod.Thenumberofcoursefacilitatorsneededwilldependonthe
chosen format of the course and the number of participants. In general, it is recommended that a
maximumof15participantsbeenrolledforeverytwoorthreefacilitators.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
4
Course sessions

The course starts with an opening session, followed by 12 core sessions covering key aspects of
nutrition care and support for people living with HIV. Each of these 12 main sessionsis designed in
thesamewayandcontainsthreeparts:(a)notesofup-todatebasicknowledgeandprinciplesonthe
topic; (b) practical activities and exercises; and (c) a summary of the key points covered in the
session.Thecourseconcludeswithareviewandplanningsession,followedbyaclosingsession.

Thesequenceanddurationofeachsessionisoutlinedbelow.
1

Session Session Session Session Duration Duration Duration Duration
Openingsession 50minutes
1.
LinksbetweennutritionandHIV 30minutes
2.
Introductiontocommunicationskills 105minutes
3.
Eatingwisely 80minutes
4.
Foodsafety 45minutes
5.
Improvingfoodintake 45minutes
6.
Preventingweightlossandpromotingphysicalactivity 60minutes
7.
Nutritionforpeopleonanti-retroviraltherapy(ART) 70minutes
8.
NutritionforHIV-positivepregnantandbreastfeedingwomen 50minutes
9.
FeedingoptionsforinfantsofHIV-positivemothers 35minutes
10.
FeedingachildlivingwithHIV 45minutes
11.
Improvingfoodaccess 55minutes
12.
Useofnutritionalsupplementsandherbalremedies 40minutes
13.
Coursereviewandactionplanning 70minutes
Closingsession 20minutes

The course is classroom-based and involves a variety of facilitation methods, interactive lectures,
role-plays, group discussions, individual reading and group brainstorming exercises to facilitate the
exchange of ideas and encourage participants to apply knowledge and skills acquired during the
varioussessions.

1
Ifthereareadditionalopeningandclosingceremoniesorspeeches,extratimewillbeneeded.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
5

Course design: the story of Sam and Suzi

There is a story about a couple - Sam and Suzi - which runs throughout the course sessions and is
intended to help participants see how the information presented applies to individuals in real life
situations. Included in the course materials, are three pictures of Sam and Suzi, each illustrating
different times in their lives. Facilitators are expected to select, adapt and use versions of the pictures
thataremostappropriatetotheirparticularlocalculturalcontext.ThefullstoryofSamandSuzicanbe
foundinAnnex1. Annex1. Annex1. Annex1.

Course materials

The course materials are packaged in three different guides, related to each other: (a) the Directors
Guide;(b)theFacilitators Guideand(c) theParticipant'sManual.Thecontentsofeacharedescribed
below.

Directors guide
The Directors Guide contains all the information that the course director needs in order to plan and
prepare for a course, and to select facilitators and participants, starting several months before the
actual programme. It contains lists of the materials and equipment needed, as well as samples of
handoutsandformsthatneedtobephotocopiedforparticipantsbeforethecourse.Italsodescribes
theDirectorsroleduringthecourseitself.
Facilitator's guide
This Facilitator's Guide contains information that the facilitator needs in order to lead participants
throughthecourse.Thisincludes:
Instructionsonhowtoconducteachsessionandtheinformationrequiredforeach;
Practicalexercisestobecompletedbyparticipants;
Lecture/discussionguides,alongwithfocusingquestionsandpossibleanswers;and
Role-playsanddemonstrations.

ReferencematerialslistedinAnnex Annex Annex Annex 4 44 4maybeusefulforansweringquestionsandprovidingadditional


information, as required. Other materials which facilitators will require for the course include the
following:




Nutritional Care and Support for People Living with HIV: Facilitators Guide
6
Overhead transparencies
Overheadtransparenciesareprovidedforthesessionsmarked showoverhead showoverhead showoverhead showoverhead.Thefiguresforthe
overhead transparencies are also printed on paper so that facilitators can copy and display the
content on flipchart paper, if an overhead projector is not available. Reprints of the key overhead
transparencies are included in the Participant's Manual. Overhead transparencies of the three
pictures of Sam and Suzi may also be enlarged and used as posters if this suits the local course
deliveryformat.Facilitatorsshouldchooseversionsofthepicturesthatbestsuittheirparticularlocal
context.
Training aids
The course will need an overhead projector if one is available. A flipchart can be used as an
alternative to an overhead projector or in addition to one. A flipchart stand, flipchart paper and a
means of fixing flipchart sheets to the wall or other display surface such as, masking tape will be
required.Additionaltrainingaidsmaybeneededforspecificsessions.Facilitatorsshouldensurethat
theyreadeachsessioncarefullyandprepareallthenecessaryaidsseveraldaysbeforethecourse.
Participant's manual
Theparticipant'smanualcontains: :: :
Asummarizedversionofinformationcoveredineachofthesessions;
Keyoverheadtransparencies;
Textsfortherole-playswithwhichparticipantswillassist;and
Exercisesthattheparticipantswilldoduringthecourse(withoutanswers).

As a copy of the manual should be provided to each participant to be used as a reference


bothduringandafterthecourse,itisnotessentialforparticipantstotakedetailednotes.
Key points
This course uses key points to emphasize information. The key points covered in each session are
clearly outlined (throughout this Facilitators Guide as well as the Directors Guide and Participants
Manual) and are expected to be reinforced throughout the course (by facilitators and participants), by
repeatedly writing them, putting them on display and reiterating them verbally. Key points from
precedingsessionsneedtobereviewedandreinforcedineachsubsequentsession.

Course follow-up activities



It is important to plan some follow-up activities to find out whether participants apply the skills that
they have learnt in the course and if they need any further assistance. The appropriate follow-up




Nutritional Care and Support for People Living with HIV: Facilitators Guide
7
methodvariesdependingonthepersoncarryingitout,thetypeofparticipantsandtheparticularlocal
contextofthecourse.WiththeassistanceoftheCourseDirector,facilitatorsneedtodevelopafollow-
upplanthatwouldbemostappropriateforeachparticulargroupofparticipants.

Afollow-upplancancontainatleastthesetwosteps:
Towardstheendofthetrainingcourse,eachparticipantshouldbeaskedtowriteaplanorlist
ofactionsthatheorshewillundertaketoapplytheskillslearnt.
Course Facilitators (with the assistance of the Course Director whenever feasible, can then
visit each participant in his or her workplace severalmonths later, in order to observe his or
herworkanddiscusswhichactionsheorshehasbeenabletoputintopractice.

Using and adapting the manual for the training course

The contents of this manual are presented in a generic format. As such, some of the technical
information will need to be adapted to the particular local context in which the course is being
delivered. Facilitators will need to read the sessions well in advance in order to identify and collect
local information that may need to be added in some sections or omitted in others to suit particular
local conditions. Adapting the information contained in the manual to local circumstances should
thereforebeconsideredasanessentialpartofpreparingforthetrainingcourse.

Whilethiscourseincludesbasicinformationoncommunicationskills,itisnotdesignedtotrainpeople
to be HIV counsellors. The nutrition information provided is at a general level and people with
complex nutrition-related concerns or co-morbidities,such as diabetes, altered lipid levels and other
conditionswouldneedtobereferredtosomeonewithmoreextensivetraininginnutrition.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
8
Using the Facilitator's Guide

SIGNSUSEDINTHEFACILITATORSGUIDE SIGNSUSEDINTHEFACILITATORSGUIDE SIGNSUSEDINTHEFACILITATORSGUIDE SIGNSUSEDINTHEFACILITATORSGUIDE
:Thissymbolandtypefaceindicatesaninstructiontothefacilitator.
: Thissymbolindicateswhatyoushouldsay/explaintoparticipants;questionsyoushouldask questionsyoushouldask questionsyoushouldask questionsyoushouldask
themarehighlightedinboldface. themarehighlightedinboldface. themarehighlightedinboldface. themarehighlightedinboldface.
: This symbol indicates important points, including key points in each session which the
facilitatorshouldemphasize.

Preparing a presentation
It is important that you are thoroughly familiar with the material, and with the order of ideas in
the presentation. This is necessary even if you are an experienced facilitator and/or
knowledgeableaboutthetopic.
Trytoreadthroughallthesessionsratherthanjustfocusingonthoseyouwillpresent.Having
anideaofhowthedifferentsessionsfittogetherwillhelpyoufocusonthe information for each
session without duplicating material that will be presented in later sessions. It also makes it
easier to draw linkages with information from previous sessions or to defer a question if the
topicwillbecoveredlateroninthecourse.
Research and keep abreast of new information of relevance to the topics covered in each
session.
Readthesessionobjectivesfromyourguidetoknowwhatthesessionaimstoachieve.
Outlinetheprogrammeatthebeginningoftheworkshopanddefinetheobjectivesclearly.
Structureyoursessionssothatbothyouandtheparticipantsunderstandtheobjectivesandthe
contenttobecovered.
Read the preparation section, so that you know what to prepare in advance for the session,
namely,trainingaidsandotherkindsofhelpthatyoumayneed.
Read through the text for each session and practise; be clear about the information to be
coveredandhowtopresentit.
Readthenotesthroughcarefully,andstudytheoverheadsthatgowiththem.
In coordination with the course director, consider splitting some session between two or more
facilitators, particularly long sessions that involve different activities such as, role-plays and
othergroupexercises.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
9
Go through the text, and add in your own notes as necessary, e.g., to remind you of points to
emphasize or those of special local importance. Try to think of your own stories and ways to
presenttheinformationnaturallyinyourownway.
Prepare your overheads and/or flipcharts. Have the overheads required for each session
arrangedinthecorrectorder.

Ifanoverheadprojectorisnot availableanditemsneedto becopiedonflipchartpaper beforehand,


preparethesewellbeforethesession. Writeclearly.Duringthesession,anotherfacilitatorcanwrite
additionalitemsontheflipchartasnecessary,allowingyoutokeepeye-contact withtheparticipants
atalltimes.

KeepyourFacilitatorsGuidewithyouatalltimesandrefertoitthroughoutthe coursepreparation,
deliveryandfollow-upasneeded.
Giving a presentation
Talk in a natural and lively way. It is preferable to present the information in a conversational
mannerinsteadofreadingoutthepresentationnotesexactlyastheyarewritten.
Speakclearlyandslowly,projectingyourvoicesothatallparticipantscanhearandunderstand
whatyouaresaying.Varythetoneandpaceofyourvoiceasnecessary.
Facetheaudienceandmaintaineyecontactwithparticipantswhenspeaking.Becarefulnotto
block participants' view of the screen or board. Move around the room to keep your audience
engaged.Butavoidturningyourbacktotheaudienceformorethanashorttime.
Usenaturalhandgesturesandfacialexpressionsasnecessary.
Explaintoparticipantsexactlywhateachoverheadorflipchartshows,andhighlightclearlythe
mainpointsfromwhichtheyshouldlearn.Asyouexplaintheinformationinthetext,pointtoit
on the overhead or flipchart so that participants can easily keep track of the key points.
Remember, overheads and flipcharts are only visual aids to help your teaching;do not expect
participantstolearnfromthemwithoutyourhelp.

Involving the participants


You will have to present some of the information in lecture form, in order to cover all the
materialintheallottedtime.
Constantly read the mood and atmosphere of the group. Is everyone participating? Do people
lookinterestedornot?Respondaccordingly.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
10
Use ice-breakers and warm-ups if the energy level seems low. Consider having a five-minute
breakifparticipantsappeartiredoroverwhelmedbytheamountofinformationbeingpresented.
Involve all participants. Read and use both verbal and non-verbal cues to encourage
participation. Pose questions directly to quiet individuals. Use paired work or small group
discussionstomaximizeengagement.
Ensurethatparticipantsgetachancetospeakoneatatime;assignthemanorderinwhichto
speak if necessary. People are less likely to interrupt others if they know that they will have a
turntotalk.
Ensurethatthediscussionisnotdominatedbyoneortwopeopleandthatallparticipantshave
a chance to pose and answer questions. Encourage quieter participants to talk. Ask someone
who has not spoken to answer, or move near someone to bring attention to that person and
encouragehimorhertoparticipate.
Encourageparticipantstomakesuggestions;discusstheirsuggestionsandthencontinuewith
thesession.
Acknowledgeallparticipants'responsesinordertoencouragecontinuedengagement.
If a participant gives an incorrect answer, invite others to express their views and suggest
alternativeanswers,thussteeringthediscussiontowardsthecorrectanswer.Makeparticipants
feelthatitisgoodtomakeasuggestion,evenifitisnotthecorrectanswer.
Reinforce correct answers given by participants by expanding on them as necessary or by
askingotherstocommentonthem.
Encourage succinct answers by commenting on the presentation of participants who give
responsesthatareshortandtothepoint.
Re-capandreflectonthepointsraisedregularlythroughoutthesessions.
Ensurethateachparticipanthashis/hercopyoftheParticipant'sManualavailable throughout
thecourse.

Preparing role-plays
Thesessionsincludeanumberofshortdemonstrationsofcommunicationtechniquesandotherskills.
Read through these role-play exercises carefully so that you understand the points being made in
each.Makesurethatyouhavealltheequipmentthatyouneed.

Taking part in the role-play exercises can be an effective learning experience for participants as it
increasestheirinvolvementandteachesthemcommunicationskills.Askparticipantstohelpwithrole-
playswellinadvanceofthesessionsothattheyhavetimetopreparethemselvesandtodiscussand
understandwellwhattheyareexpectedtodo.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
11

If you feel that participants are not ready to do the role-plays, ask other facilitators to help
demonstrate the exercises first. This can help participants better understand role-playing and
encouragethemtotakepartthemselves.

Practising role-plays
Practise giving the demonstration by yourself, with your assistant or with another facilitator, so that
you know how long it takes, and to ensure that you have all that is needed, including extra tables,
chairsorotherpropstohelpmakethedemonstrationasconvincingaspossible.
Attheendofeachsession,leavetimeforparticipantstoaskquestions.Doyourbesttoanswerthem.
You do not need to know the answer to every question. Other participants may be able to offer
informationoryoucanreferthemtoalocalsourceoffurtherinformation.

Basic requirements of a facilitator and principles of adult learning

This section explains the basic requirements of a facilitator as well as the principles and
methodologies underlying adult learning that should to guide the course. You should read it before
youstartconductingsessions.

Thefacilitatorshould:
Have a warm and welcoming manner and an ability to show approval and acceptance of
participants.
Beabletodevelopagoodrapportwiththegroup.
Beenthusiasticaboutthesubjectandhaveacapacitytodeliveritinaninterestingway.
Be able to create an interactive environment, i.e. by asking questions, moving around the
room,alwaysaddressingthewholegroup,andavoidingfocusingonasmallgrouporindividual.
Alwaysspeakclearlyandinunderstandablelanguage,addressingallparticipants.
Beabletoleadwithoutstiflingparticipation.

Thefacilitatorneedsto:
Ensure that the appropriate visual materials, such as flipcharts or overhead transparencies/
projectorsareavailableandready.
Keepvisualaidssimpleandlegible.
Usetheroomandvisualaidsasrequiredwithoutcreatinginterferenceintheprocess.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
12
Regularly check that participants understand the information being presented and keep them
interestedandengaged.
Useinteractivetechniques,suchasaskingopen-endedquestionswhichrequireparticipantsto
explainandgivedetailedanswersthatdemonstratetheircomprehension.
Ask participants to keep their manuals closed while answering discussion questions so that
theythinkaboutpossibleanswersratherthanreadingtheinformationfromtheirmanuals.
Give participants a genuine chance to arrive at the answers to the questions included in each
sessionthemselves.Questionsareaskedinsuchawaythatparticipantsshouldbeabletofind
theappropriateanswerbylookingattherelevantfiguresdisplayedorbydrawingfromtheirown
experience,orfrommaterialthathasbeencoveredpreviouslyinthecourse.
Sometimes,participantsmayneedadditionalhelpinfindingtheanswer;insuchcases,youmayopt
togivethemahint.Inotherinstances,youmayfindthataskingthequestionagaininadifferentway
canhelp.

Principles of adult learning


Inlinewiththekeyprinciplesofadultlearning,facilitatorsshouldalsoaimto:
Encourage discussion and sharing of ideas and experience. Learning is more effective and
fasterwhenitbuildsonwhatlearnersalreadyknoworhaveexperienced.
Ensure to have a non-judgemental attitude to participants (even if he or she does not share
theirviews).
Create conditions so that the participants will learn in an atmosphere of acceptance, respect
and encouragement, one in which they will feel free to ask questions and contribute to
discussions.
Communicateclearmessagestolearners;thisminimizesconfusionandfacilitateslearning.
Presentinformationinalogicallyorderedandstructuredway.
Facilitatelearningbyusingavarietyoftrainingmethodsandtechniques.
Buildtrustwithlearnersbydemonstratingthatheorsheisequallycommittedtothetrainingand
iswillingtosharehisorherownexperience.
Provideopportunitiesforlearnerstopractisewhattheyarelearningandtoaddressfeelings
andideasastheyarise.
Encourageteamworkandasenseofbelongingthroughactiveparticipation.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
13

REMEMBER REMEMBER REMEMBER REMEMBER! !! !
HIV HIV HIV HIVisaveryemotivetopic.Beawarethatparticipantsmayhavestrongfeelingsaboutthistopic. isaveryemotivetopic.Beawarethatparticipantsmayhavestrongfeelingsaboutthistopic. isaveryemotivetopic.Beawarethatparticipantsmayhavestrongfeelingsaboutthistopic. isaveryemotivetopic.Beawarethatparticipantsmayhavestrongfeelingsaboutthistopic.
It is also likely that some participants are themselves living with HIV or have close family or It is also likely that some participants are themselves living with HIV or have close family or It is also likely that some participants are themselves living with HIV or have close family or It is also likely that some participants are themselves living with HIV or have close family or
frie frie frie friends who are living with the disease. Help participants to understand and accept each others nds who are living with the disease. Help participants to understand and accept each others nds who are living with the disease. Help participants to understand and accept each others nds who are living with the disease. Help participants to understand and accept each others
experiencesandperspectivesandtoshowmutualrespectwithoutpassingjudgement.Avoidand experiencesandperspectivesandtoshowmutualrespectwithoutpassingjudgement.Avoidand experiencesandperspectivesandtoshowmutualrespectwithoutpassingjudgement.Avoidand experiencesandperspectivesandtoshowmutualrespectwithoutpassingjudgement.Avoidand
rectifyanycommentsthatcansoundcriticalofthoseinfectedoraffec rectifyanycommentsthatcansoundcriticalofthoseinfectedoraffec rectifyanycommentsthatcansoundcriticalofthoseinfectedoraffec rectifyanycommentsthatcansoundcriticalofthoseinfectedoraffected. ted. ted. ted.


Checklistoffacilitationskills Checklistoffacilitationskills Checklistoffacilitationskills Checklistoffacilitationskills
Takecentrestage;avoidstandinginacornerorbehindadesk.
Facetheaudience;donotfacetheboardorscreenwhenspeaking.
Avoidblockingtheaudiencesview.
Makeeye-contactwithpeopleinallsectionsoftheaudience.
Movements Movements Movements Movements
Usenaturalgesturesandfacialexpressions.
Move around the room; approach people to get their attention and
encouragetheirparticipation.
Speakclearly,slowlyandloudlyenoughforeveryonetohear;benaturaland
lively;varythetoneofyourvoiceasappropriate.
Speech Speech Speech Speech
Writedifficultnewwordsontheflipchart;pronounceandexplainthem.
Interact with and engage all participants; address them by name as
appropriate.
Ask the questions suggested in the text; ask different participants;
encouragequietparticipantstospeak.
Allow time for participants to answer; do not give the answers too quickly;
drophintsifneeded.
Respondencouraginglyandpositivelytoallanswers;correcterrorswithtact
andsensitivity.
Interaction Interaction Interaction Interaction
Avoid discussions which are off the point or distracting; postpone them if
necessary.Trytogivesatisfactoryanswerstoquestionsfromparticipants.
Have the required aids and equipment ready; check and arrange them
beforethesession.
Makesurethateveryonecanseeclearly;arrangetheroomsotheycan
Point to what you are talking about on the projector or on the screen as
appropriate.
Ifusingaflipchartoraboard,writeinlarge,clearletters.
Visualaids Visualaids Visualaids Visualaids
Cover,turnoff,orremovevisualaidsthatarenotinuseanymore.
Followthesessionplanaccuratelyandcompletely;useyourguide.
Prepare thoroughly; read and obtain any materials that you need
beforehand.
Prepare your helpers (e.g., for role-plays) before the session; practise if
possible.
Useofmaterials Useofmaterials Useofmaterials Useofmaterials
Donotlearnthesessionbyheart;followtheguidebuttalkinyourownway.
Emphasizeimportantpoints;trytoavoidrepetitionunlessreallyuseful.
Dogiveafewlocalexamples;avoidintroducingtoomuchextramaterial.
Ifitisnecessarytoreadfromtheguide,lookattheaudienceregularly.
Timemanagement Timemanagement Timemanagement Timemanagement
Keep to time: pace yourself; gauge the group regularly to ensure that you
arenotmovingtoofastortooslow;donottaketoolongwiththeearlyparts
ofthesession.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
14

Openingsession Openingsession Openingsession Openingsession



Learning Learning Learning Learningo oo objectives bjectives bjectives bjectives
Bytheendofthissession,participantswillbeableto:

Listtheaimsandobjectivesofthecourse;and
Refertoglossaryoftermsusedinthecourse.

Session Session Session Sessiono oo outline utline utline utline


Content Content Content Content Time Time Time Time
1 Gettingstarted 10minutes
2 Theroleofthefacilitators 3minutes
3 Pre-test 20minutes
4 Introducethecourseaimsandobjectives 7minutes
5 Reviewtheglossaryofterms 10minutes
Total Total Total Total 50minutes 50minutes 50minutes 50minutes
2


Preparing for the session

Prepareacoursetimetableandmakeacopyforeachparticipant
CollectlocaldataonHIVprevalence.Keeparecordofthesourcesofthelocaldatayouobtainso
youcansharethemwithparticipantsifneeded.
Gatherandreviewthefollowinginformation:
CurrentHIVandAIDSsituationinthecountry/area/region;
Nationalpolicies/guidelinesonnutritionandHIV;and
Nationalpolicy,documentsonpreventionofmother-to-childtransmissionofHIV(PMTCT)
Identifyhowthiscoursecansupporttheimplementationoftheseguidelinesandpolicies
Prepareoutthecourseaimandobjectivesonasheetofflipchartpaper.
Collect/preparethefollowingmaterials:
Anoverheadprojectorandscreen;and/orflipchartpaper,markersandameanstoattachflipchart
sheets to the wall or other surface. If an overhead projector is not used, the overhead may be

2
Ifthereareopeningspeeches,additionaltimewillberequired.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
15
written out/displayed on a flipchart sheet; the appropriate versions of Pictures 1-3 can also be
enlargedfordisplayasposters.
O OO OverheadOpening/ verheadOpening/ verheadOpening/ verheadOpening/1: 1: 1: 1: Courseaims Courseaims Courseaims Courseaims
Pict Pict Pict Picture ure ure ures ss s 1 1 1 1- -- -3 33 3: :: : Samand Suzi Samand Suzi Samand Suzi Samand Suzi: :: :selecttheversionssuitableforthelocalareaand prepare enlarged
copiesfordisplayaspostersifnecessary(seeAnnex1 Annex1 Annex1 Annex1).
Course Course Course Coursee ee evaluation valuation valuation valuations ss sheet heet heet heet:prepareenoughcopiesforallparticipants(seeAnnex Annex Annex Annex6 66 6).
Pre Pre Pre Pre- -- -test: test: test: test: prepareenoughcopiesforallparticipants (seeAnnex Annex Annex Annex5 55 5).

1. Getting started (10 minutes)

Indicatetheobjectivesofthesession.
Bytheendofthesession,participantswillbeableto:
Listtheaimsandobjectivesofthecourse.
Refertotheglossaryoftermsusedinthecourse.

Start by introducing yourself then ask other facilitators and participants to take turns introducing
themselves.
AskthemtodescribetheirresponsibilitiesinrelationtonutritionandHIV,wheretheyworkandto
mentiononeexpectationfromtheworkshop.
Ask your co-facilitator to help you write down participants expectation from the course on the
flipchartandpostthecompletelistonthewall.
Giveinformationonadministrativematters(e.g.perdiem,facilitiesinthetrainingsite,etc.)
Askparticipantsiftheyhaveanyquestionsontheaboveandansweranyquestionsraised.

2. The role of the facilitators (3 minutes)



Explaintotheparticipantstheroleofthefacilitators.
Indicatewhetherparticularfacilitator(s)havebeenassignedtoparticulargroupsofparticipants.

3. Pre-test (20 minutes)



DistributecopiesofthePre-testandinformparticipantsthattheyhave15minutestocompleteit.
Askparticipantstowritedowntheirnamesoruniqueidentificationnumbers(whicheveryouagree
upon)tohelpwiththeanalysisofthetestresults.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
16
4. Introduce the course aims and objectives (10 minutes)

CiteHIVprevalencestatisticsinthearea.
Inthisregion/area/country,thereareanestimated.peoplelivingwithHIV

Usethefollowinginformationforfurtherexplanation:

Infection with Human Immunodeficiency Virus (HIV) causes reduction in the bodys natural
defence system against diseases and infections leading to the Acquired Immunodeficiency
Syndrome(AIDS).
As the immune system weakens, the body becomes less able to fight infections. Other germs
takeadvantageofthisopportunityandcausevariousillnessessuchaspneumonia,tuberculosis,
oralthrushandotheropportunisticinfectionsfurtherweakeningthebody.
Whenapersonstartsdevelopingtheseopportunisticinfectionshe/shehasAIDS.Theamountof
timeittakesforthepersontoadvancefromHIVinfectiontoAIDSandhis/heroverallqualityoflife
dependsonthegeneralhealthandnutritionalstatusoftheperson.
Goodnutritionisimportanttoeveryone.Apersonwhoiswell-nourishedmayhaveabetterquality
of life. He/she is stronger and better able to fight infections. This is true for all people but is
especiallyimportantforpeoplewithHIVwhoaremoresusceptibletorecurringinfections.
On the other hand, people living with HIV are at a higher risk of malnutrition as HIV increases
nutritionalneedsevenduringearlystagesofHIVinfection,whennosymptomsareapparent.The
demandincreasessignificantlyduringthecourseof theinfectionposingadditionalchallengesto
peoplelivingwithHIVandtheircareproviders.
People living with HIV and their families need care and support. This care and support may be
provided by nurses, doctors, dieticians, other health workers, lay counsellors, support workers,
familiesandotherpeople.
During this course, we will discuss ways to support people living with HIV to enable them to be
better nourished.Foodisnota magicsolution.ItwillnotstoppeopledyingofAIDS.However,it
canhelppeoplelivelonger,bemorecomfortableandleadlivesthataremoreproductive.

ShowOverhead Overhead Overhead OverheadOpening/ Opening/ Opening/ Opening/1 11 1 andoutlinetheaimsandobjectivesofthecourse.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
17
OVERHEADOPENING/ OVERHEADOPENING/ OVERHEADOPENING/ OVERHEADOPENING/1:COURSEAIMS 1:COURSEAIMS 1:COURSEAIMS 1:COURSEAIMS

The aim of this course is to assist community level health service providers community level health service providers community level health service providers community level health service providers and other other other other
extensionworkers extensionworkers extensionworkers extensionworkersto:
Improve their knowledge and skills on nutrition care and support for people living with
HIV;
Understand the importance of using good communication skills when providing nutrition
careandsupportforpeoplelivingwithHIV;and
BeabletoeffectivelytransferthekeynutritionmessagestopeoplewithHIV,theirfamily
membersandthecommunity.
Course objectives
Bytheendofthetrainingcourseparticipantswillbeableto:
ExplainthelinkbetweennutritionandHIV.
DiscusstheeffectsofHIVonnutrition.
DescribethebenefitsofgoodnutritionforpeoplelivingwithHIV.
Demonstrateappropriatecommunicationskillsfornutritioncounselling.
DescribehowtomanageHIV-relatedsymptomsthatreducefoodintake.
Discussthebasicprinciplesofeatingwisely.
DiscussfoodsafetyforpeoplelivingwithHIVandAIDS.
Outlineguidelinesforpreventingweightlossandpromotingphysicalactivity.
Discussmanagementoffood-druginteractions.
DiscussappropriatenutritionforHIV-positivepregnantandbreastfeedingwomen.
DiscussfeedingoptionsforinfantsofmotherslivingwithHIV.
DiscussfeedingchildrenwithHIV.
Describetheoptionsforimprovingfoodaccess.
Evaluateandprovideadviceabouttheuseofnutritionalsupplementsandherbalremedies.

GiveanoverviewofthetrainingmethodologyandanexplanationaboutSamandSuzisstory.
Methodology
The course will include interactive lectures, role-plays, group discussions, individual reading and
brainstorming to facilitate exchange of ideas and encourage participants to apply knowledge and
skillsfromthesessions.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
18
The story of Sam and Suzi
The story of Sam and Suzi runs through the course so that you can see how the information
appliestoindividuals.
YouwillfindthefullstoryofSamandSuziinAnnex1. Annex1. Annex1. Annex1.
EachsessioncontainspartsofSamandSuzisstoryrelevanttothatsession.
AlsoincludedarethreepicturesofSamandSuzi,eachillustratingdifferenttimesintheirlives.

Show the three different pictures of Sam and Suzi as overheads or posters; use the versions
appropriatetothelocalarea(seeAnnex Annex Annex Annex1 11 1).
Askparticipantstoturntopage6-7oftheParticipant'sManualwheretheywillfindtheglossaryof
terms.Youmaywishtoaskoneparticipanttoreadthefirstterm,anothertoreadthenextandso
onuntiltheyareallread.Checkforunderstandingofthetermsandclarifywherenecessary.
5. Review the glossary of terms (10 minutes)

Following are definitions of some of the terms that will be used frequently throughout the
course.Askparticipantstotaketurnsreadingthetermsanddefinitionsoutloud.

Absorption Absorption Absorption Absorption Whenfoodthatiseatenisbrokendownordigested andpassesthroughthegut


wallsintothebloodstreamforusebythebody.

AIDS AIDS AIDS AIDS Acquiredimmunodeficiencysyndrome(AIDS)isthelaterstageofHIVdisease.A
personissaidtohaveAIDSwhenHIVhasweakenedthebodysimmunesystem
totheextentthattheydeveloponeormorespecificillnesses.

Anti Anti Anti Anti- -- -retrovirals retrovirals retrovirals retrovirals DrugsusedforHIVprophylaxisortreatmentthataimtosloworstoptheHIVvirus


from multiplying or increasing in the body. However, these drugs are not a cure
forHIV.

Caregiver Caregiver Caregiver Caregivers ss s Persons who assume responsibility for providing care to those in need. They
maybehealthworkers,supportworkers,community-basedcareproviders,family
membersandfriends,etc.

Dehydration Dehydration Dehydration Dehydration Excessive(unhealthy)lossofwaterandsaltsfromthebodythatoftenoccursdue


todiarrhoeaorvomiting.

Diet Diet Diet Diet Thecustomarymixorpatternoffoodanddrinktypesconsumedbyapersonona


dailybasis.

Digestion Digestion Digestion Digestion Theprocess ofbreakingdownfoodsintoformsourbodycanuse.Itbeginswhen


weputfoodinourmouthsandcontinuesuntilitgetsintothestomachandfinally
intotheintestines.

Disclosure Disclosure Disclosure Disclosure When a person with HIV reveals his/her status to other persons. There may be
fear of disclosing ones HIV status if the disclosure could result in the person
beingisolatedfromhis/herfamilyorcommunity,stigmatised,oratriskofphysical
orpsychologicalharm.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
19

Energy Energy Energy Energy Can mean the way a person feels, such as when he or she says, I am full of
energyorIhavenoenergy.Theword energy energy energy energyisalsousedtodescribefuelfor
the body. All foods can provide energy (fuel) though some foods provide more
energythanothers.

Food Food Food Food- -- -borneillness borneillness borneillness borneillness Illnesses caused by eating contaminated food containing harmful pathogens or
germs.

Foodsecurity Foodsecurity Foodsecurity Foodsecurity Situationwherepeople,atalltimes,haveaccesstosufficient,safeandnutritious


foodthatmeetstheirdietaryneeds

HIV HIV HIV HIV Human immunodeficiency virus is one of a family of viruses known as
retroviruses. HIV infects and destroys special white blood cells called CD4+
lymphocytes. These cells are an important part of the bodys immune system,
which is the bodys defence against infection. A person HIV HIV HIV HIV- -- -infected infected infected infected or HIV HIV HIV HIV- -- -
positive positive positive positivemeansthepersonhasbeentestedandthetestresultshowsthattheHIV
virusispresentinhis/herbody.

Immunedeficiency Immunedeficiency Immunedeficiency Immunedeficiency Whentheimmunesystem hasbeenweakenedandislessabletofightdisease.


HIVcanleadtoarangeofspecificopportunisticinfectionsthattakeadvantageof
theweakenedimmunesystem.

Immunesystem Immunesystem Immunesystem Immunesystem The processes in the body that help resist or overcome infections. These
processesneednutrientstoworkproperly.

Malabsorption Malabsorption Malabsorption Malabsorption Failure to absorb one or more nutrients from the food eaten into the body. This
mayoccurifthe:
gutwallisdamaged;
foodmovestooquicklythroughthegut(e.g.inthecaseofdiarrhoea);or
bodyprocessesarenotworkingadequately,e.g.ifthedigestionorgansdo
notproduceenoughfluidstobreakdownfoods.

Malnutrition Malnutrition Malnutrition Malnutrition Conditioncausedwhenthebodygetstoofewortoo manynutrientscausingthe


bodynottofunctionproperly.However,theconditionofapersonreceivingtoolittle
foodismorecommon-referredtoasundernutrition undernutrition undernutrition undernutrition.

Mastitis Mastitis Mastitis Mastitis Aninflammatoryconditionofthebreast,whichmayormaynotbeaccompanied


by infection. It is usually associated with lactation, so it is also called lactational
mastitis.

Metabolism Metabolism Metabolism Metabolism Describes the processes taking place in the body that keep it working properly
includingtheproductionandutilizationofenergy.

Nutrients Nutrients Nutrients Nutrients Nourishing substances or components of food released during digestion and
absorbedtobeusedtopromotebodyfunctions.Nutrientsmaybedividedinto:
Macronutrients(protein,fatsandcarbohydrates)
Micronutrients(vitaminsandminerals).
Thiscoursefocusesonfoodsthatweeatratherthantheindividualnutrientsthat
makeupthesefoods.

Nutrition Nutrition Nutrition Nutrition Broad term referring to processes involved in eating, digestion and utilization of
food by the body for growth, reproduction and maintenance of health. It also
helpsunderstandtherelationshipbetweenfoodandthebody.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
20
Nutritionalstatus Nutritionalstatus Nutritionalstatus Nutritionalstatus The extent to which the individual needs for nutrients are being met. Weight,
heightandothermeasuresofgrowthareoftenusedtoindicatenutritionalstatus.
Clinicalindicators,suchaslevelsofnutrientsintheblood,urine,boneaswellas
otherareas,aremoredifficulttomeasure.

Palliativecare Palliativecare Palliativecare Palliativecare Aimedatrelievingthesymptomsofanillness,suchaspain,stressandnausea,


but does not treat the actual illness. In some places, this care is provided in a
hospiceorbyahospicehomecareteam.

People living with HIV People living with HIV People living with HIV People living with HIV (PLHIV) (PLHIV) (PLHIV) (PLHIV) A general term used for all people infected with HIV, whether or not
theyareshowinganysignsand/orsymptomsofinfection.

Symptomatic Symptomatic Symptomatic Symptomatic An observable change in the body that indicates the presence of disease. The
opposite of this term is asymptomatic asymptomatic asymptomatic asymptomatic and means that the symptoms of a
conditionarenotpresenteventhoughapersonhasdisease.

Thrush Thrush Thrush Thrush Otherwiseknownas Candida,,isafungalinfectionthatcanoccurinthemouthor


other moist areas of the body. White fuzzy patches may be seen on the tongue
and insides of the cheeks. Thrush can result in a very sore mouth and make
eatingdifficult.Treatmentscanreducethrushinfection.

Viralload Viralload Viralload Viralload The amount of HIV in the blood of an HIV-positive person. The higher the viral
loadthehighertheriskofdiseaseprogressingintoAIDS.

Wasting Wasting Wasting Wasting Lossofbodyfatandmuscleleadingtotheindividualbeingweak.







Nutritional Care and Support for People Living with HIV: Facilitators Guide
21

S SS Session ession ession ession 1: 1: 1: 1: LinksbetweenHIVandnutrition LinksbetweenHIVandnutrition LinksbetweenHIVandnutrition LinksbetweenHIVandnutrition

Learning Learning Learning Learningo oo objectives bjectives bjectives bjectives
Bytheendofthissession,participantswillbeabletoexplainthelinksbetweennutritionandHIV,
including:
HowHIVaffectsthenutritionalrequirementsofthebody;
Hownutritionalstatusaffectsqualityoflife;
ThebenefitsofgoodnutritionforpeoplelivingwithHIV;and
TheimportanceofnutritioncounsellingforpeoplelivingwithHIV.

Session Session Session Sessiono oo outline utline utline utline


Content Content Content Content Time Time Time Time
1 Learningobjectivesandintroductiontothesession 5minutes
2 ThelinksbetweennutritionandHIV 7minutes
3 TheeffectsofnutritiononHIV 7minutes
4 ThebenefitsofnutritioncareandsupportforpeoplelivingwithHIVand
theirfamilies
6minutes
5 Summaryofthesessionandtransition 5minutes
Total Total Total Total 30minutes 30minutes 30minutes 30minutes

Preparation for the session

Writeanddisplaythelearningobjectivesonasheetofflipchartpaper.
Writethekeypointonasheetofflipchartpaperandkeepitasideuntilneeded.

KEYPOINT KEYPOINT KEYPOINT KEYPOINT



Awell Awell Awell Awell- -- -nourishedpersonhasastrongerbodytofightinfectionandcopewithHIV nourishedpersonhasastrongerbodytofightinfectionandcopewithHIV nourishedpersonhasastrongerbodytofightinfectionandcopewithHIV nourishedpersonhasastrongerbodytofightinfectionandcopewithHIV. .. .


Collect/preparethefollowingmaterials:
Anoverheadprojectorandscreen;and/oraflipchartstand,flipchartpaper,markersandameans
toattachflipchartsheetstothewallorothersurface.Ifanoverheadprojectorisnotavailable,the
followingmaybecopied/enlargedandpreparedfordisplayasposters.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
22
Overhead1/1: Overhead1/1: Overhead1/1: Overhead1/1:The The The The bad bad bad badc cc cycle ycle ycle ycle of of of ofp pp poor oor oor oornutritionandHIV nutritionandHIV nutritionandHIV nutritionandHIV . .. .
Overhead1/2: Overhead1/2: Overhead1/2: Overhead1/2: The The The The g gg good ood ood ood cycle cycle cycle cycle of of of ofg gg good ood ood oodnutritionandHIV nutritionandHIV nutritionandHIV nutritionandHIV. . . .
Overhead1/3: Overhead1/3: Overhead1/3: Overhead1/3: Effectsof Effectsof Effectsof Effectsofn nn nutritiononHIV utritiononHIV utritiononHIV utritiononHIV. . . .

1. Learning objectives and introduction to the session (5 minutes)


Review the learning objectives of the session
Showtheflipchartanddiscussthelearningobjectives.

Bytheendofthissession,participantswillbeabletoexplainthelinksbetweennutritionandHIV,
including:
HowHIVaffectsthenutritionalrequirementsofthebody;
Hownutritionalstatusaffectsqualityoflife;
ThebenefitsofgoodnutritionforpeoplelivingwithHIV;and
TheimportanceofnutritioncounsellingforpeoplelivingwithHIV.
Introduce the session
Food is important for everyone. It is essential for the proper functioning of the body and the
maintenanceofgoodhealth.

Foodprovidesnutrientswhichareusedbythebodyto:
Growandreplacecellswhentheyhavebeendamaged.
Produceenergyforwork,movementandwarmth.
Carryoutotherbodyfunctionssuchasdigestionandmetabolism.
Protectagainstandhelptorecoverfromdisease.
Ifthebodydoesnotgetenoughfood,itcannotfunctionproperly.Eventheimmunesystemwhich
isthebodysfightingforceagainstallthedifferentdiseaseswillbeweakened.
In a later session, we will talk more about making food choices in order to provide enough
nutrientstothebody.
Inthissession,wewilldiscussmoreaboutthelinksbetweenHIVandnutrition,specifically:
HowHIVcanaffectnutritionalstatusandqualityoflife;
The benefits of nutrition in the care and support for people living with HIV and their
families.
2. The links between HIV and nutrition (7 minutes)

Explainthefollowing:




Nutritional Care and Support for People Living with HIV: Facilitators Guide
23
Poor nutrition quickens the progression from HIV to AIDS while good nutrition slows down the
progression from HIV to AIDS. This can be explained with the cyclical link between HIV and
nutrition.
ShowO OO Overhead1/1 verhead1/1 verhead1/1 verhead1/1: :: : The The The The bad bad bad badcycle cycle cycle cycle of of of of p pp poor oor oor oorn nn nutritionandHIV utritionandHIV utritionandHIV utritionandHIV. .. .
OVERHEAD1/1:THE' OVERHEAD1/1:THE' OVERHEAD1/1:THE' OVERHEAD1/1:THE'BAD BAD BAD BADCYCLEOFPOORNU CYCLEOFPOORNU CYCLEOFPOORNU CYCLEOFPOORNUTRITIONANDHIV TRITIONANDHIV TRITIONANDHIV TRITIONANDHIV


W WW Whatdoyouseeinthispicture? hatdoyouseeinthispicture? hatdoyouseeinthispicture? hatdoyouseeinthispicture?
Give participants a few minutes to identify what they see. Write down their responses on a
flipchart(oraskaco-facilitatortowritethemforyou)fordiscussion.Explainthefollowing:
HIV weakens the bodys natural defence system against disease and infection; as a result, the
bodysabilitytofightinfectionisgreatlyreduced.
With weakened ability to fight infections, the body becomes vulnerable to infections which
normally may have not affected the person. Frequent infections and diseases make the body
weakerandacceleratetheprogressionfromHIVtoAIDS.
HIVandfrequentinfectionsincreasethenutritionneedsofpeoplelivingwithHIV.However,they
maynotbeabletotakeenoughfoodtomeettheseneeds.Thisisusuallyduetolossofappetite,
Weakened Immune System
Poor ability to fight HIV
and other Infections
Increased Vulnerability to Infections
e.g. enteric infections, flu, TB, etc.

Increased Nutritional Needs
Inability to meet increased nutritional
needs for fighting infection and viral
reproduction due to:
Loss of appetite;
Inadequate food intake; and
Poor absorption of nutrients.

Poor Nutrition
Weight loss;
Muscle wasting;
Weakness; and
Micronutrient deficiency.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
24
poor absorption and the changes in the way food is utilized by the body resulting from HIV and
frequentinfections.
The poor intake of food leads to loss of weight, body weakness, and malnutrition, which further
weakensthebodysnaturaldefencemechanism,thusaggravatingthisbadcycle.
In the early stages of infection a person shows no visible signs of illness. But later many of the
signs of AIDS will become apparent, including weight loss, fever, diarrhoea and other
opportunisticinfectionssuchas,sorethroatandtuberculosis(TB).Poornutritionmayaccelerate
theonsetoftheseinfections.

Explain that the discussion in the rest of thissession focuses on how people living with HIV can
avoidorbreakthebadcycleofpoornutritionandHIV.

ShowOverhead1/2: Overhead1/2: Overhead1/2: Overhead1/2:The The The Theg gg good ood ood oodc cc cycleof ycleof ycleof ycleofg gg good ood ood oodn nn nutritionandHIV utritionandHIV utritionandHIV utritionandHIV. .. .
Ifapersoniseatingwell,whateffectcouldthishaveontheHIV Ifapersoniseatingwell,whateffectcouldthishaveontheHIV Ifapersoniseatingwell,whateffectcouldthishaveontheHIV Ifapersoniseatingwell,whateffectcouldthishaveontheHIV- -- -nutrition nutrition nutrition nutritioncycle cycle cycle cycle? ?? ?
Give participants a few minutes to respond by identifying what they see. Write down their
responsesonaflipchart(oraskaco-facilitatortowritethemforyou)fordiscussion.

Discussthefollowingpoints:
The bodys defence system is strengthened against disease and infection and the body has
enough stores of nutrients. The body can therefore easily respond to infection and delay
progressiontoAIDS.
Thebodycanbetterresistinfection.ThishelpspeoplelivingwithHIVtostaystrongerandableto
eatwellandabsorbnutrientsrequiredbythebody.
When people living with HIV are able to meet their bodys food needs, they willnot lose weight;
theywillbeabletostaystrongandwell-nourished.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
25
OVERHEAD1/2:THE OVERHEAD1/2:THE OVERHEAD1/2:THE OVERHEAD1/2:THEGOODCYCLE GOODCYCLE GOODCYCLE GOODCYCLE OFGOODNUTRITIONANDHIV OFGOODNUTRITIONANDHIV OFGOODNUTRITIONANDHIV OFGOODNUTRITIONANDHIV

Showthekeypointdisplayed.

KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Awell Awell Awell Awell- -- -nourishedpersonhasastrongerbodytofightinfectionandcopewithHIV nourishedpersonhasastrongerbodytofightinfectionandcopewithHIV nourishedpersonhasastrongerbodytofightinfectionandcopewithHIV nourishedpersonhasastrongerbodytofightinfectionandcopewithHIV. .. .

Readitandreinforceitwiththefollowingexplanation:

The well-nourished body is able to build strength to fight HIV and other infections because the
bodyhasenoughnutrientsstored.Theimmunesystemisstrengthenedevenfurtherandthecycle
continues.

3. The effects of nutrition on HIV (7 minutes)

ThethreewaysinwhichHIVcanaffectthenutritionalstatusofapersonareby:
Reducingfoodintake;
Loweringfoodabsorption;and
Increasingenergyrequirements.
Discussthesethreeeffectsinturn,askingparticipantsaboutthepossiblecausesofeach.
Good Nutritional Status
Weight gain
Muscle size maintained
Strong body
Nutritional Needs Well-met
Adequate food intake/
absorption
Reduced Vulnerability to Infections
Slower progression of HIV to AIDS
Strengthened Ability to Fight
HIV and Other Infections




Nutritional Care and Support for People Living with HIV: Facilitators Guide
26
Giveparticipantsafewminutestogivetheirsuggestionsandlisttheirresponsesonaflipchartfor
discussion.
Explainthefollowing,focusingonlyonanswersthatmayhavebeenmissed.

Reduced food intake


ForwhatreasonsmightapersonwithHIVreducehisorherfoodintake? ForwhatreasonsmightapersonwithHIVreducehisorherfoodintake? ForwhatreasonsmightapersonwithHIVreducehisorherfoodintake? ForwhatreasonsmightapersonwithHIVreducehisorherfoodintake?
Reducedfoodintakecanresultfromoneormoreofthefollowingreasons:
Difficultieswitheatingorswallowingbecauseofpainfulsoresinthemouthand/orthroat.
Alteredtasteoffood,nauseaandvomiting.
Poorappetiteasaresultoftiredness,depressionandotherpsychologicalfactors.
Less quality and quantity of food in household due to insufficient money, inability to grow
cropsand/ordifficultiesinshoppingandpreparingfood.
Lackofawarenessoftheimportanceofnutrition,especiallywhenrecoveringfromillness.
Sideeffectsofmedications,includingnausea,vomiting,metallictasteinthemouth,diarrhoea
andabdominalcramps.
Lower food absorption
Howmightthebodysabilitytoabsorbfoodbereduced? Howmightthebodysabilitytoabsorbfoodbereduced? Howmightthebodysabilitytoabsorbfoodbereduced? Howmightthebodysabilitytoabsorbfoodbereduced?
Duringdigestion,thefoodweeatisbrokendownintosmallpartscallednutrients.Thesenutrients
areabsorbedthroughthegutintothebloodstreamtobeusedbythebody.Reducedabsorptionof
nutrientscanresultfromoneormoreofthefollowingreasons:
Damage of the gut due to infection and/or the breakdown of cells can result in lower food
absorption.
Infectionssuchasdiarrhoeamakethefoodpasstooquicklythroughthegut,reducing/notgiving
enoughtimefordigestionandabsorption.
Poorabsorptioncancausedifficultyincontrollingbloodsugarlevels,whichmayleadtodiabetes.
Increased energy requirements
What happens when the body is unable to meet its increased energy requirements through What happens when the body is unable to meet its increased energy requirements through What happens when the body is unable to meet its increased energy requirements through What happens when the body is unable to meet its increased energy requirements through
adequatefoodintakeandabsorption? adequatefoodintakeandabsorption? adequatefoodintakeandabsorption? adequatefoodintakeandabsorption?
Iffoodintakeandabsorptionarenotsufficientfor meetingincreasedenergyneeds,musclesare
brokendown(musclewasting).
Inturn,excessivemusclebreakdownleadsto:
Weightloss;
Swellingofthefeetand/orotherpartsofthebody;




Nutritional Care and Support for People Living with HIV: Facilitators Guide
27
Reduced production of saliva and other digestive fluids needed to break down foods into
nutrients,whichfurtherreducestheabsorptionoffood.

Emphasizethefollowingpoints:
For those who are losing weight, add extra quantities of fats and oils such as, butter, margarine
andcookingoiltoincreaseenergyintake.Ifdiarrhoea,vomitingordiscomfortarisesduetothese
increasedintakes,thenreduceintaketoalevelthebodyisabletotolerate.

Refer participants to page 13 of their manual. Ask a participant to read the following statement
andemphasizeitsimportance:
Since the effects of HIV starts even in the early stages of HIV infection, nutrition becomes an
important aspect of care for people living with HIV at all times. It is thus important to find
appropriate ways of encouraging healthy eating as soon as possible so that the person stays
healthy.

4. The benefits of nutrition care and support for PLHIV and their families
(6 minutes)

Good nutrition is particularly important at the initial stages of HIV infection. Nutrition counselling
andeducationatthisearlystagegivesthepersonachancetobuilduphealthyeatinghabitsand
totakeactiontoimproveaccesstofoodandadoptotherhealthypractices.
I II IfapersonhasHIV,whatdifferencew fapersonhasHIV,whatdifferencew fapersonhasHIV,whatdifferencew fapersonhasHIV,whatdifferencewould ould ould oulditmakeifthey itmakeifthey itmakeifthey itmakeiftheywere were were werewell well well well- -- -nourished? nourished? nourished? nourished?
Takeresponsesfromafewparticipants.
Show Overhead 1/3 Overhead 1/3 Overhead 1/3 Overhead 1/3: Impact of good nutrition for people living with HIV. Ask participants to
commentonthisoverhead.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
28
OVERHEAD1/3:IMPACTOFGOODNUTRITIONFORPEOPLELIVINGWITHHIV OVERHEAD1/3:IMPACTOFGOODNUTRITIONFORPEOPLELIVINGWITHHIV OVERHEAD1/3:IMPACTOFGOODNUTRITIONFORPEOPLELIVINGWITHHIV OVERHEAD1/3:IMPACTOFGOODNUTRITIONFORPEOPLELIVINGWITHHIV

UsethefollowingpointstoemphasizetheimportanceofgoodnutritionforpeoplelivingwithHIV:
PeoplelivingwithHIVwhoarewell-nourishedarelikelyto:
Haveimprovedqualityoflife,beingabletoworkandcontributetothefamilysincome;
Haveprolongedgoodhealth,remainingactiveandabletocareforthemselvesandhelpwith
thecareofchildrenandotherdependants;
Have reduced illnesses and recover more quickly from infections, thereby reducing costs for
healthcare.
Maintainagoodappetiteandstableweight.
ChildrenwithHIVwhoarewell-nourishedcan:
Gotoschoolregularly,resultinginbettereducationanddevelopment;
Havemoreenergytoplayandhavefun.
TheprovisionofnutritioncareandsupporttopeoplelivingwithHIVandtheirfamiliespromotes
well-being,self-esteemandapositiveattitudetowardslife.
GoodnutritionshouldbeoneofthegoalsofcounsellingandcareforPLHIV.
Effectivenutritioncounselling,careandsupportwillimprovethequalityoflifeofpeopleliving
withHIV.
As health workers and caregivers we need to have knowledge and skills that can help
improvethenutritionforpeoplelivingwithHIV.Forexample,counsellorsmayencouragewise
eatingevenonabriefvisit.

Improved
quality of life

Remains active
and productive

Maintains a good appetite
and stable weight

Less illness and ability
to recover more quickly


WELL-NOURISHED
PERSON LIVING WITH HIV




Nutritional Care and Support for People Living with HIV: Facilitators Guide
29
5. Summary of the session and transition (5 minutes)
Show/reviewthekeypointdisplayedagain.

KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Awell Awell Awell Awell- -- -nourishedpersonhasastrongerbodytofightinfectionandcopewithHIV nourishedpersonhasastrongerbodytofightinfectionandcopewithHIV nourishedpersonhasastrongerbodytofightinfectionandcopewithHIV nourishedpersonhasastrongerbodytofightinfectionandcopewithHIV. .. .

Food is vital to keep our body working. A well-nourished person has a stronger body for coping
withHIVandfightingadditionalinfections.
MalnutritioninpeoplelivingwithHIVmayresultinweightloss,duetomusclewastingandlossof
bodyfat.Italsoincreasestheriskofinfections,resultingin,e.g.mouthsoresanddiarrhoea,which
inturnfurtherlimitfoodintakeandabsorption.
Good nutrition is veryimportant from the time a person isinfected with HIV. Nutritional care and
supportcanimprovethequalityoflifeofapersonlivingwithHIV.
Askifthereareanyquestions,orifanythingneedsclarifying.
Inthenextsession,wewilldiscusscommunicationskills.
Thenextsessionwillbepresentedby:
Statethenameofthepresenter.






Nutritional Care and Support for People Living with HIV: Facilitators Guide
30

S SS Session ession ession ession2: 2: 2: 2:Introductiontocommunicationskills Introductiontocommunicationskills Introductiontocommunicationskills Introductiontocommunicationskills

Learning Learning Learning Learningo oo objectives bjectives bjectives bjectives

Bytheendofthissession,participantswillbeableto:
Explaintheimportanceofusingacounsellingapproachwithclients;
Demonstratetheappropriateuseofthesixlisteningandlearningcommunicationskills;and
Demonstratetheappropriateuseofthesixskillsforbuildingconfidenceandgivingsupport.

Session Session Session Sessiono oo outline utline utline utline
Content Content Content Content Time Time Time Time
1 Learningobjectivesandintroductiontothesession 5minutes
2 Introductiontocommunicationskills 15minutes
3 Environmentforcommunication 10minutes
4 Skillsthatfacilitatethecounsellingprocess 50minutes
5 Role-plays 20minutes
6 Summaryofthesessionandtransition 5minutes
Total Total Total Total 105minutes 105minutes 105minutes 105minutes

Preparation for the session

Thissessionshouldbepreparedandconductedbyatleasttwofacilitators.Thisisoneofthe
mostimportantsessions.
Healthandnutritionworkersandothercaregiverswillgainsomecommunicationcompetenciesto
betterconveynutritionmessagestotheirclients.
Writeanddisplaythelearningobjectivesonasheetofflipchartpaper.
Writethekeypointsonaflipchartsheetandkeepitasideuntilneeded:
KEYPOINTS KEYPOINTS KEYPOINTS KEYPOINTS
Whenyouensurephysicalcomfort,listenandtalkaboutfoodandeating, Whenyouensurephysicalcomfort,listenandtalkaboutfoodandeating, Whenyouensurephysicalcomfort,listenandtalkaboutfoodandeating, Whenyouensurephysicalcomfort,listenandtalkaboutfoodandeating,
youshowthatyoucareabouttheperson youshowthatyoucareabouttheperson youshowthatyoucareabouttheperson youshowthatyoucareabouttheperson. .. .

Whenyouassureconfidentialityandgiveclientssupportbypraisingtheirpositiv Whenyouassureconfidentialityandgiveclientssupportbypraisingtheirpositiv Whenyouassureconfidentialityandgiveclientssupportbypraisingtheirpositiv Whenyouassureconfidentialityandgiveclientssupportbypraisingtheirpositive e e e
practicesrelatedtofoodandeating,youhelpbuildtheirself practicesrelatedtofoodandeating,youhelpbuildtheirself practicesrelatedtofoodandeating,youhelpbuildtheirself practicesrelatedtofoodandeating,youhelpbuildtheirself- -- -confidence confidence confidence confidence.

Write each communicationskill on different coloured papers ready to stick on the flipchart when
needed.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
31
Collect/preparethefollowingtrainingmaterials:
An overhead projector and screen; and/or a flipchart stand, flipchart paper, markers, coloured
paper and means to attach flipchart sheets to the wall or other display surface. If an overhead
projector is not available, the following overheads may be written out/ prepared for display on
flipchartsheets;anenlargedcopyoftheappropriateversionofPicture1canalsobepreparedfor
displayasaposter.

Overhead2/1: Overhead2/1: Overhead2/1: Overhead2/1: Whatg Whatg Whatg Whatgoodcommunication oodcommunication oodcommunication oodcommunicationmeans means means means
Overhead 2/ Overhead 2/ Overhead 2/ Overhead 2/2 22 2: : : : Six l Six l Six l Six listening and learning skills istening and learning skills istening and learning skills istening and learning skills (Alternative: write and display each skill on
differentcolouredcards).
Overhead2/ Overhead2/ Overhead2/ Overhead2/3 33 3: : : : Sixs Sixs Sixs Sixskills kills kills killsforbuilding forbuilding forbuilding forbuildingconfidenceand confidenceand confidenceand confidenceandgiving giving giving givingsupport support support support
Picture1 Picture1 Picture1 Picture1: : : : SamandSuzi SamandSuzi SamandSuzi SamandSuzi (seeA AA Annex1 nnex1 nnex1 nnex1).

1. Learning objectives and introduction to the session (5 minutes)


Review the learning objectives of the session
Showandoutlinethelearningobjectivesdisplayed.
Bytheendofthissession,participantswillbeableto:
Explaintheimportanceofusingacounsellingapproachwithclients;
Demonstratetheappropriateuseofthesixlisteningandlearningcommunicationskills;
Demonstratetheappropriateuseofthesixskillsforbuildingconfidenceandgivingsupport.
Introduce the session
Inthelastsession,wediscussedsomeinformationonnutritionandHIVthatwouldbeusefulfora
healthornutritionworker.Inthissession,wewill:
Explaintheimportanceofusingacounsellingapproach;
Learn about the communication skills of listening and gathering information, how to offer
suggestionsandhowtofollowup.
Communication skills are introduced early in the course so that you can see examples of them
usedasthecourseprogresses.
2. Introduction to communication skills (10 minutes)

Communicationskillsareonlyintroducedatabasiclevelinthiscourse.Theseskillsimprovewith
practice.
Communicationskillscanbepracticed/usedathomewithyourfamily,aswellasinworksettings.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
32
The communication skills that we will review can also be called counselling skills or using a
counsellingapproach.Thisapproachaimstoincreasethepersonsconfidencesothathe/shecan
decidetoadoptandcarryoutcertainnewpractices.
Thinkofasituationwhensomeonetoldyouwhatyoushoulddo;forexample,thatyoushouldeat
freshvegetableseveryday.Describehowyoufelt.
Allowoneortwoparticipantsdescribehowtheyfelt;then,explainthefollowingpoints:

Good communication is not just telling or advising a person what they should do. It is a way of
working with people to help them decide for themselves what they think is best to do in their
situation.
Good communication skills can be used in many situations when you are talking to a client. In
nutritionwecouldusegoodcommunicationskillsto:
Gatherinformationonnutritionpracticesandchallengestheclientfaces.
Praisegoodpractices.
Give information on eating wisely or infant and young child feeding practices and suggest
changes,ifneeded.
A discussion may include other family members. However, it is the decision of the persons
themselvesastowhomtoincludeinthediscussion.

W WW Whatdoesgoodcommunicationmean? hatdoesgoodcommunicationmean? hatdoesgoodcommunicationmean? hatdoesgoodcommunicationmean?


ShowOverhead2/1 Overhead2/1 Overhead2/1 Overhead2/1andaskparticipantstotaketurnsreadingeachpoint.

OVERHEAD2/1:WHATGOODCOMMUNICATIONMEANS OVERHEAD2/1:WHATGOODCOMMUNICATIONMEANS OVERHEAD2/1:WHATGOODCOMMUNICATIONMEANS OVERHEAD2/1:WHATGOODCOMMUNICATIONMEANS
Listeningtoandunderstandingwhattheclientissayingabouthis/herproblem;
Exploringwiththeclientallthepossibleoptionsavailabletosolveaproblem;
Providingaclientwiththenecessaryinformationtomakeinformeddecisions;
Evaluatingwiththeclienttheoptionsavailabletosolveaproblem
Helpingtheclientreachthebestdecisiontosolvetheproblemhe/shefaces;
Providing skill-building, coaching or mentoring to ensure the client solves the problem
successfully;
Identifyingthehelporsupportneededanddeterminingthenextsteps;
Following-upwiththeclienttoevaluatehowtheactionplanisproceeding;and
Helpingtheclientmodifyorchangetheactionplanifnecessary.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Whatmightinfluenceapersonsdecisiontocarryoutaparticularnutritionpractice? Whatmightinfluenceapersonsdecisiontocarryoutaparticularnutritionpractice? Whatmightinfluenceapersonsdecisiontocarryoutaparticularnutritionpractice? Whatmightinfluenceapersonsdecisiontocarryoutaparticularnutritionpractice?
Allow a few minutes for participants to respond; write down their responses on a flipchart sheet
andthencompletethelistgivenbyparticipants,usingthefollowing:
Many people may not do what they want to do or what you may suggest they do. Clients
decisionsmaydependonanumberofinfluences.
Otherpeoplesbeliefs,opinionsandneeds;
Whocontrolsthehouseholdmoneyandresources;
Localculture,themediaandthepersonssocialstatus;
Thehealthstatusoftheperson;
Whetherthepersonhasdisclosedhis/herHIVstatus;and/or
Whetherthereareanyperceivedriskstotakingtheparticularactioninquestion.

3. Environment for communication (10 minutes)
The story of Sam and Suzi

ShowP PP Picture icture icture icture1 1 1 1:SamandSuzi SamandSuzi SamandSuzi SamandSuzi. .. .

PICTURE1:S PICTURE1:S PICTURE1:S PICTURE1:Sam am am am and and and andS S S Suzi uzi uzi uzi







Nutritional Care and Support for People Living with HIV: Facilitators Guide
34
Readthestory. .. .

THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI

Sam and Suzi are a young couple expecting their first baby. They have come to the health
centretotalktothecounsellor.
InordertotalkwithSamandSuzi,thecounsellormustcreateacomfortableenvironmentfor
them--onethatputsthemateaseandencouragesthemtotalkopenly.

Askparticipantstoclosetheirmanuals.
Ask one participant to turn to page 17 of the Participants Manual and to read the section on
E EE Environmentforcommunicatio nvironmentforcommunicatio nvironmentforcommunicatio nvironmentforcommunication. n. n. n.
Askotherstodescribehoweachelementcanbeachieved,thenexplainthefollowing:

Thecounsellormustcreateacomfortableenvironmentthatputspeopleateaseandencourages
themtotalkopenly.Anenvironmentthatencouragescommunicationisonethatis:
physicallycomfortable;
private;
psychologicallysafe;thatis,oneinwhichtheclienttruststhehealthworkerorcaregiverand
believesthatwhatisbeingpresentedwillbeconsideredconfidential;and
offerssufficienttimeandattentionforfulldiscussionoftheissues.
A client may feel that the presence of someone such as a family member or friend whom they
trustandsupportshim/her,willcontributepositivelytohis/hercareandsupport.Itisfortheclient
todecidewhoattendshis/hercounsellingsession.

4. Skills that facilitate the counselling process (50 minutes)

Introducetheskillsthatfacilitatethecounsellingprocess.
Once the session begins, the counsellor must use good communication skills to build a
relationshipthatwillhelpthecounsellortogatherinformationandhelpclientsbuildconfidencein
order to constructively address the issues they face. There are two major categories of
communicationskillsthatcouldbeused:
Listeningandlearningskills;and
Skillsthathelpbuildconfidenceandgivesupport.
Discusseachoftheseskill-setsindetail.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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3.1 Listening and learning skills
Explainthefollowing:
The counsellor needs to listen carefully to what the client is saying in order to gather as much
informationaspossibleabouttheclientsproblem.
The counsellor needs to do less talking than the client because the necessary information is
comingfromtheclient.Thecounsellorcanalsolearnalot abouttheclientsnutritionalstatusby
justobserving,beforeaskinganyquestions.
SometimesthisapproachisreferredtoasTheTripleL(L LL Listen, isten, isten, isten,L LL Lookand ookand ookand ookandL LL Learn earn earn earn ) approach.
There are six six six six listening and learning skills that help the counsellor communicate better and
facilitatethecommunicationprocess.

W WW Whatarethelisteningandlearningskillsthatcanfacilitate hatarethelisteningandlearningskillsthatcanfacilitate hatarethelisteningandlearningskillsthatcanfacilitate hatarethelisteningandlearningskillsthatcanfacilitateinformationgathering? informationgathering? informationgathering? informationgathering?


Allowafewparticipantstorespondandthendiscussthelisteningandlearningskillsindetail.
Introduce each of the six skills in turn. Attach the relevant coloured card on the flipchart for
displayasyouexplaineachandmoveontothenextskilluntilyouhavecompletedallsix.

OVERHEAD2/2:SIXLISTENINGANDLEARNINGSKILLS OVERHEAD2/2:SIXLISTENINGANDLEARNINGSKILLS OVERHEAD2/2:SIXLISTENINGANDLEARNINGSKILLS OVERHEAD2/2:SIXLISTENINGANDLEARNINGSKILLS
1.Usinghelpfulnon-verbalcommunication;
2.Usingresponses/gestureswhichshowinterest;
3.Empathising;
4.Askingopen-endedquestions;
5.Reflectingbackwhattheclientsays;and
6.Avoidingwordswhichsoundjudgemental.

Usethefollowingpointstoexplaineachofthelisteningandlearningskills

Skill 1: Use helpful non-verbal communication
Non-verbal communication means showing your attitude through your posture, your expressions
andgestureswithoutspeaking.Goodnon-verbalcommunicationskillswillencouragetheclientto
talkmore,focushis/herresponsesandestablishapositiveenvironment.

Followingarefivenon-verbalmeansofcommunication,variousformsofwhichcaneitherhelpor
hindercommunication:




Nutritional Care and Support for People Living with HIV: Facilitators Guide
36

H HH Helps elps elps elps H HH Hinders inders inders inders
1 11 1. .. . Posture Posture Posture Posture Sitsothatyourheadislevelwith
theotherpersons
Standwithyourheadhigherthan
theotherpersons.
2 22 2. .. . Eyecontact Eyecontact Eyecontact Eyecontact Lookattheclientandpayattention
ashe/shespeaks
Lookawayatsomethingelseor
down
atyournotes.
3 33 3. .. . Barriers Barriers Barriers Barriers Removethetableorthenotes Sitbehindatable,orwritenotes
whileyoutalk.
4 44 4. .. . Takingtime Takingtime Takingtime Takingtime

Makethepersonfeelthatyouhave
time.Sitdown,greetwithouthurry,
thenjustremainquietsmilingand
waitingforhim/hertorespond.
Beinahurry.Greetquickly,show
signsofimpatience,andlookat
yourwatch.

5 55 5. .. . Touch Touch Touch Touch Touchtheclientappropriately. Touchtheclientinappropriately.



Skill 2: Ask open-ended questions
To start a discussion with a client, you need to ask some questions. It is important to ask
questionsinawaywhichencouragesaclienttotalkandgiveinformation.Thiscansaveyoufrom
askingtoomanyquestionsandenableyoutolearnmoreinthetimeavailable.
Explainthevalueofopen-endedquestionsbycomparingthemtoothertypesofquestions.

Open-ended questions are very helpful. This is because to answer such a question a client
mustgivesomeinformation.
Open-endedquestionsstartwithHow?What?When?Where?Why?
Forexample:Howareyoueating?
Closed questions are less helpful. They communicate that the answer that you expect is
either,YesorNo
ClosedquestionsstartwithAreyou?orDidhe?orHashe?orDoesshe?
Forexample:Areyoueatingwell?
Whether the client answers Yes or No, you still will not understand much about his/her
eating habits and will not have sufficient information to identify whether there are any
problemstobeaddressed.
Oneideaatatime:Askingtheclientmorethanonequestionatthesametimeallowshim/her
tochoosewhichquestiontoansweravoidingtheother(s).




Nutritional Care and Support for People Living with HIV: Facilitators Guide
37
For example: When will you tell your parents about your status and how do you think they
willreact?Theclientmayavoidsuchaquestionthathe/shedoesnotwanttoanswer.Ifthe
unanswered question is an important one, you must remember to ask it again in a different
way.
No /Why questions often sound psychological and may make the client feel uneasy or
defensive.IfaclientrespondstoaquestionbysayingNo,startthefollow-upquestionwith
Tellme/ExplainthereasonsratherthansimplyaskingWhy?

Skill 3: Use responses and gestures to show interest
In order to encourage the client to continue talking, you must show that you are listening and
interestedinwhathe/sheissaying.
Keywaystoshowyouarelisteninginclude:
Gestures:forexample,maintainingeyecontact,noddingandsmiling
Simpleexpressionsofacknowledgement:forexample,saying:Aha,orMmm.

Skill 4: Reflect back what the client says


Itisusefultoreflectbackorrepeatwhataclientsays.Itshowsthatyouunderstand,andhe/she
ismorelikelytosaymoreaboutwhatisimportanttohim/her.
Itisbesttorepeatwhattheysayinaslightlydifferentway,sothatitdoesnotsoundasthoughyou
aresimplycopyinghim/her.
Forexample:
Ifaclientsays:MymouthgetssoreandIcannoteat
Youcouldsay:Yourmouthgetssoreandthatmakesitdifficultforyoutoeat
Theclientcouldsay:lfeeltooweaktofetchvegetablesfromthegarden
Youcouldsay:Youaretooweakandthatmakesitdifficultforyoutofetchvegetablesfromthe
garden

ACTIVITY2/1:FORMULATINGCLOSEDANDOPEN ACTIVITY2/1:FORMULATINGCLOSEDANDOPEN ACTIVITY2/1:FORMULATINGCLOSEDANDOPEN ACTIVITY2/1:FORMULATINGCLOSEDANDOPEN- -- -ENDEDQUESTIONS(15minutes) ENDEDQUESTIONS(15minutes) ENDEDQUESTIONS(15minutes) ENDEDQUESTIONS(15minutes)



Ask participants to form groups of five. Formulate two questions that are nutrition-related for
eachgroup.Askthemtoclassifytheseintoclosedoropen-endedquestions.Listtheiranswers
intherelevantcolumnsonaflipchartsheet(5minutes).
Ask the groups to reassemble and discuss the responses with all participants, making
correctionsasappropriate(10minutes).




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Skill 5: Empathize - show that you understand how the client feels
When a client says something which shows how he/she feels, it is helpful to respond in a way
whichshowsthatyouunderstandhis/herfeelingfromhis/herpointofview.
Notethatempathyissignificantlydifferentfromsympathy.Whenyousympathizeyouaresorryfor
aperson,butyoulookathis/herconcernsfromyourownpointofview.
Empathy should not only be about understanding the clients bad feelings. It is helpful to
empathizewithaclientsgoodfeelingsaswell.

Skill 6: Avoid words that sound judgemental


Wordsthatcanbeperceivedasjudgementalinclude:
right
wrong
good
bad
well
badly
enough
properly

For example: Avoid questions such as Does the baby sleep well? Instead, ask: How is the
babysleeping?
Showthefirstkeypointofthissessiondisplayed,andaskaparticipanttoreaditoutloud.

K KK KEYPOINT EYPOINT EYPOINT EYPOINT


Whenyouensurephysicalcomfort,listenandtalkaboutfoodandeating, Whenyouensurephysicalcomfort,listenandtalkaboutfoodandeating, Whenyouensurephysicalcomfort,listenandtalkaboutfoodandeating, Whenyouensurephysicalcomfort,listenandtalkaboutfoodandeating,
youshowthatyoucareabouttheperson. youshowthatyoucareabouttheperson. youshowthatyoucareabouttheperson. youshowthatyoucareabouttheperson.
3.2. Skills that build confidence and give support
Introducethisgroupofskills.
People with HIV can easily lose their self-confidence. They are thus likely to succumb to
pressuresfromothersaroundthem.Insomecases,thismayleadtounhealthypractices.
You therefore need skills to help them feel confident and good about themselves. By doing so,
you can help them resist pressures which may prevent them from successfully adopting healthy
practices.
W WW Whataresomeoftheskillsyoucouldusetobuildconfidenceandgivesupporttoclie hataresomeoftheskillsyoucouldusetobuildconfidenceandgivesupporttoclie hataresomeoftheskillsyoucouldusetobuildconfidenceandgivesupporttoclie hataresomeoftheskillsyoucouldusetobuildconfidenceandgivesupporttoclients? nts? nts? nts?
Allow one or two participants to respond and then discuss the six communication skills for
buildingconfidenceandgivingsupportinturn,displayingthecorrespondingcolouredcardasyou
introduceeach.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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OVERHEAD2/3:SIXSKILLSFORBUILDINGCONFI OVERHEAD2/3:SIXSKILLSFORBUILDINGCONFI OVERHEAD2/3:SIXSKILLSFORBUILDINGCONFI OVERHEAD2/3:SIXSKILLSFORBUILDINGCONFIDENCEANDGIVINGSUPPORT DENCEANDGIVINGSUPPORT DENCEANDGIVINGSUPPORT DENCEANDGIVINGSUPPORT

1. Acceptingwhataclientthinksandfeels;
2. Recognisingandpraisingwhataclientisdoingright;
3. Givingpracticalhelp;
4. Givingalittle,relevantinformationwhichcanbeofimmediateusetotheclient;
5. Usingsimplelanguage;and
6.Makingafewsuggestions,ratherthangivingcommands.

Skill 1: Accept what a client thinks and feels
Acceptingmeansrespondinginaneutralway,withoutagreeingordisagreeing.
Forexample:Theclientmaysay:Idonoteatfish;itisbadforsomeonewithHIVinfection.
Youcouldrespondinaneutralwaybysaying:Isee.

Skill 2: Recognize and praise what a client is doing right
The idea is not just to look for what a client is doing wrong, and try to correct him/her. We must
first recog recog recog recogni ni ni niz zz ze ee e what he/she is doing right right right right and praise him/her or show approval of the good
practices.Praisinggoodpracticeswillhelp:
Buildaclientsconfidence;
Encouragehim/hertocontinuethosegoodpractices;and
Makeiteasierforhim/hertoacceptsuggestionslateron.

Skill 3: Give practical help
Practicalhelpisthemostsupportiveintervention.
When clients have a problem that they need to solve, the counsellor should help them walk
throughthestepsthatwillgivethemtheconfidencetosolvetheprobleminaconstructiveway.
Forexample:
When a client says: I no longer feel comfortable to continue with exclusive breastfeeding
becauseldonotknowiflamproducingenoughbreastmilk,
You could ask: Why do you think that you do not have enough breast milk? or Does the
babycontinuecryingafterfeeding?,and
You could suggest that the mother try breastfeeding the baby more frequently, in order to
havemoremilkforthebaby.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Skill 4: Give a little relevant information which can be of immediate use to the client
Itisimportanttogiveinformationwhichisrelevanttotheclientssituationnow.Practicalmeasures
thathe/shecantaketoday,ratherthaninafewweekstime.
Trytogiveonlyoneortwopiecesofsuchinformationatatime.
Giveinformationinapositiveway,sothatitdoesnot soundcritical,ormaketheclientthinkthat
he/she has been doing something wrong. This is especially important if you want to correct a
mistakenidea.
You do not need to give new information or correct a mistaken idea immediately. Wait until you
havebuilttheclientsconfidence,byacceptingwhathe/shesays,andpraisingwhathe/shedoes
well.

Skill 5: Use simple language
Itisimportanttousesimplelanguageandfamiliartermstoexplainthingstotheclients.
Avoidusingmedicaltermsortechnicaljargon.
Forexample:Aclientmaynotnecessarilyunderstandthetermexclusivebreastfeeding.Thus,when
informing her about this practice, you could talk about giving a baby breast milk only and not any
othermilkorfood,notevenwater.

Skill 6: Make a few suggestions rather than commands


Caremustbetakennottotellorcommandclientstodosomething.Thisdoesnothelphim/herto
feelconfident.
Instead you should suggest what he/she could do. Then he/she can decide to do it or not. This
leaveshim/herfeelingincontrolandconfident.
Examplesofcommandwords:always;never;must;should.
Examplesofphrasesformakingsuggestions:
Haveyouconsidered.?
Woulditbepossible.?
Whatabouttryingtoseeifitworksforyou?
Wouldyoubeableto?
Haveyouthoughtabout.?Insteadof.?
Youcouldchoosebetween.and.and.
Itmaynotsuityou,butsomemothersafewwomen.
Perhaps.mightwork...
Usually.Sometimes.Often.

Askparticipantstochangethefollowingcommandintoasuggestion:
Youshouldeatmorefruitsthanvegetables
Insteadofsaying:Youshouldeatmorefruitsandvegetables;youcouldsay:Whatabouttrying
somefruitsandvegetablesatmeals?




Nutritional Care and Support for People Living with HIV: Facilitators Guide
41
Itisalsoimportanttocheckthatthepersonunderstandstheinformationandifshe/hecan,andis
willing to apply the suggestions you are making. Also necessary is some follow-up action to
evaluatehowwelltheclientimplementsthedecision(s)he/shemade.

Showthesecondkeypointdisplayed,andaskaparticipanttoreaditoutloud.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
W WW Whenyou henyou henyou henyouassure assure assure assureconfidential confidential confidential confidentiality ity ity ityand and and andgive give give giveclients clients clients clientssupportbypraising supportbypraising supportbypraising supportbypraisingtheir their their theirpositive positive positive positivepractices practices practices practices
relatedtofoodandeating relatedtofoodandeating relatedtofoodandeating relatedtofoodandeating, , , ,y yy youhelpbuildth ouhelpbuildth ouhelpbuildth ouhelpbuildtheir eir eir eirself self self self- -- -confidence confidence confidence confidence. .. .

5. Role-plays (20 minutes)

Introduce R RR Role ole ole ole- -- -p pp play 2 lay 2 lay 2 lay 2A: A: A: A: The The The The e ee effects of counselling styles on the patterns of interaction between ffects of counselling styles on the patterns of interaction between ffects of counselling styles on the patterns of interaction between ffects of counselling styles on the patterns of interaction between
clientandcounsellor clientandcounsellor clientandcounsellor clientandcounsellor . .. .(H HH Handout andout andout andout2/1 2/1 2/1 2/1 on page26 oftheParticipant'sManual).
Ask two participants to role play (one as the counsellor and the other as the client, i.e. Sam or
Suzi,asappropriate).
Allow them three minutes for preparation, considering that you had already allowed preparation
timebeforethesession.

I II Isthecounselloragreeing sthecounselloragreeing sthecounselloragreeing sthecounselloragreeingor or or ordisagreeing disagreeing disagreeing disagreeingwith, with, with, with,oracceptingwhatSamorSuziis oracceptingwhatSamorSuziis oracceptingwhatSamorSuziis oracceptingwhatSamorSuziissaying? saying? saying? saying?
Introduce R RR Role ole ole ole- -- -play play play play 2B: 2B: 2B: 2B: Demonstration of how to use counselling skills to gather information Demonstration of how to use counselling skills to gather information Demonstration of how to use counselling skills to gather information Demonstration of how to use counselling skills to gather information
(H HH Handout andout andout andout2/2 2/2 2/2 2/2onpage27oftheParticipant'sManual).
Askfortwoparticipantstoroleplay(Aclientandahealthworkertalking)
Allow them three minutes for preparation, considering that you had already allowed preparation
timebeforethesession.
Askparticipantstoobserveandwritedownthetypeofinterventionthehealthworkermakeswhen
respondingtotheclient.
Askthemtoreportwhattheyobservedafterthedemonstration.

6. Summary of the session and transition (5 minutes)
Show/reviewbothkeypoints.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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KEYPOINTS KEYPOINTS KEYPOINTS KEYPOINTS
Whenyouensurephysicalcomfort,listenandtalkaboutfoodandeating, Whenyouensurephysicalcomfort,listenandtalkaboutfoodandeating, Whenyouensurephysicalcomfort,listenandtalkaboutfoodandeating, Whenyouensurephysicalcomfort,listenandtalkaboutfoodandeating,
youshowthatyoucareabouttheperson. youshowthatyoucareabouttheperson. youshowthatyoucareabouttheperson. youshowthatyoucareabouttheperson.

Whenyoua Whenyoua Whenyoua Whenyouassureconfidentialityandgiveclientssupportbypraisingtheir ssureconfidentialityandgiveclientssupportbypraisingtheir ssureconfidentialityandgiveclientssupportbypraisingtheir ssureconfidentialityandgiveclientssupportbypraisingtheir
positivepracticesrelatedtofoodandeating,youhelpbuildtheirself positivepracticesrelatedtofoodandeating,youhelpbuildtheirself positivepracticesrelatedtofoodandeating,youhelpbuildtheirself positivepracticesrelatedtofoodandeating,youhelpbuildtheirself- -- -confidence. confidence. confidence. confidence.

Readandreinforcethekeypoints,addingthefollowingpoints.
Goodcommunicationisnotsimplytellingoradvisingapersonwhattheyshoulddo.Itisawayof
working with people to help them decide for themselves what they think is best to do in their
situation.
Listen, Look and Learn Listen, Look and Learn Listen, Look and Learn Listen, Look and Learn: : : : Do less talking than the client because the necessary information is
comingfromtheclient.
Reviewthevarioustypesofcommunicationskillscoveredinthesession,assummarizedbelow:

Usehelpfulnon-verbalcommunication
Askopenquestions
Useresponsesandgestureswhichshowinterest
Reflectbackwhattheclientsays
Empathize: Show that you understand how the client
feels
Listeningand Listeningand Listeningand Listeningandl ll learning earning earning earning
Avoidwordswhichsoundjudgemental

Acceptwhataclientthinksandfeels
Buildingconfidenceandgivingsupport Buildingconfidenceandgivingsupport Buildingconfidenceandgivingsupport Buildingconfidenceandgivingsupport
Recognizeandpraisewhataclientisdoingright

Givepracticalhelp

Givealittlerelevantinformationwhichcanbeof
immediateusetotheclient

Usesimplelanguage

Makeafewsuggestionsratherthancommands

Inthenextsession,wewilldiscusseatingwisely.
Thenextsessionwillbepresentedby:
Statethenameofthepresenter.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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HANDOUT2/1 HANDOUT2/1 HANDOUT2/1 HANDOUT2/1
ROLE-PLAY 2A: The effects of counselling styles on patterns of interaction between client
and counsellor
The clients are Sam and Suzi who are HIV positive. They will be talking to three different
counsellors who have three different styles of interacting in order to illustrate the effect of
counselling styles on the patterns of interaction between client and the counsellor. Listen to
determine whether the counsellor is agreeing, disagreeing or accepting what Sam or Suzi is
saying.

1. 1. 1. 1.
COUNSELLOR1: Foodsfromanimalscanhelpyoutostayhealthy.
Couldyoueatsomeofthesefoods?

SAM/SUZI: Idonothavethemoneytobuyanimalfoods.
Ibuythespecialtabletsinthemarkettokeepmehealthyand
theyareveryexpensive.

COUNSELLOR1: Ohno,thosetabletsareawasteofyourmoney.
Youshouldnotbuythem.
Disagreeing Disagreeing Disagreeing Disagreeing
Judgemental Judgemental Judgemental Judgemental

2. 2. 2. 2.
COUNSELLOR2: Foodsfromanimalscanhelpyoutostayhealthy.
Couldyoueatsomeofthesefoods?

SAM/SUZI: Idonothavethemoneytobuyanimalfoods.Ibuythespecial
tablets
inthemarkettokeepmehealthyandtheyareveryexpensive.

COUNSELLOR2: Yes,manypeoplebuythosetabletstokeepthemhealthy.
Iamsuretheywillhelpyou.
Agreeingwith Agreeingwith Agreeingwith Agreeingwith
awrongidea awrongidea awrongidea awrongidea

3. 3. 3. 3.
COUNSELLOR3: Foodsfromanimalscanhelpyoutostayhealthy.
Couldyoueatsomeofthesefoods?

SAM/SUZI: Idonothavethemoneytobuyanimalfoods.
Ibuythespecialtabletsinthemarkettokeepmehealthyand
theyareveryexpensive.

COUNSELLOR3: Youfindbuyingthetabletsveryexpensiveandthisleaves
youwithlessmoneyforfood.

Reflectingback Reflectingback Reflectingback Reflectingback







Nutritional Care and Support for People Living with HIV: Facilitators Guide
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HANDOUT2/2 HANDOUT2/2 HANDOUT2/2 HANDOUT2/2
ROLE-PLAY 2B: Demonstration of how to use counselling skills to gather information
A client and a health worker are talking. Observe and note the communication skills the health
workeruses.

COMMUNICATION COMMUNICATION COMMUNICATION COMMUNICATION
SKILLUSED SKILLUSED SKILLUSED SKILLUSED
HEALTHWORKER Pleasesitdown(name).Welcome.
Howareyoutoday?
O OO Open pen pen penquestion question question question
CLIENT Well,IamOK.
HEALTHWORKER Describehowyoufeel? Openquestion Openquestion Openquestion Openquestion
CLIENT Ihavemoreenergytodomywork
HEALTHWORKER Anythingelse? O OO Openquestion penquestion penquestion penquestion
CLIENT Iseemtohavemorecolourinmyface.
HEALTHWORKER Iseeyouwereweighedearlierbythedoctorandyour
weighthasstayedsteadysinceIlastsawyou.Thats
verygood.Describewhatyouhavebeeneating?
Recogni Recogni Recogni Recognition tion tion tion
Praise Praise Praise Praise
Openquestion Openquestion Openquestion Openquestion
CLIENT Ididsomeofthethingsyousuggestedthelasttime.
HEALTHWORKER Specificallytellmewhichsuggestionsyoufollowed.


PAUSE
HEALTHWORKER I am glad some of the suggestions were useful to
you.Areyouhavinganyproblemseating?
Buildingconfidence Buildingconfidence Buildingconfidence Buildingconfidence
CLIENT Yes,sometimes.
IDENTIFYINGTHEPROBLEM
HEALTHWORKER Describetheproblemsthatyouarehaving? Openquestion Openquestion Openquestion Openquestion
CLIENT Well,mymouthgetssore.
HEALTHWORKER Yourmouthgetssore.Doesitgetsorewhenyoueat
certainfoodsordoesitjustbecomesore?
Reflectingback Reflectingback Reflectingback Reflectingback
Openquestion Openquestion Openquestion Openquestion
PAUSE
CLIENT Justsometimes,itissoreandhardtoeat.
HEALTHWORKER Youfindthatishardtoeatbecauseyourmouthgets
sore. Let me tell you about some things that might
helpyoutoeatmorecomfortably?
Empathy Empathy Empathy Empathy





Nutritional Care and Support for People Living with HIV: Facilitators Guide
45

Session3:Eatingwisely Session3:Eatingwisely Session3:Eatingwisely Session3:Eatingwisely



Learning Learning Learning Learningo oo objectives bjectives bjectives bjectives

Bytheendofthissession,participantswillbeableto:

Describetheroleoffoodinourbody,forgrowth,repair,energyandprotection;
Outlinetheprinciplesofhealthyeatingoreatingwisely;and
Discusshowfoodchoicesaremade.

Session Session Session Sessiono oo outline utline utline utline
Content Content Content Content Time Time Time Time
1 Learningobjectivesandintroductiontothesession 3minutes
2 Nutrientsandtheirroleinthebody 10minutes
3 Aneatingwiselydemonstrationtalk 30minutes
4 Eatingwisely:summaryanddiscussion

(Role-play3A:Discussing eatingwiselywiththecaregiverofayoung
child)
15minutes
(Total)

(10minutes)
5 Foodchoices

(Exercise3/1:FoodChoicesWorksheet)
20minutes
(Total)
(15minutes)
6 Summaryofthesessionandtransition 2minutes
Total Total Total Total 80minutes 80minutes 80minutes 80minutes

Preparation for the session

Writeanddisplaythelearningobjectivesonasheetofflipchartpaper
Writethekeypointonasheetofflipchartpaperandkeepitasideuntilneeded.

KEYPOINT KEYPOINT KEYPOINT KEYPOINT


Aimtoeatawidevarie Aimtoeatawidevarie Aimtoeatawidevarie Aimtoeatawidevarietyoffoodsateachmeal,every tyoffoodsateachmeal,every tyoffoodsateachmeal,every tyoffoodsateachmeal,everyday day day day. .. .

This session may be divided between two facilitators, with one facilitator presenting the theory
sectionsandonefacilitatorgivingthedemonstrationtalk.
Decideonexamplesoffoodsthatareusedintheareaandaddorreplacewiththefoodsonthe
tables.Youmayalsousefoodpostersifavailable.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
46
The discussion in this session is based on an image of a variety of foods. If you use another
imagethatismorefamiliarinthearea,ensurethatitiseasytounderstand.
Focusonfoodratherthannutrients.Ifyouareusinganothermethodofexplainingeatingwisely,
practisethedemonstrationsoitfitsintotheallocatedtimeof30minutes.
Use locally available pictures and handouts relevant to eating wisely during the talk, if these fit
withtheinformationyouareproviding.
Prepareacollectionoffoodmodelsorflashcardsfordemonstration
Youwillneedeightsheetsofcolouredpapertolistdowntheeighteatingwiselyguidelines,each
onadifferentsheet,inboldletters;keeptheseasideuntilneededduringthedemonstrationtalk.

Eating wisely guidelines


1. Enjoyavarietyoffoods.
2. Makestaplesorstarchyfoodsthelargestpartofyourmeal.
3. Eatpeas,beans,lentils,nutsandseeds,ifpossibleeveryday.
4. Eatanimalandmilkproductsregularly.
5. Eatawidevarietyofvegetablesandfruitseveryday.
6. Usefatsandoilsaswellassugarandsugaryfoodsregularlybutinmoderation.
7. Usefoodsthatarefortifiedwithessentialnutrients,ifpossible.
8. Drinkplentyofsafewater.

Ask two participants to assist with the demonstration talk by asking prepared questions. The
questionsareattheendofthetextfortheEatingwiselytalkinthisguide.
Give each of the participants assisting you a question written on a piece of paper and explain
whentoaskthesequestions.
AskparticipantstoformthreegroupsforExercise 3/1: 3/1: 3/1: 3/1: Foodchoices Foodchoices Foodchoices Foodchoicesworksheet worksheet worksheet worksheet (foundonpage
41oftheParticipantsManual).
Collectafewpacketsandtinsoffortifiedfoodsavailablelocallyandbringthemfordemonstration
inthesession.Mentionaregionalbrandoffortifiedfoodproductsifoneexists.
Fordiscussionof H HH Handout3/1: andout3/1: andout3/1: andout3/1: Foodpo Foodpo Foodpo Foodpor rr rtion tion tion tions: s: s: s: sizesofahealthymeal sizesofahealthymeal sizesofahealthymeal sizesofahealthymeal , ,, ,collectafew household
utensils used for serving or measuring food such as, cups, teaspoon, tablespoon, as well as
samplesofafewfruitsfordemonstration.
Collect/preparethefollowingtrainingmaterials.
Anoverheadprojectorandscreen;and/oraflipchartstand,flipchartpaper,markers,sheetsof
coloured paper and means to attach sheets to the wall or other surface. If an overhead
projectorisnotavailable,overheadsmaybewrittenoutonflipchartsheetsorenlargedcopies
canbepreparedfordisplayasposters..




Nutritional Care and Support for People Living with HIV: Facilitators Guide
47
Overhead3/1: Overhead3/1: Overhead3/1: Overhead3/1: Nutrients Nutrients Nutrients Nutrients
Overhead3/2 Overhead3/2 Overhead3/2 Overhead3/2 Grow,Go,Glow Grow,Go,Glow Grow,Go,Glow Grow,Go,Glow
Overhead3/3 Overhead3/3 Overhead3/3 Overhead3/3 Av Av Av Avarietyoffoods arietyoffoods arietyoffoods arietyoffoods (thiscanbesubstitutedbyalocalillustration)
Overhead3/4 Overhead3/4 Overhead3/4 Overhead3/4: : : : Eatingwiselyguidelines Eatingwiselyguidelines Eatingwiselyguidelines Eatingwiselyguidelines
Overhead3/5 Overhead3/5 Overhead3/5 Overhead3/5; ; ; ;I I I Increasedenergyrequirement ncreasedenergyrequirement ncreasedenergyrequirement ncreasedenergyrequirements ss sforpeoplelivingwithHIV forpeoplelivingwithHIV forpeoplelivingwithHIV forpeoplelivingwithHIV
Overhead3/6 Overhead3/6 Overhead3/6 Overhead3/6: Foodchoices Foodchoices Foodchoices Foodchoices
Table Table Table Table3/ 3/ 3/ 3/1: 1: 1: 1: L LL Legumesandpulses,nutsandoilseeds egumesandpulses,nutsandoilseeds egumesandpulses,nutsandoilseeds egumesandpulses,nutsandoilseeds
Table Table Table Table3/ 3/ 3/ 3/2: 2: 2: 2: M MM Milkandmilkproducts,meats,poultr ilkandmilkproducts,meats,poultr ilkandmilkproducts,meats,poultr ilkandmilkproducts,meats,poultryandfish yandfish yandfish yandfish
Table Table Table Table 3 33 3/3 /3 /3 /3: : : : Starchyfoods Starchyfoods Starchyfoods Starchyfoods
Table Table Table Table3/ 3/ 3/ 3/4: 4: 4: 4: Sugarsandfats Sugarsandfats Sugarsandfats Sugarsandfats
Table Table Table Table3/ 3/ 3/ 3/5: 5: 5: 5: V VV Vegetablesandfruits egetablesandfruits egetablesandfruits egetablesandfruits
Handout3/1 Handout3/1 Handout3/1 Handout3/1: : : : Foodpo Foodpo Foodpo Foodpor rr rtion tion tion tions:s s:s s:s s:sizesofahealthymeal izesofahealthymeal izesofahealthymeal izesofahealthymeal (availableattheendofthissession)
Role Role Role Role- -- -play play play play3A 3A 3A 3A: : : : Discussing Discussing Discussing Discussing eatingwisely eatingwisely eatingwisely eatingwisely withthecaregiver withthecaregiver withthecaregiver withthecaregiverofayoungchild ofayoungchild ofayoungchild ofayoungchild
Exercise3/1: Exercise3/1: Exercise3/1: Exercise3/1:Foodchoicesworksheet Foodchoicesworksheet Foodchoicesworksheet Foodchoicesworksheet(availableattheendofthissession)

1. Learning objectives and introduction to the session (3 minutes)


Review the learning objectives of the session

Showtheflipchartanddiscussthelearningobjectives.
Bytheendofthissession,participantswillbeableto:
Describetheroleoffoodinourbodyforgrowth,repair,energyandprotection;
Outlinetheprinciplesofhealthyeatingoreatingwisely;and
Discusshowfoodchoicesaremade.
Introduce the session
Sam and Suzi thought about what the HIV counsellor had said to them about how eating wisely
helpspeopletostayhealthylonger.Theydecidedtheywouldgotothetalkatthehealthcentre.
Inthissession,wewillhearatalkasifitwerebeinggiventoagroupinahealthcentre.Thistalk
willdescribetheroleoffoodingrowth,repair,energyandprotectionandoutlinetheprinciplesof
eating wisely. We will discuss how similar information could be used with an individual and how
peoplemakechoicesaboutwhatfoodtheyeat.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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2. Nutrients and their role in the body (10 minutes)

ShowO OO Overhead:3 verhead:3 verhead:3 verhead:3/1: /1: /1: /1: Nutrients Nutrients Nutrients Nutrients andexplainthefollowingpoints

OVERHEAD OVERHEAD OVERHEAD OVERHEAD 3/1: 3/1: 3/1: 3/1:NUTRIENTS NUTRIENTS NUTRIENTS NUTRIENTS

Macro Macro Macro Macro- -- -nutrients nutrients nutrients nutrients:carbohydrates,proteinandfat

Micro Micro Micro Micro- -- -nutrients: nutrients: nutrients: nutrients:vitaminsandminerals

Foodismadeupofnutrientsneededbythebody.Thesenutrientsaredividedintomacro-nutrients
suchas,carbohydrates,proteinandfat, whichareneededinlargeamounts;andmicro-nutrients
suchas,vitaminsandminerals,whichareneededonlyinsmallamounts.
Nutrientsworkasateamandneedeachother.Thebodycannotfunctionproperlyifevenoneof
nutrientsismissing.
A healthy diet provides foods in the right amounts and combinations that are safe and free from
diseaseandharmfulsubstances.
Emphasizethefollowingpoint:

People think of eating food rather than eating nutrients. In this session, we will often talk about
foodandnotnutrients.Thesessionwillalsooutlinedietaryguidelinesdiscussingwhattodowith
everygroupoffood.

3. An eating wisely demonstration talk (30 minutes)

Some ofyoumayneedto talktoa groupabouthealthyeating.Theinformation inthissectionis


presentedinawaythatyoumightintroducethissubjecttoagroup.Theinformationisatabasic
level;additionalinformationcanbeprovidedifpeopleaskquestions.
Thisisonlyoneofmanypossiblewaysinwhichinformationonhealthyeatingcanbepresented.
Facilitatorsmaychoosetoincorporateotherideasoruseotherformatstomakethepresentation
morerelevantandunderstandabletoparticulargroups.
This talk assumes you have only a short time and limited facilities. If you have more time
available,thetalkcaninvolvemoreactivities.
Duringthisdemonstrationtalk,youwillpretendtobethegroupofpeopleattendingthetalkgiven
byahealthworkeratahealthcentre.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
49
Aspartofthedemonstrationtalk,therewillbesomequestionswhereyoustillpretendyouarethe
peopleinthathealthcentregroup.Afterthedemonstrationtalk,wewillcontinuethesessionwith
youasparticipantsinthiscourse.

Ensurethatparticipantsunderstandthattheyareexpectedtopretendtobepeopleattendingthe
talkatahealthcentrethroughoutthissession.Remindthemofthisrepeatedlyatthestartofeach
topic(Sections3.1 Sections3.1 Sections3.1 Sections3.1.to3.11. .to3.11. .to3.11. .to3.11.)below.
Introducethepersonwhowillgivethetalkifthesessionissharedbetweenfacilitators.
Presenttheeatingwiselytalk
3.1. Eating wisely: introduction
Welcomethegroupandexplainwhatthetalkisabout.
Goodafternoon/morningandwelcome.
Today,wewilltalkaboutfoodandeating.
Foodisimportanttoallofus.
ShowO OO Overhead3/2 verhead3/2 verhead3/2 verhead3/2: :: :T TT Theroleoffoodinthebody heroleoffoodinthebody heroleoffoodinthebody heroleoffoodinthebodyandexplaintheimportantfunctionsoffood.

OVERHEAD3/2:THEROLEOFFOODINTHEBODY OVERHEAD3/2:THEROLEOFFOODINTHEBODY OVERHEAD3/2:THEROLEOFFOODINTHEBODY OVERHEAD3/2:THEROLEOFFOODINTHEBODY



Foodhelpsusto Foodhelpsusto Foodhelpsusto Foodhelpsusto:

GROWGOGLOW GROWGOGLOW GROWGOGLOW GROWGOGLOW


Foodisusedbythebodyto:
Grow Grow Grow Grow: : : :Foodisessentialforourbodiestodevelop,replaceandrepaircellsandtissues.
Children need food to grow. For adults, food serves to repair cells and tissues. To illustrate this
processitisusefultothinkofthebodyasawallmadeofmanybricks.Ifabrickisdamaged,itistaken
outandreplacedbyanewone.Thewallmaystayinthesameshapebutitisrepairedorrenewedin
parts.Foodisessentialforthiscontinualrepairprocesstotakeplaceinthehumanbody.

Go Go Go Go: : : :Foodisessentialforourbodiestoproduceenergy,tokeepwarm,tomoveandwork.
Foodprovidesuswithenergyorfueltomoveaboutandbeactive;tokeepthebodyworking,theheart
topumpblood,thelungstobreathe,andtoproducebodyfluidssuchasblood,breastmilk,salivaand




Nutritional Care and Support for People Living with HIV: Facilitators Guide
50
digestivefluids.Thebodyalsoneedsfoodtocarryouttheprocessoffooddigestion.Inthesameway
thatacarcannotgowithoutfuel,thebodybecomesweakwithoutfoodandcannotfunction.

Glow Glow Glow Glow: :: : Foodisessentialtoprotectourbodiesfromdisease,tofightinfectionandtorecoverfrom


illness. .. .
Foodthus,enablesourbodiestogloworshinewithhealth.

Ifsomebodyweretoaskyouaboutwhatyouthinkeatingwiselymean Ifsomebodyweretoaskyouaboutwhatyouthinkeatingwiselymean Ifsomebodyweretoaskyouaboutwhatyouthinkeatingwiselymean Ifsomebodyweretoaskyouaboutwhatyouthinkeatingwiselymeans ss s,whatwouldyousay? ,whatwouldyousay? ,whatwouldyousay? ,whatwouldyousay?


Remind participants that they should still be role-playing as people attending an Eating wisely
talkatahealthcentre.
Takeafewresponsesfromthegroupandexplainthefollowing:

Eatingwiselymeanseatingavarietyoffoodsintherightquantity,combinationandfrequencyto
providethebodywiththerequirednutrientsonadailybasis.Thismeansthattostayhealthy,we
needtotrytoeatmanydifferentkindsoffoodateachmeal.
It is essential for all people to understand and follow the principles of eating wisely in order to
ensureadequatefoodformeetingtheirnutritionalneeds.
ShowO OO Overhead3/3 verhead3/3 verhead3/3 verhead3/3: : : : Varietyoffoods Varietyoffoods Varietyoffoods Varietyoffoods andexplaintheguidelinesthatanindividualcanfollowfor
eatingwisely.

OVERHEAD3/3:V OVERHEAD3/3:V OVERHEAD3/3:V OVERHEAD3/3:VARIETYOFFOODS ARIETYOFFOODS ARIETYOFFOODS ARIETYOFFOODS





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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3.2. Enjoying a variety of foods
Remind participants that they should still be role-playing as people attending an Eating wisely
talkatahealthcentre.
Showthefirstcolouredpaperenjoyavarietyoffoodandexplainthefollowing:
No single food or group of foods contains all the nutrients that the body needs in the right
quantitiesandcombinations,exceptbreastmilkforinfantsuptosixmonths.
Eating a variety of different foods will provide the nutrients that are essential for our bodies. It is
important to include different food and food groups in ones diet as well as to alter methods of
preparation.
Bytakingcaretochoosefoodsthatareinseasonandlocallyavailable,eatingcanbeenjoyable,
healthyandaffordable.
3.3. Eating wisely: Group activity
Remind participants that they should still be role-playing as people attending an Eating wisely
talkatahealthcentre.
Askthemtogetintogroupsofthree;giveeachgroupastackoffoodflashcards.
Ask each group to single out flash cards with pictures of foods that are easily available in their
regioninonepile.Takebacktheflashcardswithfoodsthatarenotavailable.
Askthemtodiscusshowtheywillusethesefoodsinordertoenjoyavarieddiet.
Askthemtosuggestreasonsthatmightmakeitdifficulttofollowthisguideline.
Usethefollowingpointsfordiscussion:
It might not be possible for all people to enjoy a variety of foods at each meal. However, it is
importantthatatleastthemealsconsumedthroughoutthedayarevaried.
Anexampleofamixedmealofoptimalvarietyisonemadeupofmaize-meal,chicken,pumpkin
andspinach.
Ask participants to provide a similar example of a mixed meal comprising a variety of locally
availablefoods.
Thiscouldbeexchangedwithotherfoodsinothermealsanddays.
Forexample,maize-mealcanbeeatenwithothermeats,animalproductsorlegumes,insteadof
chicken. In addition, try to buy fruits and vegetables that are in season, such as, oranges and
traditional green leafy vegetables, to add variety. Fruits and vegetables can also be grown at
home.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
52
Inaddition,thesamefoodcouldbecookeddifferently.Forexample,insteadofalwaysfryingfood
infatoroil,youcouldtrysteaming,baking,andgrilling.
Vegetables need not always be cooked but can also be used as salad. It is important to clean
vegetablesthoroughlyiftheyaretobeconsumedraw.
3.4. Make staples or starchy foods the largest part of your meal
Remind participants that they should still be role-playing as people attending an Eating wisely
talkatahealthcentre.
Show the second coloured paper/card: M MM Make staples or starchy foods the larg ake staples or starchy foods the larg ake staples or starchy foods the larg ake staples or starchy foods the largest part of your est part of your est part of your est part of your
meal meal meal meal andexplainthefollowing:
Staple foods should be eaten with every meal. When planning meals, the staple or starchy food
shouldbethecentralormainfood,andtherestofthemealshouldbeplannedaroundthisfood.
Askparticipantstosingleoutandputasidestarchyfoodsfromtheirpileofflashcards.
ClarifyanyconfusionsandshowT TT Table able able able3/ 3/ 3/ 3/1 1 1 1formoreexamples.

Table Table Table Table3/ 3/ 3/ 3/1:Examplesof 1:Examplesof 1:Examplesof 1:Examplesofstaplesor staplesor staplesor staplesorstarchyfoods starchyfoods starchyfoods starchyfoods

Askparticipantstosuggestreasonsthatmightmakeitdifficulttofollowthisguideline.
Usethefollowingpointsfordiscussion:
These foods are relatively cheap and provide mainly energy or fuel to give us G GG Go o o o, as well as
somenutrientstohelpus Grow Grow Grow Grow andGlow Glow Glow Glow .
However,staplesalonearenotenoughtoensureadequatevarietyoffoodandtoprovideallthe
nutrientsthatthebodyneeds.Thus,weneedotherfoodsaswell.
3.5. Eat pulses and legumes, nuts and oil seeds, if possible everyday.
Remind participants that they should still be role-playing as people attending an Eating wisely
talkatahealthcentre.
ShowthethirdcolouredpaperE E E Eat at at atpulsesandlegumes, pulsesandlegumes, pulsesandlegumes, pulsesandlegumes,nutsand nutsand nutsand nutsandoil oil oil oilseeds,ifpos seeds,ifpos seeds,ifpos seeds,ifpossibleeveryday. sibleeveryday. sibleeveryday. sibleeveryday.
andexplainthefollowing:
CerealsandGrains CerealsandGrains CerealsandGrains CerealsandGrains StarchyRootsorTubers StarchyRootsorTubers StarchyRootsorTubers StarchyRootsorTubers StarchyFruits StarchyFruits StarchyFruits StarchyFruits
Maize/CornMeal Cassava(Fresh) Breadfruit
Millet CassavaFlour Plantain
Rice Potato
Sorghum SweetPotato
WheatFlour Yam




Nutritional Care and Support for People Living with HIV: Facilitators Guide
53
Thesefoodsareneededto Grow Grow Grow Grow astheyhelpdevelopandrepairofthebodyandalsotobuildup
strongmuscles.Theyalsocontainsomenutrientstohelp Glow Glow Glow Glow . .. .
Askparticipantstosingleoutandputaside,pulsesandlegumes(e.g.peas,beans,lentils),nuts
andoilseedsfromtheirpileofflashcards.
ClarifyanyconfusionandshowT TT Table able able able3/ 3/ 3/ 3/2 2 2 2formoreexamples.

Table Table Table Table3/ 3/ 3/ 3/2:Exam 2:Exam 2:Exam 2:Examplesof plesof plesof plesofpulsesandlegumes pulsesandlegumes pulsesandlegumes pulsesandlegumes,nuts ,nuts ,nuts ,nutsand and and andoil oil oil oilseeds seeds seeds seeds

Askparticipantstosuggestreasonsthatmightmakeitdifficulttofollowthisguideline.
Usethefollowingpointsfordiscussion:
Thesefoodsarecheapersourcesofproteinthananimalproductssuchas,beefandchicken,and
shouldbeeateneveryday,ifpossible.
However,mostofthemmayrequirethoroughcookingtohelptheirdigestion.
Soakingbeansandpeasinwaterpriortocooking,andusinglocally-made,fuel-efficientcookers
willreducetheamountoffirewoodneededtocookthemwell.
3.6. Eat poultry, meat, fish, eggs, milk and milk products regularly
Remind participants that they should still be role-playing as people attending an Eating Wisely
talkatahealthcentre.
Show the fourth coloured paper Eat Eat Eat Eat poultry poultry poultry poultry, meat, fish, eggs, milk and , meat, fish, eggs, milk and , meat, fish, eggs, milk and , meat, fish, eggs, milk and milk products milk products milk products milk products. . . . and
explainthefollowing:
Thesefoodsareusefulforgrowthandrepair,fortheformationofblood,tostrengthenmuscles
andtheimmunesystemtofightinfections.
Ask participants to single out and put aside, poultry (chicken, turkey, duck and other domestic
birds)meat,fish,eggs,milkandmilkproductsfromtheirpileofflashcards.
ClarifyanyconfusionandshowT TT Table able able able 3 33 3/3 /3 /3 /3formoreexamples.

Pulse Pulse Pulse Pulses ss sandLegumes andLegumes andLegumes andLegumes NutsandOilseeds NutsandOilseeds NutsandOilseeds NutsandOilseeds
Chickpeas GroundNuts
Cowpeas MelonSeeds
KidneyBeans Peanut
Lentils PumpkinSeed
PigeonPeas Sesame
Soybean




Nutritional Care and Support for People Living with HIV: Facilitators Guide
54

Table3 Table3 Table3 Table3/3 /3 /3 /3: : : :Poultry,meat,fish,eggs,milkandmilkproducts Poultry,meat,fish,eggs,milkandmilkproducts Poultry,meat,fish,eggs,milkandmilkproducts Poultry,meat,fish,eggs,milkandmilkproducts

Explainthefollowingpoints:
Liverandotherorganmeatsoroffalareparticularlyvaluablefortheformationofblood.
Fermentedmilkisbeneficialifapersonhasdiarrhoeabecauseitiseasilydigested,mayhelpin
digestionandabsorptionofotherfoodsandisagoodsourceofenergy.Fermentedmilkmaybe
readilyavailableanddoesnotneedtobestoredinarefrigerator.
Breastmilkisagoodfoodforinfantsandyoungchildren.Ithelpsthemto G GG Grow row row row, , , , G GG Go o o o and G GG Glow low low low.

Askparticipantstosuggestreasonsthatmightmakeitdifficulttofollowthisguideline.
Explainthefollowing:
Poultry,meat,fish,eggs,milkandmilkproductsmaybeexpensivebutitisimportanttoinclude
evensmallportionsofsuchfoodsinthemealasoftenaspossible.
3.7. Eat a wide variety of vegetables and fruits everyday
Remind participants that they should still be role-playing as people attending an Eating wisely
talkatahealthcentre.
ShowthefifthcolouredpaperEatawidevarietyofvegetablesandfruitseveryday. Eatawidevarietyofvegetablesandfruitseveryday. Eatawidevarietyofvegetablesandfruitseveryday. Eatawidevarietyofvegetablesandfruitseveryday.andexplain
thefollowing:
Milkand Milkand Milkand Milkandmilk milk milk milkproducts products products products Poultry Poultry Poultry Poultry, , , ,meatandfish meatandfish meatandfish meatandfish
Cowmilk(fresh) Chicken,turkey,duck,geese,etc.
Goatmilk(fresh) Beef(Cow/Bull)
Fermentedmilk Goat
Cheese Lamb(Sheep)
Curd Pork
Yoghurt Rabbit
Deer
Fish

Insects

Organmeats/offal,e.g.liver

Eggs




Nutritional Care and Support for People Living with HIV: Facilitators Guide
55
Vegetablesandfruitsareanimportantpartofahealthydiet.Theysupplyfoodsthatkeepthebody
functioningandtheimmunesystemstrong.
Theyareknownasprotectivefoodsbecausetheyareimportantforpreventingandfighting
infections.
ThesefoodsareespeciallyimportantforpeoplelivingwithHIVtofightinfections.Aimtoeata
widevariety,aseachonehasadifferentwaytohelpus G GG Glow low low lowwithhealth.

Askparticipantstosingleoutandputaside,vegetablesandfruitsfromtheirpileofflashcards.
ClarifyanyconfusionandshowT TT Table able able able3/4 3/4 3/4 3/4formoreexamples.

Table Table Table Table3/ 3/ 3/ 3/4:Vegetablesandfruits 4:Vegetablesandfruits 4:Vegetablesandfruits 4:Vegetablesandfruits



Askparticipantstosuggestreasonsthatmightmakeitdifficulttofollowthisguideline.
Usethefollowingpointsfordiscussion:
Mostvegetablesandfruitscanbeeasilygrowninhomegardens.Thosewhodonothaveaccess
to land for a home garden, may consider organizing communal gardens for growing such
nutritiousfruitsandvegetables.
Eat vegetables and fruits that are dark-green, yellow, orange or red in colour; many of these are
richinvitaminAanutrientessentialforgoodvisionandgrowth.Examplesinclude:
greenleafyvegetables(spinach,pumpkinandcassavaleaves);greenpepper;
apricot,papaya,mango;carrot.
EatothervegetablesandfruitsrichinvitaminCtohelpfightinfections;examplesinclude:
cabbage,tomato,baobabfruit,guava,lemon,orangeandpineapple.
Vegetableslosesomeoftheirgoodnessifsoakedorboiledforalongtime.Cookthemforasshort
atimeaspossibleandreusethecookingwaterinsoupsandotherfoods.
Vegetables Vegetables Vegetables Vegetables Fruits Fruits Fruits Fruits
Carrot Apricot
Kale Banana
Okra Lemon
Pumpkin Mango
Tomato Orange
Traditionalgreenleafyvegetables Passionfruit
Spinach Pawpaw
SweetPepper Pineapple




Nutritional Care and Support for People Living with HIV: Facilitators Guide
56
3.8. Use fats and oils as well as sugar and sugary foods regularly but in moderation
Remind participants that they should still be role-playing as people attending an Eating wisely
talkatahealthcentre.
ShowthesixthcolouredpaperUsefatsandoilsaswell Usefatsandoilsaswell Usefatsandoilsaswell Usefatsandoilsaswellassugarandsugaryfoods assugarandsugaryfoods assugarandsugaryfoods assugarandsugaryfoodsregularlybut regularlybut regularlybut regularlybut
inmoderation inmoderation inmoderation inmoderationandexplainthefollowing:
Toimproveenergyintake,useoilsandfatsaswellassugarandsugaryfoodsbecausetheyare
richinenergy.Theyalsoaddflavourtofood,therebystimulatingappetite.Duringillness,aperson
withapoorappetitemayeatbetterifsmallamountsofsugarorfatsareadded.
Addingextraquantitiesofoil/fatandsugarmayhelponeto gainbodyweight.Thisisparticularly
importantforthoselivingwithHIVandchildren.
However, care should be taken in the case of patients diagnosed with Candida (oral thrush) as
sugar can make this condition worse. In such cases, patients should avoid eating sweet foods
suchassugar,honey,andsweetfruitanddrinks.
In addition, as excess weight gain can lead to health problems such as, heart disease, it is
essentialtocloselymonitoronesweightandadjustfatandsugarintakeasappropriate.

Askparticipantstosingleoutandputaside,fats,oils,sugarsandsugaryfoodsfromtheirpileof
flashcards.
ClarifyanyconfusionandshowT TT Table able able able3/ 3/ 3/ 3/5 55 5formoreexamples.

Table3/5:Sugars,fatsandoil Table3/5:Sugars,fatsandoil Table3/5:Sugars,fatsandoil Table3/5:Sugars,fatsandoils ss s

SugarandSugaryfoods SugarandSugaryfoods SugarandSugaryfoods SugarandSugaryfoods Fats Fats Fats Fats Oils Oils Oils Oils
Biscuits Butter Coconutoil
Cakes Fatfrommeat Cornoil
Fruitjuices Ghee Groundnutoil
Honey Fatfromfish Palmoil
Jam Margarine Sunfloweroil
Sodas
SugarCane
Table/TeaSugar




Nutritional Care and Support for People Living with HIV: Facilitators Guide
57
Explainthefollowing:
Although fats and sugars are good sources of energy, they are not rich in other nutrients. Thus,
theyshouldbeeateninadditiontootherfoodsandnotinplaceofthem.Closelymonitoringones
weightwillensurethatfats/oilsandsugarsareconsumedinmoderation.
Askparticipantstosuggestreasonsthatmightmakeitdifficulttofollowthisguideline.
Usethefollowingpointsfordiscussion:
Because fats/oils, sugar and sugary products enhance the flavour of food and boost ones
appetite,peopletendtooverusethem.Itcanthenbecomedifficulttoreducetheirintake.
People living with HIV who are not experiencing weight loss should be encouraged to regulate
theirfat/intakeby:
choosingmorefoodswithadequatenaturalfats/oilsandneedlittleornoextraoilforcooking,
and/orusingcookingmethodssuchas,steaming,grillingandboilingasoftenaspossible;and
choosing fewer foods that are rich in sugar, such as fizzy drinks, cakes, sweets, chocolate
andsweetenedfruitjuice.
In case of excess weight gain, sugar and fat intake should be reduced gradually, while closely
monitoringonesweight.Forexample,ifonenormallytakesthreeteaspoonsofsugar,thiscanbe
reducedtotwoandahalfandthengraduallytotwoorless,untiloptimallevelsarereached.
3.9. Drink plenty of clean and safe water
Remind participants that they should still be role-playing as people attending an Eating Wisely
talkatahealthcentre.
Show the seventh coloured paper with Drink plenty of clean and safe water Drink plenty of clean and safe water Drink plenty of clean and safe water Drink plenty of clean and safe water and explain the
following:
Waterisimportantforlifeandisnecessaryeveryday.Apersonneedsabouttwotothreelitresor
eightlargecupsoffluidseachday.
When it is very hot, while working, sweating or suffering from diarrhoea, vomiting or fever, a
personneedstodrinkevenmoretoreplacethewaterthathasbeenlost.Somemedicationsmay
notworkwellifthepersonisdehydrated.Breastfeedingwomenalsoneedextrawater.
Children also need adequate water. However, care should be taken to avoid filling a child with
waterydrinksinplaceoffoods.
Exclusivelybreastfedinfants(<6monthsofage)donotneedextrawater.
Ifdrinkingwateriscollectedfromaprotectedwellorriverthewatershouldbeboiledforatleast10
minutesandstoredincleancontainer(seethediscussioninS SS Session5 ession5 ession5 ession5onFoodSafety).
Inadditiontodrinkingcleanwater,fluidcanalsocomefromjuices,soups,vegetablesandfruitas
wellasmealsthathave gravyorsauces.Thirstisagoodguide;ifyouarefrequentlythirsty,you
needtoincreaseyourfluidintakesignificantly.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
58
However, one should not rely on tea, coffee and alcohol drinks as source of water, as they can
interferewithabsorptionofnutrientsandmayinteractpoorlywithmedicine.
Alcoholicdrinksremovewaterfromthebodyandassucharenotagoodsourceoffluid.
3.10. Use foods that are fortified with essential nutrients, if possible
Remind participants that they should still be role-playing as people attending an Eating wisely
talkatahealthcentre.
Show the eighth coloured paper Use foods that are fortified with essential nutrients, if possible Use foods that are fortified with essential nutrients, if possible Use foods that are fortified with essential nutrients, if possible Use foods that are fortified with essential nutrients, if possible
andexplainthefollowing;
Fortifiedfoodshaveaddednutrientstoimprovethenutritionalvalueofreadilyavailablefoods.
Examples of fortified foods include: salt with iodine, maize meal with vitamins, and oil with
vitaminA.
Where available and affordable, such fortified foods can be used to improve ones nutritional
intake.
It is important to read labels and/or ask for advice regarding the nutrients contained in fortified
foods.Attentionshouldalsobepaidtotheirexpirydates.
Likefruitsandvegetables,fortifiedfoodsshouldnotbeover-cookedasthismayresultintheloss
ofnutrients.

Askthegrouptonamelocallyavailablefortifiedfoods.
Show examples of packets/tins you brought with you and explain how to identify the added
nutrientstheycontain.
3.11. Optimal quantity and frequency of meals
Remind participants that they should still be role-playing as people attending an Eating wisely
talkatahealthcentre.
Explainthefollowing:
People have different needs and so eat different amounts of foods depending on their age,
gender,levelofactivity.
Pregnantandbreastfeedingwomenandpeoplewhoareillalsohavespecialnutritionalneeds.
In particular, because people living with HIV have increased energy needs, they should be
encouragedto:
Increasethefrequencyoftheirmealsandsnacks:
It is easier to eat wisely if you eat three or more times daily, rather than having large meals
once or twice in the day. Having small, frequent meals about three to four hours apart
everydayhelpstoincreaseenergyintake.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
59
Increasetheamountandvarietyoffoodconsumedduringeachmeal.
Thereisoftenuncertaintyregardingtheappropriateamountoffoodtobeeaten.Peopleoften
ask How do I know when I am eating enough? The simplest way of knowing that the
appropriate amount of food is being consumed is by regularly monitoring ones weight and
ensuringthatitiswithinthenormalrangeforonesagegroupandheight.
Measuringportionsoffoodusingcommonutensilssuchas,cupsandspoonscanhelpensure
thatappropriatequantitiesofdifferentfoodtypesareincludedineachmeal.
Ask participants to look at H HH Handout andout andout andout 3 33 3/1 /1 /1 /1: :: : Portion sizes of a health Portion sizes of a health Portion sizes of a health Portion sizes of a healthy y y y meal meal meal meal on page 40 of the
Participant'sManual.
The purpose of this table is to familiarize participants with commonly accepted ways for
measuringportionsofvariousfoodstoensureahealthydiet.Theportionsandexamplesprovided
are intended only as a general reference. The appropriate portions of particular foods to be
included in daily meals will depend on the particular nutritional requirements of individuals and
should be modified as necessary, by following the eating wisely guidelines and closely
monitoringonesbodyweight.
Usingthesampleofutensilsyoubroughtforthesession,discusseachfoodportion;thenexplain
thefollowing:
Increasingnutritionalintakemaymeanconsumingadditionalportionsoffoodsuchas,onetotwo
extraportions(aboutoneortwofistsfull)ofmealymealoronetotwocupsofporridgeduringthe
day.Itcanalsomeananadditionalmealduringtheday.
Makeeveryportioncountbychoosingavarietyoffoodsthatarerichinnutrients.
Ones diet can also be enhanced by adding nutrient-rich foods, including foods fortified with
essential nutrients in each meal. In families with one or more members living with HIV, it is
especiallyimportantfortheentirefamilytoeatwisely.
HIV-positive people need to pay attention to their diet even before they have any symptoms.
Eatingwiselycanhelpthemtostayhealthylonger.
It is essential that people living with HIV understand and follow the eating wisely guidelines to
ensurethattheirfoodintakeisadequateformeetingtheirnutritionalneeds.
3.12. Review of the eating wisely talk: questions and answers
Remind participants that they should still be role-playing as people attending an Eating wisely
talkatahealthcentre.
Askthreeparticipantstorepeatthefollowingpoints:
Themainpointstorememberare:
Eatingwiselyisimportanttoeveryone.
Aimtoeatavarietyoffoods.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
60
Adjusttheamounteatenandhowoftenfoodiseatendependingonindividualneeds.

Askthegrouptoraisequestionsfromthepreparedlistofquestionsanddiscusstheanswers.
Prepared question 1
Allthisfoodseems Allthisfoodseems Allthisfoodseems Allthisfoodseemsveryexpensive.Willeatinglikethiscostalotofmoney? veryexpensive.Willeatinglikethiscostalotofmoney? veryexpensive.Willeatinglikethiscostalotofmoney? veryexpensive.Willeatinglikethiscostalotofmoney?
Answer: Answer: Answer: Answer:
Eatingwiselydoesnotneedtobeexpensive.Vegetablescanbethosethatareavailablelocally.
Giveexamplesoflocallyavailablevegetables.
Some vegetables could be grown in home gardens. Small amounts of animal foods can make a
difference; large amounts are not necessary. Some animal foods such as, tinned fish or chicken
partsmaybeaffordable.
Giveotherlocalexamplesofreadilyavailableanimalfoods,asappropriate.
Prepared question 2
Wh Wh Wh Which ich ich ichsupplementsaregoodforpeoplewithHIV? supplementsaregoodforpeoplewithHIV? supplementsaregoodforpeoplewithHIV? supplementsaregoodforpeoplewithHIV?
Answer: Answer: Answer: Answer:
Supplements do not prevent or cure HIV or AIDS. A variety of good foods will provide adequate
vitaminsandminerals.Itisworthspendingmoneyongoodfoods.
It is rare to have a deficiency of only one vitamin or mineral. It is more common to find a
combination of deficiencies. There is no evidence that taking large doses of a single vitamin or
mineralhelps,unlessthereisanestablisheddeficiencyofthatparticularnutrient.
SomepeoplewithHIVmayneedextravitaminsandmineralsbecausetheyhaveotherconditions
suchasironanaemia.Theymaybeprescribedasupplementthatcontainsawiderangeofvitamins
andminerals,ifavailable.Thisisasupplement,notareplacementforfoods.
It is best to talk individually to your health care provider about using a supplement rather than
choosing a supplement yourself. Nutritional care and support can have a positive impact on
health,evenwithouttheuseofsupplements.
2

Askthegroupforanyadditionalquestionsoftheirown.
After discussing the answers to the questions raised, thank the group for their interest and
attendanceoftheEatingwiselytalk.
End of demonstration talk
Explaintoparticipantsthatthedemonstrationtalkhasnowendedandthattheynolongerneedto
berole-playingaspeopleattendingahealthcentretalk.
Returntotherestofthesession.

2
NewinformationontheroleofvitaminandmineralsupplementsinHIVbecomesavailablefrequently.Keepup-
to-date.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
61

4. Eating wisely: summary and discussion (15 minutes)

Inthiseatingwiselytalkweheardanotherkeypoint:
Showthekeypointdisplayed.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Aimtoeatawidevarietyoffoods,ateachmeal,everyday. Aimtoeatawidevarietyoffoods,ateachmeal,everyday. Aimtoeatawidevarietyoffoods,ateachmeal,everyday. Aimtoeatawidevarietyoffoods,ateachmeal,everyday.

Whatcommunicationskills Whatcommunicationskills Whatcommunicationskills Whatcommunicationskillswereused wereused wereused wereusedint int int inthe he he hee ee eatingwiselytalk atingwiselytalk atingwiselytalk atingwiselytalk? ?? ?
Allowparticipantstodiscussthisandusethefollowingpointstoaddthediscussion.
Communicationskillsusedintheeatingwiselytalkincluded,openquestions,reflecting,offering
smallamountsofrelevantinformationandsuggestions,praiseandcheckingofunderstanding.
Ifthesesimpleapproachesdonothelptoimprovetheclientsdiet,thenhe/shemightneedtobe
referred to a nutritionist or dietician or other specialized caregiver for a more detailed nutritional
assessment.

Wherecouldyouuseatalklikethis? Wherecouldyouuseatalklikethis? Wherecouldyouuseatalklikethis? Wherecouldyouuseatalklikethis?


Takeresponsesfromafewparticipantsandexplainthefollowing:
Such a general talk on Eating wisely can be used with many groups. It could be used with
communitygroups,religiousgroups,homecaregivers,groupsofpeopleattendinghealthfacilities
andothers,asappropriate.Thetalkcouldalsobeadaptedtofocusmoreonthegroupsparticular
needs.Forexample,laterinthiscourse,wewillseeatalkintendedforwomenwhoarepregnant.
Thistalkcouldalsoincludedemonstrationsofrecipesandmoreexamplesoflocallyavailableand
affordablenutritiousfoods.

More information on eating wisely


The information presented in this demonstration talk was basic. You may be asked about other
areas not included in the talk, e.g. what to do in cases where animal foods are not eaten. The
followingpointscanbeusedtoexplaintheappropriatemeasurestobetakeninsuchcases.
Animalfoodssuchas,meat,poultry,fishandinsectsarevaluablefoodsforpeoplelivingwith
HIV. Many animal foods are a good source of iron. If animal foods are not eaten, foods
enriched with iron, such as fortified cereals, can help meet these needs. A supplement with
iron and zinc may also be needed if animal foods are not eaten. However, as iron
supplementsmaycausedigestiveproblemsforsomepeople,theiruseneedstobediscussed
onanindividualbasis.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
62
Animalproductssuchas,eggsandmilkproductsaregoodsourcesofmanyothernutrientsas
well.EggyolkandmilkfatarerichsourcesofvitaminA.
As an alternative, dried milk powder can be added to soups to give more food value.
However,coffeecreamersandwhitenersdonotaddfoodvalue.

Askifthereareanyquestionsorpointsthatneedtobemadeclearer.
The demonstration talk in which you participated was designed for a group. The demonstration talk in which you participated was designed for a group. The demonstration talk in which you participated was designed for a group. The demonstration talk in which you participated was designed for a group. How would you How would you How would you How would you
communicatesimilarinformat communicatesimilarinformat communicatesimilarinformat communicatesimilarinformationtoanindividualpersonorfamily? iontoanindividualpersonorfamily? iontoanindividualpersonorfamily? iontoanindividualpersonorfamily?
Allowparticipantstorespondandexplainthefollowing:
Whenyoutalkwithonepersonoronefamily,youcanprovideinformationrelevanttotheirspecific
needs. You could start by listening and asking about what is eaten at present, praising and
reinforcingthepositivepracticesthatshouldbecontinued.Youcouldthenoffersomeinformation
andsuggestions,checkunderstandingandarrangefollow-up.

Role-play 3A: Discussing eating wisely with the caregiver of a young child
(10 minutes)
Explain to participants that the purpose of this exercise is for them to identify different
communicationskillsastheyarebeingused.
Askparticipantstogetintopairsandtoturntopage38oftheParticipant'sManual.
Ask them to fill out the third column of the table, i.e. to identify the type of communication skills
beingusedbythehealthworkeratdifferentpointsinRole-play3A.Giveparticipantsfiveminutes
tocompletethisexercise.
Attheendoffiveminutes,askeachpairtoreporttheirresponsetoeachintervention,addingonly
whathasnotalreadybeencoveredbyotherpairs.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
63
ROLE-PLAY 3A: Discussing eating wisely with the caregiver of a young child
COMMUNICATION COMMUNICATION COMMUNICATION COMMUNICATION
SKILLSUSED SKILLSUSED SKILLSUSED SKILLSUSED
HEALTHWORKER Goodmorning,(Name).Pleasesitdown.Howareyou
today?
HowcanIhelpyou?
O OO Openquestion penquestion penquestion penquestion
CAREGIVER Goodmorning.Wearewell.Iwantedtotalksomemore
because(Childsname)sweightisstilllow.

HEALTHWORKER Yes,thankyouforcomingtoday.Thelasttimewe
spoke,youweregoingtotrytogive(Childsname)afull
bowloffoodthreetimesintheday,plussomething
smallbetweenthemeals.Howdidthatwork?
Openquestion Openquestion Openquestion Openquestion
CAREGIVER Well,itseemsalotoffoodtogiveayoungchild.
Does(he/she)reallyneedthatmuchfood?

HEALTHWORKER Itseemstoyoulikealotoffoodforayoungchild.
(Childname)isgrowingveryfastatthisage.Togrow
well,childrenneedplentyoffood.
Reflect Reflect Reflect Reflect
Giver Giver Giver Giverelevant elevant elevant elevant
i ii inform nform nform nformation ation ation ation
CAREGIVER Butwhatif(he/she)didnteatitall?Idonthaveextra
foodtowaste.

HEALTHWORKER Youareworriedaboutwastingthefoodifitisnoteaten.
Whataboutincreasingtheamountslowlyaddingone
ortwoextraspoonfulseachdayuntilitisafullbowl?
Empathi Empathi Empathi Empathiz zz ze ee e

Suggest Suggest Suggest Suggestion ion ion ion
CAREGIVER Icouldtrythat.ThenIwouldseeif(he/she)eatsit
withoutwastingit.

HEALTHWORKER Thatsagoodidea.
Sowhatwouldyouputinthebowleachtime?
Praise Praise Praise Praise
Check Check Check Check
understanding understanding understanding understanding
CAREGIVER Illputabitmorefoodineachdayuntil(he/she)iseating
afullbowlthreetimesaday.

HEALTHWORKER Exactly.Andyoualreadygiveavarietyoffoods
includingsomeanimalfoodwheneveryoucan,sokeep
doingthis.
Canyoutryitfortwoweeksandthencomebackandtell
mehowitwent?
Praise Praise Praise Praise

Arran Arran Arran Arrange ge ge ge
follow follow follow follow- -- -up up up up
CAREGIVER OK,Illdothat.Thankyou.Good-bye.
HEALTHWORKER Good-bye.

5. Food choices (20 minutes)

SamandSuzinowhavesomeinformationon SamandSuzinowhavesomeinformationon SamandSuzinowhavesomeinformationon SamandSuzinowhavesomeinformationon eatingwisely eatingwisely eatingwisely eatingwisely .Isthisinformationallthatisneeded .Isthisinformationallthatisneeded .Isthisinformationallthatisneeded .Isthisinformationallthatisneeded
forthemtoeatwisely? forthemtoeatwisely? forthemtoeatwisely? forthemtoeatwisely?
Whatcould Whatcould Whatcould WhatcouldaffectSamandSuzisdecisiontoeatwisely? affectSamandSuzisdecisiontoeatwisely? affectSamandSuzisdecisiontoeatwisely? affectSamandSuzisdecisiontoeatwisely?

Wemakechoicesaboutthefoodwewilleatorgivetochildrenorotherswecareforbasedon:
Whatfoodsareavailable/affordable;
Time,energyandequipment;
Knowledge,culture,habit,familypreferencesandbeliefsaboutfood;aswellas
Hungerorappetite.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
64
Knowledge about what foods to eat is not enough. The food a person eats is affected by his/her
access to foods as well as customs and beliefs. Check that any suggestions you give are
acceptableandcanbecarriedout.
When suggesting food to another person, consider their preferences, culture, habits and beliefs.
Foods may be chosen or avoided because of religious beliefs, family tradition, local customs or
personalpreference.
Exercise 3/1: Food choices worksheet (15 minutes)
Askparticipantstoformthreegroups.
Ensurethateachgrouphasacopyofthe Exercise Exercise Exercise Exercise3/1:Foodchoicesworksheet 3/1:Foodchoicesworksheet 3/1:Foodchoicesworksheet 3/1:Foodchoicesworksheetonpage41 of
theParticipant'sManual.
Eachgroupshoulddiscussoneofthethreepointsoutlined(allow5minutesfordiscussion).
Checkthatparticipantsunderstandwhichspecificpointtheyaretodiscuss.
After 5 minutes, bring the three groups back together and ask each to report the main points of
theirdiscussiontothewholegroup.
Attheendofthefeedback,thanktheparticipantsfortheircomments.
Whatkeypointdidwe Whatkeypointdidwe Whatkeypointdidwe Whatkeypointdidwecover cover cover coverinthissession? inthissession? inthissession? inthissession?
Showthekeypointdisplayedonaflipchartsheet
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Aimtoeatawidevarietyoffoods,ateachmeal,everyday. Aimtoeatawidevarietyoffoods,ateachmeal,everyday. Aimtoeatawidevarietyoffoods,ateachmeal,everyday. Aimtoeatawidevarietyoffoods,ateachmeal,everyday.

6. Summary of the session and transition (2 minutes)

Food is needed for energy, to build and repair, to protect and to keep the body functioning. We
needavarietyoffoods.Theamounttoeatandhowoftentoeatdependsonindividualneeds
ShowO OO Overhead verhead verhead verhead3/4 3/4 3/4 3/4: :: : E EE Eatingwiselyguidelines atingwiselyguidelines atingwiselyguidelines atingwiselyguidelines (ortheeightcolouredcardspreparedfordisplaying
theguidelines).





Nutritional Care and Support for People Living with HIV: Facilitators Guide
65
OVERHEAD3/4:Eatingwiselyguidelines OVERHEAD3/4:Eatingwiselyguidelines OVERHEAD3/4:Eatingwiselyguidelines OVERHEAD3/4:Eatingwiselyguidelines

1. Enjoyavarietyoffoods.
2. Makestaplesorstarchyfoodsthelargestpartofyourmeal.
3. Eatpeas,beans,lentils,nutsandseeds,ifpossibleeveryday.
4. Eatanimalandmilkproductsregularly.
5. Eatawidevarietyofvegetablesandfruitseveryday.
6. Usefatsandoilsaswellassugarandsugaryfoodsregularlybutinmoderation.
7. Usefoodsthatarefortifiedwithessentialnutrients,ifpossible.
8. Drinkplentyofsafewater.

Explainthefollowingpoints;
ItisrecommendedthatalleightEatingwiselyguidelinesarefollowed,inordertoensurethatthe
bodygetsallthenutrientsitneedsto Go Go Go Go ,Glow Glow Glow Glow and Grow Grow Grow Grow. . . .
Knowledge about what foods to eat is not enough. Ones diet is affected by the type of foods to
whichonehasaccessaswellasvariouspreferences,customsandbeliefs.
Help clients to deal with the barriers that could hinder them from following the eating wisely
guidelinesandcheckthatanysuggestionsyougiveareacceptableandcanbecarriedout.

Askifthereareanyquestionsandifanythingneedsclarifying.
Inthenextsession,wewilldiscussfoodsafetyforpeoplewithHIV.
Thenextsessionwillbepresentedby:

Statethenameofthepresenter.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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HANDOUT3/1:Foodportions:sizesofahealthymeal HANDOUT3/1:Foodportions:sizesofahealthymeal HANDOUT3/1:Foodportions:sizesofahealthymeal HANDOUT3/1:Foodportions:sizesofahealthymeal

FOODGROUP FOODGROUP FOODGROUP FOODGROUP EXAMPLES EXAMPLES EXAMPLES EXAMPLES 1PORTION 1PORTION 1PORTION 1PORTION PORTIONS PORTIONS PORTIONS PORTIONSFOR FOR FOR FORDAILYMEALS DAILYMEALS DAILYMEALS DAILYMEALS
Bread 1slice
Rice/Pasta cup(measuredafter
cooked)
Maize-meal 1cup(orabout1fistful)
STAPLES&
STARCHY
FOODS
Potatoes 1mediumsizepotato
6PORTIONS 6PORTIONS 6PORTIONS 6PORTIONS- -- - Example:
Breakfast:1cupofporridge
Snack:1sliceofbread
Lunch:1cupofriceduringlunch
Snack:1sliceofbread
Supper:1cupofmaizemeal

Chicken,beef,
lamb,fish
Equivalentsizetoone
chickenthigh
Eggs 1egg
MEAT,FISH,
POULTRY&MILK
Milk(fresh/
fermented)
1cup
3PORTIONS+1PORTIONOF 3PORTIONS+1PORTIONOF 3PORTIONS+1PORTIONOF 3PORTIONS+1PORTIONOF
MILK MILK MILK MILK
Example:
Lunch:1thighofchicken
Snack:2tablespoonsofpeanut
butter
Supper:1cupofcookedbeans
Snack:1glassofmilkforsnacks

PULSES&
LEGUMES/NUTS
&OILSEEDS
Cookedbeans 1cup
Nuts 1cup
Peanutbutter 2tablespoons

Fruits 1mediumsizepieceof
fruit
FRUITS
Fruitjuices 1glass
3PORTIONS 3PORTIONS 3PORTIONS 3PORTIONS- -- - Example:
Breakfast:1glassoforangejuice
Lunch:1pieceoffruit
Snack:1pieceoffruit

Rawchopped
vegetables
1cup VEGETABLES
Cookedvegetables cup
5PORTIONS 5PORTIONS 5PORTIONS 5PORTIONS- -- - Example:
Breakfast:cupofgreenbeans
Lunch:1cupofmixedvegetables
Snack:1cupvegetablesalad
Supper:1cupofgreenleafy
vegetables
FATS&OILS 1teaspoon 5PORTIONS 5PORTIONS 5PORTIONS 5PORTIONS(INCLUDING
NATURALFATSFOUNDIN
MEAT)
Example:1teaspoonofoilfor
everymeal

WATER 1glass 8PORTIONS 8PORTIONS 8PORTIONS 8PORTIONS: : : :8glassesofsafe


waterandfluidsspreadout
throughouttheday.







Nutritional Care and Support for People Living with HIV: Facilitators Guide
67

EXERCISE3/1:Foodchoicesworksheet EXERCISE3/1:Foodchoicesworksheet EXERCISE3/1:Foodchoicesworksheet EXERCISE3/1:Foodchoicesworksheet
1. 1. 1. 1.Foodavailability Foodavailability Foodavailability Foodavailability
Whataffectstheavailabilityoffoods?
Whatfoodsaregrownorproducedinthearea?
Aretherefoodsthatarecommonlyavailableatonlycertaintimesoftheyear?
Howfardothepeopleyouworkwithneedtogotogettheirfood?
Does the distance differ depending on what the food is? For example, can rice be
obtainednearbybutvegetablesoranimalfoodsarefurtheraway?
Cost is a major factor in availability. Which foods are seen as affordable for many
people?
Which foods mentioned in the Eating wisely talk are considered too expensive for
regularuse?(Wewilldiscussfoodsubsidies,grantsandfoodaidlaterinthecourse.)

2.Time,energyandequipment 2.Time,energyandequipment 2.Time,energyandequipment 2.Time,energyandequipment
How much time is needed everyday to prepare food in order to eat wisely? How does
thisaffectfoodchoices?
Energycanbeoftwokinds.Theenergy orfueltocookthe foodand thehumanenergy
requiredtoprepareit.Howcaneachkindaffectfoodchoices?
Canyouthinkofanyequipmentthatmightnotbeavailabletosomeofthefamiliesyou
careforthatwouldaffecttheirfoodchoices?

3.Culture,habit,familypreferencesandbeliefsaboutfood 3.Culture,habit,familypreferencesandbeliefsaboutfood 3.Culture,habit,familypreferencesandbeliefsaboutfood 3.Culture,habit,familypreferencesandbeliefsaboutfood


AretherefoodsthatmightbeavoidedbypeoplelivingwithHIVbecauseofcertainbeliefs
orcustoms?
Aretherefoodsthatareconsideredbeneficialforpeoplewhoareill,especiallyforHIV?
Aresomefoodsavoidedbecausetheyareassociatedwithpoverty?Arethereanyfoods
thatmaybechoseninplaceofothersbecausetheyarethoughttobeofhigherstatus?
Howdolocalpeoplecommonlylearnaboutwhatfoodstouseandhowtopreparethem?




Nutritional Care and Support for People Living with HIV: Facilitators Guide
68

Session4:FoodsafetyforpeoplewithHIV Session4:FoodsafetyforpeoplewithHIV Session4:FoodsafetyforpeoplewithHIV Session4:FoodsafetyforpeoplewithHIV

Learning Learning Learning Learningo oo objectives bjectives bjectives bjectives
Bytheendofthissession,participantswillbeableto:
Explaintheimportanceoffoodsafety,especiallyforpeoplewithHIV;
Describehowfoodandwatercanbecomesourcesofinfection;
Discussthefivekeystosaferfoods;and
Developanduseanobservationguidetohelpidentifycommonfoodsafetyproblemsand
theirappropriatesolutions.

Session Session Session Sessiono oo outli utli utli utline ne ne ne


Content Content Content Content Time Time Time Time
1 Learningobjectivesandintroductiontothesession
2minutes
2 Causesoffood-borneillness:germs
6minutes
3 Othercausesoffood-borneillness:poisons
3minutes
4 ImportanceoffoodsafetyforpeoplelivingwithHIV
10minutes
5 Exercise4/1: Developinganobservationguideforkeepingfoodsafe
12minutes
6 Keepingfoodsafe
10minutes
7 Summaryofthesessionandtransition
2minutes
Total Total Total Total 45minutes 45minutes 45minutes 45minutes

Preparation for the session

Writeanddisplaythelearningobjectivesonaflipchartsheet.
Writethekeypointonasheetofflipchartpaperandkeepitasideuntilneeded:
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Followthef Followthef Followthef Followthefivekeystepstosaferfoods ivekeystepstosaferfoods ivekeystepstosaferfoods ivekeystepstosaferfoodsand and and andstop stop stop stopping ping ping pinggermsfrom germsfrom germsfrom germsfrom
makingyouandthose makingyouandthose makingyouandthose makingyouandthosearoundyou aroundyou aroundyou aroundyouill. ill. ill. ill.

Find out about the local sources and quality of household water supply. Gather information on
local hygiene practices, particularly relating to washing hands and waste/faecal disposal, how
foodisgenerallystoredandpreparedandwhatpeopleknowaboutkeepingfoodandwatersafe.
Findoutinformationfromlocalhealth,water,andfoodsafetyauthoritiesonwhattheyaredoingto
improvethesafetyofthefoodsupplyandpreventionoffood-borneillnesses.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
69
Be familiar with dangerous germs and recent food-borne illness outbreaks if any in the area/
region.
Findouthowagriculturalchemicalsareusedandhowtheyarehandled.
Prioritizetheimportantinformationtobeemphasized.
Writeoutthreesetsofrole-playsforExercise4A.Therole-playsdescribethreecasesinwhichthe
client is not keeping his/her food safe. The health worker will be asked to discuss these cases
withtheclientandhelphim/hermakechangestoimprovefoodsafety.
Writethelearningobjectivesonasheetofflipchartpaperfordisplay.
Collect/preparethefollowingtrainingmaterials:
An overhead projector and screen; and/or flipchart paper, markers and a means to attach
flipchart sheets to the wall or other surface. If an overhead projector is not available the
overheadmaybewrittenoutanddisplayedonaflipchartsheet.

Overhead4/1: Overhead4/1: Overhead4/1: Overhead4/1:Fivekey Fivekey Fivekey Fivekeys ss s to to to tosaferfoods saferfoods saferfoods saferfoods. .. .
Handout Handout Handout Handout 4/1 4/1 4/1 4/1:Observation :Observation :Observation :Observationg gg guide uide uide uide
Handout4/2: Handout4/2: Handout4/2: Handout4/2: Fivekeys Fivekeys Fivekeys Fivekeysto to to tosaferfoods saferfoods saferfoods saferfoods
Handout4/3:Exampleofwatertreatment Handout4/3:Exampleofwatertreatment Handout4/3:Exampleofwatertreatment Handout4/3:Exampleofwatertreatment

1. Learning objectives and introduction to the session (2 minutes)

Review the learning objectives of the session
Bytheendofthissession,participantswillbeableto:
Explaintheimportanceoffoodsafety,especiallyforpeoplelivingwithHIV;
Describehowfoodandwatercanbecomesourcesofinfection;
Discussthefivekeystosaferfoods;and
Developanduseanobservationguidetohelpidentifycommonfoodsafetyproblemsand
theirappropriatesolutions.
Introduce the session
In Session 3 Session 3 Session 3 Session 3, we talked about how important it is to eat enough food, how to choose nutritious
foods and eat wisely. Eating safer food is also an important part of good nutrition. As a part of
goodnutrition,itisimportantthatthefoodweeatandthewaterwedrinkissafe.
Foodcaneasilybecontaminatedbyharmfulgermsorpoisonatanytimebeforeeating,ifitisnot
handled, prepared and stored in a safe way. A person eating these contaminated foods may




Nutritional Care and Support for People Living with HIV: Facilitators Guide
70
become ill and experience symptoms such as stomach pains, nausea, vomiting and diarrhoea.
Thisillnessiscalledfood-borneillness.
The consequences of food-borne illness are more severe for people with low immunity such as
peoplelivingwithHIV.
Inthissession,wewilldiscusstheimportanceoffoodsafety,especiallyforPLHIVandsomekey
guidelines for ensuring food safety. It is important that all people follow these food safety
guidelines,whethertheyhaveHIVornot.

2. Causes of food-borne illness: germs (6 minutes)



2.1. What are germs?
Allowparticipantstomakeoneortwosuggestions,beforediscussingthefollowingpoints
Germs are very small living things -- so small that they cannot be seen with the naked eye. It
takes one million germs to cover the head of a pin. Bacteria, viruses, yeasts, moulds and
parasitesareallgerms.Germscanbe:
G G G Goodgerms oodgerms oodgerms oodgerms ,usefulformakingfoodanddrinkslikecheese,yoghurt,beerandwine,aswell
asmedicinessuchaspenicillin.Theyalsohelpdigestthefoodinthegut.
Badgerms Badgerms Badgerms Badgerms, ,, ,whichcausefoodtospoil,smellbad,tastehorribleandlookdisgusting.
D DD Dangerousgerms angerousgerms angerousgerms angerousgerms , , , ,whichmakepeoplesickandcanevenkillthem.Mostofthesegermsdo
notchange the appearanceofthefood.Itistherefore,difficulttotelliffoodisspoiledsimply
byitsappearance,tasteandsmell.Somebadgermsdospoilandchangetheappearanceof
food and are also dangerous. For example, green mould on bread can produce harmful
toxins.
Givelocalexamplesofgermswhichcausefoodspoilageandarealsodangerous.
2.2. Where do germs live?
Allowparticipantsmakeoneortwosuggestions,beforediscussingthefollowingpoints:
Germsareeverywhere,butaremostlyfoundin:
Faeces:humanandanimalfaecescontaindisease-causinggerms
Soilandwater:ateaspoonofsoilcontainsmorethan1billiongerms.
Rats,mice,insectsandpests:alllivingthingshavegermsassociatedwiththem
Domestic, marine and farm animals: e.g. dogs, fish, cows, chickens and pigs; animals carry
germsontheirfeet,theirmouthsandontheirskin.
People:mouth,nose,bowels,hands,fingernailsandskin.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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In order to move around, germs rely on someone or something. Hands are one of the most
commonmeansofmovinggermsfromoneplacetoanother.Forexample,ifyoutouchyourface
with your hands and then touch some food with the same hand, the food can become
contaminated.
Germscanalsobespreadthroughcontaminatedfoodandwater.Petsanddomesticanimalscan
alsobeasourceofcontamination.
2.3. How do germs grow?
Allowparticipantstomakeoneortwosuggestions,beforediscussingthefollowingpoints:
Mostgermsgrowbymultiplication.Tomultiply,germsneedfood,water,warmthandtime.
Meat,seafood,cookedriceandpasta, milk,cheeseandeggsprovideidealconditionsforgerms
togrow.
Raw and under-cooked chicken, meat, fish and eggs, raw milk, contaminated, raw vegetables,
raw/smokedfishandunsafewatercouldcontaindangerousgerms.
Feeding children with infant formula and other foods prepared with unsafe water may cause
dangerousillnessandevendeath.
3

Discusswithparticipantssomelocalfoodsthatdoordonotprovideidealconditionsforthegrowth
ofgerms,e.g.drycereals:

3. Other causes of food-borne illness: poisons (3 minutes)

Apartfromgerms,whatareothercausesoffood Apartfromgerms,whatareothercausesoffood Apartfromgerms,whatareothercausesoffood Apartfromgerms,whatareothercausesoffood- -- -borneillness? borneillness? borneillness? borneillness?
Allowparticipantstomakeoneortwosuggestions,beforediscussingthefollowingpoints:
People can also get sick from being poisoned. The sickness can result from chemical
contamination, from exposure to the chemicals on an ongoing basis, for an extended period of
time.
These toxins and chemicals include: natural toxins, metals and environmental pollutants,
chemicals used for treating animals, improperly used pesticides and food additives, as well as
variouschemicalsusedforcleaning.
Discuss with participants local examples of some toxins and dangerous chemicals that could be
sourcesofcontamination.
Some natural toxins, such as aflatoxin aflatoxin aflatoxin aflatoxin, , , , may be caused by moulds growing on food stored in
damp places. Maize and peanuts are some of the foods that can have aflaxtoxin if they are not
storedproperly.Ingestingaflatoxinsmayhaveharmfuleffectsontheliverthatcanleadtocancer.

3
Safemeansthatwaterandfoodarefreefromdangerousgermsandtoxicchemicalsatlevelsthatcouldcause
illnessand/ordisease.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
72
Some types of cassavas may cause cyanide poisoning when they are not processed well. In
severecases,thismayleadtokidneyfailureanddeath.
Foods grown near highways or roads in areas where most vehicles use leaded fuel may be a
causeofleadtoxicity.
Simple measures, such as, washing and peeling may reduce risk from chemicals found on the
surfaceoffoods.
Appropriatestoragecanhelpavoidorreducetheformationofsomenaturaltoxins.

Discussappropriatecookware.
Usingcookwareandutensilsglazedwithmaterialscontainingheavymetals(e.g.lead,cadmium)
canresultinchemicalpoisoning.
Itisimportanttoreadandunderstandinstructionsonthelabelsofchemicalsusedforcleaning.

4. Importance of food safety for people with HIV (10 minutes)



W WW Whyis hyis hyis hyisdiscuss discuss discuss discussing ing ing ingfoodsafetywith foodsafetywith foodsafetywith foodsafetywithpeoplelivingwith peoplelivingwith peoplelivingwith peoplelivingwithHIV HIV HIV HIVsoimportant? soimportant? soimportant? soimportant?
Allowparticipantstomakeoneortwosuggestionsbeforediscussingthefollowingpoints:
Everypersonisatriskoffood-borneillness.Evenhealthypeoplesometimesexperiencestomach
pains,diarrhoea,nauseaandvomiting,withoutknowingwhatcausedit.Thisisoftentheresultof
eatingcontaminatedorspoiledfood.
The immune system of a healthy body is well-equipped to fight harmful germs but when the
immunesystemisweakenedthebodybecomeslessabletofightsuchgerms.
FoodsafetyisveryimportantforpeoplelivingwithHIVbecauseoftwomainreasons:(a)because
oftheirlowimmunity;and(b)consequencesandsymptomsoffood-borneillness.
Low immunity:
Theimmunesystemofahealthybodyiswell-equippedtofightharmfulgerms.However,
HIVweakenstheimmune systemmakingthebody ofpeoplelivingwithHIVlessableto
fight harmful germs. This exposes people living with HIV to a higher risk of infections,
includingfood-borneillnesses
Consequences and symptoms of food-borne illness:
The symptoms of food-borne illness such as stomach pains, nausea, vomiting and
diarrhoeaaremoresevereinPLHIVandaremorelikelytocauseseriousconditionssuch
asmeningitis.
These symptoms may also affect food intake, absorption of nutrients and increase the
needforextranutrientstofightinfection.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
73
Food-borneillnessesarealsodifficulttotreatandcanoftenpersistorrecur.PLHIVmay
alsohaveahardertimerecoveringfromtheillnesses.
Food-borneillnessmaycauseweightloss,thusfurtherloweringthebodysresistanceto
otherinfections.
Itistherefore,importantthatextra extra extra extracare care care careistakentoensurefoodsafetyforPLHIV.

5. Exercise 4/1: Developing an observation guide for keeping food safe (10
minutes)

Ask participants to get in pairs to design an observation guide, using the outline provided
(Handout 4/1 Handout 4/1 Handout 4/1 Handout 4/1 found on page 48 of the Participants Manual), they should think of a guide that
couldbeusedtoevaluatehowwelltheirclientiskeepingfoodandwatersafe.
Encourageparticipantstothinkaboutobservingtheentirehouse.
Remindthemthat:
Often,whathouseholdmembersdoinonepartofthehousewillaffecthowfoodiskeptinanother
partofthehouse,likethekitchen.
Haveamemberfromeachpairreportthecriteriatothelargegroup.
Posttheitemsreportedupontheflipchart.Askotherstoadditemstothelistthathavenotbeen
mentioned.
Checkthattheparticipantsunderstandandagreethattheitemslistedarerelevanttoassessinga
clientssituation.

Explainthefollowing:
As we discuss more information on food safety you should record any additional items that are
appropriatefortheObservationGuideandaddtheseitemstotheguideattheendofeachsection
ofthepresentation.

6. Keeping food safe (12 minutes)

Introduction to guidelines for keeping food safe

No food is 100 per cent safe at all times. But the risks of illness can be reduce by following five
simplerulesaboutfoodsafetythatcanhelppreventmostfood-borneillnesses.

Doyouknowof/c Doyouknowof/c Doyouknowof/c Doyouknowof/canyousuggestany anyousuggestany anyousuggestany anyousuggestanymeasuresforensuring measuresforensuring measuresforensuring measuresforensuringfo fo fo foodsafety odsafety odsafety odsafety? ?? ?





Nutritional Care and Support for People Living with HIV: Facilitators Guide
74
Allowparticipantstomakeoneortwosuggestions.
ShowOverhead4/1 Overhead4/1 Overhead4/1 Overhead4/1Fivekeystepstosaferfoods Fivekeystepstosaferfoods Fivekeystepstosaferfoods Fivekeystepstosaferfoodsandexplainthattopreventfood-borneillness
itisessentialthatweunderstandandfollowthefivekeyguidelinestosaferfoods.

OVERHEAD4/1:Fivekey OVERHEAD4/1:Fivekey OVERHEAD4/1:Fivekey OVERHEAD4/1:Fivekeys ss stosaferfoods tosaferfoods tosaferfoods tosaferfoods



Keepyourself,yoursurroundingsandcookingutensilsclean
Keeprawandcookedfoodsseparate
Cookfoodthoroughly
Keepfoodatsafetemperatures
Usesafewaterandrawmaterials/ingredients

E EE Exercise xercise xercise xercise4/2: 4/2: 4/2: 4/2:Adapting Adapting Adapting Adaptingthef thef thef thefive ive ive ivek kk key ey ey eysteps steps steps stepstosaferfoods tosaferfoods tosaferfoods tosaferfoodstothelocalcontext tothelocalcontext tothelocalcontext tothelocalcontext

Ask participants to form three groups. Give each group a role-play and ask them to provide
counselling to a family living with HIV using the observation guide developed in the previous
exerciseandtheFiveKeysforSaferFood:

Ask them to discuss in their groups appropriate ways for following the guidelines within the
particularcontextoftheirlocalarea/region.
Refer them to Handout Handout Handout Handout 4/ 4/ 4/ 4/2 22 2 (found at the end of this session and on pages 49-52 of the
Participant'sManual).
Remind them that the practices they suggest for following each guideline must be feasible and
practicalintheirlocalcontext.
Afterthegroupworkaskeachgrouptopresenttheirsuggestionsandallowtimefordiscussion.
Clarifyanyissuesthatmighthavebeenleftoutusingthefollowingadditionalfacts.
6.1. Keep clean
Dangerous germs are easily carried on hands; wiping cloths and utensils, especially cutting-
boards,andtheslightestcontactcantransferthemtofoodandcausefoodborneillness.
Always wash hands with safe water and soap: advise people and families to always wash their
hands with safe water and soap (or ashes), dry hands by shaking and rubbing them together or
usingacleancloththatiskeptonlyforthispurposeandtokeepfingernailsshortandclean.
Advisepeopleandfamiliesabouthygienearoundthehome.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
75
Just because something looks clean does not mean that it is. It takes over 2.5 billion germs to
make 250 ml of water look cloudy, but in some cases it takes only 15-20 dangerous bacteria to
causeillness.
6.2. Separate raw and cooked foods to stop germs from spreading
Raw food, especially meat, poultry, seafood and their juices can contain dangerous germs that
may be transferred onto other foods during preparation and storage. This is called c cc cross ross ross ross- -- -
contam contam contam contamination ination ination ination.
Adviseindividualsandfamiliestoalways:
Separate raw and cooked food during cooking and preparation, including the animal
slaughteringprocess.
Keeprawmeat,poultryandseafoodseparatefromotherfoods.
Useseparateequipmentsuchasknivesandcuttingboardsforhandlingrawfoods.
If possible, use one cutting board for meat, chicken and fish and another for vegetables
and bread. Alternatively, clean the board well with soap and hot water after using it for
eachtypeoffood.
Storefoodsincoveredcontainerstoavoidcontactbetweenrawandcookedfoods.

Explainthefollowing:
Cross Cross Cross Cross- -- -contamination contamination contamination contaminationisatermusedtodescribethetransferofgermsfromrawtocookedfood.
Separationmustoccurnotonlywhencooking,butduringallphasesoffoodpreparation,including
theslaughteringprocesses.
6.3. Cook food thoroughly in order to kill germs
Propercookingcankillalmostalldangerousgerms.Foodsthatrequirespecialattentioninclude:
mincedmeats,rolledroasts,largejointsofmeatandwholepoultry.
Adviseindividualsandfamiliestoalways:
Cookfoodthoroughly,especiallymeat,poultry,eggs,fishandseafood.
Bringfoodslikesoupsandstewstoboilingpoint.Formeatandpoultry,makesurejuices
areclear,notpink.
Reheat cooked food thoroughly. Bring to boil or heat until too hot to touch. Stir while re-
heating.
It is not safe to eat raw eggs or foods with raw eggs added. Eggs may carry illness-
causing bacteria that can survive even in cool temperatures but can easily be killed by
heating.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
76
6.4. Keep food at safe temperatures to slow the growth of germs
Keephotfoodhotandcoldfoodcold.
Itisnotsafetoleavecookedfoodatroomtemperatureformorethantwohours.Germscangrow
andmultiplyveryquicklyiffoodisstoredatroomtemperature.
Adviseindividualsandfamiliestoalways:
Buyfreshfoods,suchasmeatandfishonthedaytheywilleatthem.
Preparefoodinsmallamountstoreduceleftovers.Foodforinfants,childrenandpeople
withlowimmunityshouldbefreshlypreparedandeatenassoonaspossible.
Store fresh foods (especially foods from animals), and cooked food in a cool place, or a
refrigeratorifavailable.
Avoidstoringleftoversformorethanafewhours(unlessrefrigerated).Alwaysstorethem
coveredandreheatthemthoroughlyuntilhotandsteaming(bringliquidfoodstoarolling
boil).
Discuss other practical food storage methods which may be applicable in the local area/region.
Forexample:theuseofcoldwaterforstoringfoodandmilkinsealedcontainers;storingfoodina
special dugout hole in the ground; buying foods which keep well for long periods, such as
potatoesandcassava,etc.

Explainthefollowing:
Foodcanbecooledquicklyby:puttingthefoodontoopentrays;slicinglargepiecesofmeatinto
smallerpieces;placingfoodinacool,cleancontainer;orstirringregularlyforsoups.
6.5. Use safe water/ foods to stop germs and chemicals from entering the home
Raw materials, including water and ice, may be contaminated with dangerous germs and
chemicals. Toxic chemicals may be formed in damaged and mouldy foods. Care in selection of
rawmaterialsandsimplemeasuressuchaswashingandpeelingmayreducetheserisks.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
77
Safe water
Adviseindividualsandfamiliestoalways:
Use safe water such as, treated piped water or water from a safe source such as, a
protected well. Untreated water from rivers and canals contain germs which can cause
diarrhoea,typhoidordysenteryandarenotsafe!Waterthatisnotsafeshouldbeboiled
beforedrinkingoruseforfoodpreparation.
4

Use clean containers to collect and store water with a lid or covered with a clean cloth.
Rainwater collected in clean tanks is safe as long as the tank is protected from
contamination from birds or other animals. Cool drinks and ice cubes should also be
madewithwaterthatissafe.
Safe food
Adviseindividualsandfamiliestoalways:
Buy fresh foods such as, meat and fish. Look for signs that indicate the poor quality of
food.
Foodswithanysignsofpoorqualityarelikelytohavebeencontaminated.

7. Summary of the session and transition (2 minutes)

Wh Wh Wh Which ich ich ichkeypointsdidwe keypointsdidwe keypointsdidwe keypointsdidwediscuss discuss discuss discussinthissession? inthissession? inthissession? inthissession?
Showthekeypointdisplayedandreadit.

KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Followthef Followthef Followthef Followthefivekeystepstosaferfoodsandstoppingg ivekeystepstosaferfoodsandstoppingg ivekeystepstosaferfoodsandstoppingg ivekeystepstosaferfoodsandstoppinggermsfrom ermsfrom ermsfrom ermsfrom
makingyouandthosearoundyouill. makingyouandthosearoundyouill. makingyouandthosearoundyouill. makingyouandthosearoundyouill.

Eatingsafefoodscanhelpmaintaingoodnutritionalstatus.
Food-borne illness can be life-threatening for PLHIV due to their lower immunity to fight off
infections.
Thefivekeyguidelinestosaferfoodarethekey key key keytopreventingfoodbornillnesses.
Keepyourself,yoursurroundingsandcookingutensilscleantostopgermsfromgrowing
andspreading.
Keeprawandcookedfoodsseparatetostopgermsfromspreading.
Cookfoodthoroughlytokillgerms.
Keepfoodatsafetemperaturestoslowthegrowthofgerms.

4
Findoutabouttheappropriatemethodfortreatingwaterinyourlocalareaorregion.Oneexampleisthebleach
method(seeHandout4/6 Handout4/6 Handout4/6 Handout4/6).




Nutritional Care and Support for People Living with HIV: Facilitators Guide
78
Use safe water, food and raw materials to stop germs and chemicals from entering the
home.
Askparticipantsiftheyhaveanyquestionsorifanythingneedsclarifying.
Inthenextsession,wewilldiscussimprovingfoodintake.
Thenextsessionwillbepresentedby:
Statethenameofthepresenter.

HANDOUT4/1: HANDOUT4/1: HANDOUT4/1: HANDOUT4/1:Observation Observation Observation Observationg gg guide uide uide uide
Keepclean(includeshandwashing,cleankitchen,dishes,utensils,cleaneatingplaces,separation
ofgarbage,andprotectionfromhumanwaste).

Separaterawandcooked(includesseparationofcuttingandotherutensils).

Cookthoroughly(includesattentionandobservationofcookingequipmentormaterials).

Keepfoodatsafetemperatures(includesobservationofleftovers,foodstorage).

Usesafewaterandrawmaterials(includesobservationofwaterstorage,sourceofdrinkingwater,
watercontainers,watertreatmentandhandling).





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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HANDOUT4/2:Fivekeys HANDOUT4/2:Fivekeys HANDOUT4/2:Fivekeys HANDOUT4/2:Fivekeysto to to tosaferfoods saferfoods saferfoods saferfoods
1.Keep 1.Keep 1.Keep 1.Keepc cc clean lean lean lean
Dangerous germs are easily carried on hands, wiping cloths and utensils, especially cutting-boards,
andtheslightestcontactcantransferthemtofoodandcausefood-borneillnesses.
Alwayswashhandswithsafewaterandsoap.
Adviseindividualsandfamiliestoalwayswashtheirhandswithsafewaterandsoap(orashes):
Beforeandafterpreparingfoodandeating;
After being in contact with faeces, e.g., after going to the toilet, cleaning babys bottom or cleaning
cloths,dirtybedlinenorsurfacescontainingfaeces;
Beforefeedingachildorasickperson(makesuretheywashtheirhandstoo);
Dry hands by shaking and rubbing them together or using a clean cloth that is kept only for this
purpose;
Keepfingernailsshortandclean.
Maintainh Maintainh Maintainh Maintainhygienearoundthehome ygienearoundthehome ygienearoundthehome ygienearoundthehome
Adviseindividualsandfamiliestoalways:
Keepkitchen,dishesandutensilsclean.
Washallworksurfaces(tabletops,counters,shelves)anddisheswithsoapandsafewater.
Protectkitchenareasandfoodfrominsects,pestsandotheranimals.
Keeprubbishincoveredbinorrubbishpit.Emptyandwashthebinorburnrubbishregularly.
Wash kitchen cloths, sponges and scourers with soap. Sunlight is an effective way to kill germs
naturally.Dryclothsinthesun.
Keepkitchenwellventilated.Thishelptopreventthegrowthofmouldsandfungus.
Keepfoodpreparationareasingoodcondition(repairwallcracksorholes).
Make composed for the garden with suitable waste food, garden rubbish and animal faeces;
compostingdestroysgermsinfaeces.
Otherwaysofkeepingclean Otherwaysofkeepingclean Otherwaysofkeepingclean Otherwaysofkeepingclean
Adviseindividualsandfamiliestoalways:
Avoidcoughingandsneezingnearthefoodorwater.
Coveranywoundsonhandstopreventcontaminationoffoodduringpreparation.
Usealatrineandkeepitawayfromflies.
Teachchildrentousepotty,anddiscardchildrensfaecesinthetoilet.
Cleanupfaecesfromanimals.
Justbecausesomethinglookscleandoesnotmeanthatitis.Ittakesover2.5billiongermstomake
250mlofwaterlookcloudy,butinsomecasesittakesonly15-20dangerousbacteriatocauseillness.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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2.Separaterawandcookedfoodstostopgermsfromspreading 2.Separaterawandcookedfoodstostopgermsfromspreading 2.Separaterawandcookedfoodstostopgermsfromspreading 2.Separaterawandcookedfoodstostopgermsfromspreading


Rawfood,especiallymeat,poultry,seafoodandtheirjuicescancontaindangerousgermsthatmaybe
transferredontootherfoodsduringpreparationandstorage.ThisiscalledCross-contamination.
Advisepeopleandfamiliestoalways:
Separaterawandcookedfoodduringcooking,preparationincludingslaughteringprocesses.
Keeprawmeat,poultryandseafoodseparatefromotherfoods.
Useseparateequipmentsuchasknivesandcuttingboardsforhandlingrawfoods.
If possible, use onecutting boardfor meat,chickenandfishandanotherforvegetableandbreador
cleantheboardwellwithsoapandhotwateraftereachtypeoffood.
Storefoodsincoveredcontainerstoavoidcontactbetweenrawandcookedfoods.
Beawareofthefollowing;
Cross-contaminationisatermusedtodescribethetransferofgermsfromrawtocookedfood.
Separation must occur not only when cooking, but during all phases of food preparation including
slaughteringprocesses.
3.Cookthoroughlytokillgerms 3.Cookthoroughlytokillgerms 3.Cookthoroughlytokillgerms 3.Cookthoroughlytokillgerms
Proper cooking can kill almost all dangerous germs. Foods that require special attention include
mincedmeats,rolledroasts,largejointsofmeatandwholepoultry.
Adviseindividualsandfamiliestoalways:
Cookfoodthoroughly,especiallymeat,poultry,eggs,fishandseafood.
Bringfoodslikesoupsandstewstoboilingpoint.Formeatandpoultry,makesurejuicesareclear,not
pink.
Reheatcookedfoodthoroughly.Bringtoboilorheatuntiltoohottotouch.Stirwhilere-heating.
Itisnotsafetoeatraweggsorfoodswithraweggsadded.Eggsmaycarrybacteriathatcauseillness
thatcansurviveevenincooltemperaturesbutcaneasilybekilledbyheating.
4.Keepfoodatsafetemperaturestoslowt 4.Keepfoodatsafetemperaturestoslowt 4.Keepfoodatsafetemperaturestoslowt 4.Keepfoodatsafetemperaturestoslowthegrowthofgerms hegrowthofgerms hegrowthofgerms hegrowthofgerms
Keephotfoodhotandcoldfoodcold.
Itisnotsafetoleavecookedfoodatroomtemperatureformorethantwohours.Germscangrowand
multiplyveryquicklyiffoodisstoredatroomtemperature.
Adviseindividualsandfamiliestoalways:
Buyfreshfoods,suchasmeatandfishonthedaytheywilleatthem.
Prepare food in small amounts to reduce leftovers. Food for infants, children and people with low
immunityshouldbefreshlypreparedandeatenassoonaspossible.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Storefreshfoods,(especiallyfoodsfromanimals)andcookedfoodinacoolplace,orarefrigeratorif
available.
Avoidstoringleftoversformorethanfewhours(unlessrefrigerated).Alwaysstorethemcoveredand
reheatthemthoroughlyuntilhotandsteaming(bringliquidfoodtoarollingboil).
Beawareofthefollowing:
Food can be cooled quickly by putting the food onto open trays, slicing large pieces of meat into
smallerpieces,placingfoodinacool,cleancontainer;orstirringregularlyforsoups.
Other food cooling and storage methods applicable in the local area/region; for example: cooling
containersoffoodbydippingthemincoldwater;diggingaholeandburyingfoodssuchaspotatoes
andcassava.
5.Usesafewaterandfoods 5.Usesafewaterandfoods 5.Usesafewaterandfoods 5.Usesafewaterandfoods tostopgermsandchemicals tostopgermsandchemicals tostopgermsandchemicals tostopgermsandchemicalsfromcomingintothehome fromcomingintothehome fromcomingintothehome fromcomingintothehome
Rawmaterials,includingwaterandice,maybecontaminatedwithdangerousgermsandchemicals.
Toxicchemicalsmaybeformedindamagedandmouldyfoods.Careinselectionofrawmaterialsand
simplemeasuressuchaswashingandpeelingmayreducerisk.
Safewater Safewater Safewater Safewater
Adviseindividualsandfamiliestoalways:
Safe waterisneeded for drinking, towash fruitsandvegetables, toadd tofood, to makedrinksand
ice,aswellasforcleaningcooking/eatingutensilsandwashinghands.
Usesafewatersuchastreatedpipedwaterorwaterfromatreatedsourcesuchasprotectedwell.If
thewaterisnotsafe,itshouldbeboiledbeforedrinkingorbeingusedforfoodpreparation.Untreated
waterfromriversandcanalscontaingermswhichcancausediarrhoea,typhoidordysenteryandare
notsafe!
Usecleancontainerstocollectandstorewaterwithalidorcoveredwithacloth.Rainwatercollectedin
clean tanks is safe as long as the tank is protected from contamination from birds or other animals.
Cooldrinksandicecubesshouldalsobemadewithwaterthatissafe.
Beawareofthefollowing:
Boiling,chlorinationandfiltrationareimportantmeanstoslowgrowthorkilldangerousgerms,butdo
notremoveharmfulchemicals.
Safefood Safefood Safefood Safefood
Advisepeopleandfamiliestoalways:
Buyfreshfoods,suchasmeatandfish.Lookforsignsofpoorqualityoffood.
Foodswithanyofthepoorqualitysignsarelikelytohavebeencontaminatedandincreasechancesof
food-borneillness.
Washallrawfruitsandvegetablesthoroughlywithsafewaterbeforeuse.Ifitisnotpossibletowash
themproperly,peelthembeforeeating.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Table4/1 Table4/1 Table4/1 Table4/1: :: :Signsofpoorqualityoffood Signsofpoorqualityoffood Signsofpoorqualityoffood Signsofpoorqualityoffood
FOODS FOODS FOODS FOODS SIGNSOFPOORQUALITY SIGNSOFPOORQUALITY SIGNSOFPOORQUALITY SIGNSOFPOORQUALITY
Cerealsandotherdry
foods
Contain insects and dirt, look or smell damp or mouldy; bag is
broken;legumesarewrinkled;flourislumpy
Vegetablesandfruits Wilted,toosoft,rottenspots,bruised
Meat,poultryandfish Badsmellorcolour;fishhavedulleyesorloosescales.Uninspected
meat,liverandotheroffalmaycontaindangerousparasites
Freshmilk Smellsbad;is,orhasbeen,exposedtodirtandflies
Cannedfoods Canisswollen,rustyordamaged;foodhasleakedout;foodlooksor
smellsortastesbad.Anyofthesesignsmeansthefoodmaybevery
poisonous.
Advisepeopletochecksellby(anduseby)datesonlabelsandnottobuy(oruse)foodsafter
thisdate.

Dry cereals and legumes thoroughly and store them in a dry place to avoid moulds from growing.
Mouldycerealsandlegumescontainaflatoxinthatcanmakethemseriouslyill.
Food may also be contaminated from the point of production. Involve extension workers for more
informationongoodagriculturalpractisestoensureproductionofsaferfoods
PeoplewithHIVshouldavoidtastinganyfoodthatmightbespoiled.Theymighthavedonethisinthe
pastandnevergotillbutrememberthingsaredifferentwithHIV.
Some foods are poor value for money because they contain few nutrients. Examples are sodas
(bottled fizzy drink), ice lollies and sweets, which are mainly sugar. These foods should be kept as
treatsnoteatenoften.
Otherinformation Otherinformation Otherinformation Otherinformationonfood onfood onfood onfood- -- -borneillnesses borneillnesses borneillnesses borneillnesses
Food-borneillnesscanalsoleadtolong-termhealthproblemsandsevereillnesses,includingcancer,
arthritis and mental disorders especially among children, people who are sick, pregnant women and
theelderly.
Adviseindividualsandfamiliesto:
Seekmedicaladviceimmediatelywhensymptomsaresevere;forexample,whenbowelmovements
areveryfrequent,verywateryorcontainblood,orlastbeyond3days.
Trynottohandleorpreparefoodwhileilland2daysafterrecoveringespeciallyfromvomitingand/or
diarrhoea.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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HANDOUT4/3:Exampleofwatertreatment HANDOUT4/3:Exampleofwatertreatment HANDOUT4/3:Exampleofwatertreatment HANDOUT4/3:Exampleofwatertreatment
Thebleachmethod Thebleachmethod Thebleachmethod Thebleachmethod

Add1teaspoonoronecapfulifthebottlehasascrewcap(5ml)ofbleachto25litresofwater.

Mixitwellandletitstandfor2hours(orpreferablyovernight)beforeusing.

Storesafewaterincleancontainerwithalidorcoveredwithacloth.








Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Session5:Improvingfoodintake Session5:Improvingfoodintake Session5:Improvingfoodintake Session5:Improvingfoodintake

Learning Learning Learning Learningo oo objectives bjectives bjectives bjectives

Bytheendofthissession,participantswillbeableto:

Discuss common eating difficulties that may affect the food intake of people living with HIV;
and
Describe strategies and techniques for improving food intake by overcoming loss of appetite,
sore mouth and throat, nausea and vomiting, change in taste, diarrhoea and other common
difficultiesexperiencedbypeoplelivingwithHIV.

Session Session Session Sessiono oo outline utline utline utline


Content Content Content Content Time Time Time Time
1 Learningobjectivesandintroductiontothesession 5minutes
2 CommoneatingdifficultiesthatmayaffectthefoodintakeofPLHIV:
soremouth/throat;
drymouth/changeintaste;
diarrhoea;and
nauseaandvomiting.
25minutes
3 Eatingduringrecoveryfromillness 5minutes
4 Preparinganoralre-hydrationsolution(ORS)totreatdehydration 5minutes
5 Summaryofthesessionandtransition 5minutes
Total Total Total Total 45minutes 45minutes 45minutes 45minutes

Preparation for the session

Writeanddisplaythelearningobjectivesonasheetofflipchartpaper.
Writethekeypointonasheetofflipchartpaperandkeepitasideuntilneeded.

KEYPOINT KEYPOINT KEYPOINT KEYPOINT


Eatwella Eatwella Eatwella Eatwellandwisely ndwisely ndwisely ndwiselyduringillnessandwhenrecoveringfromanillness duringillnessandwhenrecoveringfromanillness duringillnessandwhenrecoveringfromanillness duringillnessandwhenrecoveringfromanillness. .. .





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Collect/preparethefollowingtrainingmaterials:
Anoverheadprojectorandscreen;and/oraflipchartstand,flipchartpaper,markersandameans
toattachflipchartsheetstothewallorothersurface.Ifanoverheadprojectorisnotavailable,the
followingmaybewrittenout/preparedfordisplayonflipchartsheets.
Prepareasheetofflipchartsheetforeacheatingdifficultyusingthefollowingheadings:
Soremouth/throat;
Drymouth/changeintaste;
Diarrhoea;and
Nauseaandvomiting.
Addanyothereatingdifficultiesyouwishtodiscuss.
H HH Handouts5/1 andouts5/1 andouts5/1 andouts5/1to to to to5/ 5/ 5/ 5/4 44 4(availableattheendofthissessionandonpages57-60oftheParticipants
Manual) provide suggestions for addressing the main eating difficulties. Adapt the suggested
measurestolocalfoodsandcircumstancesasappropriate.Encourageparticipantstomaketheir
ownlistsratherthanjustcopyingthese.
H HH Hando ando ando andout5/5 ut5/5 ut5/5 ut5/5: : : : P PP Preparationof reparationof reparationof reparationofano ano ano anoral ral ral ralr rr re ee e- -- -hydration hydration hydration hydration s ss solution olution olution olution (availableattheendofthissessionand
onpage61oftheParticipantsManual). .. .

1. Learning objectives and introduction to the session (5 minutes)



Review the learning objectives of the session

Showtheflipchartanddiscussthelearningobjectives.
Bytheendofthissession,participantswillbeableto:
Discuss common eating difficulties that may affect the food intake of people living with
HIV;and
Describestrategiesandtechniquesforimprovingfoodintakeinordertoovercomelossof
appetite, sore mouth and throat, nausea and vomiting, change in taste, diarrhoea and
othercommondifficultiesexperiencedbypeoplelivingwithHIV.
Introduce the session
PeopleinfectedwithHIVoftenexperiencesymptomsthatleadtothereductionoffoodintakeand
arethus,moreatriskofmalnutrition.Reducedfoodintakemaybeforashorttimeorcontinuefor
longtime.Iffoodintakeisreducedforalongtimeapersonmayexperienceweightlossandthen
malnutrition.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Inaprevioussession,wementionedwaystoenrichfoodsandtoaddextraenergy,forexample,
byaddingmilk,eggs,sugaraswellasfatsandoils.Wealsodiscussedsuggestionstoofferwhen
apersondoesnotfeellikeeating.
In this session, we will discuss more ways of improving food intake when a person with HIV is
having difficulty eating. This is done in order to combat malnutrition and weight loss so that the
personhasabetterqualityoflife.

2. Common eating difficulties that may affect the food intake of people
living with HIV (25 minutes)

Whatarethecommon Whatarethecommon Whatarethecommon Whatarethecommoneating eating eating eatingdifficultiesthataffectthefoodintakeof difficultiesthataffectthefoodintakeof difficultiesthataffectthefoodintakeof difficultiesthataffectthefoodintakeof peoplelivingwith peoplelivingwith peoplelivingwith peoplelivingwithHIV HIV HIV HIV? ?? ?
Allowparticipantstorespondandlisttheirresponsesonasheetofflipchartpaper.
Usethelistbelowtoadditemsthatmayhavebeenmissedbytheparticipants.

Soremouth/throat Soremouth/throat Soremouth/throat Soremouth/throat Thrush, herpes, infections and other conditions may cause sore mouth/throat-
making it difficult to eat. Patients diagnosed with (Candida) oral thrush should
avoideatingsweetfoodssuchas,sugar,honey,sweetfruitanddrinksasthese
can make the condition worse. Mouth hygiene such as rinsing the mouth with
cleanwaterbeforeandaftermealsandcleaningtheteeth,isimportantandcan
helpthepersontofeelbetter.
Dry mouth/change Dry mouth/change Dry mouth/change Dry mouth/change
intaste intaste intaste intaste
A person may find that they have a taste in their mouth; their mouth may feel
dry; or they may be more aware of the texture or feel of food in their mouth.
Somemedicationsmaymakeseasoningssuchas,mint,garlicandgingertaste
lesspleasant.
Diarrhoea Diarrhoea Diarrhoea Diarrhoea When a person passes a loose or watery stool three or more times a day,
he/shehasdiarrhoea.Thereareseveralcausesofdiarrhoeaincludingbacterial
infections,medicationsideeffectsandcontaminationoffoodresultingfromfood
safetyandhygieneproblems.Severediarrhoeamaycausedehydration,lossof
appetite, poor food digestion and absorption, weight loss and malnutrition
resulting in weakness and further illnesses. In young children, diarrhoea can
quicklybecomeseriousandifuntreatedcanleadtodeath.
Nausea/vomiting Nausea/vomiting Nausea/vomiting Nausea/vomiting These symptoms may be caused by infection, stress, certain foods, hunger or
lack of water. Unpleasant smells or a side-effect of some medications or
treatments.Nausea/vomitingmayalsoreducetheappetite.

Inadditiontothesefourmaintypesofeatingdifficulties,peoplelivingwithHIVmayexperiencea
generallossofappetite.Lossofappetitemaybeasignofotherinfectionssuchas,tuberculosis.
It could also be related with pain in the mouth or gut, or be due to depression, anxiety or
tiredness.Thefeelingofhungermaydisappearorthepersonmayfeelsatisfiedandthereforenot
wanttoeat.ItisrecommendedthatpeoplelivingwithHIVexperiencingappetitelossarereferred
totheirdoctor/healthcareproviderfordeterminingandtreatingthecause.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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ExplainaboutSamsillhealth,usingthetextbelow.

THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI
Sam was feeling much better for a while. After he talked with the support worker and had
treatmentfortuberculosis,hewaseatingwell,notlosingweightandabletodosomework.
Now,heisnotaswellashewasbefore.Hehasboutsofdiarrhoea,asoremouthandiseating
lessagain.Heislookingforsuggestionsthatmighthelphimwiththesenewproblems.

WhatmightthesupportworkersuggesttoSamtoimprovehisfoodintake? WhatmightthesupportworkersuggesttoSamtoimprovehisfoodintake? WhatmightthesupportworkersuggesttoSamtoimprovehisfoodintake? WhatmightthesupportworkersuggesttoSamtoimprovehisfoodintake?
AllowparticipantstorespondandthenintroduceA AA Activity5/1:Suggestionstoimprovefoodintake ctivity5/1:Suggestionstoimprovefoodintake ctivity5/1:Suggestionstoimprovefoodintake ctivity5/1:Suggestionstoimprovefoodintake. .. .
Explain the importance of giving suggestions that are relevant and realistic to the particular
circumstancesoftheperson.

ACTIVITY5/1:Suggestionstoimprovefoodintake ACTIVITY5/1:Suggestionstoimprovefoodintake ACTIVITY5/1:Suggestionstoimprovefoodintake ACTIVITY5/1:Suggestionstoimprovefoodintake
Ask participants to get into four groups and assign one of the four main types of eating
difficultiestoeachgroupasfollows:
Group1:Soremouth/throat
Group2:Drymouth/changeintaste
Group3:Diarrhoea
Group4:Nauseaandvomiting

Ask the groups to write down their suggestions for dealing with the eating difficulty they are
assigned.
Explaintotheparticipantsthatsomesuggestionsaregiveninthehandoutsforthissessionwhich
canbefoundonpages57-60oftheParticipant'sManual.Encouragegroupstodeveloptheirown
listsratherthansimplycopyingthese.
It is recommended that one facilitator should work with each group to check that participants
understandthetask.
Askeachgroupinturntoreporttheirrespectivesuggestionsfordiscussion;thenwritedownand
displaytheseonsheetsofflipchartpaper.





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3. Eating during recovery from illness (5 minutes)

THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI
Samtriessomeofthesuggestionsandheiseatingbetter.
Hisstrengthimprovesandheisabletotakeregularwalkswithhisfamily.
ButSamsweightremainslowernowthanitwasafewmonthsago.

WhatmightthesupportworkersuggesttoSamabouteat WhatmightthesupportworkersuggesttoSamabouteat WhatmightthesupportworkersuggesttoSamabouteat WhatmightthesupportworkersuggesttoSamabouteatingduringrecovery? ingduringrecovery? ingduringrecovery? ingduringrecovery?
Allowparticipantstogivetheirsuggestionsandexplainthefollowing:
Samtalkstothesupportworkerwhoremindshimthatittakestimetoregainhislostweight.Itcan
takeweeks,notjustdays.Therefore,Samneedstopayspecialattentiontowhatheeatsandto
continuetoeatwisely.
Toregainweightafterrecoveringfromillness,itisimportanttoincreasefoodintakebeyondwhat
onenormallyeats,ratherthanjustgoingbacktoonesnormaldiet.
Emphasizethefollowing;
When recovering from illness, a person has to make sure to eat extra well, by increasing the
quantity and quality of his/her food intake in order to regain weight. The same is recommended
forchildrenrecoveringfromillness,whomustalsobefedmorethanusual,inordertomakeup
formissedmeals.
Remindparticipantsoftheimportanceoffoodsafety(asdiscussedinS SS Session4 ession4 ession4 ession4).
Safefoodpracticesareimportantforeveryone.Infectionsfromwaterandfoodcanmakeaperson
ill or worsen conditions that may cause reduced food intake. Therefore, prevention of infection
fromfoodandwaterisveryimportant.
Discuss, with the people for whom you provide care, ways in which they can keep food safe in
theirhouseholdasdiscussedinS SS Session4 ession4 ession4 ession4.
Discusstheimportanceofreferralfortreatment.
ItisimportanttoencouragepeopleinfectedwithHIVtoseekearlytreatmentwhen:
Diarrhoealastsformorethanthreedays;
An infant or young child is not able to drink or breastfeed, is drinking poorly, becomes
sickerandweak,hasbloodinthestool,developsfever;and/or
Inthecase ofillnessessuchastuberculosis,fever,oralthrushanddepressionthatmay
causelossofappetite.





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4. Preparing an oral re-hydration solution to treat dehydration (5 minutes)

Ask participants to look at Handout Handout Handout Handout 5/5: 5/5: 5/5: 5/5: Preparing Preparing Preparing Preparing an oral re an oral re an oral re an oral re- -- -hydration solution (ORS) hydration solution (ORS) hydration solution (ORS) hydration solution (ORS) to treat to treat to treat to treat
dehydration dehydration dehydration dehydration(foundattheendofthissessionandonpage61oftheParticipant'sManual).

Explainthefollowing:
Dehydrationiscausedbyexcessivelossofwaterandsaltsfromthebodythatoftenoccursdueto
diarrhoeaorvomiting.
NotallpeoplewithdiarrhoeaneedORS,onlythosethataredehydrated.
Inyoungchildren,diarrhoeacanquicklybecomeseriousandifuntreatedcanleadtodeath.Itis
therefore,importanttotreatdehydrationpromptly.
Totreatdehydrationthepersonshouldreceiveanoralre-hydrationsolution(ORS),TheORScan
bepreparedbyusingsafewaterandoneofthefollowing:
apre-preparedORSpacket;
saltandsugar;or
powderedcereal.
RefertoHandout5/5 Handout5/5 Handout5/5 Handout5/5anddiscussthethreedifferentwaysofpreparingORS.
In addition to ORS, it is also recommended that the person experiencing dehydration be given
foodsandfluidswhichhe/shecantolerate.

5. Summary of the session and transition (5 minutes)



Showthekeypointondisplayandaskaparticipanttoreaditoutloud.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Eatwellandwiselyduringillnessandwhenrecoveringfromanillness Eatwellandwiselyduringillnessandwhenrecoveringfromanillness Eatwellandwiselyduringillnessandwhenrecoveringfromanillness Eatwellandwiselyduringillnessandwhenrecoveringfromanillness. .. .

Summarizethesessionusingthefollowingpoints:
InapersonwithHIV,reducedfoodintakemaybecausedbyconditionssuchassoremouthand
throat,drymouth/changeintaste,nauseaandvomiting,diarrhoeaandlackofappetite.
Reducedfoodintakeforalongtimemayleadtoweightlossandmalnutrition.
The suggestions given to a person to improve their food intake during these difficultiesin eating
mustberelevantandrealistictotheperson.
EncouragethepersontoseektreatmentearlyforHIV-relatedillnessesthatmayleadtoreduced
foodintake
Askparticipantsiftheyhaveanyquestionsorifanythingneedsclarifying.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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In the next session, we will discuss more about preventing weight loss and promoting physical
activity.
Thenextsessionwillbepresentedby:
Statethenameofthepresenter.

HANDOUT5/1:Suggestionsf HANDOUT5/1:Suggestionsf HANDOUT5/1:Suggestionsf HANDOUT5/1:Suggestionsfordealingwithasoremouth/sorethroat ordealingwithasoremouth/sorethroat ordealingwithasoremouth/sorethroat ordealingwithasoremouth/sorethroat



Rinsewithslightlysaltywarmwater:usecleanboiledwater.
Cleanmouthfrequently,atleasttwiceadaymorningandevening,preferablyaftereverymeal.
Usecinnamonteaasamouthwash(1/4teaspoonofcinnamontoonecupofboilingwater;cover
andallowtocool).
Takeaspoonfuloflemonjuicemixedwithhoneytorelievesorethroats.
Addgravy,sauceorcustardtomealstomakethemmoist(butnotsticky)ordipfoodsinliquid.
Eatsoftfoodssuchasmashedfoods,soupsandjuices.
Useastrawtodrinkliquidstoeaseswallowing.
PatientsdiagnosedwithCandida(oralthrush)shouldavoideatingsweetfoodssuchassugar,
honey,andsweetfruitanddrinks.
Avoidroughfoodssuchastoastorrawvegetables.
Avoidstickyfoodssuchaspeanutbutter.
Avoidveryhotorverycoldfoods.
Avoidalcohol,inparticularspirits.
Avoidspicy,saltyoracidicfoodsthatirritateyourmouth.
Usefermentedproductssuchas,yoghurt.
Ifsolid foodis toohard to eat, drinknourishingliquidssuch as,beef broth,lentilor peasoup and
enrichedporridge.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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HANDOUT5/2:Suggestionsfordealingwithdrymouth/changeintaste HANDOUT5/2:Suggestionsfordealingwithdrymouth/changeintaste HANDOUT5/2:Suggestionsfordealingwithdrymouth/changeintaste HANDOUT5/2:Suggestionsfordealingwithdrymouth/changeintaste

Drymouth Drymouth Drymouth Drymouth

Stimulatesalivaproductionbysuckingahardsweetorchewinggum.
Serveliquidswithmealsandsipcolddrinksfrequentlyduringtheday.
Rinsemouthwithcleanwarmsaltywater.
Avoidveryhotfoodsanddrinkshighincaffeinesuchas,coffee,strongteaandsodas.

Changeintaste Changeintaste Changeintaste Changeintaste

Cleanyourmouthfrequentlybyrinsingitwithslightlysaltedwarm(safe/boiled)water.
Use salt, sugar, spices, vinegar, lemon, and other flavours to help change any unpleasant taste in
yourmouth.
Eatthefoodsyoudolike.
Tryavarietyoffoodsasyourtastemaycomebackafterafewweeks.
Verycoldfoodsmaytastebetter.
Freshfruitsandfruitjuicearerefreshingandmayleaveapleasanttasteinyourmouth.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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HANDOUT5/3:Suggestionsfortreatingdiarrhoea HANDOUT5/3:Suggestionsfortreatingdiarrhoea HANDOUT5/3:Suggestionsfortreatingdiarrhoea HANDOUT5/3:Suggestionsfortreatingdiarrhoea

Continuetoeatanddrinkwhichyoucantoleratewhenexperiencingdiarrhoea.
Drink lots of fluids: more than 8 cups a day especially clean boiled water, to prevent dehydration.
Ifdehydrated,prepareandtakeanoraldehydrationsolution(seeHandout5/5 Handout5/5 Handout5/5 Handout5/5).
Eatsmallmeals,fiveormoretimesintheday.Eatslowlyandchewwell.
Payparticularattentiontofoodhygiene.Usecleanboiledwater,keepfoodandutensilsveryclean,
storefoodforasshortatimeaspossibleinacoldplace.Ifyouarereheatingfood,makesureitis
veryhot.Keeprawfoodseparatefromcookedfoods.
Makericesoupbyboilingonecupofricein56cupsofcleanwaterwithabitofsaltforonehour.
Eatboththericeandthericewater.
Eatripeyellowbananas,cookedapplesormango;avoidunripefruits.
Peelandcookvegetablesratherthaneatingthemraw.
Eatrefinedcerealsratherthanwholegraincerealsandflourwhenyouhavediarrhoea.
Avoidbeans,gas-formingfoods,fizzydrinksandhighly-spicedfoods.
Eatfoodswarm,ratherthanveryhotorcold.
Fatisagoodsourceofenergy,sodonotcutoutfatifitisnotcausingyouaproblem.Reducefatty
foodstemporarilyiftheymakeyoufeelworsebutintroduceagainlater.
Someadultsmayfindthatavoidingmilkandmilkproductsmayhelp.Takeallmilkproductsoutof
yourdietforaday,andthenputitbackingraduallytoabouttwocupsintheday.Fermentedmilkor
yoghurtcanbeusedifavailable.
For children: sometimes cows milk or dried milks purchased from the shops can be a problem.
Ifbreastfeeding,continue,orincreasebreastfeeding.Ifavailable,fermentedmilkcanbeusedforthe
olderchild.
Trydifferentfoodsuntilyoufindsomethingthatsuitsyouoryourchild.






Nutritional Care and Support for People Living with HIV: Facilitators Guide
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HANDOUT5/4:Suggestionsfortreatingnauseaandvomiting HANDOUT5/4:Suggestionsfortreatingnauseaandvomiting HANDOUT5/4:Suggestionsfortreatingnauseaandvomiting HANDOUT5/4:Suggestionsfortreatingnauseaandvomiting

Haveenoughliquidin theday.Tryto use fluidssuch as, milkand otherenergy-rich drinks. Thisis
particularlyimportantforchildren.
Drinkliquidsabouthalfanhouraftermeals,ratherthanwithmeals.
Drinkliquidsslowly.
Eatsmall,frequentmeals:eatsomethingevery23hours.
Eatwheneveryouarehungryorfeellikeeating.Donotwaituntilmealtime.
On days when you feel better, eat well by increasing the quantity and variety of your food intake
(threemealsadayplussnacksin-between).
Chewfoodswelltomakethemeasiertodigest.
Eatslowlyandrelaxaftereating.Avoidlyingdownimmediatelyafterameal.
Eathighenergysnacksavailable:nuts,yoghurt,andbreadwithaspread.
Somepeoplefindsourfoodseasiertoeatthansweetfoods.
Avoidcookingsmells;asksomeoneelsetopreparefood.
Awalkinthefreshairbeforemealsandeatinginawell-ventilatedroommayhelp.
Trydryfoodssuchasdrybread,toastorplainbiscuitsandkeepmealsdry.
Avoidlargeamountsoffizzydrinksandbeerthatcanmakeyoufeelbloated.
Choosefoodsthatdonothaveastrongsmell.Coldfoodsgenerallyhavelesssmell
Increasestarchyfoodsandreducefattyfoodstemporarily.
Nauseamaybeaside-effectofdrugtreatments;talktoyourdoctoraboutit.
There are also medications which can reduce nausea, so discuss these with a health worker if
needed.






Nutritional Care and Support for People Living with HIV: Facilitators Guide
94
HANDOUT 5/5: Preparing an oral re HANDOUT 5/5: Preparing an oral re HANDOUT 5/5: Preparing an oral re HANDOUT 5/5: Preparing an oral re- -- -hydration solution (ORS) for treating dehydration hydration solution (ORS) for treating dehydration hydration solution (ORS) for treating dehydration hydration solution (ORS) for treating dehydration

Usecleanwater,boiledifpossible.
Fromapacket: Fromapacket: Fromapacket: Fromapacket:Followdirectionsonthepacket.
With salt and sugar: With salt and sugar: With salt and sugar: With salt and sugar: To one litre of water, add half a teaspoon of salt and eight teaspoons of
sugar.Stirorshakewell.Thesolutionshouldtastenomoresaltythantears.
Withpowderedcereals: Withpowderedcereals: Withpowderedcereals: Withpowderedcereals:Toonelitreofwater,addhalfateaspoonofsaltandeightteaspoonsof
powderedcereals.Riceisbest,butfinegroundwheatflour,maize,sorghumorcookedmashed
potatoes can also be used. Boil for five to seven minutes to make a liquid soup or watery
porridge.Coolthedrinkquickly.
InadditiontoORS,alsoeatanddrinkfoodsandfluidsthataretolerated.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
95

Session Session Session Session 6: 6: 6: 6: Preventing weight loss Preventing weight loss Preventing weight loss Preventing weight loss and and and and promoting physical promoting physical promoting physical promoting physical
activity activity activity activity

Learning Learning Learning Learningo oo objectives bjectives bjectives bjectives

Bytheendofthissession,participantswillbeableto:

Explaintheimportanceofmaintainingbodyweight;
Describewaystoincreaseenergyintakeandreduceweightloss;and
OutlinetheimportanceofphysicalactivityforpeoplelivingwithHIV.

Session Session Session Sessiono oo outline utline utline utline


Content Content Content Content Time Time Time Time
1 Learningobjectivesandintroductiontothesession 5minutes
2 Importanceofmaintaininggoodbodyweight 5minutes
3 Assessmentofweightloss 2minutes
4 Suggestionsforpreventingweightlossandre-gaininglostweight 5minutes
5 Howtoaddextranutritiontoeverydayfood(Handout6/1) 3minutes
6 Howtoboostonesappetite(Handout6/2) 3minutes
7 Recommendingfoodexamplesfromthelocalarea(Activity6/1) 10minutes
8 Otherfactorsthatinfluenceweightloss 3minutes
9 Role-play6A:Weightconcerns 10minutes
10 Physicalactivity 4minutes
11 Role-play6B:Physicalactivity 10minutes
12 Summaryofthesessionandtransition 2minutes
Total Total Total Total 62 62 62 62minutes minutes minutes minutes

Preparation for the session

Writeanddisplaythelearningobjectivesonasheetofflipchartpaper
Writethekeypointonasheetofflipchartpaperandkeepitasideuntilneeded.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
96

KEY KEY KEY KEYPOINTS POINTS POINTS POINTS


Whensymptomsstart,increaseenergyintaketoreduceorpreventweightloss. Whensymptomsstart,increaseenergyintaketoreduceorpreventweightloss. Whensymptomsstart,increaseenergyintaketoreduceorpreventweightloss. Whensymptomsstart,increaseenergyintaketoreduceorpreventweightloss.
Physicalactivitycanhelpyoufeelbetter. Physicalactivitycanhelpyoufeelbetter. Physicalactivitycanhelpyoufeelbetter. Physicalactivitycanhelpyoufeelbetter.

Collect/preparethefollowingtrainingmaterials:
Anoverheadprojectorandscreen;and/oraflipchartstand,flipchartpaper,markersandameans
toattachflipchartsheetstothewallorothersurface.Ifanoverheadprojectorisnotavailable,an
enlargedcopyofPicture2canbepreparedfordisplayasaposter.
Role Role Role Role- -- -play6A: play6A: play6A: play6A: Weight Weight Weight Weightc cc concerns oncerns oncerns oncerns
Role Role Role Role- -- -play6B: play6B: play6B: play6B: Physical Physical Physical Physicala aa activity ctivity ctivity ctivity
Picture1:SamandSuzi:Physicalactivity Picture1:SamandSuzi:Physicalactivity Picture1:SamandSuzi:Physicalactivity Picture1:SamandSuzi:Physicalactivity
Picture2:SamandSuzi Picture2:SamandSuzi Picture2:SamandSuzi Picture2:SamandSuzi: : : :W WW Weightloss eightloss eightloss eightloss (seeAnnex1 Annex1 Annex1 Annex1;selectversionsuitableforthelocalarea)
Handout6/1: Handout6/1: Handout6/1: Handout6/1: Suggestions Suggestions Suggestions Suggestionsforadding foradding foradding foraddingextranutritiontoeverydayfood extranutritiontoeverydayfood extranutritiontoeverydayfood extranutritiontoeverydayfood (availableattheendofthis
session)
Handout6/2: Handout6/2: Handout6/2: Handout6/2: Suggestions Suggestions Suggestions Suggestionsforimprovingappetite forimprovingappetite forimprovingappetite forimprovingappetite (availableattheendofthissession)

1. Learning objectives and introduction to the session (5 minutes)



Review the learning objectives of the session
Showandoutlinethelearningobjectivesdisplayed.

Bytheendofthissession,participantswillbeableto:
Explaintheimportanceofmaintainingbodyweight;
Describewaystoincreaseenergyintakeandreduceweightloss;and
OutlinetheimportanceofphysicalactivityforpeoplelivingwithHIV.
Introduce the session
AIDSischaracterizedbyprogressiveweightlossandwasting.
Leanbodymusclesmakeupmostofthebodyweightandareresponsibleforvariousfunctionsinthe
body. As damage to the defence system and weight loss increases, the body becomes less able to
performthesefunctions.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Whenapersondoesnoteatenoughfood,orthefoodeatenispoorlyabsorbedandutilized,thebody
derives energyfromitsownstoresof fat andmuscle. As aresult, thepersonlosesweight because
bodyfatandmusclesarelost.

2. Importance of maintaining good body weight (5minutes)



WhatarethelinksbetweenHIV/AIDSandbodyweight? WhatarethelinksbetweenHIV/AIDSandbodyweight? WhatarethelinksbetweenHIV/AIDSandbodyweight? WhatarethelinksbetweenHIV/AIDSandbodyweight?
Allowparticipantstorespond.Showanddiscussthekeypointsdisplayed,addingthefollowing:
Weightlossleadstogeneralweakness,lowerimmunityandincreasestheprogressionofHIVtoAIDS.
Weightlossincreases thechances of gettingsevereinfections that may furtherlead toweightloss,
thusresultinginaviciouscycle.
Maintaininggoodbodyweightandpreventingweightlosscanimprovethequalityoflifeanddelaythe
onset of illness. People with symptomatic HIV need to increase weight and build muscle stores in
ordertopreventfurtherweightloss.
Inthissession,wewilldiscussweightloss,waystoincreaseenergyintakeandthebenefitsofphysical
activity.

3. Assessment of weight loss (2 minutes)



Insomecases,weightlossmaybesogradualthatitisnoteasilydetected.
Refer back to the story of Sam and Suzi and show Picture 2: Sam and Picture 2: Sam and Picture 2: Sam and Picture 2: Sam and Suzi: Weight loss Suzi: Weight loss Suzi: Weight loss Suzi: Weight loss to
illustratethispoint:
Samhaslostweightbutheisnotsurebecausehedoesnothaveaweighingscale.

PICTURE2: PICTURE2: PICTURE2: PICTURE2: SamandSuzi:Weightloss SamandSuzi:Weightloss SamandSuzi:Weightloss SamandSuzi:Weightloss




HowcanSamtellwhenlosingweight? HowcanSamtellwhenlosingweight? HowcanSamtellwhenlosingweight? HowcanSamtellwhenlosingweight?






Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Allow participants to respond; list indicators for weight loss on a sheet of flipchart paper and
discussthese,addingthefollowingpoints:
Samcandetectwhetherheislosingweightif:
hisclothesaregettinglooser,hefindsthatheincreasinglyneedstotightenhisbelt;and/or
peoplearoundhimrepeatedlycommentthathelooksthinner.
It is necessary to discuss with Sam the importance of regular check-ups for early identification of
weightlossandotherinfectionsrequiringpromptaction.Hisweightshouldbemonitoredandrecorded
regularly, preferably on the same day each month. This may mean regular visit to health care and
supportcentre.
Discuss the feasibility of regular visits to the care and support centre. There should not be long
intervalsbetweenvisits.

4. Suggestions for preventing weight loss and regaining lost weight


(5 minutes)

HowcanSampreventweightloss HowcanSampreventweightloss HowcanSampreventweightloss HowcanSampreventweightlossand and and andre re re regain gain gain gainthe the the theweight weight weight weighthehaslost hehaslost hehaslost hehaslost? ?? ?
Allow participants to respond and write down only the key points raised on a sheet of flipchart
paper;discusstheseaddingthefollowingpoints:
Apersonexperiencingweightlosscantryoneormoreofthefollowingstrategiestogainweight:

Increasingthequantityandvarietyofenergy-richfoods:
Eat more staples and starchy foods such as, bananas, bread, maize, millet, potatoes, rice,
sorghum, and wheat and continue to eat more until recovering initial weight. One portion of
such staples is about one fistful (see Handout 3/1 Handout 3/1 Handout 3/1 Handout 3/1 discussed in Session 3 Session 3 Session 3 Session 3). Gradually
increasetheportionsuntilreachingaboutsixormoreportionsaday.
Increase intake of beans, lentils, peas, groundnuts, peanut butter and seeds, such as
sunflowerandsesame.
Include all forms of meat, poultry, fish and eggs as often as possible. Minced meat, chicken
and fish are easier to digest. Offal such, as kidney and liver are also a good source of
nutrientsthatcancontributetoreversingweightloss.
Introduce more diary products such as, full-cream milk, sour milk, buttermilk, yoghurt and
cheeseintothediet.
Graduallyincreaseintakeoffoodscontainingfats/oils,oilseedssuchas,groundnuts,sesame
andavocados.

Addingextranutrientstofoodsormeals:
Howcanweaddextranutrientstofoodormeals? Howcanweaddextranutrientstofoodormeals? Howcanweaddextranutrientstofoodormeals? Howcanweaddextranutrientstofoodormeals?




Nutritional Care and Support for People Living with HIV: Facilitators Guide
99
Allow participants to respond and write down only the key points raised on a sheet of flipchart
paper;discusstheseaddingthefollowingpoints:
Addingextranutrientstofoods/drinksiscalledenrichingfoods enrichingfoods enrichingfoods enrichingfoods.Food/drinkscanbeenrichedby:
Makingahotdrinkwithmilkinsteadofwater;
Eating more concentrated foods, e.g. eating the solid pieces of a stew/soup before
consumingtheliquidpart;
Increasingthefatcontentoffood,e.g.,byaddingfivetosixteaspoonsoffats/oilstofoodper
day;ifproblemsresultingfromhighfatintakeareexperienced,(especiallydiarrhoea),reduce
theamountoffatinthedietuntilthesymptomspass;thengraduallyincreaseittoalevelthat
canbetolerated;
Includingdairyproductssuch,asfull-creammilk,sourmilk,buttermilk,yoghurtandcheesein
meals; adding milk, or milk powder to foods such as stews, soups, porridge, cereals, and
mashed potatoes. Note that some people may find milk difficult to digest; milk should be
avoided,ifitcausescramps,bloating,orskinrashes.
Addingprotein-richfoodssuchas,beans,lentils,groundnuts,peanutbutteroreggstomaize,
millet,orcassavaporridge;and
Addingonetotwoteaspoonsofextraofsugar,honeyandothersweetproductstofood.

Whileincreasingthefatcontentoffoodscanhelptoregainlostweight,careshouldbetakenthat
sugaryandfattyfoodsarenoteatenassubstitutesformorenutritiousfoods.

Eatingmorefrequentlyandincreasingtheamountsoffood:
Increasingthenumberofmealsandsnackseatendaily;and/oreatinglargeramountsoffood,
especiallyattimeswhenoneisfeelinglikeeating;
Including snacks that are readily available and can be eaten without much preparation in-
between meals. Snacks may include foods such as, nuts, seeds, fruits, yoghurt, carrots,
boiledcassava/sweetpotatoes,chips,andpeanutbuttersandwiches.

Eatingatleastthreemealsadayandsnacksin-betweencanpreventweightlossandreducethe
likelihoodofmalnutrition.

5. How to add extra nutrition to everyday foods (3 minutes)



Ask participants to look at Handout 6/1: Suggestions on how to Handout 6/1: Suggestions on how to Handout 6/1: Suggestions on how to Handout 6/1: Suggestions on how to add extra nutrition to everyday add extra nutrition to everyday add extra nutrition to everyday add extra nutrition to everyday
foods foods foods foods(found attheendofthissessionandonpage69oftheParticipant'sManual).




Nutritional Care and Support for People Living with HIV: Facilitators Guide
100
Explain that the handout provides specific examples of how to enrich or add extra nutrition to
everyday meals in order to prevent weight loss/regain lost weight. Go over the examples with
participants.

6. How to boost ones appetite (3 minutes)



Ask participants to look at Handout 6/2: Suggestions to try when a patient does not feel like Handout 6/2: Suggestions to try when a patient does not feel like Handout 6/2: Suggestions to try when a patient does not feel like Handout 6/2: Suggestions to try when a patient does not feel like
eating eating eating eating(foundattheendofthissessionandonpage70oftheParticipant'sManual).
Explainthatthehandoutprovidesarangeofsuggestionsforboostingappetitewhenapersonwith
HIVdoesnotfeellikeeating.Gooverthesuggestionswithparticipants.

7. Recommending food examples from the local area (10 minutes)



ACTIVITY 6/1: Recommendations to help Sam regain weight
Developing examples of improved meals based on local recipes
Explainthatthisactivitywillhelpparticipantstodevelopexamplesofimprovedmealsbased
on recipes from their local communitys diet, which they can recommend to those to whom
theyprovidecare/support.
Ask participants to form four groups and assign each group one of the daily meals as
follows:
Group1:Breakfast
Group2:Snacks
Group3:Lunch
Group4:Dinner
Give each group a sheet of flipchart paper and markers and ask them to choose a person
whowillpresenttheoutcomeoftheirdiscussions.
Alloweachgroup10minutestorecordandanalysethetypeoffooditemsusuallyeatenby
local people during the meal which they have been assigned. Wherever possible, they
should also approximate the amount of each food item typically consumed, e.g. 1 cup, 1
slice,etc.
Onceparticipantshavecompletedtheexercise,askeachgrouptopresenttheirsuggestions.
fordiscussion.
Thendiscusshowtoimprovethefoodthatisusuallyeateninordertomakethemealmore
suitableforapersonwhoislosingweight.

8. Other factors that influence weight loss (3 minutes)



Wh Wh Wh Which ich ich ichotherfactorscouldinfluenceweightloss? otherfactorscouldinfluenceweightloss? otherfactorscouldinfluenceweightloss? otherfactorscouldinfluenceweightloss?
Allow participants to respond and write down only the key points raised on a sheet of flipchart
paper;discussthese,addingthefollowingpoints:




Nutritional Care and Support for People Living with HIV: Facilitators Guide
101
Inadditiontoincreasingfoodintake,itmaybenecessaryto:
Preventotherinfectionsbyimmunization,de-wormingandanti-retroviraltreatment;thiscan
bedonewhenthepersonvisitsthehealthcareandsupportcentreregularly;
Treatotherinfections,suchastuberculosis,thatmaycontributetoweightloss;and
Increasestrengthandpreservemusclesbyincreasingphysicalactivity.

9. Role-play 6A: Weight concerns (10 minutes)

Choosetwovolunteerparticipantsandaskthemtopreparefortherole-play.
Samhascometoseethehealthworkerbecauseheisworriedthatheislosingweight.Listentothe
conversation between the health worker and Sam and list the counselling skills the health worker is
usingaswellasthereactionsofSam.

ROLE-PLAY 6A: Weight concerns




COMMUNICATION COMMUNICATION COMMUNICATION COMMUNICATION
SKILLUSED SKILLUSED SKILLUSED SKILLUSED
HEALTH
WORKER
Goodmorning,Sam.Pleasesitdown,howcanlhelpyou
today?
Open Open Open Open question question question question
SAM: Goodmorning.Ihavebeenlosingweightrecentlyandthis
isnotagoodsign.

HEALTHWORKER Youareworriedabouttheweightloss. Empath Empath Empath Empathize ize ize ize
SAM: Yes.ItisprobablyjusttheHIVgettingworse.Suzisaidto
cometotalktoyou.

HEALTHWORKER Itisgoodthatyoucametotalk.Weightisimportant.It
helpsyoutostaywelllongerifyoucankeepyourweight
up.
Prais Prais Prais Praise ee e
Giver Giver Giver Giverelevant elevant elevant elevant
in in in information formation formation formation
SAM Howdoldothat?Sometimesljustdonotfeellikeeating
anything.

HEALTHWORKER Well,onesuggestionistohavesomeready-and-easyto
eatfoodsavailable.Perhapssomenuts,yoghurt,orbread
withsomethingonit,whichdonotrequirealotof
preparation.Alsotrytoeatsomethingevery23hours:
smallfrequentmealsratherthanjustonelargemeal.
Couldyoudothat?
Suggestion Suggestion Suggestion Suggestion
Suggestion Suggestion Suggestion Suggestion
Question Question Question Question
SAM Idontknow.Ihavetroublemakingmyselfeatoncea
day.Icouldnotfaceeatingeveryfewhours.

HEALTHWORKER Itishardtothinkabouteatingsometimes.Whenyoudo
feellikeeating,youcouldaddextranutritiousfoodsto
yourmeals.Forexample,addmilk,cheese,butteroroilto
Reflect Reflect Reflect Reflect
Practicalhelp Practicalhelp Practicalhelp Practicalhelp
Suggestion Suggestion Suggestion Suggestion




Nutritional Care and Support for People Living with HIV: Facilitators Guide
102
mashedvegetables,ortosoups.
Whatdoyouthinkaboutaddingsuchextrafoodstoyour
meals?
Open Open Open Open- -- -ended ended ended ended
question question question question
SAM Icantrythat.Thereisusuallyoilandsometimesthereis
extramilkinthehouse.

HEALTHWORKER Youcantrytoaddextranutritiousfoodstoyourmeals,to
eatsomethingsmalleveryfewhoursandalsodrinkwater
andotherfluidsfrequently.Therearesomeotherideas
thatyoumightliketotryinthisleaflet.Youcanalsobring
whoevercooksandshopsforfoodinyourhouseholdinto
talk,ifthatwouldhelp.Comebackagainifyouwantto
talkmore.
Suggestions Suggestions Suggestions Suggestions

Optionsfor Optionsfor Optionsfor Optionsforfollow follow follow follow- -- -up up up up
SAM Thankyou.Iwillshowtheleaflettomywifeandwecan
talktoyouagainmaybe.


Takingoneissueatatimeaskparticipantsthefollowing:

HowhelpfulwasthehealthworkersdiscussionwithSam? HowhelpfulwasthehealthworkersdiscussionwithSam? HowhelpfulwasthehealthworkersdiscussionwithSam? HowhelpfulwasthehealthworkersdiscussionwithSam?


Describewhatwashelpfultohim. Describewhatwashelpfultohim. Describewhatwashelpfultohim. Describewhatwashelpfultohim.
Howw Howw Howw HowwelldidthehealthworkerusecommunicationskillsincounsellingSame? elldidthehealthworkerusecommunicationskillsincounsellingSame? elldidthehealthworkerusecommunicationskillsincounsellingSame? elldidthehealthworkerusecommunicationskillsincounsellingSame?

Sam starts to feel a lot better and is also able to eat better. Because he sought care early, he
avoidedfurtherweightlossandgettingmoreinfections.

Showthefirstkeypointdisplayed,andaskaparticipanttoreaditoutloud.

KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Whensymptomsstart,increaseenergyintaketoreduceorpreventweightloss. Whensymptomsstart,increaseenergyintaketoreduceorpreventweightloss. Whensymptomsstart,increaseenergyintaketoreduceorpreventweightloss. Whensymptomsstart,increaseenergyintaketoreduceorpreventweightloss.

10. Physical activity (4 minutes)

Introducethetopicofphysicalactivity

To further build up the body, physical activity should be encouraged during the early stages of
HIVandduringthesymptomaticphase.
Physicalactivityisgenerallygoodforeveryone.
Physical activity may include daily activities such as, household chores and light work in the
gardenorinthefield.Lightactivityeachdayisbetterthanintensiveexerciseonceaweek.
Activitymaybelimitediffoodintakeisverylowandthepersonisveryweak.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
103

Whatarethebenefitsofphysicalactivit Whatarethebenefitsofphysicalactivit Whatarethebenefitsofphysicalactivit Whatarethebenefitsofphysicalactivity yy y? ?? ?

Allow participants to respond and write down only the key points raised on a sheet of flipchart
paper;discussthese,addingthefollowingpoints:

OVERHEAD6/1:Benefitsofphysicalactivity OVERHEAD6/1:Benefitsofphysicalactivity OVERHEAD6/1:Benefitsofphysicalactivity OVERHEAD6/1:Benefitsofphysicalactivity


Physicalactivitycan:

Strengthenandbuildmuscles;
Strengthenbones;
Strengthentheimmunesystem;
Helprelievestress;
Increaseappetite;
Helpdigestion;
Helptheheartandlungstoworkwell;and
Improveonessenseofwell-being.

Physical activity uses up energy so it is important to increase ones food intake. It is also
necessarytodrinkextrawaterwhenexercising.

11. Role-play 6B: Physical activity (10 minutes)

Choosetwovolunteerparticipantsandaskthemtopreparefortherole-play.
Introducetherole-play:
The health/nutrition worker talks with Sam to find some physical activity that Sam could do
regularly.ListthecounsellingskillsthesupportworkerisusingaswellasthereactionsofSam.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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ROLE-PLAY 6B: Physical activity
COMMUNICATION COMMUNICATION COMMUNICATION COMMUNICATION
SKILL SKILL SKILL SKILL USED USED USED USED
HEALTHWORKER Goodmorning,Sam.Youarelookingwelltoday.
Howareyoufeeling?
Open Open Open Open- -- -endedquestion endedquestion endedquestion endedquestion
SAM Goodmorning.Iamfeelingbettersincethelasttime
wetalked.
NowIhavemoreenergysoIwasthinkingaboutwhat
yousaidaboutbeingmoreactive.

HEALTHWORKER Yes,activitycanhelptomaintainyourstrength.
Whatphysicalactivitydoyoudoatthemoment?
Reflect Reflect Reflect Reflect
Open Open Open Open- -- -endedquestion endedquestion endedquestion endedquestion
SAM Well,whenIwasillrecently,Istoppeddoingmost
activities.

HEALTHWORKER Wellwhataboutstartinggently?Maybeawalkwithyour
youngsonorplayingballwithhimfor10or15minutes.
Howdoesthatsound?
Suggestion Suggestion Suggestion Suggestion
SAM IcoulddothateasilyImsure.
HEALTHWORKER Maybeyoucouldalsotryweightlifting!Liftyoursonupa
fewtimesandincreasethenumberofliftsasyoucan.
Thiscanstrengthenyourmuscles.Wouldyoubeableto
dosomelifts?
Suggestion Suggestion Suggestion Suggestion
SAM Yes,probably.Whenyouthinkaboutit,thereare
exercisesIcaneasilydoaroundthehouse.

HEALTHWORKER Physicalactivitydoesnotneedtobespecialexercises.
Wecandoalotbyjustincreasingournormalactivity.
Tryitforafewweeksandcomebackagainifyouwantto
talkmore.
Information Information Information Information
Follow Follow Follow Follow- -- -up up up up

SAM Thankyou.IwillseehowIgetonwithincreasingmy
activity.

Takingoneissueatatimeaskparticipantsthefollowing:
How How How HowhelpfulwasthehealthworkersdiscussionwithSam? helpfulwasthehealthworkersdiscussionwithSam? helpfulwasthehealthworkersdiscussionwithSam? helpfulwasthehealthworkersdiscussionwithSam?
Describewhatwashelpfultohim. Describewhatwashelpfultohim. Describewhatwashelpfultohim. Describewhatwashelpfultohim.
How How How Howwell well well welldid did did didthehealthworkerusecommunicationskillsincounsellingSam thehealthworkerusecommunicationskillsincounsellingSam thehealthworkerusecommunicationskillsincounsellingSam thehealthworkerusecommunicationskillsincounsellingSam? ?? ?

Discusstheirresponsesaddingthefollowing:
Samnowfeelswellenoughtoincreasehisphysicalactivitywhichwillfurtherhelphimbuilduphis
body, increase his appetite, boost his immune system and improve his general sense of well-
being.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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ShowPicture Picture Picture Picture1 11 1:SamandSuzi :SamandSuzi :SamandSuzi :SamandSuzi doingsomephysicalactivity doingsomephysicalactivity doingsomephysicalactivity doingsomephysicalactivity (Re-usePicture1 Picture1 Picture1 Picture1; ;; ;emphasizingthat
SamandSuziaregoingforregularwalksaformoflightphysicalactivity)
PICTURE PICTURE PICTURE PICTURE1 11 1:SamandSuzi :SamandSuzi :SamandSuzi :SamandSuzi physicalactivity physicalactivity physicalactivity physicalactivity

Showthesecondkeypointdisplayed,andaskaparticipanttoreaditoutloud.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Physicalactivity Physicalactivity Physicalactivity Physicalactivitycanhel canhel canhel canhelp pp p youtofeelbetter. youtofeelbetter. youtofeelbetter. youtofeelbetter.

Introduce a light physical activity or ask participants to stretch to feel the benefits of physical
activity.

12. Summary of the session and transition (2 minutes)

Show/reviewbothkeypointsdisplayed.

KEYPOINTS KEYPOINTS KEYPOINTS KEYPOINTS
Whens Whens Whens Whensymptomsstart,increaseenergyintaketoreduceorpreventweightloss. ymptomsstart,increaseenergyintaketoreduceorpreventweightloss. ymptomsstart,increaseenergyintaketoreduceorpreventweightloss. ymptomsstart,increaseenergyintaketoreduceorpreventweightloss.
Physicalactivitycanhelpyoufeelbetter. Physicalactivitycanhelpyoufeelbetter. Physicalactivitycanhelpyoufeelbetter. Physicalactivitycanhelpyoufeelbetter.

MaintainingagoodbodyweightcanimprovethequalityoflifeforpeoplewithHIV.Aimtocheck
weightregularlyandtoactpromptlyifweightlossstarts.
Physicalactivitycanhelpimproveappetiteandonesgeneralsenseofwell-being.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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The key points on eating wisely discussed in Session Session Session Session 3 33 3 should continue to apply when
symptomsofweightlossstart.

Askifthereareanyquestions,orifanythingneedsclarifying.
Inthenextsessionwewilldiscussnutritionforpeopleonantiretroviraltherapy(ART).
Thenextsessionwillbepresentedby:
Statethenameofthepresenter.

HANDOUT6/1:Suggestionsonhowtoaddextranutritionto HANDOUT6/1:Suggestionsonhowtoaddextranutritionto HANDOUT6/1:Suggestionsonhowtoaddextranutritionto HANDOUT6/1:Suggestionsonhowtoaddextranutritiontoeverydayfood everydayfood everydayfood everydayfood



Add milk,cheese,butter oroiltomashedvegetables,potatoes,rice,soups,stewsandother
foods.
Tomakefortifiedmilk,add4spoons(15mlspoon)ofmilkpowderto500mlcowsmilk.Stir
well and keep in a cool place. Use full fat milk powder if available instead of skimmed milk
powder.Usethisfortifiedmilkintea,oncerealsandincooking.
Milkpowdercanalsobeaddedtosoupstogivemoreprotein.
Stir a beaten egg into hot porridge or mashed potatoes and cook for a few minutes more to
cooktheegg.Donoteatraworundercookedeggs.Alwayscookeggs.
Putextraspreadonsandwiches,e.g.nutspreads,jam,butter/margarine,tinnedfish.
Nutsareagoodsourceofenergy.Keepthemneartoeatasasnackandputchoppednutsor
pasteintofoods.
Addcream,evaporatedmilkoryoghurttosoups,puddings,cerealsandmilkydrinks.
Uselocalfoodsthatarerichinfat,suchasavocado,fattyfish,coconutoilandfriedfoods,if
tolerated.
Sprinklecrispyfriedonions,friedfattymeatorsimilarontopofmeals.
Eat chocolates, sweets, dried fruits such as raisins and dates as an extra, not as a
replacementforameal.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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HANDOUT6/2:Suggestionsonwhattotryifyoudonotfeellikeeating HANDOUT6/2:Suggestionsonwhattotryifyoudonotfeellikeeating HANDOUT6/2:Suggestionsonwhattotryifyoudonotfeellikeeating HANDOUT6/2:Suggestionsonwhattotryifyoudonotfeellikeeating

Eatsmall,frequentmeals;eatsomethingevery23hours.
Eatwheneveryouarehungryorfeellikeeating.Donotwaituntilamealtime.
Choosefoodsthatyouenjoymost.Youaremorelikelytoeatthesefoods.
Ondaysyoufeelwell,eatwell.
Awalkinthefreshairbeforeeatingandeatinginawell-ventilatedroommayhelp.
Eatwithfamilyorotherpeoplesoitisasocialevent.Ifyouareinbed,havethemeatatyour
bedside.Childrenmaysometimeseatbetterwithothers;othertimesthismaybetoomuchofa
distraction. Be prepared to try different ways. Always stay with the child while eating, both to
watchfordifficultiesandtoencourageeating.
Makesureyouhaveenoughliquidintheday.Trytotakefluidssuchasmilkandotherenergy-
containingdrinks.Thisisparticularlyimportantforchildren.
Eatslowlyandrelaxforawhileaftereating.Avoidlyingdownimmediatelyafterameal.
Make meals as attractive as possible, e.g. enhance the presentation of food by using
garnishes,settingthetablenicely.
Somefoodsmaystimulatetheappetitesuchasgingertea,orlemonjuiceincleanboiledwater
Whentheappetitehasreturnedortheillnesshaspassed,besuretoeatextra(orfeedthechild
more)tomakeupforthemissedmeals
Lack of appetite may be a sign of an infection such as tuberculosis or of depression; talk to
yourdoctoraboutit.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
108

Session7:Nutritionforpeopleonanti Session7:Nutritionforpeopleonanti Session7:Nutritionforpeopleonanti Session7:Nutritionforpeopleonanti- -- -retroviraltreatment retroviraltreatment retroviraltreatment retroviraltreatment

Learning Learning Learning Learningo oo objectives bjectives bjectives bjectives



Bytheendofthissessionparticipantsshouldbeableto:

Explainthefoodandnutritionimplicationsofantiretroviraltreatment(ART);
DiscusstheimportanceofnutritionforpeoplelivingwithHIVonART;and
Identifybestnutritionpracticesanddiscussdrug-mealplansforpeopleondifferent
drugregimens.



Preparation for the session

Writeanddisplaythelearningobjectivesonasheetofflipchartpaper.
Writethekeypointsonasheetofflipchartpaperandkeepitasideuntilneeded.

KEYPOINTS KEYPOINTS KEYPOINTS KEYPOINTS
Understandingmedicationside Understandingmedicationside Understandingmedicationside Understandingmedicationside- -- -effectshelpscarefulselectionoffoodsforprepar effectshelpscarefulselectionoffoodsforprepar effectshelpscarefulselectionoffoodsforprepar effectshelpscarefulselectionoffoodsforpreparing ing ing ing
nutritiousmealsand nutritiousmealsand nutritiousmealsand nutritiousmealsandagoodnutrition agoodnutrition agoodnutrition agoodnutritionp pp plan lan lan lan. .. .
ARTworks ARTworks ARTworks ARTworksbetter better better betterinpeoplewho inpeoplewho inpeoplewho inpeoplewhohavegoodnutr havegoodnutr havegoodnutr havegoodnutritionalpractices itionalpractices itionalpractices itionalpractices. .. .

FindouttheARVdrugcombinationthatiscommonlyusedinyourarea/region.
FindoutwhatlocaldoctorsadviseabouttheinteractionsbetweenART,food,herbs.etc.
Session Session Session Sessiono oo outline utline utline utline
Content Content Content Content Time Time Time Time
1 Learningobjectivesandintroduction 5minutes
2 Interactionsbetweendrugs,foodandnutrition 15minutes
3 Nutritionpracticesformanagingtheside-effectsofantiretroviral
(ARV)drugs
15minutes
4 Makingadrugfoodplan(Exercise) 20minutes
5 Medicationandphysicalactivity(Role-play7) 15minutes
6 Summaryofthesessionandtransition 5minutes
Total Total Total Total 75 75 75 75minutes minutes minutes minutes




Nutritional Care and Support for People Living with HIV: Facilitators Guide
109
Find out from health facilities about the local/regional selection criteria and procedures for
accessingARVdrugs.

Asktwoparticipantstoassistwiththerole-playfoundonpages77-78oftheParticipant'sManual.
Collect/preparethefollowingtrainingmaterials:
Anoverheadprojectorandscreen;and/oraflipchartstand,flipchartpaper,markersandameans
to attach flipchart sheets to the wall or other surface. If an overhead projector is not available,
overheads may be written out on flipchart sheets or enlarged copies prepared for display as
posters,asappropriate.
Overhead1/1: Overhead1/1: Overhead1/1: Overhead1/1: The The The The bad bad bad badcycle cycle cycle cycle ofpoornutritionand ofpoornutritionand ofpoornutritionand ofpoornutritionandHIV HIV HIV HIV ; ;; ;
Overhead 7/1: Overhead 7/1: Overhead 7/1: Overhead 7/1: Interactionbetween drugs, foodandnutrition Interactionbetween drugs, foodandnutrition Interactionbetween drugs, foodandnutrition Interactionbetween drugs, foodandnutrition (fullversionavailableattheendof
thissession).
Overhead7/2: Overhead7/2: Overhead7/2: Overhead7/2: SupportingmanagementofARV SupportingmanagementofARV SupportingmanagementofARV SupportingmanagementofARVdrugs, drugs, drugs, drugs,foodandnutritioninteractio foodandnutritioninteractio foodandnutritioninteractio foodandnutritioninteractions ns ns ns
Handout Handout Handout Handout 7/1: 7/1: 7/1: 7/1: Recommended nutrition practi Recommended nutrition practi Recommended nutrition practi Recommended nutrition practic cc ces for es for es for es for dealing with the dealing with the dealing with the dealing with the side side side side- -- -effects of AR effects of AR effects of AR effects of ARV VV V
medication medication medication medications s s s(availableattheendofthissession).
Handout7/ Handout7/ Handout7/ Handout7/2 22 2: :: : Daily Daily Daily Dailydrug drug drug drug- -- -foodplanner foodplanner foodplanner foodplanner (availableattheendofthissession).
Role Role Role Role- -- -play7: play7: play7: play7: Discussingeatingw Discussingeatingw Discussingeatingw Discussingeatingwiselywiththecaregiverofayoungchild iselywiththecaregiverofayoungchild iselywiththecaregiverofayoungchild iselywiththecaregiverofayoungchild

1. Learning objectives and introduction to the session (5 minutes)


Review the learning objectives of the session
Showandoutlinethelearningobjectivesdisplayed.
Bytheendofthissession,participantswillbeableto:
Explainthefoodandnutritionimplicationsofantiretroviraltreatment(ART);
DiscusstheimportanceofnutritionforpeoplelivingwithHIVonART;and
Identify best nutrition practices and discuss drug-meal plans for people on different drug
regimens.
Introduce the session

Show O OO Overhead 1/1: verhead 1/1: verhead 1/1: verhead 1/1: The The The The bad bad bad bad cycle cycle cycle cycle of of of of poor nutrition and poor nutrition and poor nutrition and poor nutrition and HIV HIV HIV HIV and ask participants to reflect
backonwhatwasdiscussedaboutthebadcycleinSession1. Session1. Session1. Session1.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
110

OVERHEAD1/1:The OVERHEAD1/1:The OVERHEAD1/1:The OVERHEAD1/1:The' '' 'bad bad bad bad cycle cycle cycle cycleofpoornutritionandHIV ofpoornutritionandHIV ofpoornutritionandHIV ofpoornutritionandHIV



Explainthefollowingpoints:

WhenthecycleofHIVandmalnutritionrepeatsitselfmanytimes overseveralyears,the bodys
naturaldefencesystemisseverelyreducedandtheHIVisabletomultiplyrapidly,thusincreasing
theviralloadandthechancesofotherinfections.
At this stage, ART is recommended to slow down or stop multiplication of HIV. ART work better
when given in combinations of three drugs. ART helps improve the bodys defence system, and
enhancesthepatientssurvivalandqualityoflife.
Asacounsellor,itisimportanttobefamiliarwiththelocal/regionalproceduresforaccessingART
inordertoadvisepeoplelivingwithHIVtoconsiderARTwhentheirbodystartsgettingweaker.

Whydoyouthink Whydoyouthink Whydoyouthink Whydoyouthinkgoodnutritionisimportantfor goodnutritionisimportantfor goodnutritionisimportantfor goodnutritionisimportantforpeopleona peopleona peopleona peopleonantiretroviral ntiretroviral ntiretroviral ntiretroviralt tt treatment reatment reatment reatment? ? ? ?
Give participants a few minutes to respond, and then ask one of them to read the following
points.
Explainthewordshighlightedinboldface.

Weakened Immune System
Poor ability to fight HIV
and other Infections

Increased Vulnerability to
Infections
e.g. enteric infections, flu, TB, etc.


Increased Nutritional Needs
Inability to meet increased nutritional
needs for fighting infection and viral
reproduction due to:
Loss of appetite;
Inadequate food intake; and
Poor absorption of nutrients.

Poor Nutrition
Weight loss;
Muscle wasting;
Weakness; and
Micronutrient deficiency.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Poornutritionreducestheabilityto a aa absorb bsorb bsorb bsorbmedicationandthepersonmayfindithardertocope


withtheside-effects.
GoodnutritionwillimprovetheeffectofARThelpingthepersonrecovertheirdefencesystem defencesystem defencesystem defencesystemand
improvingtheoverallwell-being.
ART can also interact with food interact with food interact with food interact with food and nutrients resulting in good or bad effects. Some drugs only
workproperlywhentakenataspecifictimeinrelationtoameal.

Explainthefollowingpoints:
Starting ART is a life-long commitment to medication. Enduring the initial period of unpleasant
side-effects requires regular food supply, good nutrition plan and continuous support to ensure
healthyeating.
In this session, we will discuss basic information on interactions of ARV drugs interactions of ARV drugs interactions of ARV drugs interactions of ARV drugs with food and
nutritionandwhatactionswecantaketosupporthealthyeatingandadherencetomedication.

2. Interactions between drugs, food and nutrition (15 minutes)

Have you observed any Have you observed any Have you observed any Have you observed any interactions between drugs, food and nutrition among interactions between drugs, food and nutrition among interactions between drugs, food and nutrition among interactions between drugs, food and nutrition among the the the the people people people people with with with with
whom whom whom whomyouworkorlive youworkorlive youworkorlive youworkorlive? ?? ?
Take responses from a few participants and show O OO Overhead 7/1: verhead 7/1: verhead 7/1: verhead 7/1: Interaction between drugs, Interaction between drugs, Interaction between drugs, Interaction between drugs,
food and nutrition food and nutrition food and nutrition food and nutrition (a complete version of which is found at the end of this session). Show one
figureatatimeandexplainthemessageswrittenbeloweachfigure.

OVERHEAD OVERHEAD OVERHEAD OVERHEAD7 77 7/1:Interactionbetweendr /1:Interactionbetweendr /1:Interactionbetweendr /1:Interactionbetweendrugs,foodandnutrition ugs,foodandnutrition ugs,foodandnutrition ugs,foodandnutrition

a) a) a) a)W WW WhentakenwithARVdrugs hentakenwithARVdrugs hentakenwithARVdrugs hentakenwithARVdrugs,certainfoods ,certainfoods ,certainfoods ,certainfoodsmayincreaseorreduceuseofthedrugbythebody mayincreaseorreduceuseofthedrugbythebody mayincreaseorreduceuseofthedrugbythebody mayincreaseorreduceuseofthedrugbythebody. .. .

FOOD

AFFECTS

DRUGABSORPTIONANDUSEINTHEBODY
Example:FattyfoodsandfattymealsmayreduceabsorptionofARVdrugssuchasefavirenz efavirenz efavirenz efavirenz
(orotherbrandsusedlocally).

b) b) b) b)CertainARVdrugsaffectthewaynutrientsareusedinthebody. CertainARVdrugsaffectthewaynutrientsareusedinthebody. CertainARVdrugsaffectthewaynutrientsareusedinthebody. CertainARVdrugsaffectthewaynutrientsareusedinthebody.

DRUGS

AFFECT

NUTRITIONABSORPTIONANDUSEINTHEBODY
Example: ARV drugs such as, d4T d4T d4T d4T(or other brands used locally) may change the way the body
usesfatandcarbohydrates.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
112

c) c) c) c)Side Side Side Side- -- -effectssuchaschangesintaste,headache,fever,diarrhoeaandvomitingreducefoodintake effectssuchaschangesintaste,headache,fever,diarrhoeaandvomitingreducefoodintake effectssuchaschangesintaste,headache,fever,diarrhoeaandvomitingreducefoodintake effectssuchaschangesintaste,headache,fever,diarrhoeaandvomitingreducefoodintake


andabsorption. andabsorption. andabsorption. andabsorption.

DRUG
SIDE-
EFFECTS

AFFECT

FOODINTAKEANDABSORPTION
Examples: Some medications, e.g. 3TC 3TC 3TC 3TC and d4T d4T d4T d4T (or other brands used locally) may lead to
changeintaste;AZTmayalsocausenauseaandvomiting,resultinginreducedfoodintakeand
weightloss.

d)T d)T d)T d)Theinteraction heinteraction heinteraction heinteraction ofcertainARV ofcertainARV ofcertainARV ofcertainARVdrugs drugs drugs drugswithcertainfoodsmaycreateunhealthysideeffects. withcertainfoodsmaycreateunhealthysideeffects. withcertainfoodsmaycreateunhealthysideeffects. withcertainfoodsmaycreateunhealthysideeffects.

MEDICATION + ++ +
CERTAINFOOS

CREATES

UNHEALTHYSIDE-EFFECTS
Examples: Intake of drinks containing alcohol together with ARV drugs may cause liver and
pancreasproblems.Alcoholisalsooftencauseofpooradherencetotreatmentandmayreduce
theappetiteofthepersonlivingwithHIV.
IntakeofsomeherbalremediestogetherwithARVdrugsmayincreasesevere-sideeffects.
CounsellorsneedtomakepeopletakingARVdrugsawareoftheinteractionsofsuchfoodswith
thedrugstheyaretakingsothatthesefoodscanbeavoidedorreduced.

Showthefirstkeypointdisplayed,andaskaparticipanttoreaditoutloud.

KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Understandingmedicat Understandingmedicat Understandingmedicat Understandingmedicationside ionside ionside ionside- -- -effectshelpscarefulselectionoffoodsforpreparing effectshelpscarefulselectionoffoodsforpreparing effectshelpscarefulselectionoffoodsforpreparing effectshelpscarefulselectionoffoodsforpreparing
nutritiousmealsandagoodnutritionplan. nutritiousmealsandagoodnutritionplan. nutritiousmealsandagoodnutritionplan. nutritiousmealsandagoodnutritionplan.


3. Nutrition practices for managing the side-effects of ARV drugs
(15 minutes)

Introducethissectionbyexplainingthefollowing:
While majority of people who take ARV drugs experience some side-effects, the frequency and
severity of side-effects varies for different ARV drugs and different individuals. A combination of
threedifferentARVdrugsisusuallygiventopatientsandtheinteractionsofeachdrugwithfood
mustbeconsidered.
Gooddietandregularfoodintakehelpstoimproveadherencetotreatmentwhichiscriticalfor
Thewell-beingofpeoplelivingwithHIV
Treatmenteffectiveness




Nutritional Care and Support for People Living with HIV: Facilitators Guide
113
Preventingdrug-resistance
ThegoalsofnutritioncounsellingforpeopleonARTareto:
Reduce minor side-effects that can result in reduced food intake, e.g., changes in taste,
headache,fever,nauseaandvomiting,upsetstomachanddiarrhoea.
Reduce chronic side-effects such as,increased blood sugar, high fat levelsin the blood and
liverorkidneydamage.
Improvethegeneralwell-beingofpeoplelivingwithHIVwhoareonART.
FailuretomanagetheinteractionsbetweenvariousfoodsandARVdrugs,mayresultinreduced
food intake. The patient may also interrupt or stop taking the medication. Interrupting ART or
takingitincorrectlymayleadto:
Poorhealth,frequentinfectionsandfasterprogressionofthedisease;and
Drug-resistantHIVleadingtofailureoftreatment.

Suggestions for nutrition practices should be based on a clear understanding of the specific
requirementsofthedrugsthatapersonistaking.

Wh Wh Wh Which ich ich ichnutritionpracti nutritionpracti nutritionpracti nutritionpractic cc cesdoyouknowthatmay esdoyouknowthatmay esdoyouknowthatmay esdoyouknowthatmayreduce reduce reduce reducetheside theside theside theside- -- -effectsofAR effectsofAR effectsofAR effectsofARVdrugs Vdrugs Vdrugs Vdrugs? ?? ?
Allow a few participants to respond, then show and discuss O OO Overhead verhead verhead verhead 7/2: 7/2: 7/2: 7/2: Supporting Supporting Supporting Supporting
managementofARV managementofARV managementofARV managementofARV andfoodandnutritioninteractions andfoodandnutritioninteractions andfoodandnutritioninteractions andfoodandnutritioninteractions . .. .





Nutritional Care and Support for People Living with HIV: Facilitators Guide
114
OVERHEAD OVERHEAD OVERHEAD OVERHEAD7/2:SupportingthemanagementofARVdrugsandfood/nutritioninteractions 7/2:SupportingthemanagementofARVdrugsandfood/nutritioninteractions 7/2:SupportingthemanagementofARVdrugsandfood/nutritioninteractions 7/2:SupportingthemanagementofARVdrugsandfood/nutritioninteractions

Know and understand what medication the client is taking (see Handout 7/1 Handout 7/1 Handout 7/1 Handout 7/1) and make the
clientandothertreatmentsupportersorfamilymembersawareoftheirpotentialside-effects.
Discusshowtoadjustthetimingofdrugandfoodintakeasappropriate.
Discusshowtomanagethepossibleside-effectsanddifficultiesthatmayreducefoodintake.
Identify foods to be increased, decreased or avoided, depending on their effects on drug
absorption.
Supporttheclienttoidentifylocallyavailablefoodsthatwouldhelpinhealthyeatingbasedon:
TheEatingwiselyguidelines;
Drug-foodinteractions;and
Thenutritionalneedsoftheperson.
Support the client to make a drug-meal plan that will guide him/her in choosing appropriate
foodsfordifferentmeals(Exercise7/1 Exercise7/1 Exercise7/1 Exercise7/1).
Followupandassessanydifficultiesandsupportinmakingnecessaryadjustments.
Seekhelpthroughthereferralsystemto otherprogramsandservicesthataddressfoodand
nutrition issues, (e.g., nutritional counselling services, programs focused on promoting
householdaccesstofood)asneeded.

Refer participants to Handout 7/1: Recommended nutrition practices for dealing with the side Handout 7/1: Recommended nutrition practices for dealing with the side Handout 7/1: Recommended nutrition practices for dealing with the side Handout 7/1: Recommended nutrition practices for dealing with the side- -- -
effectsofARVdrugs effectsofARVdrugs effectsofARVdrugs effectsofARVdrugsonpages80-81oftheParticipant'sManual.
Inform participants about the combinations of ARV drugs commonly used in the local area and
askthemtohighlighttheinformationonthoseparticulardrugs.
Explainthefollowing:
Theseareexamplesofdifferentdrugs,their-sideeffectsandtherecommendednutritionpractices
toreducetheseside-effects.
Thisisjustalistofsuggestions,whichshouldbekeptup-to-date.
Thehandoutcouldbeusedasaguideforhelpingclientswhoareexperiencingside-effectsfrom
their medication. However, you should always urge clients to consult with their doctor
immediately.

4. Making a drug-food plan (20 minutes)

AskoneoftheparticipantstovolunteerandreadthestoryofSamandSuzi





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI
Sam is feeling weak and his health has generally deteriorated. His doctor recommends
severaltestandsomedrugs.
Based on the test results, the doctor needs to start Sam on ART. Sam is prepared and
enrolledforART.
Histreatmentconsistsofacombinationofthreedrugs:d4T+3TC+EFV.

Explaintheexamplebelowofadrug-foodplanthatthecounsellorcouldusetostartdiscussions
withSam.
4.1. Identifying the medication being taken (10 minutes)
Medication Medication Medication Medicationbeingtaken beingtaken beingtaken beingtaken
Morning d4T+3TC d4T+3TC d4T+3TC d4T+3TC
Night d4T+3TC+EFV d4T+3TC+EFV d4T+3TC+EFV d4T+3TC+EFV

AsktheparticipantstolookattheH HH Handout7/1 andout7/1 andout7/1 andout7/1againtoidentifytheseparticularARVdrugs.



What instructions would you give Sam regarding What instructions would you give Sam regarding What instructions would you give Sam regarding What instructions would you give Sam regarding the interaction of the interaction of the interaction of the interaction of his ARV drugs his ARV drugs his ARV drugs his ARV drugs with his with his with his with his food food food food/ // /
nutrition? nutrition? nutrition? nutrition?
Giveparticipantsafewminutestodiscusstheinformationonthedrugcombinationd4T,3TCand
EFV,aspresentedinthehandoutanddiscussthefollowingpoints:
Informtheclientthat:
The absorption of some ARV drugs is not affected by the foods consumed, but taking them with
foodcanhelpreducetheirside-effects.
AvoidingfattyfoodscanimproveabsorptionanduseofARVdrugs.
Avoidingalcoholicdrinkswillreduceside-effects.

Whatside Whatside Whatside Whatside- -- -e ee effects ffects ffects ffectsis is is isSam Sam Sam Samlikelyto likelyto likelyto likelytoexperienceandhowcouldwemanagetheseside experienceandhowcouldwemanagetheseside experienceandhowcouldwemanagetheseside experienceandhowcouldwemanagetheseside- -- -effects? effects? effects? effects?
Give participants a few minutes to discuss the side-effects related to the drugs as presented in
Handout 7/1 Handout 7/1 Handout 7/1 Handout 7/1 (available on pages 80-81 of the Participant's Manual). and refer them to the
suggestionsprovidedinS SS Session5 ession5 ession5 ession5on Improvingfoodintake Improvingfoodintake Improvingfoodintake Improvingfoodintake . .. .
Explainthehowthevariousside-effectscanbemanagedusingthefollowing:
Mouthulcers(soremouth/sorethroat):Handout5/1 Handout5/1 Handout5/1 Handout5/1
Excessivegasinthestomach,stomachdiscomfortdiarrhoea:Handout5/3 Handout5/3 Handout5/3 Handout5/3
Nausea,vomitingandlossofappetite:H HH Handout5/4 andout5/4 andout5/4 andout5/4




Nutritional Care and Support for People Living with HIV: Facilitators Guide
116
Fever: drink plenty of fluids and eat energy and nutrient-rich foods, i.e. adding seeds, such as
groundnutorsesamepastesorpeanutbutteroreggstomaize/millet/cassavaporridge.
High fat levels in blood: closely monitor intake of fatty foods and meals; eat plenty of fruits and
vegetablesdaily;increasephysicalactivityaccordingtothecapacityofthepatient.
4.2. Meal planning (10 minutes)
Askparticipantstogetintogroupsoffiveandgiveeachgrouponeofthedailymealstodiscuss
asfollows:
Group1:Morning
Group2:Mid-morning
Group3:Mid-day
Group4:Evening
Group5:Night
Askgroupstodiscusslocallyavailablefoodsthatcouldbetakenateachmealtime.
AskeachgrouptowritedowntheirsuggestionsintheappropriatesectionsofH HH Handout7/2 andout7/2 andout7/2 andout7/2 (found
onpage82oftheParticipantsManual)andtopresentthemfordiscussion.(Thesecanbelater
typedandprintedasareferenceforcareprovidersinthelocalarea).
Showthesecondkeypointdisplayedandaskaparticipanttoreaditoutloud.

KEYPOINT KEYPOINT KEYPOINT KEYPOINT
ARTworks ARTworks ARTworks ARTworksbetter better better betterinpeoplewho inpeoplewho inpeoplewho inpeoplewhohavegoodnutritionalpractices havegoodnutritionalpractices havegoodnutritionalpractices havegoodnutritionalpractices. .. .

5. Medication and physical activity: Role-play 7 (10 minutes)

The health/nutrition worker talks with Sam about his medication and physical activity. List the
counsellingskillsthesupportworkerisusingaswellasthereactionsofSam.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
117
ROLE-PLAY 7: Discussion with Sam about medication and physical activity
COMMUNICATION COMMUNICATION COMMUNICATION COMMUNICATION
SKILL SKILL SKILL SKILL USED USED USED USED
HEALTHWORKER Welcome,Sam.Pleasesitdown.Howareyou
today?

SAM Well,IamOK.Ihavecometotalktoyoumoreabout
themedicationwhichIhavebeentaking.

HEALTHWORKER Yes,Itisgoodthatyoucametotalkaboutyour
medicine.Howareyoudoingwithyourmedication?
Praise Praise Praise Praise
Open Open Open Open- -- -ended ended ended ended
question question question question
SAM Well,IfeelbettersinceIstartedtakingthem.
However,sometimesIreallyhavedifficultiesafter
takingtheminthemorning.Ivomitandsometimesl
justdonotfeellikeeatingatall.

HEALTHWORKER Yes,themedicationsometimesmaymakeyoufeel
likevomitingandcausedifficultiesineating.
Howdoyoutakeyourmedicationinthemorning?
Empathy Empathy Empathy Empathy
Open Open Open Open- -- -ended ended ended ended
question question question question
SAM ItakemymedicationinthemorningassoonasI
wakeup.Thisway,therearelesschancesof
forgettingtotakemymedicine.

HEALTHWORKER Thatsaverygoodidea.
Whatdoyoutakeyourmedicationwith?
Praising Praising Praising Praising
Open Open Open Open- -- -ended ended ended ended
question question question question
SAM Iswallowmymedicinewithlotsofwater.
HEALTHWORKER Doyouthinkthatyoucouldtryeatingordrinking
somethingelsewithyourmedication?
Maybetakingthemedicationonanemptystomach
mightbethereasonforyoufeelinglikevomiting
Checking Checking Checking Checking
understanding understanding understanding understanding
Information Information Information Information
SAM
Itisverydifficultformetoeatanythingearlyinthe
morning.
Ihaveevenstoppedgoingformymorningwalks
becauseIalwaysstartfeelinglikevomitingonmy
wayback.

HEALTHWORKER Awalkinthefreshairisveryuseful.Howabout
startingwiththewalkinthemorningandtryingtotake
yourmedicationwithsomefoodwhenyougetback?
Suggestion Suggestion Suggestion Suggestion
SAM Icouldtrythat.Suzialwaysmakessomethick
porridgetowhichsheaddslemonandsugarwhichI
likeverymuch.

HEALTHWORKER Yes,porridgeisgoodandwillgiveyourbody
strength,addinglemonwillpreventyoufromfeeling
likevomiting.Iamgladthatyoulikeit.
Information Information Information Information
Suggestion Suggestion Suggestion Suggestion




Nutritional Care and Support for People Living with HIV: Facilitators Guide
118
COMMUNICATION COMMUNICATION COMMUNICATION COMMUNICATION
SKILL SKILL SKILL SKILL USED USED USED USED
SAM Thefeelingofvomitingalwayscomesbeforemeal
timesandevenwhenIamhungry,Idonotfeellike
eating.

HEALTHWORKER Well,trynottokeepyourstomachempty.Youdonot
havetowaitonlyformealtimesbeforeyoueat.
Maybeyoucouldalsotrytakingsomethingevery23
hours,evenifitisonlyaglassofmilkapieceoffruit,
vegetables,yoghurtortoastedbreadandpeanut
butter.

Suggestion Suggestion Suggestion Suggestion
SAM Yes,probablyIcouldtrythat.Thereisalwayssome
milk,bananasandorangesinthehouse.

HEALTHWORKER Thatwouldbegreat.Canyoutrythatfortwoweeks?
Andthenyoucancomebackandwecantalkabout
howitwent.
Checking Checking Checking Checking
Follow Follow Follow Follow- -- -up up up up
SAM Thankyou.IwillseehowIgetonwiththeplan.
Good-bye

HEALTHWORKER Good-bye

Takingoneissueatatimeaskparticipantsthefollowing:
HowhelpfulwasthehealthworkersdiscussionwithSam? HowhelpfulwasthehealthworkersdiscussionwithSam? HowhelpfulwasthehealthworkersdiscussionwithSam? HowhelpfulwasthehealthworkersdiscussionwithSam?
Describewhatwashelpfultohim. Describewhatwashelpfultohim. Describewhatwashelpfultohim. Describewhatwashelpfultohim.
Evaluatehowwellthehealth Evaluatehowwellthehealth Evaluatehowwellthehealth EvaluatehowwellthehealthworkerusedcommunicationskillsincounsellingSam. workerusedcommunicationskillsincounsellingSam. workerusedcommunicationskillsincounsellingSam. workerusedcommunicationskillsincounsellingSam.

6. Summary of the session and transition (5 minutes)

Show/reviewbothkeypointsdisplayed.
KEYPOINTS KEYPOINTS KEYPOINTS KEYPOINTS
Understandingmedicationside Understandingmedicationside Understandingmedicationside Understandingmedicationside- -- -effectshelpscarefulselectionoffoodsforpreparing effectshelpscarefulselectionoffoodsforpreparing effectshelpscarefulselectionoffoodsforpreparing effectshelpscarefulselectionoffoodsforpreparing
nutriti nutriti nutriti nutritiousmealsandagoodnutritionplan. ousmealsandagoodnutritionplan. ousmealsandagoodnutritionplan. ousmealsandagoodnutritionplan.

ARTworks ARTworks ARTworks ARTworksbetter better better betterinpeoplewho inpeoplewho inpeoplewho inpeoplewhohavegoodnutritionalpractices havegoodnutritionalpractices havegoodnutritionalpractices havegoodnutritionalpractices. .. .

Reviewalltheotherkeypointsdisplayed.
ARTworksbetterinpeoplewhohavegoodnutritionalpractices.BeforeorduringinitiationofART
people with HIV need to be supported to eat wisely. Good nutrition will strengthen their bodys
abilitytoabsorbmedicationandreduceside-effects.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
119
AppropriatedietarychangescanhelptomanageandreducetheimpactofcertainARVdrugside-
effectsonnutrition.
It is important to use drug-specific information when managing the interactions between ARV
drugs,foodandnutrition.
Failuretomanagedrug-food/nutritioninteractionsmayleadtothepersoninterruptingorstopping
taking medication. This can result in poor health and drug-resistant HIV which cannot be
effectivelytreated.
ARTcanimprovethehealthofPLHIV;butitcanalsocreateadditionalfoodandnutritionalneeds.
Always discuss and follow up with clients to assess any difficulties and to provide support in
makingnecessaryadjustments.

Askparticipantsifthereareanyquestionsorifanythingneedsclarifying.
Inthenextsession,wewilldiscussnutritionforpregnantandbreastfeedingwomenwithHIV.
Thenextsessionwillbepresentedby:
Statethenameofthepresenter.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
120


OVERHEAD7/1:Interactionbetweendrugs,foodandnutrition OVERHEAD7/1:Interactionbetweendrugs,foodandnutrition OVERHEAD7/1:Interactionbetweendrugs,foodandnutrition OVERHEAD7/1:Interactionbetweendrugs,foodandnutrition

FOOD

AFFECTS

DRUGABSORPTIONANDUSEINTHEBODY

DRUGS

AFFECT

NUTRITIONABSORPTIONANDUSEINTHEBODY

DRUG
SIDE-
EFFECTS

AFFECT

FOODINTAKEANDABSORPTION

MEDICATION + ++ +
CERTAINFOOS

CREATES

UNHEALTHYSIDE-EFFECTS









Nutritional Care and Support for People Living with HIV: Facilitators Guide
121
HANDOUT7/1:Nutritionpracticesforreducingside HANDOUT7/1:Nutritionpracticesforreducingside HANDOUT7/1:Nutritionpracticesforreducingside HANDOUT7/1:Nutritionpracticesforreducingside- -- -effectsofARVdrugs effectsofARVdrugs effectsofARVdrugs effectsofARVdrugs
MEDICATION MEDICATION MEDICATION MEDICATION POTENTIALSIDE POTENTIALSIDE POTENTIALSIDE POTENTIALSIDE- -- -EFFECTS EFFECTS EFFECTS EFFECTS

RECOMMENDEDNUTRITION RECOMMENDEDNUTRITION RECOMMENDEDNUTRITION RECOMMENDEDNUTRITION
PRACTICES PRACTICES PRACTICES PRACTICES
Zidovudine Zidovudine Zidovudine Zidovudine
(AZT) (AZT) (AZT) (AZT)
Fatigue,anaemia,gastrointestinal
intolerance(nausea,vomiting,abdominal
pain,dyspepsia,diarrhoea,flatulence,
constipation),tastedisturbance,headache,
fever,anorexia,somnolence,insomnia;
Takewithfoodtoreduceside
effects.
Lamivudine Lamivudine Lamivudine Lamivudine
(3TC) (3TC) (3TC) (3TC)

.nausea,vomiting,diarrhoea,abdominal
pain,headache,fatigue,insomnia,malaise,
fever,rash,anaemia.
Takewithoutregardtomeals.
Combivi Combivi Combivi Combivi
(3TC/AZT) (3TC/AZT) (3TC/AZT) (3TC/AZT)
SimilartoAZTand3TC. Takewithoutregardtomeals.
Didanosine Didanosine Didanosine Didanosine
ddl ddl ddl ddl

Nausea,;diarrhoea,nausea,vomiting,dry
mouth,headache,hypoglycaemia,liver
failure,insomnia,dizziness,maycause
problemswiththepancreas.

Takeonanemptystomach1
hourbeforeor2hoursaftera
meal.
Donottakewithjuice,antacids
orsupplementsthatcontain
aluminiumormagnesium.
Abacavir Abacavir Abacavir Abacavir
ABC ABC ABC ABC
Hypersensitivity,fever,rash,headache,
Lossofappetite,nausea,vomiting,
diarrhoea,anorexia,fatigue,malaise,sore
throat,cough,shortnessofbreath.Alcohol
increaseslevels.
Rashandgastrointestinaldisturbances
morecommoninchildren.
Takewithoutregardtomeals.
(ABC,3TC, (ABC,3TC, (ABC,3TC, (ABC,3TC, AZT) AZT) AZT) AZT) Seeindividualprofiles. Takewithfoodtoreduceside
effects.
Stavudi Stavudi Stavudi Stavudine ne ne ne
D DD D4T 4T 4T 4T
Nausea,vomiting,diarrhoea,constipation,
anorexia,abdominaldiscomfort,chestpain,
dyspnoea,headache,dizziness,insomnia,
moodchanges,abnormaldreams,
cognitivedysfunction,drowsiness,
depression,anxiety,rash.Maycause
problemswithfatstorageinthebody.
Takewithoutregardtomeals.
Avoidalcohol.
Nevirapine Nevirapine Nevirapine Nevirapine
NVP NVP NVP NVP
Rash,nausea,hepatitis,headache.Less
commonly,vomiting,abdominalpain,
fatigue,fever.Rarelydiarrhoea.
Takewithoutregardtomeals.
Efavirenz Efavirenz Efavirenz Efavirenz
EFV EFV EFV EFV
Rash,abdominalpain,diarrhoea,nausea,
vomiting,anxiety,depression,dizziness,
headache,insomnia,somnolence,
abnormaldreams,fatigue,impaired
concentration.
Takeonanemptystomach.
Indinavir Indinavir Indinavir Indinavir
IDV IDV IDV IDV
Tastechange(metallictaste),
gastrointestinalintolerance(nausea,
diarrhoea,abdominalpain,vomiting,
dyspepsia,flatulence),headache,blurred
vision,dizziness,rash,hyperglycaemia,
maycauseproblemswithfatstorageinthe
body.
Takeonanemptystomach
1hourbeforeor2hoursaftera
meal.
Maytakewithskimmilkorlow-
fat,lightmeal.
Ifgivenwithdidanosineallow2
hourbetweenthedrugs.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
122
MEDICATION MEDICATION MEDICATION MEDICATION POTENTIALSIDE POTENTIALSIDE POTENTIALSIDE POTENTIALSIDE- -- -EFFECTS EFFECTS EFFECTS EFFECTS

RECOMMENDEDNUTRITION RECOMMENDEDNUTRITION RECOMMENDEDNUTRITION RECOMMENDEDNUTRITION
PRACTICES PRACTICES PRACTICES PRACTICES
Ritonavir Ritonavir Ritonavir Ritonavir
RTV RTV RTV RTV
Tastechanges,gastrointestinalintolerance
(nausea,vomiting,diarrhoea,abdominal
pain,dyspepsia,anorexia),throatirritation,
headache,drowsiness,dizziness,sleep
disturbances,fatigue,rash,drymouthand
ulceration,anxiety,fever,weightloss,
sweating,anaemia,hyperlipidemia,
hyperglycaemia,fatmaldistribution.
Takewithfoodtodecreaseside
effects.
Indinavir Indinavir Indinavir Indinavir
Ritonavir Ritonavir Ritonavir Ritonavir
Seeindividualprofiles. Foodhaslittleeffect.Takewith
foodtoreducesideeffects.
Saquinavir Saquinavir Saquinavir Saquinavir
SQV SQV SQV SQV
Gastrointestinalintolerance(nausea,
vomiting,diarrhoea,abdominalpain,buccal
andmucosalulceration),taste
disturbances,headache,chestpain,
dizziness,insomnia,moodchanges,
fatigue,fever,rash.
Maycauseproblemswithfatstorageinthe
body,hyperglycaemia.
.
Takewithin2hoursofameal
whentakenwithRTV.
Administerwithorafterfood.
Avoidgarlic.
Nelfinavir Nelfinavir Nelfinavir Nelfinavir
NFV NFV NFV NFV
Diarrhoea,;nausea,vomiting,flatulence,
abdominalpain,rash,fever,pruritus,
hyperglycaemia,hyperlipidemia,fat
maldistribution.
Takewithorafterfood.
Powdermaybemixedwith
water,milk,pudding.
Itshouldnotbemixedwith
acidicfoodsorjuicesbecause
ofitstaste.

l ll lopinavir opinavir opinavir opinavir/ // /


R RR Ritonavir itonavir itonavir itonavir
Gastrointestinalintolerance(nausea,
vomitingdiarrhoea,),anorexia,anaemia,
sleepdisturbances,fatigue,headache,
dizziness,tastedisturbances,rash,
hyperlipidemia,hyperglycaemia,fat
maldistribution.
Takewithfood.
Tenofovir Tenofovir Tenofovir Tenofovir
TDF TDF TDF TDF
Headache,diarrhoea,nausea,vomiting,
abdominalpain,flatulence,anorexia,
dizziness,headache,insomnia,
depression,sweating,rash,renal
insufficiency.
Takewithoutregardtomeals.
Tabletscanbedissolvedinat
least100mlwater,orangejuice
orgrapejuiceforpatientswith
difficultyswallowing.
Thislistshouldbekeptup-to-date.
ItisalsogenerallyrecommendedthatwhentakingARVdrugs,oneshouldavoidintakeof:
-Drinkscontainingalcoholwhichmaycauseliverandpancreasproblems;
-FattyfoodsandfoodshighinsugarwhichmayreduceabsorptionofmostARVdrugs
Drinkingplentyofsafewater,about8glassesaday,isalsorecommendedtoreduceside-effects
ofthemedication.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
123

HANDOUT HANDOUT HANDOUT HANDOUT7/2: 7/2: 7/2: 7/2:N NN Nutritionpractic utritionpractic utritionpractic utritionpracticesfor esfor esfor esforreducingthe reducingthe reducingthe reducingtheside side side side- -- -effectsofA effectsofA effectsofA effectsofARV RV RV RVdrugs drugs drugs drugs (Worksheet) (Worksheet) (Worksheet) (Worksheet)
MEAL MEAL MEAL MEAL ART ART ART ART LISTOFFOODSTOBETAKEN LISTOFFOODSTOBETAKEN LISTOFFOODSTOBETAKEN LISTOFFOODSTOBETAKEN
Morning Morning Morning Morning





Mid Mid Mid Mid- -- -morning morning morning morning




Mid Mid Mid Mid- -- -day day day day







Mid Mid Mid Mid- -- -afternoon afternoon afternoon afternoon/ // /
Evening Evening Evening Evening




Night Night Night Night







Nutritional Care and Support for People Living with HIV: Facilitators Guide
124
Session 8: Nutrition for pregnant and breastfeeding women Session 8: Nutrition for pregnant and breastfeeding women Session 8: Nutrition for pregnant and breastfeeding women Session 8: Nutrition for pregnant and breastfeeding women
withHIV withHIV withHIV withHIV

Learning Learning Learning Learningo oo objectives bjectives bjectives bjectives


Bytheendofthissession,participantswillbeableto:

DiscussthenutritionalconcernsofpregnantorbreastfeedingwomenlivingwithHIV;and
DiscussgoodnutritionpracticesforpregnantandbreastfeedingwomenlivingwithHIV.


Session Session Session Sessiono oo outline utline utline utline
Content Content Content Content Time Time Time Time
1 Learningobjectivesandintroductiontothesession 5minutes
2 NutritionalconcernsofpregnantandbreastfeedingwomenwithHIV 15minutes
3 AnEatingwiselyduringpregnancydemonstrationtalk 15minutes
4 Maternalnutritionduringbreastfeeding 5minutes
5 Foodbeliefsandpractices 15minutes
6 Summaryofthesessionandtransition 5minutes
Total Total Total Total 60 60 60 60minutes minutes minutes minutes


Preparation for the session

Writeanddisplaythelearningobjectivesonaflipchartsheet.
Writethekeypointsonasheetofflipchartpaperandkeepitasideuntilneeded.

KEYPOINTS KEYPOINTS KEYPOINTS KEYPOINTS
Eatingwiselyduringpregnancyhelpsthemotherandthebabytostayhealthy. Eatingwiselyduringpregnancyhelpsthemotherandthebabytostayhealthy. Eatingwiselyduringpregnancyhelpsthemotherandthebabytostayhealthy. Eatingwiselyduringpregnancyhelpsthemotherandthebabytostayhealthy.

Eatingwiselyduringbreastfeedinghelpsthemotherandthebabytostayhealthy. Eatingwiselyduringbreastfeedinghelpsthemotherandthebabytostayhealthy. Eatingwiselyduringbreastfeedinghelpsthemotherandthebabytostayhealthy. Eatingwiselyduringbreastfeedinghelpsthemotherandthebabytostayhealthy.

Findoutifdifferentnutritionrecommendationsaregivenforpregnant andbreastfeeding women


whoareHIV-positiveandthosewhoarenot.
Findoutiftherearefoodproductsfortifiedwithironthatareavailable(andaffordable)locally.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
125
Check what the routine policy is regarding vitamin and micronutrient supplementation during
pregnancyandlactation,includingthemanagementofanaemia.Prepareahandoutsummarising
thisinformationifneeded.
Gatherexamplesofanylocaleducationalmaterialsformothersonnutritionduringpregnancy.
Ask two participants to assist with the demonstration talk by asking prepared questions. The
questions are at the end of the text of the talk. Give each of the participants assisting you a
questionwrittenonapieceofpaperandexplainwhentheyaretoaskthesequestions.

Collect/preparethefollowingtrainingmaterials:
Anoverheadprojectorandscreen;and/oraflipchartstand,flipchartpaper,markersandameans
to attach flipchart sheets to the wall or other surface. If an overhead projector is not available,
enlargedcopiesoftheoverheadsmaybepreparedfordisplayasposters.
O OO Overhead3/3:Varietyoffoods verhead3/3:Varietyoffoods verhead3/3:Varietyoffoods verhead3/3:Varietyoffoods
Handout Handout Handout Handout8/1 8/1 8/1 8/1: : : :Increasing Increasing Increasing Increasingironabsorption ironabsorption ironabsorption ironabsorption (availableattheendofthissession;oruse
overhead/pictureposterofalocalillustration).
Overhead8/ Overhead8/ Overhead8/ Overhead8/1 11 1: :: : Increasingironabsorption Increasingironabsorption Increasingironabsorption Increasingironabsorption
Worksheet8/1:Foodbeliefsandpractices Worksheet8/1:Foodbeliefsandpractices Worksheet8/1:Foodbeliefsandpractices Worksheet8/1:Foodbeliefsandpractices

1. Learning objectives and introduction to the session (5 minutes)
Review the learning objectives of the session

Showandoutlinethelearningobjectivesdisplayed.
Bytheendofthissessionparticipantsshouldbeableto:
DiscussthenutritionalconcernsofpregnantandbreastfeedingwomenlivingwithHIV;and
DiscussgoodnutritionpracticesforpregnantandbreastfeedingwomenlivingwithHIV.
Introduce the session

Food is important for all of us. Pregnant and breastfeeding women have extra nutritional
requirements due to the changes in their bodies and the needs of the growing baby. This is the
sameforallpregnantwomen,whethertheyareHIV-infected ornot.Pregnantandbreastfeeding
womenwithHIVareatahigherriskofinfection,malnutritionandprematurebirthandwillrequire
extraenergyandothernutrients.
In this session, we will discuss how to provide support to pregnant and breastfeeding mothers
withHIVtoincreasetheirfoodintakeandtomeetenergyandothernutrientneeds.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
126

2. Nutritional concerns of pregnant and breastfeeding women with HIV (15
minutes)

Why Why Why Why do pregnant and breastfeeding HIV do pregnant and breastfeeding HIV do pregnant and breastfeeding HIV do pregnant and breastfeeding HIV- -- -positive positive positive positive women have greater nutri women have greater nutri women have greater nutri women have greater nutritional needs than tional needs than tional needs than tional needs than
thosewhoareHIV thosewhoareHIV thosewhoareHIV thosewhoareHIV- -- -negative negative negative negative? ?? ?

Allow participants to discuss responses and write down the key points raised on a sheet of
flipchartpaper;discusstheseandexplainthefollowing:

PregnantandbreastfeedingwomenwithHIVwillneed:
Extrafoodforbodyfunctions;
Extrafoodforchangesintheirbodyandtheneedsofthegrowingbaby;
ExtrafoodtoreplacenutrientslostduetoHIVinfection;and
Extrafoodforgrowthanddevelopmentifthemotherisadolescent(12-16years).

Motherswhoeatwiselyduringpregnancyandbreastfeedingarelikelyto:
Bemorehealthyandnotbeillsooften;
Gainenoughweightduringpregnancyandbreastfeeding;
ReducechancesofHIVtransmissiontotheirbabies;
Havebabieswithgoodweightandgoodhealth;and
Feedandcarefortheirbabiesproperly.

3. An eating wisely during pregnancy demonstration talk (15 minutes)


3.1. Introduce the demonstration talk

Information on appropriate nutrition during pregnancy is presented in this section as a part of a


talkonEatingwiselyduringpregnancy.
UsethestoryofSamandSuzitoexplainthecontextoftheEatingwiselyduringpregnancytalk.

THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI



SuziandSamattendtheantenatalclinicduringthepregnancy.
During one of their visits there is a talk about eating wisely during pregnancy. Sam comes to
hearthetalkwithSuzi.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
127
Encouragemotherstoincludefriendsorfamilymembersinthediscussions,sothattheytoocan
understandthemothersneedforadequatefoodandrestbothbeforeandafterthebabyisborn.

Explainthatthistalkcanbedeliveredtoabroaderaudienceaspartofalonger,moregeneraltalk
onhowtoeatwisely.
Checkthatparticipantsunderstandthattheyshouldberole-playingaspeopleattending thetalk
atanantenatalclinic.
Ifthesessionissharedbetweenfacilitators,introducethepersonwhowillgivethetalk.
Presentthetalk.
3.2. Eating wisely during pregnancy
Welcome/greetthegroup.
Today,wewilltalkabouteatingwiselyduringpregnancy.
Statethekeypointofthetalk(thefirstkeypointofthesession).

KEYPOINT KEYPOINT KEYPOINT KEYPOINT


Allpregnantwomenneedtoeatwiselyfortheirhealthandthehealthofthebaby. Allpregnantwomenneedtoeatwiselyfortheirhealthandthehealthofthebaby. Allpregnantwomenneedtoeatwiselyfortheirhealthandthehealthofthebaby. Allpregnantwomenneedtoeatwiselyfortheirhealthandthehealthofthebaby.

Foodisimportantforallofus.Apregnantwomanhasextranutritionalneedsduetothechanges
inherbodyandtheneedsofthegrowingbaby.Thisisthesameforallpregnantwomen,whether
theyareHIV-infectedornot.
Wheneatingwisely,youaimtoeatavarietyoffoodstoensurethatyougetallthenutrientsyou
require.
Animal foods are particularly valuable to eat during pregnancy. They are a good source of iron.
Theironfromanimalfoodsiswellabsorbedbythebody.Ironreducesanaemia,whichiscommon
in women during pregnancy. People who are anaemic get tired easily and are more likely to get
infections.Itistherefore,importanttoincreasedailyintakeofanimalfoods.
Beans, peas, lentils, and dark-green leafy vegetables contain iron but this iron may not be well
absorbed by the body. However, iron absorption can be increased by eating these foods with
vegetablesandfruitsrichinvitaminCsuchas,tomatoesorlemons.
ShowO OO Overhead3/3 verhead3/3 verhead3/3 verhead3/3:V :V :V :Varietyoffoods arietyoffoods arietyoffoods arietyoffoods fromSession3. Session3. Session3. Session3.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
128
OVERHEAD3/3:Varietyoffoods OVERHEAD3/3:Varietyoffoods OVERHEAD3/3:Varietyoffoods OVERHEAD3/3:Varietyoffoods

Show O OO Overhead 8/ verhead 8/ verhead 8/ verhead 8/1 11 1: :: : Increasing iron absorption Increasing iron absorption Increasing iron absorption Increasing iron absorption and distribute H HH Handout 8/ andout 8/ andout 8/ andout 8/1: 1: 1: 1: Increasing Increasing Increasing Increasing iron iron iron iron
absorption absorption absorption absorption (found at the end of this session and on page 89 of the Participant's Manual) or
displayitifyouareusingthehandoutasaposter.

OVERHEAD8/1:Increasingironabsorption OVERHEAD8/1:Increasingironabsorption OVERHEAD8/1:Increasingironabsorption OVERHEAD8/1:Increasingironabsorption

Foodsmayalsohaveironaddedtothem(findoutlocallyavailableandaffordablefoodsthatare
fortifiedwithiron).Increasetheuseofthesefoodsduringpregnancy.
Eating vitamin C-
rich vegetables and
fruits with a meal
helps the body to
use iron




Nutritional Care and Support for People Living with HIV: Facilitators Guide
129
Your doctor or midwife will talk to you if you need vitamin and mineral supplements. If they are
given to you, only take what you are told you need. More is not always better; too much
supplementscanalsocauseproblems.
During pregnancy, you are storing food for your body to use during the pregnancy, at birth and
during the first few months of the babys life. As the baby grows during pregnancy, your weight
should increase. If you are not gaining weight, you may need to eat more food and eat more
often.
Physicalactivityandfreshairaregoodforyouwhenyouarepregnant.Awalkoutsideinsunlight
alsohelpsstrengthenyourbonesandthoseofyourbaby.
Youmayexperienceheartburnandnausea,aswellasachangeintasteandappetitewhenyou
arepregnant.Itmayhelpifyouhavesmallfrequentmeals,drinkmorefluidsandavoidfoodsthat
makeyoufeelill.
Apregnantwomanmayalsosufferfromconstipation.Itmayhelptoeatmorevegetablesandfruit
aswellaswholegraincereals.Drinkingplentyofcleanwaterisalsoimportant.
Let your midwife or doctor know if you are experiencing constipation, heartburn and other
problemsthatmayreducefoodintake.Donotwaituntilafterthebabyisborntoseeifyoureating
orweightimproves.
Safefoodandwaterareveryimportantforallpregnantwomen.Unsafefoodandwatercanlead
todiarrhoeaandvomiting,resultinginweightlossand,inveryseverecasesthelossofthebaby.
Themainpointstorememberfromthistalkare:
Pregnantwomenneedtoeatwiselyfortheirownhealthandthehealthoftheirbaby.
Eatingavarietyoffoodsensuresgettingallthenutrientsneeded;animalfoodsareparticularly
valuable.
Watch your weight; eat larger quantities of food; extra meals and rest more often, if
necessary.
Takevitamins,ironandfolicacidassupplementsifsuggestedbyyourdoctorormidwife.
Visittheclinicregularlyforearlydetectionandtreatmentofinfections.

Askthegroupifthereareanyquestions,orifanythingneedsclarifying.
Remind participants that they should still be role-playing as people attending an Eating wisely
duringpregnancytalkatanantenatalclinic.
Askthegrouptoraisequestionsfromthepreparedlistofquestionsanddiscusstheanswers.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
130
Prepared question 1
Idonotwanttohaveabigbabythatishardto Idonotwanttohaveabigbabythatishardto Idonotwanttohaveabigbabythatishardto Idonotwanttohaveabigbabythatishardtodeliver deliver deliver deliver.IfIeatlesswillmybabybesmall? .IfIeatlesswillmybabybesmall? .IfIeatlesswillmybabybesmall? .IfIeatlesswillmybabybesmall?

Answer Answer Answer Answer: :: :
Somewomeneatlessfoodduringpregnancybecausetheybelievethiswillhelpensurethatthey
haveasmallbabythatiseasilydelivered.Otherseatlesshopingtopreventhavingacaesarean
section.However,foodrestrictiondoesnotmakedeliveryeasy.
Difficult deliveries often occur in cases where the mothers pelvis is small relative to the
circumferenceofthebabyshead.Neitherthesizeofamotherspelvisnorthesizeofthebabys
headisaffectedbytheamountoffoodthemothereatsduringpregnancy.
Also,asmallbabyatbirthismorelikelytohavehealthproblems;soitisbettertoeatwellduring
pregnancytoensureastrong,healthybabyandmother.

Prepared question 2
HowcanIeatenoughtoputonweightifIfeelsickallthetime? HowcanIeatenoughtoputonweightifIfeelsickallthetime? HowcanIeatenoughtoputonweightifIfeelsickallthetime? HowcanIeatenoughtoputonweightifIfeelsickallthetime?

Ans Ans Ans Answer wer wer wer: :: :


Many women feel sick, especially early in pregnancy. It may help to eat small amounts of food
every hour or two rather than a big meal and to avoid foods that make you feel ill. Frequent
sipping of water or other clear fluids, such as diluted fresh juice, may also help. When you feel
well,eatextratomakeupforthetimesyoudonotfeellikeeatingandthelostnutrients.
Askthegroupiftheyhaveanyotherquestions.
Thankthegroupfortheirinterestandattendance

End of demonstration talk


Explaintoparticipantsthatthedemonstrationtalkhasnowendedandthattheynolongerneedto
berole-playingaspeopleattendingatalkataclinic.
----------

Inthisdemonstrationhealthtalkweheardanotherkeypoint:
Showthesecondkeypointdisplayedandaskaparticipanttoreaditoutloud.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Eatingwiselyduringpregnancyhelpsthemotherandbabystayhealthy. Eatingwiselyduringpregnancyhelpsthemotherandbabystayhealthy. Eatingwiselyduringpregnancyhelpsthemotherandbabystayhealthy. Eatingwiselyduringpregnancyhelpsthemotherandbabystayhealthy.






Nutritional Care and Support for People Living with HIV: Facilitators Guide
131
Watchweightgainduringpregnancy.Asthebabygrows,thewoman'sweightshouldincrease.
5
If
thewomanisnotgainingweightduringthe pregnancy,heown bodyfoodstoresarebeingused
up. If the woman was underweight before the pregnancy, she can be encourage to gain extra
weight.
Somewomenmayneedspecialattentiontotheirweightgainduringpregnancy.

Askthegroupwhichwomenmayneedspecialattentiontotheirweightgainduringpregnancy.
A young woman is still growing herself, so has very high nutrient needs. The mother expecting
twinsorwhostartedthepregnancylowinweightalsohashigherfoodsneeds.
Apregnantwomanwithaheavyworkloadwillusealotofenergy.Alighterworkloadandtimeto
restmayhelptoincreaseweightandimproveherhealth.
Ifapregnantwomanisnotgainingweight,discusswhatsheiseatingandwhatfoodisavailable
toher,totrytoimprovehereatingandweightgain.
In some areas, vitamin and mineral supplements are available to pregnant women. Multivitamin
supplementsduringpregnancymayimprovetheweightgainamongHIV-infectedwomen.

4. Maternal nutrition during breastfeeding (5 minutes)
6


Whataresomeofthe Whataresomeofthe Whataresomeofthe Whataresomeofthe eatingwisely eatingwisely eatingwisely eatingwisely guidelinesyou guidelinesyou guidelinesyou guidelinesyouc cc cangivetomotherswhoarebreastfeeding angivetomotherswhoarebreastfeeding angivetomotherswhoarebreastfeeding angivetomotherswhoarebreastfeeding? ?? ?

Allowtwoorthreeparticipantstogivetheirsuggestionsbeforehighlightingthefollowing:

Itishardworktorecoverfromthebirthofachild,totakecareofababyandperhapsotherfamily
membersaswell.Allmothersneedgoodnutritionandcare,irrespectiveoftheirHIVstatus.
Eating a variety of foods will ensure and adequate supply of all the nutrients a mother needs to
stayhealthy.Extraenergymaymeaneatinganextramealdaily.
During pregnancy, the body retains fluid and lays down fat stores to provide energy when
breastfeeding. Women who breastfeed may lose this fluid and fat over 46 months after birth.
ThisisnormalandisnotthesameaswastingduetoHIVinfection.
Ifthewomansweightafterdeliveryislowerthanherweightbeforepregnancy,evenwhensheis
eating well, her continued weight loss may be a sign of illnesses associated with HIV. Refer
motherswhoarelosingweightandnotfeelingwelltotheclinic.


5
Startingwiththefourthmonth,aweightgainofaround1.5-2kgisnormalandabout10-12kgduringthewhole
pregnancy.
6
TheriskofHIVtransmissionduringbreastfeedingisdiscussedinthenextsession.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Herewehaveanotherkeypoint:
Showthesecondkeypointdisplayed,andaskaparticipanttoreaditoutloud.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Eatingwiselyduringbreastfeedinghelpsthemotherandbabystayhealt Eatingwiselyduringbreastfeedinghelpsthemotherandbabystayhealt Eatingwiselyduringbreastfeedinghelpsthemotherandbabystayhealt Eatingwiselyduringbreastfeedinghelpsthemotherandbabystayhealthy. hy. hy. hy.

5. Food beliefs and practices (15 minutes)



What are the food bel What are the food bel What are the food bel What are the food beliefs and practices in this area/region iefs and practices in this area/region iefs and practices in this area/region iefs and practices in this area/region that that that that may may may may encourage encourage encourage encourage or discourage or discourage or discourage or discourage
pregnant pregnant pregnant pregnantor or or orbreastfeedingmother breastfeedingmother breastfeedingmother breastfeedingmothers ss sand and and andtheir their their theirbab bab bab babies ies ies iesto to to toeatwelland eatwelland eatwelland eatwellandstayhealthy? stayhealthy? stayhealthy? stayhealthy?
Allowtwoorthreeparticipantstorespondandthenexplainthefollowing:
There are some specific beliefs and practices about foods for pregnant and breastfeeding
mothersindifferentcommunities.
Mothers need to be counselled and informed about food beliefs and practices that may be
beneficial,neutralorharmful.

Show W WW Worksheet 8/1 orksheet 8/1 orksheet 8/1 orksheet 8/1: :: : F FF Food beliefs and practi ood beliefs and practi ood beliefs and practi ood beliefs and practic cc ces es es es (found at the end of this session and on page
90oftheParticipant'sManual).
This worksheet can also be used as a guideline for discussing food beliefs and practices with
mothers.
6. Summary of the session and transition (5 minutes)

Show/review both key points on display; reinforce them and summarise the session using the
followingpoints.
KEYPOINTS KEYPOINTS KEYPOINTS KEYPOINTS
Eatingwiselyduringpregnancyhelpsthemotherandthebabyto Eatingwiselyduringpregnancyhelpsthemotherandthebabyto Eatingwiselyduringpregnancyhelpsthemotherandthebabyto Eatingwiselyduringpregnancyhelpsthemotherandthebabytostayhealthy. stayhealthy. stayhealthy. stayhealthy.
Eatingwiselyduringbreastfeedinghelpsthemotherandthebabytostayhealthy. Eatingwiselyduringbreastfeedinghelpsthemotherandthebabytostayhealthy. Eatingwiselyduringbreastfeedinghelpsthemotherandthebabytostayhealthy. Eatingwiselyduringbreastfeedinghelpsthemotherandthebabytostayhealthy.


Goodnutritionisimportant forallofus.PoornutritioninawomanwithHIVcanaffectherhealth
andthatofherbaby.PoornutritionmayalsofacilitatetransmissionofHIVtoherbaby.
Encouragepregnant,breastfeedingornewmotherstocareforthemselvesandtheirbabyby:
Eatingwiselyandaincludingavarietyoffoodsintheirdiets;




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Eatingfoodwithenoughvitaminandminerals;and
Visitingtheclinicforearlydetection andtreatmentofanyinfectionsandtoobtain guidance on
vitaminandmineralsupplements.
When discussingabout nutritionduringpregnancyandbreastfeedingwitha mother,itisimportant
toknowifthewomanhasdisclosedherHIVstatustoherfamilyandfriends.Somesuggestionsto
improvenutritionmaybedifficulttofollowifthewomanhasnotdisclosedherstatus.
Mothers need to be counselled and informed about local food beliefs and practices that may be
beneficial,neutralorharmful.
Askifthereareanyquestions,orifanythingneedsclarifying.
Inthenextsession,wewilldiscussfeedingoptionsforinfantsofmotherslivingwithHIV.
Thenextsessionwillbepresentedby:
Statethenameofthepresenter.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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HANDO HANDO HANDO HANDOUT8/1: UT8/1: UT8/1: UT8/1:Increasingironabsorption Increasingironabsorption Increasingironabsorption Increasingironabsorption

Theamountofironthatapersonabsorbsfromfooddependson:
Theamount amount amount amountofironinthefood;
The type type type type of iron (iron from meat and fish is better absorbed than iron from plants, milk
andeggs);
Thetypesof otherfoods otherfoods otherfoods otherfoods present present present presentinthesamemeal(some increase increase increase increaseironabsorption, e.g.
meatandcitrus,whileothersreduce reduce reduce reduceit,e.g.tea.);and
Whetherthepersonhasanaemia anaemia anaemia anaemia(moreironisabsorbedifthepersonisanaemic).

The amount of iron absorbed from eggs, milk and plant foods such as, low fibre cereals,
pulses, seeds, and vegetables are increased increased increased increased by eating these together with the following in
thesamemeal:
Foods rich in vitamin C, such as, tomato, broccoli, guava, mango, pineapple, paw-paw,
orangeandothercitrusfruits;
Germinatedorfermentedcerealsorpulses,suchas,beansprouts;
Small amounts (about 30 grams) of the flesh or organs/offal of animals, birds, fish and
otherseafood.

Ironabsorptionisincreased increased increased increasedby:


Cookinginironpots,particularlyifthefoodisacidic.

Ironabsorptionisdecreased decreased decreased decreasedby:


Drinkingteas(includingherborbushteas)andcoffee;
Eatingcerealfoodshighinfibresuchasbran.






Nutritional Care and Support for People Living with HIV: Facilitators Guide
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WORKSHEET8/1:Findingoutaboutfoodbeliefsandpracticesinthelocalregion WORKSHEET8/1:Findingoutaboutfoodbeliefsandpracticesinthelocalregion WORKSHEET8/1:Findingoutaboutfoodbeliefsandpracticesinthelocalregion WORKSHEET8/1:Findingoutaboutfoodbeliefsandpracticesinthelocalregion

1 11 1. .. . Dopregnantwomeninyourareabelievetherearesomefoodsoreatingpracticesthatare
harmfulduringpregnancy?

2 22 2. .. . Dopregnantwomeninyourareabelievetherearesomefoodsoreatingpracticesthatare
specialorbeneficialduringpregnancy?

3 33 3. .. . Dobreastfeedingwomeninyourareabelievetherearesomefoodsoreatingpracticesthatare
harmfulwhenbreastfeeding?

4 44 4. .. . Dobreastfeedingwomeninyourareabelievetherearesomefoodsoreatingpracticesthatare
specialorbeneficialwhenbreastfeeding?

5 55 5. .. . Canyouidentifythebeneficialandharmfulbeliefsandpractices?Givereasons.







Nutritional Care and Support for People Living with HIV: Facilitators Guide
136

Session Session Session Session9: 9: 9: 9:FeedingoptionsforinfantsofHIVpositivemothers FeedingoptionsforinfantsofHIVpositivemothers FeedingoptionsforinfantsofHIVpositivemothers FeedingoptionsforinfantsofHIVpositivemothers


Learning Learning Learning Learningo oo objectives bjectives bjectives bjectives
Bytheendofthissession,participantswillbeableto:
DiscusstherisksandbenefitsofthedifferentfeedingoptionsforinfantsofHIVpositive
mothers;and
ProvideguidancetoHIVpositivemotherstochoosethemostsuitablefeedingoptions
fortheirsituation.

Session Session Session Sessiono oo outline utline utline utline
Content Content Content Content Time Time Time Time
1 Learningobjectivesandintroductiontothesession 3minutes
2 Infantfeedingoptions 8minutes
3 Risksandbenefitsofdifferentinfantfeedingoptions
Demonstrationtalkforpregnantwomenonfeedingtheirbabies
15minutes
4 Providingongoingsupporttomothers 3minutes
5 Transitionfromexclusivebreastfeedingtocomplementaryfeeding 3minutes
6 Summaryofthesessionandtransition 3minutes
Total Total Total Total 35minutes 35minutes 35minutes 35minutes


Preparation for the session

Writeanddisplaythelearningobjectivesonasheetofflipchartpaper.
Writethekeypointonaflipchartsheetandkeepitasideuntilneeded.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
AllmotherswithHIVshouldreceivecounsellingtoguidethem AllmotherswithHIVshouldreceivecounsellingtoguidethem AllmotherswithHIVshouldreceivecounsellingtoguidethem AllmotherswithHIVshouldreceivecounsellingtoguidetheminchoosing inchoosing inchoosing inchoosinginfantfeeding infantfeeding infantfeeding infantfeeding
optionsmostsuitablefortheirsituation. optionsmostsuitablefortheirsituation. optionsmostsuitablefortheirsituation. optionsmostsuitablefortheirsituation.

Familiarise yourself with the national policies and guidelines on infant feeding in the context of
HIV,iftheyexist.Summarizetheseonasheetofflipchartpaper.
Writethewords:Acceptable,Feasible,Affordable,SustainableandSafe Acceptable,Feasible,Affordable,SustainableandSafe Acceptable,Feasible,Affordable,SustainableandSafe Acceptable,Feasible,Affordable,SustainableandSafeondifferentcolouredA4
sheetsorcardsandkeepthemasideuntilneeded.
FindoutifthereareinfantfeedingcounsellorsavailableinthelocalareaformotherswhoareHIV-
positive.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Asktwoparticipantstoassistwiththedemonstrationtalkbyaskingpreparedquestions.
The prepared questions are found at the end of the text for the demonstration talk (see also
handouts for photocopy in the Directors Guide). Give each of the participants assisting you a
preparedquestionwrittenonapieceofpaperandexplainwhentheyaretoaskthesequestions.
Read more information on the WHO/UNICEF "Infant and Young Child Feeding Counselling: An
integrated course" the job aids on HIV and infant feeding, and WHO/UNICEF Breastfeeding
Counselling:ATrainingCourse.(SourcesoffurtherinformationareprovidedinA AA Annex nnex nnex nnex4 4 4 4). ). ). ).

Collect/preparethefollowingmaterials:
An overhead projector and screen; and/or flipchart paper, markers and a means to attach
flipchartsheetstothewallorothersurface.Ifanoverheadprojectorisnotavailable/used,the
following may be written out on flipchart sheets or enlarged copies prepared for display as
posters,asappropriate.
Overhead9 Overhead9 Overhead9 Overhead9/ // /1: 1: 1: 1: Policyofsupportingbreastfeeding Policyofsupportingbreastfeeding Policyofsupportingbreastfeeding Policyofsupportingbreastfeeding
Overhead Overhead Overhead Overhead9/2: 9/2: 9/2: 9/2: TheUnitedNationsAgencies TheUnitedNationsAgencies TheUnitedNationsAgencies TheUnitedNationsAgencies Recommendation Recommendation Recommendation RecommendationforHIV forHIV forHIV forHIV- -- -positivewomen positivewomen positivewomen positivewomen
Overhead9 Overhead9 Overhead9 Overhead9/ // /3 33 3: : : : Exclusivebreastfee Exclusivebreastfee Exclusivebreastfee Exclusivebreastfeeding ding ding ding
Overhead9 Overhead9 Overhead9 Overhead9/4: /4: /4: /4: R RR Replacementfeeding eplacementfeeding eplacementfeeding eplacementfeeding
Overhead9/5 Overhead9/5 Overhead9/5 Overhead9/5: :: : 20 20 20 20babiesof babiesof babiesof babiesofmotherswithHIV motherswithHIV motherswithHIV motherswithHIV (fordemonstrationtalk)
Handout 9/1: Handout 9/1: Handout 9/1: Handout 9/1: Risks and benefits of different infant feeding options Risks and benefits of different infant feeding options Risks and benefits of different infant feeding options Risks and benefits of different infant feeding options (available at the end of
thissession)
P PP Picture3 icture3 icture3 icture3:SamandSuzi :SamandSuzi :SamandSuzi :SamandSuzi(seeA AA Anne nne nne nnex1 x1 x1 x1; usetheversionmostsuitableforthelocalarea).

1. Learning objectives and introduction to the session (3 minutes)
Review the learning objectives of the session

Showandoutlinethelearningobjectivesdisplayed.
Bytheendofthissessionparticipantsshouldbeableto:
Discuss the risks and benefits of the different feeding options for infants of HIV-positive
mothers;and
ProvideguidancetoHIVpositivemotherstochoosethemostsuitablefeedingoptionsfor
theirsituation.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Introduce the session

ShowO OO Overhead9/1: verhead9/1: verhead9/1: verhead9/1: Policyofsupportingbreastfeeding Policyofsupportingbreastfeeding Policyofsupportingbreastfeeding Policyofsupportingbreastfeeding



OVERHEAD9/1:Policyofsupportingbreastfeeding OVERHEAD9/1:Policyofsupportingbreastfeeding OVERHEAD9/1:Policyofsupportingbreastfeeding OVERHEAD9/1:Policyofsupportingbreastfeeding

Asageneralprinciple,inallpopulations,irrespectiveofHIVinfectionrates,breastfeeding
shouldcontinuetobeprotected,promotedandsupported.

HIVandInfantFeeding:APolicyStatement HIVandInfantFeeding:APolicyStatement HIVandInfantFeeding:APolicyStatement HIVandInfantFeeding:APolicyStatement,developedcollaborativelybyUNAIDS/WHO/UNICEF,1997 ,developedcollaborativelybyUNAIDS/WHO/UNICEF,1997 ,developedcollaborativelybyUNAIDS/WHO/UNICEF,1997 ,developedcollaborativelybyUNAIDS/WHO/UNICEF,1997. .. .

Ask three participants to take turns reading the following (also found on pages 91-92 of the
Participant'sManual):

Participant 1:
Breastmilksuppliesallthenutrientsinfantsbodiesneedforgrowthanddevelopmentduringthefirst
sixmonthsoftheirlives.Inaddition,breastmilkprotectsthemagainstinfectionsandstrengthenstheir
immune system. However, HIV can pass from an infected mother to her baby during breastfeeding
andcaremustbetakentoreducethetransmissionrisk.

Participant 2:
Forthisreason,allpregnantwomenornewmotherswithHIVneedcounsellingwhichincludes:
Informationontherisksandbenefitsoflocallyappropriateinfantfeedingoptions;and
Guidanceinselectingthemostsuitableinfantfeedingoptionfortheirsituation.
Whateveramotherdecides,sheshouldbesupportedinherchoice.

Participant 3:
This session discusses the risks and benefits of different feeding options for infants of mothers who
have been tested for HIV and found to be positive. We will also discusssome of the information the
counsellorneedstofindoutfromthemotherwhenassessinghersituationandhelpinghertochoose
themostsuitablefeedingoptionforhersituation.

For further continued support in carrying out her choice, refer the mother to health workers who
havebeentrainedinbothbreastfeedingandHIVandinfantfeedingcounselling.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Informparticipantsthat,thissessionisonlyabriefoverviewofHIVandinfantfeedingcounselling.
GiveparticipantsmoreinformationontheWHO/UNICEFcourseInfantandYoungChildFeeding
Counselling:Anintegratedcourse,thejobaidsspecificforHIVandinfantfeedingcounsellingand
WHO/UNICEFBreastfeedingCounselling:ATrainingCourse.

2. Infant feeding options (8 minutes)

InformtheparticipantsabouttheUnitedNationsAgenciesRecommendationoninfantfeeding:.
If a woman is HIV-negative or does not know her HIV status, exclusive breastfeeding is
recommendedforthefirst6monthsofthebabyslife.

Show and ask one participant to read O OO Overhead 9/2: verhead 9/2: verhead 9/2: verhead 9/2: The The The The United Nations United Nations United Nations United Nations A AA Agencies gencies gencies gencies
R RR Recommendation ecommendation ecommendation ecommendationforHIV forHIV forHIV forHIV- -- -positivewomen positivewomen positivewomen positivewomen

OVERHEAD 9/2: The United Nations Agencies OVERHEAD 9/2: The United Nations Agencies OVERHEAD 9/2: The United Nations Agencies OVERHEAD 9/2: The United Nations Agencies r rr recom ecom ecom ecommendation mendation mendation mendation for HIV for HIV for HIV for HIV- -- -positive positive positive positive
women women women women
7


The most appropriate infant feeding option for an HIV-infected mother should depend on her
individual circumstances, including her health status and the local situation, but should take
greaterconsiderationofthehealthservicesavailableandthecounsellingandsupportsheislikely
toreceive.

Exclusive breastfeeding Exclusive breastfeeding Exclusive breastfeeding Exclusive breastfeeding is recommended for HIV-infected women for the first 6 months of life
unless replacement feeding is Acceptable, Feasible, Affordable, Sustainable and Saf Acceptable, Feasible, Affordable, Sustainable and Saf Acceptable, Feasible, Affordable, Sustainable and Saf Acceptable, Feasible, Affordable, Sustainable and Safe (AFASS) e (AFASS) e (AFASS) e (AFASS)
forthemandtheirinfantsbeforethattime.

Whenreplacementfeeding replacementfeeding replacementfeeding replacementfeedingisacceptable,feasible,affordable,sustainableandsafe,avoidanceof


allbreastfeedingbyHIV-infectedwomenisrecommended.

Informtheparticipantsthatthisrecommendationandthetermsusedwillbediscussedlaterinthe
session.

7
WHO/UNICEF/UNAIDS/UNFPA.HIVandinfantfeeding:updatebasedonthetechnicalconsultationheldon
behalfoftheInter-agencyTeam(IATT)onPreventionofHIVInfectionsinPregnantWomen,Mothersandtheir
Infants,Geneva,25-27October2006.WorldHealthOrganization,Geneva2007.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
140
2.1. Exclusive breastfeeding
Whatisexclusivebreastfeeding? Whatisexclusivebreastfeeding? Whatisexclusivebreastfeeding? Whatisexclusivebreastfeeding?
Allow a few participants to give their suggestions and show O OO Overhead 9/3: verhead 9/3: verhead 9/3: verhead 9/3: Exclusive Exclusive Exclusive Exclusive
breastfeeding breastfeeding breastfeeding breastfeeding . .. .
OVERHEAD9/3:Exclusivebrea OVERHEAD9/3:Exclusivebrea OVERHEAD9/3:Exclusivebrea OVERHEAD9/3:Exclusivebreastfeeding stfeeding stfeeding stfeeding
Exclusivebreastfeeding: Exclusivebreastfeeding: Exclusivebreastfeeding: Exclusivebreastfeeding:Feedingthebabyonly only only onlybreastmilkwithoutgivinganyotherliquidsorsolids,
not even water, with the exception of medically prescribed drops or syrups consisting of vitamins,
mineralsupplementsormedicines.
2.2. Replacement feeding
Whatisreplacementfeeding? Whatisreplacementfeeding? Whatisreplacementfeeding? Whatisreplacementfeeding?
Allow a few participants to give their suggestions and show O OO Overhead 9/3: verhead 9/3: verhead 9/3: verhead 9/3: Exclusive Exclusive Exclusive Exclusive
replacementfeeding replacementfeeding replacementfeeding replacementfeeding . .. .
OVERHEAD9/4:Replacementfeeding OVERHEAD9/4:Replacementfeeding OVERHEAD9/4:Replacementfeeding OVERHEAD9/4:Replacementfeeding

Replacementfeeding: Replacementfeeding: Replacementfeeding: Replacementfeeding:Feedingababywhoisreceivingnobreastmilk,withadietthatprovides
all the nutrients that the child needs until the age at which the baby can be fed foods eaten by
therestofthefamily.
Duringthefirstsixmonthsoflife,replacementfeedingshouldbeonly only only onlywithasuitablebreast-milk
substitute. After six months, the suitable breast-milk substitute should be complemented with
otherfoods
2.3. Questions to consider with replacement feeding
Display the coloured A4 sheets one at a time as follows: Acceptable, Feasible, Affordable, Acceptable, Feasible, Affordable, Acceptable, Feasible, Affordable, Acceptable, Feasible, Affordable,
Sustainable Sustainable Sustainable SustainableandSafe Safe Safe Safe. .. .
Allowabriefdiscussionabouteachfactorbeforedisplayingthenextcard/sheet.

Acceptable Acceptable Acceptable Acceptable? ?? ?: :: :tothemother,herfamilyandcommunity.


Feasible Feasible Feasible Feasible? ?? ?: : : : the mother and family have time, knowledge, skills and means to prepare the
replacementfeedscorrectlyatvarioustimesaday,everyday.
Affordable Affordable Affordable Affordable? ?? ?: :: : taking into account all the costs, including formula, water, fuel, soap, equipments
and other needs including, medical expenses in case the child becomes sick from unsafe
preparationandfeedingpractices.




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Sustainable Sustainable Sustainable Sustainable? ?? ?: :: : thereisacontinuoussupplyandreliablesystemof distributionof allingredients
andproductsneededforaslongastheinfantneedsit,uptooneyearorlonger.
Safe Safe Safe Safe? ?? ?: :: : replacement foods are correctly and hygienically prepared, stored and fed in enough
quantitieswithcleanhandsusingcleanutensils,preferablyacup.

3. Risks and benefits of different infant feeding options (15 minutes)

Copy the table below on a flipchart sheet and ask participants to list the benefits and risks of
breastfeedingandthenreplacementfeedingthattheyknow.

Use H HH Handout 9/1: Risks and benefits of different infant feeding options andout 9/1: Risks and benefits of different infant feeding options andout 9/1: Risks and benefits of different infant feeding options andout 9/1: Risks and benefits of different infant feeding options (available at the end of
this session and on page 99 of the Participant's Manual) to clarify or add any points that may
havebeenleftout.
Explain to participants that this handout can also be used to explain the risks and benefits of
differentinfantfeedingoptionsformothersduringcounselling.
3.1. Demonstration talk for pregnant women on feeding their babies
Introduce the demonstration talk

UsethestoryofSamandSuzitointroducethetalk.

THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI

Suzi is pregnant. Suzi and Sam were tested and are HIV-positive. They want to know more
aboutbreastfeedingandHIV.
SamandSuziaretoldattheantenatalclinicthatthereisatalkforpregnantwomen oninfant
feeding.
Theydecidetoattendsotheycandiscussthechoicesandmakeadecisionabouthowtofeed
theirbaby.

Check that participants understand that they should be role-playing as people attending the talk
atanantenatalclinic.
Presentthetalk.





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Feeding your baby: a talk for pregnant women

Welcome/greetthegroup.
Today,wewilltalkaboutfeedingyourbaby.Thefirstthingtoknowisthat:
If a woman is HIV-negative or does not know her HIV status, exclusive breastfeeding is
recommendedforthefirst6monthsofthebabyslife.
IfawomanisHIV-positive,theHIVinfectioncanpassfromtheinfectedmothertoherbabyduring
pregnancy,birthandbreastfeeding.Letuslookathowlikelyisthatriskoftransmission.
ShowO OO Overhead9/5: verhead9/5: verhead9/5: verhead9/5: 20 20 20 20babiesof babiesof babiesof babiesofmotherswithHIV motherswithHIV motherswithHIV motherswithHIV andexplainthefollowingpoints:


OVERHEAD 9/5: Twenty babies of mothers with HIV



These are 20 babies of women who have all had a test which showed that they are living with
HIV.TheHIVviruscanpassfromthesewomentotheirbabiesduringpregnancyandbirth.About
fourofthese20babiesarelikelytobeHIV-infectedduringpregnancyandbirth.
8

Now,markfour four four fourbabiesatrandomonthepicturewithamarker.
Ifthemotheristreatedwithantiretrovirals,theriskofpassingtheHIVinfectionfromthemotherto
thebabyisreduced.
9


8
The rate of transmission of HIV during pregnancy and delivery is approximately 2025% without antiretroviral drug
treatment.
9
Transmission of HIV from mother to infant if the mother is taking long term antiretroviral treatment, has a
caesareansectionandavoidsbreastfeedingislessthan2%.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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SomebabiesborntomotherswhoareHIV-positivewillbecomeHIV-positiveiftheyarebreastfed,
Up to three babies out of 20 born to women who are HIV-positive may be infected in this way,
dependingonhowandhowlongtheyarebreastfeeding.
10

Mark three three three three additional babies on the picture, with a different colour marker if possible, or a
differenttypeofmark.
Even among women who know they are HIV-positive, only a small number of their infants are
likelytobeinfectedthroughbreastfeeding.
Pointtothe3babiesmarked.
Most babies will not be infected through breastfeeding. However, given the risk, a way must be
foundtominimizetransmissionthroughbreastmilk.

Toreducethetransmission,motherswhoareHIV-positivemaychooseto:
Exclusivelybreastfeed Exclusivelybreastfeed Exclusivelybreastfeed Exclusivelybreastfeed: :: :
Givenothingelseexceptbreastmilk,notevenwater,andthenstopbreastfeedingatsixmonths.
Exclusivebreastfeedingincludes:
ExpressandheattreattheirbreastmilktokilltheHIVvirusbeforegivingittothebaby;or
UsebreastmilkfromawomanwhoisHIV-negative.

Alternatively,HIV-positivemothersmaydecideto:
A AA Avoid breastfeeding altogether void breastfeeding altogether void breastfeeding altogether void breastfeeding altogether: : : : Find a suitable replacement for the breast milk. Replacement
feeding is feasible and acceptable, if the family can afford replacement feeding for a period of
aboutayearormoreandcanpreparethereplacementfoodsafely;
However,ifthebabyisnotbreastfeedandreplacementfeedingischosen,he/sheismorelikelyto
get diarrhoea, chest infections, and other health problems. The family will also need to buy
formulatofeedthebaby,andhavecleanwaterandfueltoboilwater.Also,awomanwhoisnot
breastfeeding may become pregnant again sooner if sexually active. The mother needs to
considertheseissueswhendecidingonthebestoptionforherselfandthebaby.
The risk of HIV transmission is highest when the baby is mixed fed during the first six months,
i.e., when breastfeeding is combined with replacement food (other milk, solid foods or fluids).
Thispracticeshouldbediscouraged.
Mixedfeedingincreasesthechancesofviruspassingtothebaby.
During mixed feeding, the breasts can become engorged and there is an increased risk of
infectionofthebreast.
11


10
Ifthereisnointerventiontopreventmother-to-child-transmissionofHIV,30-45%ofHIV-infectedmotherswill
passonthevirustotheirchild.Uptoabout520%ofthesewillbethroughbreastfeeding.
11
The infectionof thebreast or mastitis may increase the viral load in breast milk,thus increasing the risk of
HIVtransmission.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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IfawomanknowssheisHIV-positiveduringherpregnancy,itisagoodtimetothinkandplanon
howshewillfeedherbaby.Shecantalktoherdoctor,nurseorHIVcounsellortohelpherdecide
the best way to feed her baby in her situation and to support her in carrying out the chosen
feedingoption.

Themainpointstorememberare:
If a woman is HIV-negative or does not know her HIV status, exclusive breastfeeding is
recommended for the first six months, continuing thereafter with the addition of complementary
foods.
IfawomanisHIV-positive,sheshouldbecounselledandhelpedtodecidehowtofeedthebaby,
beforethebabyisborn.
If breastfeeding, she should breastfeed exclusively for the first six months and change to
replacementfeedingwhenacceptable,feasible,affordable,sustainableandsafe.
The risk of HIV transmission is higher in those who use mixed feeding (breastfeeding together
withotherfoodsorfluids)anditshouldbeavoided.
Ensure good hygiene and encourage mothers to breastfeed on demand, that is, as often as the
babywantstofeedorwheneverthemotherwantstofeed.Thiswillstimulatemilkproductionand
keepherbreastsfromgettingswollen.
Encourage good breastfeeding technique to prevent sore nipples and breast problems. If these
occur,theyshouldbetreatedpromptly.

Askthegroupiftheyhaveanyquestionsorifanythingneedsclarifying.
Asktheparticipantsselectedatthebeginningofthesession,toraisequestionsfromtheprepared
listofquestionsanddiscusstheanswers.
Prepared question 1
If I breastfeed, I will need to eat more food myself to make good milk. I cant afford this extra food. If I breastfeed, I will need to eat more food myself to make good milk. I cant afford this extra food. If I breastfeed, I will need to eat more food myself to make good milk. I cant afford this extra food. If I breastfeed, I will need to eat more food myself to make good milk. I cant afford this extra food.
Woulditbebettertouseformulaforthebabyinstead? Woulditbebettertouseformulaforthebabyinstead? Woulditbebettertouseformulaforthebabyinstead? Woulditbebettertouseformulaforthebabyinstead?

Answer Answer Answer Answer: : : :


Touseformulaforthe baby,thefamilywillneedextramoneytobuythe formula.Youwillalsoneed
water and fuel. It will take time to make up the feeds, to give it to the baby and keep the equipment
clean.Ifthereislittlemoney,itisbettertousethemoneytobuymorenutritiousfoodforthemother.
Nutritiousfoodsconsumedbythemotherarebeneficialforboththemotherandthebaby.
Breastmilkisbeneficialfordevelopmentandprotectsthebabyfrominfection.
Nutritiousfoodswillhelpyoutogainbackyournutrientstoresthatwerelostduringpregnancyand
delivery.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Recovering from the delivery and taking care of the baby is hard work. All mothers, both HIV-
infected and uninfected, need to eat wisely and take care of themselves to stay healthy and
strong.

Prepared question 2
IfamotherbreastfeedsandhasHIV,thebabymaygetHIVfromthemilk.Ifthebabygetsothermilk,the IfamotherbreastfeedsandhasHIV,thebabymaygetHIVfromthemilk.Ifthebabygetsothermilk,the IfamotherbreastfeedsandhasHIV,thebabymaygetHIVfromthemilk.Ifthebabygetsothermilk,the IfamotherbreastfeedsandhasHIV,thebabymaygetHIVfromthemilk.Ifthebabygetsothermilk,the
babymaygetsickanddie.Howcanamotherdecidewhattodo? babymaygetsickanddie.Howcanamotherdecidewhattodo? babymaygetsickanddie.Howcanamotherdecidewhattodo? babymaygetsickanddie.Howcanamotherdecidewhattodo?
Answer: Answer: Answer: Answer:
Itisadifficultdecision.Thesolutionisnotthesameforeveryfamily.EachmotherwhoisHIV-positive
needs to consider if replacement feeding is acceptable, feasible, affordable, sustainable and can be
safely prepared for the whole time her baby will need it. If it is not, she may decide exclusive
breastfeedingisabetterchoice.Thewomanneedstotalkaboutthedecisionwiththoseclosetoher
andaninfantfeedingcounsellorsothatshehasalltheinformationsheneedsinordertodecideand
supporttosticktoherdecision.

Askthegroupiftheyhaveanyotherquestionsorifanythingneedsclarifying.
Thankthegroupfortheirinterestandattendance.
End of demonstration talk
Explaintoparticipantsthatthedemonstrationtalkhasnowendedandthattheynolongerneedto
berole-playingaspeopleattendingahealthcentretalk.
Returntotherestofthesession.
----------

4. Providing ongoing support to mothers (3 minutes)

Discussthefollowingpointswithparticipants:
Whenamotherdecidesto breastfeed,itisimportantthatshereceivesthesupportsheneedsto
breastfeedexclusivelyandtodiscusswithherhowshecancarryoutherdecisionby:
Gettingmoreinformationonsaferbreastfeedingpractices;and
Eatingwiselytobuildandstorenutrientsneededforherbodyandformilkproduction.

ShowP PP Picture icture icture icture3 33 3: :: :SamandSuzi SamandSuzi SamandSuzi SamandSuzi,thebabyandgrandmother ,thebabyandgrandmother ,thebabyandgrandmother ,thebabyandgrandmother.

PICTURE3:SamandSuzi PICTURE3:SamandSuzi PICTURE3:SamandSuzi PICTURE3:SamandSuzi,thebabyandgrandmother ,thebabyandgrandmother ,thebabyandgrandmother ,thebabyandgrandmother






Nutritional Care and Support for People Living with HIV: Facilitators Guide
146

AskoneoftheparticipantstovolunteerandreadthestoryofSamandSuzi.

THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI

SuziandSamdecidethatexclusivebreastfeedingisthebestchoiceforthem.Thecounsellor
praisesthemforthinkingaboutthisduringpregnancyandforcomingtodiscusstheirchoice.
Thecounsellorgivesthemsomemoreinformationonsaferbreastfeedingpractices.
SuziandSamsbabyboyisborn.Suziisbreastfeedingexclusively.Everythingisgoingwell.
Suzi is eating wisely, taking some rest and feeding her baby frequently using good
breastfeedingpractices.
However, they do have one problem. Sams mother, Granny, thinks the baby needs water
and tea as well as breast milk. She cannot understand why Suzi and Sam are so insistent
thatthebabyonlyhasbreastmilk.
SuziexplainstoGrannythatexclusivebreastfeedingisbestforbabies.Thebabygetsallhe
needsfrombreastmilk.Hedoesnotneedwaterortea.
Granny keeps asking about giving water and other things to the baby. Sam and Suzi are
afraidGrannywillstartgivingthebabywaterandotherfoodsherself.
SamandSuzidecidetotellGrannythattheyareHIV-positive.Theydothisandexplainwhy
itisveryimportanttobreastfeedexclusivelytoreducetheriskofthebabygettingtheHIV.

Explainthefollowing:
When you discuss infant feeding with a mother who is HIV-positive, also discuss how she will
carry out her decision. If she has not disclosed her status, she will have a hard time getting the
supportsheneedstofeedherbaby.HIVorPMTCTcounsellorscanhelpwomenmakeadecision
aboutdisclosingtheirHIVstatus.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
147

5. Transition from exclusive breastfeeding to complementary feeding


(3 minutes)

Explainthefollowing:

Mothersneedtobesupportedtodevelopaspecificplanthatwillenablethemtominimizeriskand
discomfortduringthetransitionperiod.

ContinuewithSamandSuzisStory.Askoneoftheparticipantstovolunteerandreadtheirstory.
THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI
Suzi breastfeeds exclusively. When little Sam is about five months, she decides she would stop
breastfeeding completely and starts giving other foods and fluids to the baby when he is six
monthsold.
However, if Suzi stops breastfeeding suddenly, she may get engorged breasts and feel ill; her
babywillalsoneedanothersourceoffoodandcomfort.
So she will need to go and discuss her decision to stop breastfeeding with a breastfeeding
counsellortominimizeriskanddiscomfortduringthistransition.

Emphasizethefollowingpoint:
Ifthemotherthinksthatsheisreadytostopbreastfeedingorthechildisoldenoughfordoingso,
refermotherandherbabytoaninfantfeedingcounsellor.

6. Summary of the session and transition (3 minutes)

Show/reviewthekeypointdisplayed.

KEYPOINT KEYPOINT KEYPOINT KEYPOINT


AllmotherswithHIVshouldreceivecounsellingtoguidethem AllmotherswithHIVshouldreceivecounsellingtoguidethem AllmotherswithHIVshouldreceivecounsellingtoguidethem AllmotherswithHIVshouldreceivecounsellingtoguidetheminchoosing inchoosing inchoosing inchoosinginfant infant infant infant
feedingoptionsmostsu feedingoptionsmostsu feedingoptionsmostsu feedingoptionsmostsuitablefortheirsituation. itablefortheirsituation. itablefortheirsituation. itablefortheirsituation.






Nutritional Care and Support for People Living with HIV: Facilitators Guide
148
If a woman is HIV-negative or does not know her HIV status, exclusive breastfeeding is
recommendedforthefirst6months.
WomenwhoaretestedandshowntobeHIV-positiveneedinformationandindividualcounselling
todecidewhichfeedingoptionisthebestforthem,giventheirsituation.
Replacement feeding needs to be acceptable, feasible, affordable, sustainable and safe for it to
beselectedasachoice.
Mothers need ongoing support and information so they can carry out their infant feeding
decisions.
Itisimportanttoencouragemotherstotalktotheirhealthcareproviderstoobtaintheadviceand
supporttheyneed.

Askifthereareanyquestionsorifanythingneedsclarifying.
Inthenextsession,wewilldiscussfeedingachildwithHIV.
Thenextsessionwillbepresentedby:
Statethenameofthepresenter.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
149
HANDOUT HANDOUT HANDOUT HANDOUT9/1:Risksandbenefitsofdifferentinfantfeedingoptions 9/1:Risksandbenefitsofdifferentinfantfeedingoptions 9/1:Risksandbenefitsofdifferentinfantfeedingoptions 9/1:Risksandbenefitsofdifferentinfantfeedingoptions


EXCLUSIVEBREASTFEEDING EXCLUSIVEBREASTFEEDING EXCLUSIVEBREASTFEEDING EXCLUSIVEBREASTFEEDING REPLACEMENTFEEDING REPLACEMENTFEEDING REPLACEMENTFEEDING REPLACEMENTFEEDING
Benefits Benefits Benefits Benefits Breastmilkcontainsallthefoodthe
babyneedsforthefirstsixmonths.
Breastmilkiseasytodigest.Doesnot
needwater.
Breastmilkprotectsthebabyfrom
diarrhoea,pneumoniaandother
infections.
Breastmilkisfree,alwaysavailableand
doesnotneedanyspecialpreparation.
Breastfeedingcreatesabondbetweena
motherandherbaby.
Exclusivebreastfeedinghelpsmothers
recoverfromchildbirthandprotectsthem
fromgettingpregnantagaintoosoon.
Exclusivebreastfeedingforfirstfew
monthslowerstheriskoftransmittingHIV
totheinfant.
NoriskoftransmissionofHIVfrom
themothertotheinfant.Mostofthe
nutrientsherbabyneedshave
alreadybeenaddedtotheformula.
Othermembersofherhousehold
canbeinvolvedintheinfants
feeding.

Risks Risks Risks Risks Aslongasthebabyisbreastfed,therisk
ofpassingHIVtothebabyexists.
Otherpeoplemayalsopressurizethe
mothertogivewater,otherliquidsor
foodstothebabywhilesheis
breastfeeding.Thispracticeknownas
mixedfeeding,increasestheriskof
diarrhoeaandotherinfections.

Entailsahigherriskofnon-HIV
infectionssuchas,diarrhoeaand
chestinfectionssincetheinfantwill
nothavetheprotectiveantibodies
obtainedfrombreastmilk.
Theexpenseofobtainingthe
appropriatefoodsforthebaby,as
wellascleanwaterandfuel.
Questionsthatmayberaisedby
othersaboutthemothersHIV
statusbecausesheisnot
breastfeeding.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
150

Session10:FeedingachildwithHIV Session10:FeedingachildwithHIV Session10:FeedingachildwithHIV Session10:FeedingachildwithHIV

Learning Learning Learning Learningo oo objectives bjectives bjectives bjectives

Bytheendofthissession,participantswillbeableto:

Understandtheimportanceofoptimalinfantfeedingforgrowthanddevelopment;
DiscussthenutritionalconcernsofchildrenwithHIV;and
MakesuggestionsforfeedingachildwithHIVandduringillnessandrecovery.

Session Session Session Sessiono oo outline utline utline utline


Content Content Content Content Time Time Time Time
1 Learningobjectivesandintroductiontothesession 2minutes
2 NutritionalconcernsforchildrenwithHIV 5minutes
3 FeedingachildwithHIV(includingmealplanning) 30minutes
4 Feedingachildduringillnessandrecovery 5minutes
5 Summaryofthesessionandtransition 3minutes
Total Total Total Total 5 55 50minutes 0minutes 0minutes 0minutes


Preparation for the session

Writeanddisplaythelearningobjectivesonaflipchartsheet.
Writethekeypointsonaflipchartsheetandkeepitasideuntilneeded.

KEYPOINTS KEYPOINTS KEYPOINTS KEYPOINTS
When When When Whenfeedingachild,respondtohis/hercuesandsignalsand feedingachild,respondtohis/hercuesandsignalsand feedingachild,respondtohis/hercuesandsignalsand feedingachild,respondtohis/hercuesandsignalsand
feedwithcareandpatience. feedwithcareandpatience. feedwithcareandpatience. feedwithcareandpatience.
Feedachildextrafoodduringillnessandrecovery. Feedachildextrafoodduringillnessandrecovery. Feedachildextrafoodduringillnessandrecovery. Feedachildextrafoodduringillnessandrecovery.

Find out about the standard policy regarding vitamin and micronutrient supplementation for
childreninthelocalarea/region.
Familiarize yourself with the national policies and guidelines on infant feeding in the context of
HIVandAIDS,iftheyexist.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
151
FindoutiftherearechildfeedingcounsellorsformothersandfamilieswithHIV-positivechildren
availableinthelocalarea.

Collect/preparethefollowingmaterials:
An overhead projector and screen; and/or flipchart paper, markers and a means to attach
flipchart sheets to the wall or other surface. If an overhead projector is not used, overheads
maybewrittenoutonflipchartsheetsorenlargedcopiespreparedfordisplayasposters,as
appropriate.
Overhead10/1: Overhead10/1: Overhead10/1: Overhead10/1: Responsivefeeding Responsivefeeding Responsivefeeding Responsivefeeding
Overhead10/2: Overhead10/2: Overhead10/2: Overhead10/2: Feedingthechildwhoisill Feedingthechildwhoisill Feedingthechildwhoisill Feedingthechildwhoisill
Overhead10/3: Overhead10/3: Overhead10/3: Overhead10/3: Feeding Feeding Feeding Feedingachild achild achild achildduringrecovery duringrecovery duringrecovery duringrecovery
Handout10/ Handout10/ Handout10/ Handout10/1: 1: 1: 1: S S S Sample ample ample ampledaily daily daily dailymealp mealp mealp mealplan lan lan lanforchildren forchildren forchildren forchildren (availableattheendofthissession).
W WW Worksheet10/1 orksheet10/1 orksheet10/1 orksheet10/1: : : : Daily Daily Daily Dailymealplanner mealplanner mealplanner mealplannerforchildren forchildren forchildren forchildren (availableattheendofthissession).

1. Learning objectives and introduction to the session (2 minutes)


Review the learning objectives of the session

Showtheflipchartandoutlinethelearningobjectives.
Bytheendofthesession,participantswillbeableto;

Understandtheimportanceofoptimalinfantfeedingforgrowthanddevelopment;
DiscussthenutritionalconcernsofchildrenwithHIV;and
MakesuggestionsforfeedingachildwithHIVandduringillnessandrecovery.

Introduce the session
WhatmakesitparticularlyimportantforanHIV WhatmakesitparticularlyimportantforanHIV WhatmakesitparticularlyimportantforanHIV WhatmakesitparticularlyimportantforanHIV- -- -infectedchildtogetadequatenutrition? infectedchildtogetadequatenutrition? infectedchildtogetadequatenutrition? infectedchildtogetadequatenutrition?
Allowparticipantstogivetheirsuggestionsandthen,explainthefollowing:

Allchildrenneedadequatenutritionforgrowthanddevelopment.However,HIV-infectedchildren
mayneedspecialattentiontoensurethattheyreceiveadequateamountsoffoodandnutrients.
Mothers with children infected with HIV therefore, need to be given information and support to
ensurethattheirchildrengetextraenergy,aswellasproteinandallthemicronutrientsneededfor
theirgrowthanddevelopment.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
152
BecauseofthechallengesinassessingtheHIVstatusofyoungchildren,allHIV-positivemothers
needtoensurethattheirchildrenhaveenoughfoodintakeandnutritionalcare.
Inthissession,wewilldiscussnutritionconcernsforchildrenwithHIV.
Thesessionalsoincludessuggestionsforfeedingachildwhoisillorrecoveringfromanillness.

2. Nutritional concerns for children with HIV (2 minutes)



Explainthefollowing:
HIV-infected children are at greater risk of poor growth, common childhood illnesses such as,
diarrhoea,chestinfections,malariaandmalnutrition.

WhatarethefactorsthatcanmakeitdifficultforacaregivertogivechildrenwithHIVthenutrition WhatarethefactorsthatcanmakeitdifficultforacaregivertogivechildrenwithHIVthenutrition WhatarethefactorsthatcanmakeitdifficultforacaregivertogivechildrenwithHIVthenutrition WhatarethefactorsthatcanmakeitdifficultforacaregivertogivechildrenwithHIVthenutrition


theyneed? theyneed? theyneed? theyneed?
Allow participants to give their suggestions and then summarize the discussion using the
followingpoints;
Factorsthatmayleadtopoorgrowth,frequentillnessesandmalnutritioninHIV-positivechildren
includethefollowing:
Like adults, HIV-infected children may have difficulties eating due to poor appetite,
difficultiesinswallowing,nauseaandvomiting.
Lackofattentiontothechildateatingtimes.
Thetypeoffoodgiventothechildmaynotbewelltoleratedbythechild.
Parentswhoareillarelessabletoimplementappropriatefeedingpractices.

Because of these factors that may reduce food intake in children with HIV, mothers will need
guidanceandsupportforappropriatefeedingpracticesandtoensuretheimprovedfoodintakeof
theirchildrenduringillnessandrecovery.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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3. Feeding a child with HIV (30 minutes)

RefertotheStoryofSamandSuzitoillustratethediscussion.
THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI THESTORYOFSAMANDSUZI

SamandSuzisson,littleSamis18monthsoldandgrowingwell.HisHIVstatusisknown:he
hasbeenfoundtobeHIV-negative.
A neighbour of the family has a daughter Leila, who is two years old. Leila has not met her
developmentaltargetsandsheisoftenill.
LeilasfamilyisworriedthatLeilamayhaveHIValthoughshehasnothadatest.
LeilasmotherisillandLeilasfatherdiedayearago.
BecauselittleSamishealthy,LeilasmotherasksSuziforhelpinfeedingLeila.

Explainthefollowing:

Itisnotjustwhat what what whattypeoffoodthatisgiventhatmatters,butalsohow how how howthefoodisgiven,aswellas


theoverallcareofthechild.
3.1. Responsive feeding practices
SuzimaysuggesttoLeilasmotherthedifferentwaysofresponsivefeeding,thatshehaslearned
fromherhealthcareprovider.

Whatisresponsivefeeding? Whatisresponsivefeeding? Whatisresponsivefeeding? Whatisresponsivefeeding?



AllowparticipantstorespondandthenshowO OO Overhead10/1: verhead10/1: verhead10/1: verhead10/1: Responsivefeeding Responsivefeeding Responsivefeeding Responsivefeeding . .. .
OVERHEAD10/1:Responsivefeeding OVERHEAD10/1:Responsivefeeding OVERHEAD10/1:Responsivefeeding OVERHEAD10/1:Responsivefeeding

Responsivefeedingincludesthefollowing:
Feedinginfantsandassistingolderchildrentoeat.
Noticingchildrenshungerandsatietycuesorsigns.
Feedingslowlyandpatientlywithencouragement.
Tryingdifferentfoods,texturesandmethodsofencouragement.
Minimisingdistractions.
Ensuringthatfeedingtimesarealsoforlearningaswellasforshowingloveandcare.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Ask a volunteer participant to read the following possible suggestions Suzi can give to Leilas
mother:
Itisimportanttofeedinfantsdirectlyandtoassistolderchildrentofeedthemselves.
Childrenneedtobehelpedtolearntheskillsassociatedwitheating.
Besensitivetohungerandtosatietycuesorsigns.Theyindicatethatthechildhaseatenallthat
he/shewants.Forexample,thechildmaystopopeninghermouthforfood,turnawayfromfoodor
spititout.
Feedslowlyandpatiently.Encouragethechildtoeatbutdonotforceher.
If a child refuses many foods, it is good to try different food combinations, tastes, textures and
methodsofencouragement.
Minimizedistractionsduringmealsifthechildlosesinteresteasily.
Feedingtimesareperiodsoflearningandlove:talktochildrenduringfeeding,maintainingeye-to-
eyecontact.
Showthefirstkeypointdisplayedandaskaparticipanttoreaditoutloud.

KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Whenfeedingachild,respondtohis/hercuesandsignalsand Whenfeedingachild,respondtohis/hercuesandsignalsand Whenfeedingachild,respondtohis/hercuesandsignalsand Whenfeedingachild,respondtohis/hercuesandsignalsand
feedwithcareandpatience. feedwithcareandpatience. feedwithcareandpatience. feedwithcareandpatience.

3.2. Foods to suggest for young children
Explainthefollowing:
Like adults, all children need a variety of foods, including a staple food, animal food, vegetables
and fruits and some high-energy or enriched foods, such as those discussed in the previous
sessions.
Relative to their size, children need more food than adults do. However, young children have
smallstomachs,sotheyneedmorefrequentmeals.

WhataresomeofthefoodsyouwouldsuggestforfeedingchildrenlikeLeila? WhataresomeofthefoodsyouwouldsuggestforfeedingchildrenlikeLeila? WhataresomeofthefoodsyouwouldsuggestforfeedingchildrenlikeLeila? WhataresomeofthefoodsyouwouldsuggestforfeedingchildrenlikeLeila?


Allowtwoorthreeparticipantstogiveresponsesthenexplainthefollowing:
Foodstosuggestmayinclude:
Staple foods such as, cereals (rice, wheat, maize, millet), roots (cassava, yams and potatoes),
and starchy fruits (plantain and breadfruit) give your baby energy. However, such foods do not
containallthenutrientsthechildneedsandsootherfoodsshouldbeeateninadditiontothem.
Toensurethatchildrengetallthenutrientstheyneed,ateachmealselectdifferentfoodsfromthe
differentfoodgroups(seeO OO Overhead3/3 verhead3/3 verhead3/3 verhead3/3).
Asthechildgetsolder,increasethevarietyoffoodsthathe/sheeats.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
155
Mothersshouldensurethatolderchildren(oneyearorolder)whoarenolongerbeingbreastfed,
drinkenoughregularanimalmilktomeettheirgrowthanddevelopmentalneeds.
Givesmall,frequentmeals.By24months,thebabywillneedthreetofourmainmeals(onemeal
=1cup)andtwonutritioussnacksinbetween,inadditiontomilk.Forsnacking,encouragefinger
foodswhichthechildcaneasilypickup,e.g.slicedfruitsorbreadwithbutter.
Giveenrichedfoodsthatarefullofenergyandnutrients.Foodcanbeenrichedbyaddingoneto
twoteaspoonsofoil,butter,margarine,milkorgroundnuts/sesamepaste.
Givefinelyflakedfish,eggs,beans,andground-upnuts,finelycutupmeatorothersoftandeasily
digestiblefoodsfromthefamilysmeals.
Feed mashed fruits and vegetables such as, ripe banana, pawpaw, avocado, and pumpkin as
frequentlyaspossible.
Considertheuseoffermented,germinatedorfortifiedproducts.
If the child is not receiving breast milk or animal foods, they may need a multi-micronutrient
supplementwithvitaminsandminerals.
Childrenolderthansixmonthsneedwaterevenwhentheyaredrinkingmilk.Findoutifyourbaby
isstillthirsty,byofferingsafedrinkingwateraftereating.
Donotgivethechildglucosedrinks,sodasandsoft(fizzy)drinks.Avoidgivingspicyfoodstothe
childasitmayreducethechildsappetiteforotherfoodsthatcontainavarietyofnutrients.

WhatwillbedifferentifthedoctorfindsLeilaisHIV WhatwillbedifferentifthedoctorfindsLeilaisHIV WhatwillbedifferentifthedoctorfindsLeilaisHIV WhatwillbedifferentifthedoctorfindsLeilaisHIV- -- -positive? positive? positive? positive?


Allowparticipantstogivesomesuggestionsandthenexplainthefollowing:
ChildrenwithHIVneedextracalories;caregiversofthesechildrenneedtoworkonanappropriate
mealplanwiththehealthworkersandcaregivers.

DistributetoparticipantsH HH Handout andout andout andout 10/1: 10/1: 10/1: 10/1:S S S Sample ample ample ampledailymealplan dailymealplan dailymealplan dailymealplan f ff forchildren orchildren orchildren orchildren.
Theapproximatequantitiesoffoodsprovidedinthishandoutareonlyintendedasageneralguide
andneednotbeadheredtostrictly.
A flexible approach based on experience, local preferences and the availability of food is
important in ensuring that a wide range of foods are included in planning a variety of daily meal
options.
The meal planning guidance is based on the eight eating wisely guidelines we discussed in
S SS Session3 ession3 ession3 ession3. .. .Theamountoffoodgivenshouldbebasedonresponsivefeedingpractices.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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3.3. Meal planning (20 minutes)
Askparticipantstogetintogroupsoffive.Askeachgrouptowritedownexamplesoffoodchoices
thatcouldbesuggestedforLeilasdailymeals(3mealsand2snacksfortheday).
Ask each group to present their suggestions and write them down on W WW Worksheet 10/1 orksheet 10/1 orksheet 10/1 orksheet 10/1: A daily
mealplanner(foundattheendofthissessionandonpage106oftheParticipant'sManual).
In the last column, groups should write down any special considerations such as, why the
particularfoodandpreparationmethodwaschosen.Thesecanbelatertypedupandprintedas
areferenceforcareprovidersinthelocalarea/region).

4. Feeding a child during illness and recovery (5 minutes)



Show O OO Overhead 10/2 verhead 10/2 verhead 10/2 verhead 10/2: :: : Feeding Feeding Feeding Feeding a aa a child who is ill child who is ill child who is ill child who is ill . .. . Use the points below to give further
explanations:

OVERHEAD10/2:Feedingachildwhoisill OVERHEAD10/2:Feedingachildwhoisill OVERHEAD10/2:Feedingachildwhoisill OVERHEAD10/2:Feedingachildwhoisill

Makethechildcomfortable.
Bepatientandfeedslowly.
Feedsmallamountsfrequently.
Givefoodsthatthechildlikes.
Giveavarietyoffoodsandextrafluids.
Payattentiontothechildandmakefeedingtimepleasurable.

Very ill children with HIV are at risk of dying and take a longer time to recover with just normal
foodintake.Theyneedhigherintakesofenergyandnutrientstorecoverrapidly.
However,becauseofillnesstheyfacedifficultiesineatingandmayneedmoreattentioninfeeding
andmanagingthesedifficultiesaswellasintreatingsevereillness.

Show O OO Overhead verhead verhead verhead 10/3: 10/3: 10/3: 10/3: Feeding Feeding Feeding Feeding a child a child a child a child during recovery during recovery during recovery during recovery and use the points below to explain it
further.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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OVERHEAD10/3 OVERHEAD10/3 OVERHEAD10/3 OVERHEAD10/3:Feeding :Feeding :Feeding :Feedinga a a achildduringrecovery childduringrecovery childduringrecovery childduringrecovery

Feedanextra extra extra extrameal.
Giveanextra extra extra extraamount.
Useextra extra extra extrarichfoods.
Feedwithextra extra extra extrapatience.
Giveextra extra extra extrabreastfeedsorfluids.

Feedthechildmorefrequentlythanusualandgiveanextra extra extra extrameal.
Giveextra extra extra extraamountoffoodateachmealifthechildsappetiteisgood.
Givefoodsextra extra extra extrarichinenergyand/ornutrientssuchas,enrichedporridge.
Beextra extra extra extrapatientinencouragingthechildtoeatandmakehim/hercomfortable.
Ifbreastfeeding,giveextra extra extra extrabreastfeeds.
Ifthechildisnolongerbeingbreastfed,giveextra extra extra extrafluidssuchas,water.
Discusswithparticipantsthepossibilitiesforfamiliestopracticetheseguidelines.
Showthesecondkeypointdisplayedandaskaparticipanttoreaditoutloud.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Feedachildextra Feedachildextra Feedachildextra Feedachildextrafoodduringillnessandrecovery. foodduringillnessandrecovery. foodduringillnessandrecovery. foodduringillnessandrecovery.

5. Summary of the session and transition (3 minutes)

Show/reviewbothkeypointsdisplayed.
KEYPOINTS KEYPOINTS KEYPOINTS KEYPOINTS
Whenfeedingachild,respondtohis/hercuesandsignalsand Whenfeedingachild,respondtohis/hercuesandsignalsand Whenfeedingachild,respondtohis/hercuesandsignalsand Whenfeedingachild,respondtohis/hercuesandsignalsand
feedwithcareandpatience. feedwithcareandpatience. feedwithcareandpatience. feedwithcareandpatience.
Feedachildex Feedachildex Feedachildex Feedachildextrafoodduringillnessandrecovery. trafoodduringillnessandrecovery. trafoodduringillnessandrecovery. trafoodduringillnessandrecovery.

Summarizethesessionusingthefollowingpoints:
If a child is ill frequently, he/she may become malnourished and therefore, be at higher risk of
moreillness.Likeadults,childrenneedtobefedwisely,withavarietyofnutritiousfoods.
Childrenrecovermorequicklyfromillnessandloselessweightiftheyarehelpedtoeatwhenthey
areillandrecovering.
Care and attention to eating and extra food should be given to children during illness and
recovery.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Mothersshouldbeencouragedtotalktotheirhealthworkersforothersupportonfeedingchildren
withHIV.

DistributeHandout10/1totheparticipantsandexplainthefollowing:
This sample meal plan is intended only as a general guide. A flexible approach based on
experience,localpreferencesandtheavailabilityoffoodisimportantinensuringthatawiderange
offoodsareincludedinplanningavarietyofdailymealoptions.Thissampleplanisbasedonthe
eighteatingwiselyguidelinesdiscussedinSession3. Session3. Session3. Session3.Theamountoffoodgivenshouldbebased
onresponsivefeedingpractices

Askparticipantsiftheyhaveanyquestionsorifanythingneedsclarifying.
Inthenextsession,wewilldiscussimprovingaccesstofood.
Thenextsessionwillbepresentedby:
Statethenameofthepresenter.





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159

HANDOUT10/1:Sampledailymealplanforchildren HANDOUT10/1:Sampledailymealplanforchildren HANDOUT10/1:Sampledailymealplanforchildren HANDOUT10/1:Sampledailymealplanforchildren
12 12 12 12

MEALTIME MEALTIME MEALTIME MEALTIME EXAMPLESOFFOODCHOICES EXAMPLESOFFOODCHOICES EXAMPLESOFFOODCHOICES EXAMPLESOFFOODCHOICES SPECIALCONSIDERATIONS SPECIALCONSIDERATIONS SPECIALCONSIDERATIONS SPECIALCONSIDERATIONS
Breakfast Breakfast Breakfast Breakfast


2tablespoonsfreshorangejuicediluted
withwater
1cupporridgeservedwithwholemilk
added
1smallsliceofbreadspreadwith
margarine
1smallglassofmilk
Freshfruitjuicesalsocontainhighamountsofsugarandshouldbedilutedifnecessary.
Usesafedrinkingwater.

Mid Mid Mid Mid- -- -morning morning morning morning
snack snack snack snack

Selectionof1or2fingerfoods,suchas:
3breadsticks
chunksofapple
6grapes
1smallbanana
3chunksofmelon
1glassofwater
Washedandchoppedvegetablesandfruitsarenutritioussnacksandhelpthechildgain
appetite.

High-fatpotatoproducts(e.g.,chips/crisps)shouldbegivensparinglytochildrenassnacks,
becausetheyoftencontainpoorqualityfat,arehighinsaltandalsosuppresstheappetite.

Usesafedrinkingwater.
Lunch Lunch Lunch Lunch




1sliceofchickenandtomatobread
sandwich
3tablespoonsboiledpeasand1small
choppedboiledcarrot
1smallfruityoghurt
1glassofwater
Ifanimalfoodsarenotavailableorarenottoleratedbythechild,theycanbereplacedby
beansandlentils.
Milkandplain(safe)waterareconsideredappropriatedrinksthroughouttheday.
Freshfruitjuicecanalsobegivenatmealtimes.

12
Note for the facilitator: The menu provided as example was calculated for a requirement of 1200 calories + 10% (for HIV infection) = 1320 calories, distributed in
carbohydrates(59%),proteins(17%)andfat(28%).




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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MEALTIME MEALTIME MEALTIME MEALTIME EXAMPLESOFFOODCHOICES EXAMPLESOFFOODCHOICES EXAMPLESOFFOODCHOICES EXAMPLESOFFOODCHOICES SPECIALCONSIDERATIONS SPECIALCONSIDERATIONS SPECIALCONSIDERATIONS SPECIALCONSIDERATIONS
Mid Mid Mid Mid- -- -afternoon afternoon afternoon afternoon
snack snack snack snack




1smallglassofmilk
Selectionof1or2fingerfoods,suchas:
carrotsticks(1smallcarrot)
cucumberslices(1/2acucumber)
2cherrytomatoes
1glassofwater
Washedandchoppedvegetablesandfruitsarenutritioussnacksandhelpthechildgain
appetite.
High-fatpotatoproducts(e.g.,chips/crisps)shouldbegivensparinglytochildrenassnacks,
becausetheyoftencontainpoorqualityfat,arehighinsaltandalsosuppresstheappetite.
Sup Sup Sup Supper per per per





Mincedbeefingravyservedwith2
tablespoonsofmashedpotatoes
mashedspinach/pumpkin
pineappleslice
1glassofwater
Ifanimalfoodsarenotavailableorarenottoleratedbythechild,theycanbereplacedby
beansandlentils.
Freshcookedpotatoesservedindifferentwaysprovideavarietyoftexturesandcanbea
nutritiousadditiontothechildsmeal.
Thiscanreplacedbyothersoftcookedstarchesavailablesuchas,sweetpotatoes,rice,
cassava,yams.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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WORKSHEET10/1:Adailyme WORKSHEET10/1:Adailyme WORKSHEET10/1:Adailyme WORKSHEET10/1:Adailymealplannerforchildren alplannerforchildren alplannerforchildren alplannerforchildren
MEALTIME MEALTIME MEALTIME MEALTIME EXAMPLESOFFOODCHOICES EXAMPLESOFFOODCHOICES EXAMPLESOFFOODCHOICES EXAMPLESOFFOODCHOICES SPECIALCONSIDERATIONS SPECIALCONSIDERATIONS SPECIALCONSIDERATIONS SPECIALCONSIDERATIONS
Breakfast Breakfast Breakfast Breakfast



Mid Mid Mid Mid- -- -morning morning morning morning
snack snack snack snack




Lunch Lunch Lunch Lunch




Mid Mid Mid Mid- -- -afternoon afternoon afternoon afternoon
snack snack snack snack



Supper Supper Supper Supper





Nutritional Care and Support for People Living with HIV: Facilitators Guide
162

Session11:Improvingaccesstofood Session11:Improvingaccesstofood Session11:Improvingaccesstofood Session11:Improvingaccesstofood


Learning Learning Learning Learningo oo objectives bjectives bjectives bjectives

Bytheendofthissession,participantswillbeableto:
DescribehowHIVcanaffecthouseholdaccesstofood;and
DiscusshowaccesstofoodcanbeimprovedforhouseholdsaffectedbyHIV.

Session Session Session Sessiono oo outline utline utline utline
Content Content Content Content Time Time Time Time
1 Learningobjectivesandintroductiontothesession 5minutes
2 EffectsofHIVandAIDSonaccesstofood 5minutes
3 Improvingaccesstofood 10minutes
4 Supportforimprovingaccesstofood 30minutes
5 Summaryofthesessionandtransition 5minutes
Total Total Total Total 55minutes 55minutes 55minutes 55minutes

Preparation for the session

Writeanddisplaythelearningobjectivesonaflipchartsheet.
Writethekeypointonaflipchartsheetandkeepitasideuntilneeded.

KEYPOINT KEYPOINT KEYPOINT KEYPOINT


Usethefoodsyouhaveavailableandlookforhelp Usethefoodsyouhaveavailableandlookforhelp Usethefoodsyouhaveavailableandlookforhelp Usethefoodsyouhaveavailableandlookforhelponhow onhow onhow onhowtoeatwisely. toeatwisely. toeatwisely. toeatwisely.

Find the answers to the following questions about households in your community and make
enoughhandoutsofthesequestionsandtheiranswersforalloftheparticipants,

Whatfoodsarecommonlyeatenandhowaretheseobtained?
Aretheygrown/producedbythehousehold;obtainedfromhunting,fishingorgathering;boughtin
ashop;orbartered/swappedwithotherfamilies?




Nutritional Care and Support for People Living with HIV: Facilitators Guide
163
Are some foods only available at certain times of the year? How does this affect the variety of
foodseaten?
Do families with high income and low income eat the same foods? If not, how are they different
andwhyaretheydifferent?Whatdothesedifferencesmeanforhealthandwell-being?
What programmes exist in the area that are related to food access? Who benefits from these
programmes? How do they benefit? Which local self-help and other organizations assist poor
householdswithaccesstofood?

Collect/preparethefollowingmaterials:
Anoverheadprojectorandscreen;and/orflipchartpaper,markersandameanstoattachflipchart
sheetstothewallorothersurface.Ifanoverheadprojectorisnotavailable/used,overheadsmay
be written out on flipchart sheets or enlarged copies prepared for display as posters, as
appropriate.
Overhead Overhead Overhead Overhead 11/1: 11/1: 11/1: 11/1: What to do to improve access to food for What to do to improve access to food for What to do to improve access to food for What to do to improve access to food for people livi people livi people livi people living with HIV ng with HIV ng with HIV ng with HIV and their and their and their and their
households households households households
Overhead11/2 Overhead11/2 Overhead11/2 Overhead11/2: : : :Support Support Support Supportfor for for forimprov improv improv improving ing ing ingaccesstofood accesstofood accesstofood accesstofood
Handout11/1: Handout11/1: Handout11/1: Handout11/1:Identifyingcommunitysupportfornutrition Identifyingcommunitysupportfornutrition Identifyingcommunitysupportfornutrition Identifyingcommunitysupportfornutrition (availableattheendofthissession).
Worksheet11/1:Identifyingcommunitysupportfornutrition Worksheet11/1:Identifyingcommunitysupportfornutrition Worksheet11/1:Identifyingcommunitysupportfornutrition Worksheet11/1:Identifyingcommunitysupportfornutrition (availableattheendofthissession).

1. Learning objectives and introduction to the session (5 minutes)
Review the learning objectives of the session
Showtheflipchartandoutlinethelearningobjectives.

Bytheendofthissession,participantswillbeableto:
DescribehowHIVcanaffecthouseholdaccesstofood;and
DiscusshowaccesstofoodcanbeimprovedforhouseholdsaffectedbyHIV.
Introduce the session
Household food security is assured when, at all times, household members have access to
sufficient,safeandnutritiousfoodthatmeetstheirneedsforanactiveandhealthylife.

Whatdoyouunderstandtob Whatdoyouunderstandtob Whatdoyouunderstandtob Whatdoyouunderstandtoby yy y household household household householdfoodsecurity foodsecurity foodsecurity foodsecurity ? ?? ?
Allowparticipantstorespond,andsummarizetheirresponseswithfollowingpoints:





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Householdfoodsecurityisabout:
How members of a household produce produce produce produce or acquire acquire acquire acquire food throughout the year and use
householdresources,includingtimeandmoney,togainaccesstofood;
How households process process process process
13
, preserve preserve preserve preserve
14
or store store store store their food to overcome seasonal
shortagesorimprovethequalityandsafetyoftheirfoodsupply;and
How food is used used used used and shared shared shared shared among the various household members to meet their
specificneeds.
HIVcanaffectaccesstofoodbyreducingahouseholdscapacitytoproduceoracquirefood.This
is because in order to pay for medicalcare, households are often forced to sell their assets and
foodreserves,resultinginthelossoflandandotherproductiveresourcesandincomeneededto
acquirefood.
Stigma can also contribute to uneven allocation of food in the household by favouring healthier
membersofthehouseholdandfurtherreducingtheaccesstofoodofpeoplelivingwithHIV.
Intheprevioussessions,wehavetalkedabouttheappropriateuseoffoodsuchaseatingwisely
and improving food intake. However, it will be difficult for people living with HIV to follow these
guidelines if their access to food is limited. They need additional support to help improve their
accesstofood.
Inthissession,wewilldiscussmoreabout how HIV affectsaccesstofoodforpeoplelivingwith
HIVandtheirhouseholds.Wewillalsodiscussvariouswaysofimprovingaccesstofood.These
measureswillassisthealthworkersandothercaregiverstoofferappropriatesuggestionsonhow
people living with HIV and their households can improve their access to food in different
situations.

2. Effects of HIV on access to food (5 minutes)

HowcanHIVinfluenceonesaccesstofood? HowcanHIVinfluenceonesaccesstofood? HowcanHIVinfluenceonesaccesstofood? HowcanHIVinfluenceonesaccesstofood?

AsktheparticipantstothinkabouttheinfluenceofHIVandAIDSonboththequalityandquantity
offoodaccessed.
Allowparticipantstorespondandwritedownthekeypointsraisedonaflipchartsheet;discuss
theseusingthefollowingpointsforadditionalinformation:

13
Foodprocessingisthemethodusedtochangerawfoodintoediblefood.Rawfoodmayneedtopassthrough
different steps of processing before consumption. Processing may also be required to make food last longer
withoutspoilage.

14
Food preservation is the method of handling food in such a way as to stop or slow down spoilage and to
prevent food-borne illness while maintaining nutritional quality, textureand flavour. Methods for preserving food
include: drying, smoking, salting, fermentation, heating, bottling, canning, refrigeration and addition of chemical
preservatives.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
165

2.1. Effect of HIV on how households produce or acquire food


Illnessanddeathinahouseholdcanreduceaccesstofoodthroughreducedcapacityto:
Uselandforfoodproduction,eitherbecauseofreducedphysicalabilitytodoworkonthe
land(planting,weeding,harvesting)orduetolossofland;
Earnmoney;
Gotothemarkettobuyfood;
Preparefood;and/or
Providecareforchildren,elderlyandillmembersofthehousehold.
Theamountoftimespentcaringforanillpersonorthepsychologicalpressuresinthehousehold
mayalsoresultinchildrengettinglesscare.Insuchasituation,childrenmaybeatgreaterriskof
malnutrition,eveniftheydonothaveHIVthemselves.
Older children may drop out of school to earn income and help care for ill members of the
household. Lack of education and care will also affect childrens future since they lack basic
educationandlifeskills.
Widowedwomenandorphanedchildrenmaynotbeabletostayinthesamelocationorkeepon
using the land and other resources as they once did. Because of traditional inheritance laws in
manycommunities,widowsoftenlosetheirentitlementstolandwhentheirhusbandsdie.
Money spent on health care can reduce the amount of money available for food. Savings and
foodstores,includingseedforthenextplantingseason,maybeusedupandnotreplaced.

2.2. Effect of HIV on how households process, preserve and store food
Oncefoodhasbeenplantedandharvested,householdsneedtodecidehowtoutilizethefoodfor
immediateconsumptionandtostorefoodforfutureconsumption.
Many of the methods of food processing and preservation used at home such as, grinding and
poundingaretime-consumingandlabour-intensive.Thesetasksmaynotbeeasilyperformedby
veryillpersonsorchildrenwhohavelosttheirparents/caregivers.

2.3. Effect of HIV on how households use and share the food within the family
Whenmembersofahouseholdeattogether,themannerofservingthemealandthedistribution
ofdifferentfooditemsmayaffectthefoodintakeofdifferentfamilymembers.Somepracticesmay
resultinwomenandchildrenreceivinglessfood,despitetheirhighnutritionalneeds.
Adultswhoareill,orchildren,maynotbevaluediftheyarenotproductive.Therefore,theymay
notbegiventheamountandqualityoffoodtheyneed.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
166
In order to provide people living with HIV with appropriate suggestions for meeting their specific
nutritional needs by improving food access and intake, it is important to know how food is
preparedandsharedamongvarioushouseholdmembers.

3. Improving access to food (10 minutes)

Explainthefollowing:

EarlydiagnosisofHIVwillenableimprovementstofoodaccessthatcanprolonglifeandkeepthe
personhealthyandproductiveforalongerperiodoftime.
Health workers and other support workers need to discuss with people living with HIV and their
familymembersaboutaccesstofoodandeatingconcernssoonafterdiagnosiswithHIV.
Health/supportworkersneedtoworkwiththeindividualorhouseholdtoassesstheirfoodaccess
situation and recommend improvements that are feasible or refer them to other support
programmesasappropriate.
ShowO OO Overhead verhead verhead verhead11/ 11/ 11/ 11/1: 1: 1: 1: I I I Improvingaccesstofoodfor mprovingaccesstofoodfor mprovingaccesstofoodfor mprovingaccesstofoodforpeoplelivingwith peoplelivingwith peoplelivingwith peoplelivingwithHIV HIV HIV HIVandtheirhousehold andtheirhousehold andtheirhousehold andtheirhouseholds s s s

OVERHEAD11/1:WhattodotoimproveaccesstofoodforPLHIVandtheirhou OVERHEAD11/1:WhattodotoimproveaccesstofoodforPLHIVandtheirhou OVERHEAD11/1:WhattodotoimproveaccesstofoodforPLHIVandtheirhou OVERHEAD11/1:WhattodotoimproveaccesstofoodforPLHIVandtheirhouseholds seholds seholds seholds


Askparticipantstoturntopage110oftheParticipant'sManualandaskthreeparticipantstoread
thefollowing:

Participant 1: Raising awareness


Raisingawareness abouttheeffectsofHIVonaccesstofood willensurethatpeoplelivingwithHIV
arenotexcludedfromthecommunityandpeopleknowhowtosupportthem.

Awareness-raising
aboutthelinks
betweenHIVand
nutrition

Continuous
discussiontoidentify
foodaccess
problemsand
solutions

Referraltoother
support
programmes




Nutritional Care and Support for People Living with HIV: Facilitators Guide
167
Participant 2: Continuous discussions
Continuous discussions offer an opportunity to share experiences and talk about factors affecting
access to food and suggestions to reduce or overcome the problems. All family members, including
childrenneedtobeinvolvedindiscussionsaboutaccesstofood.

Participant 3: Referral for more support
NotonlynutritionistanddieticiansplayaroleinsupportingpeoplelivingwithHIVandtheirhouseholds
to improve access to food and nutrition. Health workers, agricultural extension workers, community
development agents, teachers, religious leaders, self-help groups and other organisations can also
contribute and help the household have improved access to food. There may be also government
agencies and local organisations providing care and support to people living with HIV and their
familiestoimprovetheiraccesstofood.

For referral, a good starting point would be to make a list of local organisations, institutions, groups
and important persons in the community and the support they provide that could contribute to
improvingaccesstofood.

4. Support for improving access to food (30 minutes)

4.1. Types of support/services for improving food access
ConstructOverhead11/2 Overhead11/2 Overhead11/2 Overhead11/2withparticipantsasfollows:
Drawacircleinthemiddleofaflipchartsheetandwriteaccesstofood accesstofood accesstofood accesstofood insideit..
Draw another circle next to it, and as an example write psycho psycho psycho psychological and emotional logical and emotional logical and emotional logical and emotional
support support support support ; connect this circle to the middle circle with an arrow to show that it is among the
typesofsupportthatcanhelpimprovefoodaccess.
Askparticipantstoaddandfillinothercirclesinasimilarway.
Refer to Overhead 1 Overhead 1 Overhead 1 Overhead 11/2 1/2 1/2 1/2 and add other key factors that were not raised by participants to
completethechart.
Show O OO Overhead 11/2: Support to improve access to food verhead 11/2: Support to improve access to food verhead 11/2: Support to improve access to food verhead 11/2: Support to improve access to food and use the points below to
discusstoexplainit.





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OVERHEAD11/2:Supporttoimproveaccesstofood OVERHEAD11/2:Supporttoimproveaccesstofood OVERHEAD11/2:Supporttoimproveaccesstofood OVERHEAD11/2:Supporttoimproveaccesstofood

Supportandservicesforimprovingfoodaccessmayinclude:
Psychological and emotional support for PLHIV in making decisions regarding the
disclosure of their HIV status and generally helping them cope with living with the
disease.
Householdorcommunitygardenstoensureaccesstoplentyofaffordablefreshfoods.
Food assistance, as a temporary measure to support adults, pregnant and lactating
womenandchildrenwhomaybemalnourished.
Home-based care, hospices or day-care for ill members of the household or children, if
theparentsareill.
Incomegeneratingactivities,credit,insuranceschemesandgrantstoincreasetheability
topurchasefood,improveinputsordiversifyincomesources.
Support with policies and regulations to ensure that the most vulnerable, including
widows,orphansandtheelderlyhaveaccesstoland,productiveresourcesand/orother
resources/income for meeting their nutritional needs, e.g. instituting fair and equitable
inheritancerights,andassetprotectionmeasuresforwidows/orphans.
Other financial support which could include, meeting the direct costs of school fees and
healthcarecosts.
Simpleandeasyfoodpreservationandstoragemethodstomaintainthequalityoffoodin
storeandextendfoodstocks,inordertominimizetheneedforadditionalfoodpurchases.
Home-based
care,hospices
orday-care
Food
assistance Household/
community
gardens
Income-
generating
activities
Lifeskillsand
vocational
training
Credit,
insurance
schemes
andgrants
Improvingfood
production,
preservation
andstorage
Psychological
andemotional
support
Accessto Accessto Accessto Accessto
food food food food




Nutritional Care and Support for People Living with HIV: Facilitators Guide
169
Life skills and vocational training for children and youth to expand their employment
opportunities.
4.1. Types of support/services for improving food access

Ask participants to turn to page 113 of the Participant's Manual and read H HH Handout 11/1 andout 11/1 andout 11/1 andout 11/1: : : :
Identifying community support for nutrition Identifying community support for nutrition Identifying community support for nutrition Identifying community support for nutrition. .. . This handout can also be used to identify available
supportandimportantpersonstobecontactedfornutritioncareandsupport.
Askparticipantstonowturntopage114oftheParticipant'sManualanddiscussWorksheet11/1: Worksheet11/1: Worksheet11/1: Worksheet11/1:
Identifying community support for nutrition with participants Identifying community support for nutrition with participants Identifying community support for nutrition with participants Identifying community support for nutrition with participants; allow them to fill in the answers
appropriatetotheirlocalarea,asyouproceed.


5. Summary of the session and transition (5 minutes)

Showthekeypointdisplayedandaskaparticipanttoreaditoutloud.

KEYPOINT KEYPOINT KEYPOINT KEYPOINT


Usethefoodsyouhaveavailableandlookforhelp Usethefoodsyouhaveavailableandlookforhelp Usethefoodsyouhaveavailableandlookforhelp Usethefoodsyouhaveavailableandlookforhelponhow onhow onhow onhowtoeatwisely. toeatwisely. toeatwisely. toeatwisely.

It is important to think about HIV as affecting the entire household and not just those who are
livingwiththedisease.Supportgiventoaffectedhouseholdsshouldtherefore,addressthebasic
needsofallthemembers.
Families,includingchildren,needtobeinvolvedindiscussionsaboutaccesstofood.Trytostart
thesediscussionsbeforethesituationbecomescritical.
Health or support workers may be the first to be asked for assistance. It is therefore, very
important that they know which organisationsin the area provide support and how such support
canbeobtained.
Collaborationandlinkagesbetweendifferentserviceprovidersandsectorssuchas,health,local
welfare services, agriculture, education, as well as water and sanitation services, is essential in
ordertofacilitatetheprovisionofsupportandassistanceforimprovingfamiliesaccesstofood.

Askparticipantsiftheyhaveanyquestionsorifanythingneedstobemadeclearer.
Inthenextsession,wewilldiscusstheuseofnutritionalsupplementsandherbalremedies
Thenextsessionwillbepresentedby:
Statethenameofthepresenter.





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HANDOUT11/1:Identifyingcommunitynutritionalsupport HANDOUT11/1:Identifyingcommunitynutritionalsupport HANDOUT11/1:Identifyingcommunitynutritionalsupport HANDOUT11/1:Identifyingcommunitynutritionalsupport

TYPESOFFOOD TYPESOFFOOD TYPESOFFOOD TYPESOFFOOD- -- -SECURITY/NUTRITIONAND SECURITY/NUTRITIONAND SECURITY/NUTRITIONAND SECURITY/NUTRITIONAND
LIVELIHOODSUPPORT LIVELIHOODSUPPORT LIVELIHOODSUPPORT LIVELIHOODSUPPORT
WHOCOULDHELP? WHOCOULDHELP? WHOCOULDHELP? WHOCOULDHELP?
Informationoneatingwisely,includingfooddiversity,
improvingfoodintakeandkeepingfoodsafe.
Nutritionists/dieticians;healthworkers
Informationonfoodproductioninasmallplacethatdoes
notrequirealotoflabour.Forexample,home/communal
gardeningandrearingsmallanimals,aregoodwaysof
makingaffordablefreshfoodsavailabletoahousehold.
Agriculturalextensionworkers
Informationonhowtopreserveandstorefood,including
informationonhowtochooseprocessedfoods,incase
householdsdonothavefoodtopreserve.
Agriculturalextensionworkers
Informationonappropriatewaysofpreparingandsharing
mealswithinthefamilytoensurefairshareoffood,
especially,forpeoplelivingwithHIV,children,pregnant
andlactatingwomen.
Nutritionists,dieticians;health
workers
Income-generatingactivitiesthatcanimprovea
householdsabilitytobuyfoodandcareforafamily
memberwhoisill.
Micro-financeorganisations
Socialsupportmechanism,including,socialgrants,self-
help,andwelfareschemes.

Communitydevelopmentworkers;
communityleaders;self-help/support
groups;faith-basedgroups;social
developmentandwelfareagencies
Caringforandeducating,vulnerablechildreninthe
household,providingthemwithshelter,food,schoolfees,
lifeskillandvocationaltraining.
Communitydevelopmentworkers,
self-help/supportgroups,faith-based
groups,socialgrant/welfareagencies
Raisingawarenessaboutthespecialneedsandconcerns
ofHIV-affectedhouseholdsinordertoreducestigmaand
discriminationsothatpeoplewithHIVarenotexcluded
fromthecommunityandcommunitymembersknowhow
tohelp.
Socialandcommunitydevelopment
workers
PreventingnewHIVinfectionsandhelpingpeopleliving
withHIVandthosewhoareaffectedbythediseasetolive
longer,betterqualityandproductivelives.
Healthworkers
Providingpsychologicalandemotionalsupport,for
example,byrecognizingpeoplelivingwithHIVandtheir
familiesaspartofthecommunity;supportingthosewho
disclosetheirstatusandgenerallyhelpingthemcopewith
thedisease.
Support/caregroups;faith-based
groups

Helpingwiththecareofanillperson,orwiththechildren
inthefamilyiftheparentsareill.
Healthworkers;support/caregroups
Providingfoodtotheveryillandorphanedchildren.

Communitydevelopmentworkers;
communityleaders,support/care
groups,socialgrant/welfareagencies




Nutritional Care and Support for People Living with HIV: Facilitators Guide
171


WORKSHEET11/1:Identifyingcommunitysupportfornutritionwithparticipants WORKSHEET11/1:Identifyingcommunitysupportfornutritionwithparticipants WORKSHEET11/1:Identifyingcommunitysupportfornutritionwithparticipants WORKSHEET11/1:Identifyingcommunitysupportfornutritionwithparticipants

1.WhatkindsofsupportmaybeneededbyindividualsorfamiliesaffectedbyHIVandAIDS?
2.Whichservices,organisations,groups,andimportantpersonsworkwiththecommunitytohelp
householdsgrowfoodand/orearnmoney?
3. What services, organizations, groups, and important persons help people who are too ill to
work?
4.Arethereparticulargroupsorpeoplethatareexcludedfromjoiningorreceivingservicesfrom
some of these sources? (for example, if services are only for men, women, or for families with
short-termneeds.)Whichonesandwhy?
5. What might prevent a person or family from obtaining assistance from such people,
organisationsorservices?
6. In what ways could these local services and organisations work together to help families
acquireadequatefoodfortomeetthenutritionalneedsoftheirhouseholdmembers.
7. Is there a need for services or assistance from organisations outside the local community? If
so,whattypesofexternalservicescouldmakealong-termdifferencetothecommunity?





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Session Session Session Session 12: 12: 12: 12: Use of nutritional supplements and herbal Use of nutritional supplements and herbal Use of nutritional supplements and herbal Use of nutritional supplements and herbal
remedies remedies remedies remedies


Learni Learni Learni Learningobjectives ngobjectives ngobjectives ngobjectives
Bytheendofthissession,participantswillbeableto:
Discusstheuseofnutritionalsupplementsandherbalremedies;and
Evaluate alternative practices and products commonly recommended for/ used by people
livingwithHIV.

Sessionoutl Sessionoutl Sessionoutl Sessionoutline ine ine ine

Content Content Content Content Time Time Time Time
1 Learningobjectivesandintroductiontothesession 5minutes
2 Categoriesofproductsandherbalremedies 10minutes
3 EvaluatingproductsclaimforHIV 15minutes
4 Warningflags 5minutes
5 Summaryofthesessionandtransition 5minutes

Total Total Total Total 40minutes 40minutes 40minutes 40minutes

Preparation for the session

Writeanddisplaythelearningobjectivesonaflipchartsheet.
Writethekeypointsonaflipchartsheetandkeepitasideuntilneeded.

KEYPOINTS KEYPOINTS KEYPOINTS KEYPOINTS
Nothingcanreplaceeatin Nothingcanreplaceeatin Nothingcanreplaceeatin Nothingcanreplaceeatingwisely. gwisely. gwisely. gwisely.

Donotbelieveeverythingyouhear. Donotbelieveeverythingyouhear. Donotbelieveeverythingyouhear. Donotbelieveeverythingyouhear.
Discussthebenefitsandrisksofall Discussthebenefitsandrisksofall Discussthebenefitsandrisksofall Discussthebenefitsandrisksofallalternative alternative alternative alternativepracticesandproducts. practicesandproducts. practicesandproducts. practicesandproducts.

Findoutwhichsupplementsandtraditionalremediesarecommonlyusedinthelocalarea,ifany,
andwhattheycost.
If possible, collect some containers, leaflets or labels with information on these products for
demonstration.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Draw a table with four columns on a flipchart sheet with the following headings: Helpful Helpful Helpful Helpful , , , ,
Neutral Neutral Neutral Neutral , , , , Harmful Harmful Harmful Harmful , , , ,Donotknow Donotknow Donotknow Donotknow. .. .Discusswiththecoursedirectorandco-facilitatorsandchoose
some examples of local products that you agree fit into each category, and write them down in
theappropriatecolumn.YouwillusethistableduringtheExercise12 Exercise12 Exercise12 Exercise12/1. /1. /1. /1.
Thepurposeofthegroupactivitythissessionistohelpparticipantslearntoevaluatetreatments
ratherthancometoagroupconclusionaboutwhatistoberecommended.
Collect/preparethefollowingmaterials:
Anoverheadprojectorandscreen;and/orflipchartpaper,markersandameanstoattachflipchart
sheetstothewallorothersurface.Ifanoverheadprojectorisnotavailable/used,overheadsmay
bewrittenoutanddisplayedonflipchartsheets.
Overhead Overhead Overhead Overhead12/1: 12/1: 12/1: 12/1: Evalua Evalua Evalua Evaluatingproductsclaimsfor tingproductsclaimsfor tingproductsclaimsfor tingproductsclaimsforHIVand HIVand HIVand HIVandAIDS AIDS AIDS AIDS
Overhead Overhead Overhead Overhead12/2: 12/2: 12/2: 12/2: Warningflags Warningflags Warningflags Warningflags
Handout 12 Handout 12 Handout 12 Handout 12/1: Questions that may help in evaluating herbal remedies and other products /1: Questions that may help in evaluating herbal remedies and other products /1: Questions that may help in evaluating herbal remedies and other products /1: Questions that may help in evaluating herbal remedies and other products
(availableattheendofthissession).

1. Learning objectives and introduction to the session (5 minutes)



Review the learning objectives of the session

Showtheflipchartandoutlinethelearningobjectives.

Bytheendofthissession,participantswillbeableto:
Discusstheuseofnutritionalsupplementsandherbalremedies;and
Evaluate alternative practices and products commonly recommended for/used by people
livingwithHIV.
Introduce the session

ManypeoplewithHIVusedifferentproducts,remediesandtreatmentsforHIV.Atpresentthereis
no evidence of herbal remedies that can cure or treat HIV. However, service providers need to
understandandbesensitivetobeliefsandthekindsofalternativeproductsusedbypeopleliving
withHIV.
Someofthesenutritionalsupplementsandherbalremediesmaybebeneficialandsomemaybe
harmfultopeoplewithHIV.Itisimportanttofindoutmoreabouttheproducts,notethosethatare
harmful and discuss with people living with HIV, traditional healers or those who promote those
productswhytheuseofsuchproductsshouldbediscouraged.




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There are many information materials listing supplements and herbal remedies reported to be
beneficial.Eventhoughforsomepeoplesuchproductscouldbetheonlyoptiontheyhave,before
using herbal remedies, individuals need to evaluate products and identify those that can be
harmfulandthosethatcanbeofbenefit.PeoplelivingwithHIVshouldbesupportedindeciding
whetheraproductortreatmentmightbeusefulforthemaswellascost-effective.
Thepurposeofthissessionistodiscussthedifferentwaysofevaluatingtheseproductswiththe
aimofidentifyingthosethatcouldbeharmfulandshouldbediscouraged,whilepromotingthose
thatareeffectiveandlow-costalternativetreatments.
ThiswillenableserviceproviderstocounselpeoplelivingwithHIVaboutnutritionalsupplements
andherbalremediesthatmaybeharmful.

2. Categories of products and herbal remedies (10 minutes)


Whataresomeoftheproductsorpracti Whataresomeoftheproductsorpracti Whataresomeoftheproductsorpracti Whataresomeoftheproductsorpractic cc cesthatyouhaveheardasbeingusedorrecommended esthatyouhaveheardasbeingusedorrecommended esthatyouhaveheardasbeingusedorrecommended esthatyouhaveheardasbeingusedorrecommended


topeoplewithHIV? topeoplewithHIV? topeoplewithHIV? topeoplewithHIV?
Allowtwoorthreeparticipantstogiveexamplesandlisttheirresponsesonaflipchartsheet.
Explain that these products could be categorized into nutritional supplements nutritional supplements nutritional supplements nutritional supplements (food-based
nutritionalsupplements/nutrientsupplements)andherbalremedies herbalremedies herbalremedies herbalremedies (traditionalremedies,herbs
andspices).
Asktwoparticipantstotaketurnsreadingthefollowing:
2.1. Nutritional supplements (Participant 1)

NutritionalsupplementsmaybeneededtohelpmeetthenutrientneedsofpeoplelivingwithHIVwho
have lost their appetite/whose food intake has decreased or who are not tolerating their usual diet.
Nutritionalsupplementscanhelppreventmalnutritionincluding,micronutrientdeficiencies.However,
suchsupplementsareonlyadditionstothedietandshouldnotbeusedasasubstituteforfood.There
aretwotypesofnutritionalsupplements,namely:

Food-based nutritional supplements:


Food-basednutritionalsupplementsareintheformoffooditems.Suchsupplementscouldbegiven
topeoplelivingwithHIVwhosefoodintakeisinadequate.
15


15
Give examples of nutritional supplements that are used locally. Often, these are powders added to milk or
otherdrinksandusedanytimepeoplearenoteatingwell.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Example: Replacing solid food with fluids for persons who are unable to eat but able to drink and/or
for those with limited food access. (Contact your local Ministry of Health or nutritionist for more
information).

Suchfood-basednutritionalsupplementscouldalsobemadeathomeandareusuallyconvenientto
prepare.However,especiallyiftheyareintendedasthetotalfoodintakeofapatientformorethana
fewdays,theiruseshouldbediscussedwithadietician,nurseordoctor.

Nutrient supplements:
Nutrient supplements are vitamin and mineral products in the form of tablets, pills or liquids. Such
productscancontainasinglevitaminormineraloracombinationoftwoormorenutrients,commonly
knownasm mm multi ulti ulti ulti- -- -vitamin vitamin vitamin vitamins ss sorm mm multi ulti ulti ulti- -- -mineral mineral mineral minerals ss s.

Nutrient supplements are often not easily available; they are expensive and leave less money for
food.Amixeddietshouldprovideenoughofthesevitaminsandminerals.Itwouldtherefore,bebetter
to provide a good mixed diet including, animal products, fruits and vegetables whenever possible,
ratherthanbuyingsupplements.

In cases where the food intake of people living with HIV is very low, multi-vitamin and multi-mineral
supplements can help to meet their increased nutritional requirements. The following guidelines
shouldbeadheredto:

Seek advice from a dietician, nurse or doctor before recommending supplements to people with
HIV,inordertogetthebestvalueformoney.
Alwaystakevitaminpillsonafullstomach.Beconsistentandtakethemregularly.
It is often more practical and cheaper to take a combined product (multivitamin and mineral
supplements) rather than several pills containing different vitamins and minerals, as people
usuallyhavemorethanonedeficiency.
However, iron supplements may be a problem for people with HIV, as they can increase the
activityofsomebacteria.Supplementsthatdonotcontainironmaythereforebetter.
Take supplementation according to the advice on the label. More is not better. Taking a high
dose is a waste, can cause nausea, vomiting, decreased appetite, liver and kidney problems; it
mayalsointerferewiththeimmunedefencesystem.




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2.2. Herbal treatments and remedies (Participant 2)

Traditional and herbal remedies promoted as treatment
Herbal remedies present alternatives to formal biomedical practices, and are among the treatments
oftenofferedbytraditionalhealers.PeoplelivingwithHIVshouldbeadvisedtoalwaysdiscussother
treatmentssuchastheuseofherbalremedieswithhealthworkers,doctorsornutritionists.

PeoplelivingwithHIVshouldbemadeawareofherbalremediesthatcouldbeharmfultotheirhealth.
Health workers should explain to people living with HIV, traditional healers and others offering such
treatments,whytheuseofsuchremediesshouldbediscouraged.
Herbs and spices
Herbs and spices used in food during preparation should be differentiated from traditional herbal
remedies.Someofthebenefitsofherbsandspiceswhichinclude,improveddigestion improveddigestion improveddigestion improveddigestion,stimulationof stimulationof stimulationof stimulationof
appetite appetite appetite appetiteandfoodpreservation foodpreservation foodpreservation foodpreservationaregeneralandnotspecifictoHIV.

As the effects of such herbs and spices may not be the same for all people, they should be used in
moderate amounts. Excessiveusemaycauseproblemsand have atoxiceffect.Moreover,itshould
beemphasisedthefunctionofsuchherbsandspiceswillnotbeincreasedbytakingtheminexcess.

More evidence is needed because very littleisknown about the interactions between herbs and the
medication people living with HIV might be taking. Supplements, herbs and spices are not an
alternativetoeatingwisely.Theyshouldbeusedasadditionstofoodeaten.

Showthefirstkeypointdisplayed,,andaskaparticipanttoreaditoutloud.

KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Nothingcanreplaceeatingwisely. Nothingcanreplaceeatingwisely. Nothingcanreplaceeatingwisely. Nothingcanreplaceeatingwisely.





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3. Evaluating products claims for HIV (15 minutes)

On what basis would youevaluate whether a product does what the person selling On what basis would youevaluate whether a product does what the person selling On what basis would youevaluate whether a product does what the person selling On what basis would youevaluate whether a product does what the person selling/promoting /promoting /promoting /promotingit it it it
saysitcando? saysitcando? saysitcando? saysitcando?
Allowafewparticipantstorespond,andwritetheirresponsesdownonaflipchartsheet.
Addpointsthatmayhavebeenmissedfromthefollowing:

No secret cures or therapies for HIV exist. To help people living with HIV make decisions,
consideranddeterminewhethertheherbalremedyis:
Helpfulorbeneficial:ifthereisindependentscientificevidencetosupportit;
16

Neutral:ifthereisastrongbeliefthatitisneitherhelpfulnorharmful;or
Harmfulordangerous.
Youmayaskforopinionsfromdifferentpeoplewhohavenothingtogain.

Exercise 12/1: Evaluating practices and herbal remedies

Guiding questions that may help in evaluating the safety of herbal remedies and products are
providedinH HH Handout12/1 andout12/1 andout12/1 andout12/1attheendofthissessionandonpage120oftheParticipant'sManual.
Divide the participants into small groups and give the samples of some of the supplements or
remediesthatyouhadbroughtforthesession
Askthegroupstousethechecklistinoverhead12/1toevaluatetheproduct
Leteachgrouppresenttheirfindingsfordiscussion.

Communicating with the people with HIV about nutritional supplements and herbal remedies is
essential. The uses of questions like: What else are you using to take care of your health? is
recommended to help find out the nutritional supplements and herbal remedies that the person
maybetaking.


16
Independentscientificevidenceontheeffectivenessofaproductisyieldedbyindependentstudiesdonebysomeoneother
thanthecompanyproducing/promotingtheproduct.




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4. Warning flags (5 minutes)
ShowO OO Overhead12/2: verhead12/2: verhead12/2: verhead12/2: Warningflags Warningflags Warningflags Warningflags andaskoneparticipanttoreadoutthepoints.

OVERHEAD12/2:Warningflags OVERHEAD12/2:Warningflags OVERHEAD12/2:Warningflags OVERHEAD12/2:Warningflags

Thisisthecure;itgivesmiracleresults.
Donotuseanyothertreatments.
Thisdoctor(product/treatment)istheonlyonewhichcanhelpyou.
Itcostsalotofmoney.
Personalaccountsarethemain/mostreliablesourceofinformationonresults.
Theingredientsareasecret.

Askparticipantstoidentifythosestatementsthattheyhaveheardbeingcommonlyused.
Showthesecondkeypointdisplayed,andaskaparticipanttoreaditoutloud.

KEYPOINT KEYPOINT KEYPOINT KEYPOINT

Donotbelieveeverythingyouhear. Donotbelieveeverythingyouhear. Donotbelieveeverythingyouhear. Donotbelieveeverythingyouhear.
Discussthebenefitsandrisksofall Discussthebenefitsandrisksofall Discussthebenefitsandrisksofall Discussthebenefitsandrisksofallalternative alternative alternative alternativepracticesandproducts. practicesandproducts. practicesandproducts. practicesandproducts.

Atpresent,thereisnoevidencethatherbalremediescancureortreatHIV.
CommunicatingwithpeoplelivingwithHIVaboutnutritionalsupplementsandherbalremediesis
essentialtoensurethattheyareawareofherbalremediesthatcouldbeharmfultotheirhealth.
You can use your communication skills to ask open ended-questions, reflect and clarify, accept
whatthepersonissaying,givesomeinformationand/oroffersuggestions.
PeoplelivingwithHIVshouldbesupportedinevaluatingwhetheraproductortreatmentmaybe
h hh helpful elpful elpful elpful/beneficial beneficial beneficial beneficial,whetherthereisastrongbeliefthatitisneutral neutral neutral neutral, ,, , orh hh harmfu armfu armfu armful ll l/dangerous /dangerous /dangerous /dangerousforthem.
Seek advice from a dietician, nurse or doctor before recommending supplements, so as to
ensurethebestvalueformoney.
Traditional healers and religious leaders are esteemed and trusted in most communities; work
withthemtofindthebestwaytoshareinformationonherbalremediesandproductsthatcouldbe
harmfulforpeoplewithHIV.





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5. Summary of the session and transition (5 minutes)

Show/reviewbothkeypointsdisplayed.
KEYPOIN KEYPOIN KEYPOIN KEYPOINTS TS TS TS
Nothingcanreplaceeatingwisely. Nothingcanreplaceeatingwisely. Nothingcanreplaceeatingwisely. Nothingcanreplaceeatingwisely.

Donotbelieveeverythingyouhear. Donotbelieveeverythingyouhear. Donotbelieveeverythingyouhear. Donotbelieveeverythingyouhear.
Discussthebenefitsandrisksofallalternativepracticesandproducts. Discussthebenefitsandrisksofallalternativepracticesandproducts. Discussthebenefitsandrisksofallalternativepracticesandproducts. Discussthebenefitsandrisksofallalternativepracticesandproducts.
Askparticipantsiftheyhaveanyquestionsandifanythingneedstobemadeclearer.

In the next session, we will review the course and talk about ways in which we can use the
knowledgeandskillsacquiredfromthiscourseinourwork.
Thenextsessionwillbepresentedby:
Statethenameofthepresenter.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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HANDOUT12/1:Questionsthatmayhelpin HANDOUT12/1:Questionsthatmayhelpin HANDOUT12/1:Questionsthatmayhelpin HANDOUT12/1:Questionsthatmayhelpinevaluatingherbalremediesandotherproducts evaluatingherbalremediesandotherproducts evaluatingherbalremediesandotherproducts evaluatingherbalremediesandotherproducts



Iftheanswerto anyofthesequestionsis yes yes yes yesor do notknow do notknow do notknow do notknow,thentheproductmaybeharmfulto
thehealthofindividuals.

QUESTIONS QUESTIONS QUESTIONS QUESTIONS YES YES YES YES NO NO NO NO DO DO DO DONOT NOT NOT NOTKNOW KNOW KNOW KNOW
Does the product or herb contain substances in amounts that
couldbeharmful? (asknutritionisttohelpyoureadthelabels)

Does the product or herb have harmful interactions with other
foodsandanyothermedicationthatyouaretaking?

Does the product or therapy replace or delay seeking health
careandtreatmentthatisgenerallyregardedaseffective?

Doestheproductortherapypromoteoremphasizeaparticular
productornutrient?

Does the product provide enough energy and protein along
with a variety of other nutrients? (ask nutritionist to help you
readthelabels)

Doyouhavetopayalotofmoneyfortheproductortherapy?
Does buying this product reduce money available for buying
food?

Doesuseoftheremedyreduceyourfoodintake?







Nutritional Care and Support for People Living with HIV: Facilitators Guide
181

Session13:Courserevi Session13:Courserevi Session13:Courserevi Session13:Coursereviewandactionplanning ewandactionplanning ewandactionplanning ewandactionplanning

Learning Learning Learning Learningo oo objectives bjectives bjectives bjectives



Bytheendofthissession,participantswillbeableto:

Listkeypointsaboutnutrition,careandsupporttosharewithpeoplelivingwithHIV;
Discusstheimportanceofcaringforthecaregiver;
Outlinewaysinwhichthecourseinformationcanbeputintopractice;and
Discussanyquestionsregardingnutrition,careandsupportforpeoplelivingwithHIV.


Session Session Session Sessiono oo outline utline utline utline
Content Content Content Content Time Time Time Time
1 Learningobjectivesandintroductiontothesession 5minutes
2 Reviewofcommunicationskills 10minutes
3 Reviewofkeypoints 10minutes
4 Actionplanning 30minutes
5 Caringforcaregivers 10minutes
6 Summaryofthesessionandtransition 5minutes
Total Total Total Total 70minutes 70minutes 70minutes 70minutes

Preparation for the session



Writeanddisplaythelearningobjectivesonasheetofflipchartpaper.
Writethekeypointforthissessiononaflipchartsheetandkeepitasideuntilneeded.

KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Caregiversneedcaretoo. Caregiversneedcaretoo. Caregiversneedcaretoo. Caregiversneedcaretoo.

Thissessionshouldbefacilitatedbyallthefacilitatorsthathaveparticipatedinthecourse.
Theactivitiesforthissessionaredividedintotwomainparts:
Reviewactivitiesthatwillbedoneinplenary;and
Actionplanningactivitiesthatwillbedoneingroups.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
182
Decidewithparticipantsatthestarthowbesttodividethegroups(byparticipantsregion/local
area,orthehealthfacility/typeoffacilityorservicewheretheywork).
Collect/preparethefollowingtrainingmaterials:
An overhead projector and screen; and/or flipchart paper, markers and a means to attach
flipchart sheets to the wall or other surface. If an overhead projector is not available/used,
overheadsmaybewrittenoutonflipchartsheetsorenlargedcopiespreparedfordisplayas
posters,asappropriate.
Haveallthekeypointsdiscussedthroughoutthecourseavailablefordisplay(butkeepthem
covereduntilthestartofthesession).
Overhead Overhead Overhead Overhead 2/ 2/ 2/ 2/2 22 2: : : : Sixlisteningandl Sixlisteningandl Sixlisteningandl Sixlisteningandlearning earning earning earnings ss skills kills kills kills
Overhead Overhead Overhead Overhead 2/ 2/ 2/ 2/3 33 3; ; ; ; S SS Sixs ixs ixs ixskills kills kills killsforbuildingconfidenceandgivingsupport forbuildingconfidenceandgivingsupport forbuildingconfidenceandgivingsupport forbuildingconfidenceandgivingsupport
Overhead13/1: Overhead13/1: Overhead13/1: Overhead13/1: Plac Plac Plac Placestopromotenutritionfor estopromotenutritionfor estopromotenutritionfor estopromotenutritionforpeoplelivingwith peoplelivingwith peoplelivingwith peoplelivingwithHIV HIV HIV HIV
Post Post Post Post- -- -test: test: test: test:prepareenoughcopiesforallparticipants(seeAnnex Annex Annex Annex7 77 7).
Course Course Course Coursee ee evaluation valuation valuation valuations ss sheet heet heet heet: : : :prepareextracopiesforparticipantswhomayhavemisplacedtheir
copysincetheopeningsession.

1. Learning objectives and introduction to the session (5 minutes)


Review the learning objectives of the session
Showtheflipchartandoutlinethelearningobjectives.
Bytheendofthissession,participantswillbeableto:
Listkeypointsaboutnutrition,careandsupporttosharewithpeoplelivingwithHIV;
Discusstheimportanceofcaringforthecaregiver;
Outlinewaysinwhichthecourseinformationcanbeputintopractice;and
Discussanyquestionsregardingnutrition,careandsupportforpeoplelivingwithHIV.

Introduce the session

WehavefollowedSamandSuzithroughafewyearsoftheirlives.Sincetheyfoundoutthatthey
wereHIV-positive,theyhavefacedmanychallenges.Eatingwiselyhashelpedthemtokeepwell
forlonger.
Suzi has had a lot of contact over the last few years with support services for people living with
HIV. One of these service providers asks Suzi if she would like to work with them as a support
worker.
In this session, we will look at how Suzi learns to be a support worker. In doing so we will also
revisethekeypointsyouhavelearntthroughoutthecourse.




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Suzi becomes a support worker


Suzi likes the idea of becoming a support worker and starts the training. Part of the training is
learningaboutcommunicationskills.
Suziknowsfromherownexperiencethatithelpstoknowthatsomeonecaresenoughaboutyou
tolistenattentivelyandtalktoyouaboutfoodandeating.
Usingsuchlisteningandtalkingskillsisoneofthekeypointswehavediscussed.

2. Review of communication skills (10 minutes)

Display/uncoverthekeypoint(discussedinSession2)

KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Whenyou Whenyou Whenyou Whenyouensurephysicalcomfort, ensurephysicalcomfort, ensurephysicalcomfort, ensurephysicalcomfort,listenandtalkaboutfoodandeating,youshowthat listenandtalkaboutfoodandeating,youshowthat listenandtalkaboutfoodandeating,youshowthat listenandtalkaboutfoodandeating,youshowthat
youcareabouttheperson. youcareabouttheperson. youcareabouttheperson. youcareabouttheperson.

Whatarethemaincommunication Whatarethemaincommunication Whatarethemaincommunication WhatarethemaincommunicationskillsforSuzitorememberwhenworkingwithaclient? skillsforSuzitorememberwhenworkingwithaclient? skillsforSuzitorememberwhenworkingwithaclient? skillsforSuzitorememberwhenworkingwithaclient?

AllowparticipantstogiveresponsesthenshowO OO Overhead2/ verhead2/ verhead2/ verhead2/2 22 2: : : : Sixl Sixl Sixl Sixlistening istening istening istening and and and andl ll learning earning earning earnings ss skills kills kills kills
andaskoneparticipanttoreadouttheskills.

OVERHEAD2/2:Sixlisteningandlearningskills OVERHEAD2/2:Sixlisteningandlearningskills OVERHEAD2/2:Sixlisteningandlearningskills OVERHEAD2/2:Sixlisteningandlearningskills


1.Usinghelpfulnon-verbalcommunication;
2.Usingresponses/gestureswhichshowinterest;
3.Empathising;
4.Askingopen-endedquestions;
5.Reflectingbackwhattheclientsays;and
6.Avoidingwordswhichsoundjudgmental.

ShowO OO Overhead2/ verhead2/ verhead2/ verhead2/3 33 3: :: : Six Six Six Sixskill skill skill skills s s sfor for for forbuild build build building ing ing ingconfidenceandgiv confidenceandgiv confidenceandgiv confidenceandgiving ing ing ingsupport support support supportandaskanother
participanttoreadit.





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OVERHEAD2/3:Sixskillsforbuildingconfidenceandgivingsupport OVERHEAD2/3:Sixskillsforbuildingconfidenceandgivingsupport OVERHEAD2/3:Sixskillsforbuildingconfidenceandgivingsupport OVERHEAD2/3:Sixskillsforbuildingconfidenceandgivingsupport
1. Acceptingwhataclientthinksandfeels;
2. Recognisingandpraisingwhataclientisdoingright;
3. Givingpracticalhelp;
4. Givingalittle,relevantinformationwhichcanbeofimmediateusetotheclient;
5. Usingsimplelanguage;and
6. Makingafewsuggestions,ratherthangivingcommands.

Suzicannowusethelearningandlistening;andbuildingconfidenceandsupportskills.
Askifanyonehasanyquestionontheseskillsandhowtousethem.

3. Review of key points (10 minutes)



Suzi works as a support worker

Suzi attended this course on nutritional care and support for people living with HIV. When Suzi
workswithfamiliesaffectedbyHIV,shetellsthemhowimportantnutritioncanbetotheirquality
oflife.
WhatarethekeypointsaboutfoodandeatingthatSuzicanshare? WhatarethekeypointsaboutfoodandeatingthatSuzicanshare? WhatarethekeypointsaboutfoodandeatingthatSuzicanshare? WhatarethekeypointsaboutfoodandeatingthatSuzicanshare?
Allowparticipantstogiveresponses.Aimtogetallthekeypointsmentioned.
Youcanmakethisagame.Forexample,youcanaskallparticipantstostandupandtoonlysit
downoncetheyhavecontributedakeypointthathasnotbeenmentioned.
Display/uncovereachkeypointasitismentioned.

Suzi sees clients of various kinds and in various settings: individual adults, children, families,
groupsinthecommunity,atthehospitalandathome.
Indifferentsettingsandsituations,Suzimaygivemoreemphasistosomemessages,depending
ontheneedsofthosewithwhomsheworks.





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185
KEYPOINTS KEYPOINTS KEYPOINTS KEYPOINTS

Awell-nourishedpersonhasastrongerbodytofightinfectionandcopewithHIV.
Whenyouensurephysicalcomfort,listenandtalkaboutfoodandeating,youshowthatyou
careabouttheperson.
When you assure confidentiality and give clients support by praising their positive practices
relatedtofoodandeating,youhelpbuildtheirself-confidence.
Aimtoeatawidevarietyoffoods,ateachmeal,everyday.
Follow the five key steps to safer foods and stopping germs from making you and those
aroundyouill.
Eatwellandwiselyduringillnessandwhenrecoveringfromanillness.
Whensymptomsstart,increaseenergyintaketoreduceorpreventweightloss.
Physicalactivitycanhelpyoufeelbetter.
Understandingmedicationside-effectshelpscarefulselectionoffoodsforpreparingnutritious
mealsandagoodnutritionplan.
ARTworkswellinpeoplewhohavegoodnutritionalpractices.
Eatingwiselyduringpregnancyhelpsthemotherandthebabytostayhealthy.
Eatingwiselyduringbreastfeedinghelpsthemotherandthebabytostayhealthy.
All mothers with HIV should receive counselling to guide them in choosing infant feeding
optionssuitablefortheirsituation.
Whenfeedingachild,respondtohis/hercuesandsignalsandfeedwithcareandpatience.
Feedachildextrafoodduringillnessandrecovery.
Usethefoodsyouhaveavailableandlookforhelponhowtoeatwisely.
Nothingcanreplaceeatingwisely.
Donotbelieveeverythingyouhear.Discussthebenefitsandrisksofallalternativepractices
andproducts.
Caregiversneedcaretoo.





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186
4. Action planning (30 minutes)

ACTIVITY 13/1: How are we going to use this information?
Askparticipantstogetintothegroupsforthisactivityasagreedduringthepreparationfor
thissession.
Explainthefollowing:
The focus of this activityis on working together to discuss and commit to a plan of action
thatwecanallputintopracticeinordertoaddressthenutritioncareandsupportneedsof
peoplelivingwithHIVdiscussedthroughoutthecourse.
Askthevariousgroupsto:
Identifyandwritedownthecurrentnutritioncareandsupportsituationintheirareaofwork;
Askthemtospecifywhattheywouldwanttoimproveinthecurrentsituationbasedonthe
knowledgeandskillstheyhaveacquiredthroughthiscourse;
Ask them also how they are going to use the information from this course to improve
nutritioncareandsupportforPLHIVandtheirhouseholdsandthecommunity.
Askeachgrouptowritetheirideasonaflipchartsheet.Allowparticipants20minutesto
completethisactivity.Thenaskeachgrouptotaketurnspresentingtheirideasfor
discussion.
Encourageparticipantstowritedownsomeofthekeyactivitiesthattheyhavediscussedin
thespaceprovidedintheirParticipant'sManuals(page125)forfuturereference.

5. Care for caregivers (10 minutes)

The organisation that Suzi works with is aware that people who are providing care and support
need to be cared for themselves. Caregivers include, nurses, doctors, peer support workers,
dieticians,counsellors,aswellasfamiliesandneighbours.

Showthekeypointforthissessionandaskaparticipanttoreaditoutloud.
KEYPOINT KEYPOINT KEYPOINT KEYPOINT
Caregiversneedcaretoo. Caregiversneedcaretoo. Caregiversneedcaretoo. Caregiversneedcaretoo.

Askparticipantstodiscusswaysthatcareandsupportcouldbegiventocaregiversbythe
organisation,institutionorotherbodywithwhichthecaregiverswork.





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Whenthecaregiverisafamilymemberorneighbour,howcantherestofthecommunityprovide Whenthecaregiverisafamilymemberorneighbour,howcantherestofthecommunityprovide Whenthecaregiverisafamilymemberorneighbour,howcantherestofthecommunityprovide Whenthecaregiverisafamilymemberorneighbour,howcantherestofthecommunityprovide
careforthecaregiver? careforthecaregiver? careforthecaregiver? careforthecaregiver?

Askparticipantstofocusonthecaregiverratherthanthoseforwhomtheyprovidecare.
Writedowntheirresponsesonaflipchartsheet.
Followingaresomeexamplestosuggest,ifparticipantsfinditdifficulttothinkof waysofcaring
forthecaregiver:
Itcanbedifficultforsupportworkerstotalktoothersabouteatingwiselyiftheyareshortoffood
themselves.Someorganisationsprovidefoodparcelsfortheirworkers.
Support from other caregivers in the same situation and being able to discuss their feelings can
alsohelp.
Shared care, respite services and ensuring that caregivers have some time for themselves can
givecaregiversachancetorest.

Concludethediscussionwiththefollowingpoint.

Knowledgeandskillscanhelpacaregivertofeelmoreconfident.Theinformationprovidedinthis
course can enhance the care and support caregivers offer to people living with HIV and their
families. Many people are able to do something about the foods they eat. Caregivers can thus
alsobemotivatedbythepositiveresultsthatcanbeattainedbyputtingtheknowledgeandskills
acquiredthroughthiscourseintopractice.

6. Summary of the session and transition (5 minutes)

NutritionalcareandsupportcanmakeadifferencetothelivesofpeoplelivingwithHIVandtheir
families.Thefoodtheyeatmaybeoneareathatpeoplearelikelytohavesomecontrolover.
Nutrition care and support are not just short-term actions; they are ongoing ongoing ongoing ongoing activities, requiring
continuous reflection, dialogue and reinforcement, depending on the needs of those with whom
youareworking.
People living with HIV need the support of their families, communities and those who care for
themtocarryoutsomeoftherecommendedpractices.

ShowO OO Overhead13/1:Placestopromotenutrition verhead13/1:Placestopromotenutrition verhead13/1:Placestopromotenutrition verhead13/1:Placestopromotenutritionfor for for forpeoplelivingwith peoplelivingwith peoplelivingwith peoplelivingwithHIV HIV HIV HIV,andread/explainit.





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OVERHEAD13/1:PlacestopromotenutritionforPLHIV OVERHEAD13/1:PlacestopromotenutritionforPLHIV OVERHEAD13/1:PlacestopromotenutritionforPLHIV OVERHEAD13/1:PlacestopromotenutritionforPLHIV
Places to
promote
nutrition for
PLHIV
Part of VCT
programmes
During counselling
for clinical problems
With self-help
and support
groups
Home care visits
During
inpatient
care
Nutrition
education


You can use the information from this course in many areas. You can use the knowledge and
skills you have acquired with those you assist, to share with colleagues, your own families and
communities.
I(We)hopethatthiscoursehasgivenyousomeusefulknowledgeandskillsforprovidingsupport
andcaretopeoplelivingwithHIV.

Askparticipantsiftheyhaveanycommentsorquestions.
InformparticipantsthattheyarenowgoingtocompletethecourseP PP Post ost ost ost- -- -test test test testandthattheyhave
20minutestodoso.DistributecopiesofthePost-test.
OncetheyhavecompletedthePost-test,informparticipantsthattheyarenowreadytoproceed
totheclosingsessionofthecourse.
RemindparticipantstoalsohandintheircompletedCourse Course Course Coursee ee evaluation valuation valuation valuations ss sheets heets heets heetswhichwere
distributedduringtheopeningsession.
Introducetheperson(s)whowillclosethecourse.






Nutritional Care and Support for People Living with HIV: Facilitators Guide
189


Closingsession Closingsession Closingsession Closingsession

The duration of this closing session will vary depending on whether an external guest speech/
closing ceremony for presenting certificates of attendance is planned. If no such ceremony is
plannedtheclosingsessionwilltakeabout15minutes.

Preparation for the session

Collect/preparethefollowingmaterials:
Ifcertificatesofattendancearetobegiven,ensurethattheyarepreparedinadvance.
Makealistofallthepeoplewhoneedtobethankedfortheircontributionstothecourse.
Overhead Overhead Overhead Overheado oo opening pening pening pening/ // /1 11 1: :: :Courseaims(seeOpeningSession OpeningSession OpeningSession OpeningSession).
RemindparticipantsbeforethestartofthissessiontocompletetheCourseevaluationsheets.

Introduce the session


Explain how this closing session is organised; introduce the guest speaker if one has been
invited.
ShowO OO OverheadOpening verheadOpening verheadOpening verheadOpening/ // /1 11 1andremindparticipantsofthecourseaims.

OVERHEADOPENING/ OVERHEADOPENING/ OVERHEADOPENING/ OVERHEADOPENING/1:Courseaims 1:Courseaims 1:Courseaims 1:Courseaims


The aim of this course is to assist community level health service providers community level health service providers community level health service providers community level health service providers and other other other other
extensionworkers extensionworkers extensionworkers extensionworkersto:
Improvetheirknowledgeandskillsonnutritioncareandsupportforpeoplelivingwith
HIV;
Understand the importance of using good communication skills when providing
nutritioncareandsupportforpeoplelivingwithHIV;and
Be able to effectively transfer the key nutrition messages to people with HIV, their
familymembersandtheircommunity.

Closing remarks
Usethefollowingaspartofyourclosingremarks:
Nutrition is an essential part of the care for people living with HIV. As soon as a person knows
he/sheisHIV-positive,he/sheneedstopayattentiontotheirdietandensurethattheyareeating




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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wisely.
Briefly review some of the action plans discussed forfollowing up on the course and continuing
activities.
Thank you for participating and sharing your experiences, your thoughts and your ideas during
thiscourse.
Thankotherpeoplewhohavecontributedsuchas,theorganizers.
Presentcertificatesifneeded.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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A AA Annex nnex nnex nnex 1: 1: 1: 1:T TT The he he hestoryofSamandSuzi storyofSamandSuzi storyofSamandSuzi storyofSamandSuzi

Sam and Suzi, a young couple, recently diagnosed to be both HIV-positive who are expecting their
firstbaby.
PICTURE1/1:SamandSuzi PICTURE1/1:SamandSuzi PICTURE1/1:SamandSuzi PICTURE1/1:SamandSuziexpectingtheirfirstbaby expectingtheirfirstbaby expectingtheirfirstbaby expectingtheirfirstbaby





PICTURE1 PICTURE1 PICTURE1 PICTURE1/2 /2 /2 /2:SamandSuzi :SamandSuzi :SamandSuzi :SamandSuziexpectingtheirfirstbaby expectingtheirfirstbaby expectingtheirfirstbaby expectingtheirfirstbaby








Nutritional Care and Support for People Living with HIV: Facilitators Guide
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WefirstmeetSamandSuziinS SS Session2: ession2: ession2: ession2:Introductiontoc Introductiontoc Introductiontoc Introductiontocommunicationskills ommunicationskills ommunicationskills ommunicationskills, ,, ,whentheyhavecome
forbasicnutritioncounsellingfollowingthediagnosis.ThestoryofSamandSuziisusedtointroduce
ustothreedifferentstylesofinteractingastheymeetwiththreedifferentcounsellorstodiscussabout
nutrition.Thishelpstoillustratetheeffectofcounsellingstylesonthepatternsofinteractionbetween
clientandthecounsellor.Wethenmeet Samand Suziagainin S SS Session3:Eatingwisely ession3:Eatingwisely ession3:Eatingwisely ession3:Eatingwisely, , , , whenthey
attendtheE E E Eatingwisely atingwisely atingwisely atingwisely talk.

Later in the course, the story of Sam and Suzi is used to introduce nutrition care and support for
patientsatdifferentstagesofthedisease,indifferentphysiologicalstates(pregnancy,breastfeeding),
andatdifferentages(infants,children).InS SS Session5:Improvingfoodintake, ession5:Improvingfoodintake, ession5:Improvingfoodintake, ession5:Improvingfoodintake,Samstartstoexperience
some opportunistic infections. He first had tuberculosis that was treated, followed by bouts of
diarrhoeaandsoremouthwhichaffecthisfoodintake.Samseeksformorenutritioncounsellingand
support.Helooksforsuggestionsthatmighthelphimwithhisnewproblems.Thestoryintroducesus
to circumstances when you will need to give suggestions for improving food intake during a
counselling session. In the story, Sam tries some of the suggestions he is given. He starts eating
betterandhisstrengthalsoimproves.Heisnowabletotakeregularwalkswithhisfamily.

In S SS Session 6: ession 6: ession 6: ession 6: P PP Preventing weight loss and promoting physical activities reventing weight loss and promoting physical activities reventing weight loss and promoting physical activities reventing weight loss and promoting physical activities, the story of Sam and Suzi is
usedtointroducethemanagementofweightconcerns,specifically,weightlossasaconsequenceof
frequentopportunisticinfections.Becauseoftheseboutsoftheopportunisticinfections,Samsweight
islowerthanitwasafewmonthsago,asillustratedinPicture2 Picture2 Picture2 Picture2.Arole-playofSamandcounselloris
usedtoillustratecounsellingskillsthatcanbeusedatthisstage,aswellasthepossiblereactionsofa
client. Sam and the support worker talk more about Sams weight loss and how he can monitor his
weight at home where there is no weighing scale (e.g., by checking whether his clothes are getting
loose and paying closer attention to the comments of people around him about his weight). The
counsellorremindsSamthatitisessentialtovisitstheclinicregularlyandtoconsultwiththesupport
workerwhenhenoticessignsofweightloss.Thehealth/nutritionworkerinformsSamaboutdifferent
ways of preventing weight loss, regaining lost weight and the importance of physical activity. They
alsotalkaboutsimplephysicalactivitiesthatSamcoulddoregularly.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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PICTURE2 PICTURE2 PICTURE2 PICTURE2/1 /1 /1 /1:SamandSuzi :SamandSuzi :SamandSuzi :SamandSuzi:weightloss :weightloss :weightloss :weightloss




PICTURE2: PICTURE2: PICTURE2: PICTURE2:/2 /2 /2 /2SamandSuzi SamandSuzi SamandSuzi SamandSuzi:weightloss :weightloss :weightloss :weightloss









Nutritional Care and Support for People Living with HIV: Facilitators Guide
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In session 7: Nutrition care and support for people on ART session 7: Nutrition care and support for people on ART session 7: Nutrition care and support for people on ART session 7: Nutrition care and support for people on ART, the story of Sam and Suzi is used to
illustrate nutrition counselling at the advanced stages of HIV infection (AIDS) and particularly, when
AIDS patients start antiretroviral treatment. We meet Sam at the stage where he has become very
weak and his health has generally deteriorated. His doctor recommends several tests and some
drugs.Basedonthetestresults,thedoctorneedstostartSamonART.Samispreparedandenrolled
for ART (a combination of three drugs: d4T + 3TC + EFV). A role-play between the health/ nutrition
worker and Sam is used to illustrate nutrition counselling skills needed to interact with a person
initiatingARTtreatment.Therole-playemphasisestheinteractionbetweenfoodandmedication.

InSession8:Nutritioncareandsupportduringpregnancyandbreastfeeding, Session8:Nutritioncareandsupportduringpregnancyandbreastfeeding, Session8:Nutritioncareandsupportduringpregnancyandbreastfeeding, Session8:Nutritioncareandsupportduringpregnancyandbreastfeeding,wemeetSamandSuzi
during the E E E Eating wisely during pregnancy ating wisely during pregnancy ating wisely during pregnancy ating wisely during pregnancy demonstration talk. We meet them again in S SS Session 9: ession 9: ession 9: ession 9:
InfantfeedingoptionsforHIVpositivemothers InfantfeedingoptionsforHIVpositivemothers InfantfeedingoptionsforHIVpositivemothers InfantfeedingoptionsforHIVpositivemotherswhentheyattendanothertalkforpregnantwomenon
infantfeedingaimedathelpingthemmakeadecisionabouthowtofeedtheirbaby.Afterthetalk,they
decide that exclusive breastfeeding is the best choice for them. The counsellor praises them for
thinkingaboutinfantfeedingoptionsduringpregnancyandforcomingtodiscussit(demonstratingthe
communication skill of praising good practice). The counsellor then refers them to a lactation
counsellor,formoreinformationonsaferbreastfeedingpractices.

In S SS Session ession ession ession 9 9 9 9 we also use the story of Sam and Suzi to introduce some of the common barriers that
HIV-positive women are faced with when they choose exclusive breastfeeding for their infants. The
importanceofdisclosingonesHIVstatusatthisstageandduringthetransitionperiodwhenmothers
needtostopbreastfeedingisemphasisedasfollows.

Suzicontinuestobreastfeedexclusively.Everythinggoeswell;sheiseatingwisely,takingsomerest
and feeding her baby frequently using good breastfeeding practices. However, the couple do have
oneproblem.Samsmother,Granny,thinksthebabyneedswaterandteaaswellasbreastmilk,as
illustratedinP PP Picture icture icture icture 3 33 3ofSamandSuzi.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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PI PI PI PICTURE3 CTURE3 CTURE3 CTURE3/1 /1 /1 /1:SamandSuzi :SamandSuzi :SamandSuzi :SamandSuzi,thebabyandgrandmother ,thebabyandgrandmother ,thebabyandgrandmother ,thebabyandgrandmother




PICTURE3 PICTURE3 PICTURE3 PICTURE3/2 /2 /2 /2:SamandSuzi :SamandSuzi :SamandSuzi :SamandSuzi,thebabyandgrandmother ,thebabyandgrandmother ,thebabyandgrandmother ,thebabyandgrandmother

ThegrandmothercannotunderstandwhySuziandSamaresoinsistentthatthebabyonlyhasbreast
milk. Suzi explains to Granny that exclusive breastfeeding is best for babies. The baby gets all he
needsfrombreastmilk.Hedoesnotneedwaterortea. Grannykeepsaskingaboutgivingwaterand
other things to the baby. Sam and Suzi are afraid Granny will start giving the baby water and other




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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foodsherself. SamandSuzidecidetotellGrannythattheyareHIV-positiveandexplainwhyitisvery
importanttobreastfeedexclusivelytoreducetheriskofthebabygettingtheHIV.Grannyisupsetthat
theydidnottellhersoonerthattheyhadHIV,butsheisverysupportive.

Suzi breastfeeds exclusively little Sam and wants to stop breastfeeding completely and start giving
other foods and fluids to the baby when he is six months. However, if Suzi stops breastfeeding
suddenly; she may get engorged breasts, feel ill and her baby will need another source of food and
comfort.Suziwillneedtodiscussherdecisiontostopbreastfeedingwithabreastfeedingcounsellorto
minimiseanyhealthrisksanddiscomfortduringthistransition.

In S SS Session ession ession ession 11: 11: 11: 11: F FF Fee ee ee eeding a child with HIV ding a child with HIV ding a child with HIV ding a child with HIV, we use the story of Sam and Suzi to illustrate nutritional
management during illness and recovery, especially for children who have frequent infections that
may be due to HIV. Since Sam and Suzi took good care of themselves and the baby, Little Sam is
growingwellandisfoundtobeHIV-negativewhenheistestedat18months.Wethereforeintroduce
a new family, Sam and Suzis neighbours. The family have a daughter Leila, who is two years old.
Leilahasnotmetherdevelopmentaltargetsandsheisoftenill.LeilasfamilyisworriedthatLeilamay
have HIV although she has not been tested. Leilas mother is ill and Leilas father died a year ago.
BecauseLittleSamishealthy,LeilasmotherasksSuziforhelpinfeedingLeila.Suzi,recallssomeof
thelessonsshelearntfromthecounsellorssuchas,responsivefeedingandsharesthisinformation
andsomemealplanningpracticessheusesforLittleSamwithLeilasmother.

Finally, in Session 13 Session 13 Session 13 Session 13: :: : Review of the course Review of the course Review of the course Review of the course, we use the story of Sam and Suzi to introduce the
concept of nutrition care and support for caregivers. Since Suzi now has good knowledge and
experience about nutrition and HIV, a community-based organisation employs her as a support
worker. The organisation that Suzi works with is aware that people who are providing care and
supportneedtobecaredforthemselves.Caregiversmaybenurses,peersupportworkers,doctors,
dieticians, counsellors, families or neighbours. Course participants can use this story to try and
identifythevarioustypesofsupport/servicesthatcanbegiventosupportworkers/caregivers.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Annex 2: Nutritional care and support focus at different stages Annex 2: Nutritional care and support focus at different stages Annex 2: Nutritional care and support focus at different stages Annex 2: Nutritional care and support focus at different stages
ofHIVandAIDS ofHIVandAIDS ofHIVandAIDS ofHIVandAIDS


STAGES STAGES STAGES STAGES SIGNS SIGNS SIGNS SIGNS NUTRITONCAREAND NUTRITONCAREAND NUTRITONCAREAND NUTRITONCAREAND
SUPPORT SUPPORT SUPPORT SUPPORT
Asymptomatic Asymptomatic Asymptomatic Asymptomatic Nophysicalsignorsymptoms Educationaboutthe
importanceofnutritionfor
peoplelivingwithHIV.
Eatingavarietyoffoods.
Storingandpreparingfoods
safely.
Symptomatic(acute) Symptomatic(acute) Symptomatic(acute) Symptomatic(acute) Acuteinfections;fever;night
sweats;fatigue;headache;loss
ofappetite;lossof<10%of
bodyweight
Continuingwithearlier
activities.
Addressingfoodand
eating-relatedsymptoms.
Preventingweightloss.
Ensuringsufficientaccess
tofood.
Symptomatic(chronic)/AIDS Symptomatic(chronic)/AIDS Symptomatic(chronic)/AIDS Symptomatic(chronic)/AIDS Chronicinfections;prolonged
fever;diarrhoea;TB;
pneumonia;lossof>10%of
bodyweight
Continuingwithearlier
activities.
Providingadequateenergy
toreduceeffectsof
malnutrition
Managementofdrug-
nutrientinteractions.
Palliativecare Palliativecare Palliativecare Palliativecare Severewastingsyndrome Alleviatingsymptomsand
providingsupporttothe
clientandcaregiver.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Annex3:Nutritionalrequirements Annex3:Nutritionalrequirements Annex3:Nutritionalrequirements Annex3:Nutritionalrequirementsof of of ofpeoplelivingwithHIV peoplelivingwithHIV peoplelivingwithHIV peoplelivingwithHIV


17 17 17 17

ThenutritionalrequirementsofpeoplelivingwithHIVareinfluencedbyseveralfactors,includingage,
physiologicalchanges(pregnant,breastfeeding),physicalactivity,clinicalstagesofhealth,
metabolismandviralloadcount.
DAILY DAILY DAILY DAILYENERGY ENERGY ENERGY ENERGY
REQUIREMENTS REQUIREMENTS REQUIREMENTS REQUIREMENTS
TRANSLATIONINTOFOOD TRANSLATIONINTOFOOD TRANSLATIONINTOFOOD TRANSLATIONINTOFOOD
INTAKE INTAKE INTAKE INTAKE
Adults:HIV Adults:HIV Adults:HIV Adults:HIV- -- -negative/healthy negative/healthy negative/healthy negative/healthy 1999to2580kilocalories. Educationaboutthe
importanceofnutrition
forPLHIV.
Eatingavarietyoffoods.
Storingandpreparing
foodssafely.
Adults:HIV Adults:HIV Adults:HIV Adults:HIV- -- -positive positive positive positive
(early/asymptomaticstage) (early/asymptomaticstage) (early/asymptomaticstage) (early/asymptomaticstage)
10%moreenergy(anadditional
210kilocalories).
1additionalfistfulof
maizemealor1cupof
porridgetakenduring
thecourseofthedaily.
Adults:HIV Adults:HIV Adults:HIV Adults:HIV- -- -positive positive positive positive
(late (late (late (late/symptomaticstage) /symptomaticstage) /symptomaticstage) /symptomaticstage)
20-30%moreenergy(an
additional420to630
kilocalories).
2to3additionalfistfuls
ofmaizemealor2to3
cupsofporridgetaken
duringthecourseofthe
day.
Children:HIV Children:HIV Children:HIV Children:HIV- -- -positive positive positive positive Moreenergy,if
asymptomatic.
20-30%moreenergyif
symptomatic,withpoor
weightgain.
50-100%forthoseseverely
malnourished.
Alleviatingsymptoms
andprovidingsupportto
theclientandcaregiver.

Energy Energy Energy Energy


Therequirementsforadultsalsoapplytopregnantwomenandwomenwhoarebreastfeeding.
Pr Pr Pr Protein otein otein otein
According to WHO, there is insufficient evidence to support an increase in protein requirement for
peoplelivingwithHIVoverandabovethenormalrequirementforhealth(12%to15%oftotalenergy,
i.e.50to80gramsofproteindailyor1gramperkilogramofidealbodyweight).
Fat Fat Fat Fat
No evidence that total fat needs are increased above normal requirements for health. However,
specialadviceregardingfatintakemightberequiredforindividualsundergoingantiretroviraltherapy
orexperiencingpersistentdiarrhoea.

17
Nutrient Requirements for People Living with HIV/AIDS. Report of a technical consultation, World Health
Origination,Geneva,13-15May,2003.




Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Vitaminsandminerals Vitaminsandminerals Vitaminsandminerals Vitaminsandminerals
Adequate intake of vitamins and minerals is best achieved through a well-balanced diet. HIV-
infected adults and children should have healthy diets that ensure micronutrient intakes at
recommendedlevels.
However, dietary intake of vitamins and minerals may not be sufficient to correct nutritional
deficiencies in HIV-infected individuals. In settings where recommended intakes cannot be
achieved, multiple micronutrient supplements may be needed for high-risk groups such as,
pregnantandlactatingwomen.
Nevertheless,thereisevidencethatsomesupplementse.g.,vitamins,zinc,andiron,canproduce
adverseoutcomesinHIV-infectedpeople.
ForHIV-infectedchildren(5-59monthsold)livinginresource-limitedsettings,periodic(every4-6
months)vitaminAsupplementationisrecommended(10000IUforinfantswhoare6-12months
old)and200000IUforchildrenolderthan12months).
ThereisnodataontheefficacyofothermicronutrientsupplementsforHIV-infectedchildren.
Topreventanaemiainpregnantwomen,dailyiron-folicacidsupplementation(400goffolicacid
and 60 mg of iron) during the first 6 months of pregnancy is recommended; taking this
supplementation twice daily is recommended for treating severe anaemia. This applies to both
pregnantwomenlivingwithHIVaswellasthosewhoarenotinfected.
DailyvitaminAintakebyHIV-infectedwomenduringpregnancyandlactationshouldnotexceed
therecommendedlevels.Asinglehigh-doseofvitaminA(200000IU)shouldbegiventowomen
assoonaspossibleafterdelivery,butnolaterthansixweeksafterdelivery.





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Annex4:Sourcesoffurtherinformation Annex4:Sourcesoffurtherinformation Annex4:Sourcesoffurtherinformation Annex4:Sourcesoffurtherinformation



Courses that could complement this course
WHO/UNICEF Infant and Young Child Feeding Counselling: An integrated course.
WHO/UNICEF/USAID HIV and infant feeding counselling tools.
WHO/UNICEF Breastfeeding Counselling: A training course.
WHO Complementary Feeding Counselling: A training course

Other information sources
http://www.who.int/nutrition/en/ or
http://www.who.int/child_adolescent_health/en/

Breastfeeding and replacement feeding practices in the context of mother-to-child transmission of
HIV An assessment tool for research. Geneva, World Health Organization, 2001.
http://www.who.int/child_adolescent_health/documents/cah_01_21/en/index.html

Complementary feeding of young children in developing countries: a review of current scientific
knowledge. Geneva, World Health Organization, 1998.
http://www.who.int/nutrition/publications/infantfeeding/WHO_NUT_98.1/en/

Complementary feeding: family foods for breastfed children. Geneva, World Health Organization,
1998.
http://www.who.int/nutrition/publications/infantfeeding/WHO_NHD_00.1/en/index.html

Guiding Principles for Complementary Feeding of the Breastfed Child. PAHO/WHO, Division of
Health Promotion and Protection/Food and Nutrition Program, Washington, DC, USA, 2003.
http://www.who.int/nutrition/publications/infantfeeding/a85622/en/index.html

FAO/WHO. Living well with HIV/AIDS A manual on nutritional care and support for people living
with HIV/AIDS. Rome, Food and Agriculture Organization. 2002.
http://www.fao.org/DOCREP/005/Y4168E/Y4168E00.htm

Health Care and HIV: Nutritional Guide for Providers and Clients. HIV/AIDS Bureau, US
Department of Health and Human Services, 2002.
http://www.aidsetc.org/aidsetc?page=etres-display&resource=etres-193

HIV/AIDS: A Guide For Nutritional Care and Support. 2nd Edition. Food and Nutrition Technical
Assistance Project. Academy for Educational Development, Washington DC, 2004.
http://www.fantaproject.org/publications/HIVguide.shtml

HIV and infant feeding. A guide for health care managers and supervisors. Geneva, World Health
Organization, 2003.
http://www.who.int/nutrition/publications/hivaids/9241591234/en/index.html

HIV and Infant Feeding: Framework for Priority Action, Geneva, World Health Organization, 2003.
http://www.who.int/nutrition/publications/hivaids/9241590777/en/index.html





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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HIV and infant feeding. Guidelines for decision-makers. Geneva, World Health Organization,
2003.
http://www.who.int/nutrition/publications/hivaids/9241591226/en/index.html

HIV transmission through breastfeeding. A review of available evidence - update 2007, Geneva,
World Health Organization, 2008.
http://www.who.int/nutrition/publications/hivaids/9789241596596/en/index.html

Mastitis. Causes and Management. Geneva, World Health Organization, 2000.
http://www.who.int/child_adolescent_health/documents/fch_cah_00_13/en/

New data on the prevention of mother-to-child transmission of HIV and their policy implications.
Conclusion and recommendations of WHO Technical Consultation on behalf of the
UNFPA/UNICEF/UNAIDS Interagency Task Team on Mother-to-Child Transmission of HIV,
Geneva, World Health Organization, October 2000.
http://www.who.int/reproductivehealth/publications/rtis/RHR_01_28/en/

Nutrient requirements for people living with HIV/AIDS. Report of a technical consultation, 1315
May 2003. Geneva, World Health Organization, 2003.
http://www.who.int/nutrition/publications/hivaids/9241591196/en/index.html

Rapid advice: revised WHO principles and recommendations on infant feeding in the context of
HIV - November 2009. Geneva, World Health Organization, 2009.
http://www.who.int/child_adolescent_health/documents/9789241598873/en/index.html

Sowing Seeds of Hunger (video, 26 min.). FAO, 2003. Course organizers can request the video
from FAO Headquarters (mail request to enrique.yeves@fao.org ) or through the FAO
Representative.

The Africa Network for the Care of children Affected by AIDS (ANECCA).Handbook on paediatric
AIDS in Africa. Regional Centre of Quality Health Care, Kampala, Uganda, revised, July 2006.
http://www.fhi.org/en/HIVAIDS/pub/guide/mans1.htm

UNAIDS. AIDS: Palliative Care. UNAIDS Technical Update (Best Practice Collection). Geneva,
UNAIDS, October 2000.
http://www.unaids.org/en/PolicyAndPractice/CareAndSupport/PalliativeCare/

UNAIDS. Ancient Remedies, New Disease Involving traditional healers in increasing access to
AIDS care and prevention in East Africa. UNAIDS Case Study (Best Practice Collection).
Geneva, UNAIDS, June 2002.
http://search.unaids.org/Preview.aspx?d=en&u=Publications/IRC-pub02/jc761-
ancientremedies_en.pdf&p=%2fcgibin%2fMsmGo.exe%3fgrab_id%3d0%26page_id%3d4707%2
6query%3dancient%2520remedies%26hiword%3dancient%2520remedies%2520%26PV%3d1






Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Annex5:Coursepre Annex5:Coursepre Annex5:Coursepre Annex5:Coursepre- -- -andpost andpost andpost andpost- -- -test test test test

1. WhatisthedifferencebetweenHIVandAIDS?(writetheanswerbelow)

2. NameTHREE THREE THREE THREEwaysinwhichHIVandAIDScanaffectnutritionofPLWHIV.(writetheanswer


below)

1)

2)

3)

3. NameanyTHREE THREE THREE THREEfunctionsoffood/nutrients.(writetheanswerbelow)

1)

2)

3)

4. Name THREE THREE THREE THREE common things that may cause eating difficulties for PLWHIV. (write the
answersbelow)

1)

2)

3)

5. Name THREE THREE THREE THREE suggestions on what to do when there is no enough food for PLWHIV. (write
theanswersbelow)

1)

2)

3)





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Formultiplechoice questionsbelow,circlethecorrect answer. Somequestionshave morethanone Formultiplechoice questionsbelow,circlethecorrect answer. Somequestionshave morethanone Formultiplechoice questionsbelow,circlethecorrect answer. Somequestionshave morethanone Formultiplechoice questionsbelow,circlethecorrect answer. Somequestionshave morethanone
correctanswer correctanswer correctanswer correctanswer

6. WhatareT TT TWO WO WO WOwaysthatyoucancommunicatetoclientsduringcounselling?

a) Immediatelytelltheclientoffifshe/heisdoingsomethingwrong
b) Creatingcomfortableenvironment,whichputthemateaseandencouragethemtotalk?
c) Makeoneortwosuggestionsnotcommands

7.WhatareT TT TWO WO WO WOmajorsignsofAIDSinadultsandchildren?

a) Weightlossorwasting
b) Severediarrhoealastingmorethanonemonth
c) Troubleseeing

8.WhataretheTWO TWO TWO TWOsuggestionsyoucangivetoapersoncomplainingoflossofappetite?

a) Eatsmallfrequentmealsthroughouttheday;eatsomething2-3hours
b) Increaseintakeoffattyfoods
c) Preparetheirownfood,sincetheyaretheoneswhoknowhowtheyliketheirfood
d) Trytoeatdryfoodssuchasdrybreadorplaintoast

9.WhichisthecorrectwaytomakeOralRehydrationSolution(ORS)

a) 8tablespoonsofsugar,teaspoonofsaltandboiledwater
b) 12tablespoonsofsugar,18teaspoonsofsaltandwater
c) 8tablespoonsofsugar,12teaspoonsofcerealsandboiledwater

10.WhataretheTWO TWO TWO TWOwaysofminimizingtransmissionofHIVfrommothertochild?

a) GivingARVstothemotherduringlabourandthebabyshortlyafterbirth
b) Mixedfeeding(givingthebabybreastmilkandotherfoodsorliquids)
c) Exclusivebreastfeedingorexclusiveformulafeeding

11.Whataresomeofthewaysofpreparingsaferfood?

a) Cookfoodthoroughly.Formeatandpoultry,makesurejuicesareclear,notpink.
b) Washyourhandsbeforetouchingfoodandbetweentouchingrawandcookedfoodduring
foodpreparation
c) Wash all raw fruits and vegetables thoroughly with safe water before use or, peel them
beforeeating.
d) Alloftheabove





Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Read the following s Read the following s Read the following s Read the following statements tatements tatements tatements; check whether the statements are true or false ; check whether the statements are true or false ; check whether the statements are true or false ; check whether the statements are true or false ( ( ( (mark the appropriate mark the appropriate mark the appropriate mark the appropriate
boxwitha boxwitha boxwitha boxwitha) )) )

Statements Statements Statements Statements True True True True False False False False

12

GoodnutritionwillcureHIV

13

Awell-nourishedpersonisstrongerandabletofightinfections

14

PLWHIVshouldavoideatinganimalandmilkproducts

15

Fermentedmilkisbeneficialforpeoplewithdiarrhoea

16

GoodnutritionwillimprovetheeffectofARThelpingthepersonrecovertheir
bodysimmunityandimprovingtheoverallwell-being

17

AllbreastfeedingbabiesborntoHIVpositivemothersgetHIV

18

HIVandAIDSaffectthewaythebodyusedfood/nutrients

19

Food that gives as energy (such as rice, maize) should make the largest
partofourmeals

20

Physicalactivitysuchashouseholdchoresandlightworkinthegarden/field
areofbenefitstoPLWHIV

21

Drinking tea or coffee with meals increases absorption of iron that we get
fromthefoodweeat

22

Whensuggestingfoodstoaperson,considerhis/herpersonlikesandhabits

23

Giveextrafoodtochildrenduringillnessandwhenrecoveringfromillness

24

Excessiveintakeofsomemicronutrientscanbetoxic

25

TherearesomeherbalremediesthatcancureandtreatHIVandAIDS






Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Annex6:Courseevaluationsheet Annex6:Courseevaluationsheet Annex6:Courseevaluationsheet Annex6:Courseevaluationsheets ss s

Part1:Evaluationoftheparticipantslearning Part1:Evaluationoftheparticipantslearning Part1:Evaluationoftheparticipantslearning Part1:Evaluationoftheparticipantslearning

You have just completed the Nutritionalcare and support for people living with HIVcourse. Please
answer the following questions thoughtfully and completely. Your answers will help us improve this
course.Thankyou.

1.AftercompletingthecourseIratemyselfas(pleasetickinthechosencolumn)

Able to Partially
able to
Not able to I was able
to do this
before the
course
Listtwowaysinwhichnutrition
affectsHIV

Gatherinformationoncurrent
feedingandnutritionpractices
andconcernsofanindividual

Offersuggestionsonwaysof
improvingcurrentfeedingand
nutritionpracticesofan
individual

Participateinlocaldiscussions
onpracticalnutritionand
feedingpoliciesandpractices
forpeoplelivingwithHIV


2. Overall,Iwouldratethiscourseas(circleone):ExcellentGood ExcellentGood ExcellentGood ExcellentGood Poor Poor Poor Poor

3. Ilearntfromthiscourse(circleone):
Verymuch Verymuch Verymuch Verymuch Moderate Moderate Moderate Moderateamount amount amount amount Verylittle Verylittle Verylittle Verylittle





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4.What have you learnt from this course that would be most useful in your work with people living
withHIVandtheircaregivers?
__________________________________________________________________________
__________________________________________________________________________

Part2:Evaluationofhowthecoursewasconducted Part2:Evaluationofhowthecoursewasconducted Part2:Evaluationofhowthecoursewasconducted Part2:Evaluationofhowthecoursewasconducted



Aim Aim Aim Aim

Theaimofthecourseistoassi Theaimofthecourseistoassi Theaimofthecourseistoassi Theaimofthecourseistoassistcommunitylevelhealthworkersandotherextensionworkersto: stcommunitylevelhealthworkersandotherextensionworkersto: stcommunitylevelhealthworkersandotherextensionworkersto: stcommunitylevelhealthworkersandotherextensionworkersto:

ImprovetheirknowledgeandskillsonnutritioncareandsupportforpeoplewithHIVandtheir
families
Understandtheimportanceofusinggoodcommunicationskillswhenprovidingnutrition
counselling,careandsupportforpeoplelivingwithHIVandtheirfamilies
BeabletoeffectivelytransferthenutritioncareandsupportmessagestopeoplelivingwithHIV
andtheirfamilies

Comments:

Pleaseusethefollowinggradingscaleandcommentconstructivelyasappropriate

1verylow 1verylow 1verylow 1verylow------------------------------------------------------- ------------------------------------------------------- ------------------------------------------------------- -------------------------------------------------------5veryhigh 5veryhigh 5veryhigh 5veryhigh
Programme: Programme: Programme: Programme:

Towhatextentwasthefollowinguseful?

1.Openingremarksandgeneralpresentationofthework

2.Presentationoftheexpectedoutcomes

3.Wayforwardlistofactions

4.Closingremarks

Comments






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Process Process Process Process

Pleasegradethefollowing
Session1 Session1 Session1 Session1 NutritionandHIV NutritionandHIV NutritionandHIV NutritionandHIV
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.Howfeasibleisittoadapttothecontextinyourcounty'swork
Comments:


Session2 Session2 Session2 Session2 Introductiontocommunicationskills Introductiontocommunicationskills Introductiontocommunicationskills Introductiontocommunicationskills
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.HowfeasibleisittoadapttothecontextinSwazilandwork
Comments:



Session3 Session3 Session3 Session3 Eatingwisely Eatingwisely Eatingwisely Eatingwisely
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.HowfeasibleisittoadapttothecontextinSwazilandwork
Comments:






Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Session4 Session4 Session4 Session4 FoodsafetyforpeoplewithHIVandAIDS FoodsafetyforpeoplewithHIVandAIDS FoodsafetyforpeoplewithHIVandAIDS FoodsafetyforpeoplewithHIVandAIDS
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.HowfeasibleisittoadapttothecontextinSwazilandwork
Comments:


Session5 Session5 Session5 Session5 Improvingfoodintake Improvingfoodintake Improvingfoodintake Improvingfoodintake
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.HowfeasibleisittoadapttothecontextinSwazilandwork
Comments:


Session6 Session6 Session6 Session6 P PP Preventing reventing reventing reventingweightlossandpromotingphysicalactivity weightlossandpromotingphysicalactivity weightlossandpromotingphysicalactivity weightlossandpromotingphysicalactivity
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.HowfeasibleisittoadapttothecontextinSwazilandwork
Comments:






Nutritional Care and Support for People Living with HIV: Facilitators Guide
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Session7 Session7 Session7 Session7 NutritionforpeopleonAntiretroviralTherapy NutritionforpeopleonAntiretroviralTherapy NutritionforpeopleonAntiretroviralTherapy NutritionforpeopleonAntiretroviralTherapy
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.HowfeasibleisittoadapttothecontextinSwazilandwork
Comments:


Session8 Session8 Session8 Session8 Nutritionforpregnantandbreastfeeding Nutritionforpregnantandbreastfeeding Nutritionforpregnantandbreastfeeding NutritionforpregnantandbreastfeedingwomenwithHIV womenwithHIV womenwithHIV womenwithHIV
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.HowfeasibleisittoadapttothecontextinSwazilandwork
Comments:


Session9 Session9 Session9 Session9 Feedingopt Feedingopt Feedingopt FeedingoptionsforinfantofHIVpositivemothers ionsforinfantofHIVpositivemothers ionsforinfantofHIVpositivemothers ionsforinfantofHIVpositivemothers
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.HowfeasibleisittoadapttothecontextinSwazilandwork
Comments:






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Session10 Session10 Session10 Session10 FeedingachildwithHIV FeedingachildwithHIV FeedingachildwithHIV FeedingachildwithHIV
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.HowfeasibleisittoadapttothecontextinSwazilandwork
Comments:


S SS Session11 ession11 ession11 ession11 Improvingaccesstofood Improvingaccesstofood Improvingaccesstofood Improvingaccesstofood
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.HowfeasibleisittoadapttothecontextinSwazilandwork
Comments:


Ses Ses Ses Session12 sion12 sion12 sion12 Theuseofnutritionalsupplementsandherbalremedies Theuseofnutritionalsupplementsandherbalremedies Theuseofnutritionalsupplementsandherbalremedies Theuseofnutritionalsupplementsandherbalremedies
1.Content
2.Timemanagement
3.Facilitation
4.Style-methodologiesused
5.Yourparticipation
6.Thegroupparticipation
7.HowfeasibleisittoadapttothecontextinSwazilandwork
Comments:


Your comments are very important to us. Please write on the back of this sheet any additional
commentsorobservationsthatyouhaveaboutthecourse,includingsuggestionsforimprovements.

Thankyou.




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