LESSON 18

 COUNSELLING AND CARE

HIV/AIDS care and counselling is essentially about educating and counselling communities in the control, management and prevention of HIV/AIDS. There is widespread recognition of the misconceptions in communities that lead to negative attitudes and stereotypes, and these issues are addressed. Furthermore, it is generally accepted that there is an increasing need for a functional system of services to address HIV/AIDS. In order to meet this demand, individual service providers need to train others in the community in HIV/AIDS counselling.

At the end of this lesson, you will be able to

·         offer basic (non-expert) counseling service to people living with HIV and AIDS;

·         describe how to properly care and support children and adults with HIV/AIDS; and

·         advocate community care for HIV positive people

Numerous studies suggest that good counselling assists people to make informed decisions, cope better with their health condition, lead more positive lives, and prevents further transmission of HIV. HIV/AIDS counselling is sometimes provided by trained counsellors, though nurses and caregivers are often in the ideal position to provide effective counselling, advice, and support. However, when nurses and caregivers are busy, emotional caring and support are often overlooked, despite evidence that providing emotional support does not take any longer than not providing such care. Frequently, nurses and others indicate that they do not know how to provide more subtle counselling and emotional support, and therefore avoid this aspect of care.

Pre test counselling

The aim of pre test counselling is to provide information to the individual about the technical aspects of testing and the various implications of being diagnosed as either HIV positive or negative. Pre test counselling should focus on two main topics: (a) the person's personal history of risk behaviours, or having been exposed to HIV , and (b) assessment of the person's understanding of HIV/AIDS (including methods of transmission) and the person's previous experiences in crisis situations. Information should be up to date and given in a manner that is easy to understand. Pre-marital testing of couples and testing of blood donors is different from testing of those suspected of having HIV/AIDS. However, both groups require sensitivity. Testing should be discussed as a positive act that is linked to changes in risk behaviour, coping and increasing the quality of life.

Benefits of pre test counselling

Pre test counselling helps people to make informed choices. However, it is important to note that people who do not want pre test counselling before taking the HIV test should not be required to have it. In addition, a decision to be tested should be an informed decision. Informed consent implies awareness of the possible implications of a test result (including the window period). In some countries, the law requires explicit informed consent; in others, implicit consent is assumed whenever people seek testing. The nurse/midwife must help the person understand the policy on consent, and should explain the limits and consequences of testing. Therefore, it is important to be knowledgeable about the policies and guidelines governing your region. Access to pretest counselling is not always available, and some people might refuse this option.

Post test counselling

In post test counselling, it is important to put the person being counselled at ease. If possible, the room should be quiet, without the fear of being disturbed. Arrange the chairs so that bright light will not shine in anyone's eyes. The counsellor should then tell the person the test result. The result (either positive or negative) should then be discussed, including how the person feels about the result. Further information can be provided, though the person may be shocked, and may not fully understand all the information. In some circumstances, the post test setting might provide the only chance to counsel this person. Thus, asking them to repeat the information just presented, or to have some basic facts written down might be helpful. It is important for the person to have time to reflect on the result and understand the next course of action. Ideally, couple and/or family counselling should be started at this time and further counselling follow-up arranged.

HIV-positive test result counselling

When the test result is positive, the nurse/midwife should tell the person as gently as possible, providing emotional support and discussing how best to cope with the results. This is not a time for speculation, but rather a time to give clear, factual explanations of what the news means. Assess the emotional impact of the news, and validate the person's reactions as normal. Fear of dying, job loss, family acceptance, concern about the quality of life, the effects of treatment and response by society can be explored. If there is a concern that the person might not return for follow up counselling, then information about relevant health services should be mentioned. This would include available medical treatments such as antiretroviral therapy or treatment for opportunistic infections, and social services for financial and ongoing emotional support.

However, if follow up counselling is an option, then it would be advisable to leave this information to a later date when the person is better able to absorb the details and explore the available options. Assess the person's understanding and ability to use preventive methods. Free condoms can be given out during this session, together with advice on how to use them and where to get more.

Counselling and support activities need to address feelings of shock, fear, loss, grief, guilt, depression, anxiety, denial, anger, suicidal activity or thinking, reduced self esteem, and spiritual concerns. In addition, social issues such as loss of income, discrimination, social stigma, relationship changes, and changing requirements for sexual expression need to be explored.

HIV-negative test result counselling

If the HIV test is negative, then counselling about at risk behaviours and methods of prevention are vitally important (see Fact Sheet 12). Also, the counsellor must explain about the "window period" (between 3-6 months) when a negative result may be a false negative. If there is concern about the HIV status of the person, counsel them to return for a repeat test in 3-6 months, and ensure that they take appropriate precautions in the meanwhile, explaining that they could become infected at any time. The counselling session is an ideal time to discuss sexual practices and preferences, potential drug abuse (particularly intravenous drug use) and other at risk behaviours. Upon learning their HIV-negative status, the person may be more open to learning about safe sex practices and modifying risk behaviours. Free condoms can be given out during this session together with advice on how to use them and where to get more when needed.

Bereavement counselling

Families and friends often have little social support, or may have become isolated while caring for the PLHA. Bereavement support should be made available before the person dies, and for as long afterwards as people need it. People react to death in different ways, and need different types of support. For some, it can take months or years to come to terms with loss. Additionally, people's responses may be affected by the way the person died: for example, whether the PLHA died alone and in pain, or died peacefully, surrounded by loved ones. Those left behind often blame themselves if they think they could have done more.

Continued counselling and support

The HIV-infected person and his/her family require further counselling and support following the initial meeting. Such support helps to improve their quality of life as well as to enhance their ability to cope and make informed decisions about ongoing care. Such counselling and support might include encouraging the PLHA to join a peer support group to learn where and how to access services, to find educational resources, and to obtain treatment. Spiritual and religious support might also be required, as well as support related to financial concerns and care for the family after the person's death. Where services exist, further individual counselling might also be beneficial. Such counselling might include discussions on safer sex practices, birth control counseling, and counselling and support during the ante natal, intra partum and post natal period etc..

Care for the caregiver

In many communities, there is little value placed on counselling. Consequently, counselling receives little if any financial support. As a result, counselling services are often fragmented, with no designated time or place for counselling sessions. In addition, health care professionals are expected to fit counselling activities into their already overburdened worklife, with little financial compensation. If counselling is not valued by policy makers and governments, it will be difficult for nurses, midwives and other health care professionals to value their roles as counselors. There is considerable evidence to suggest that nurses, midwives and other counsellors themselves need ongoing support and care, since caring for the sick and dying is very stressful. Unless there is adequate education, supervision, counselling and other support services available for caregivers, the result can be "caregiver burnout." What follows are some strategies to address these concerns.

NURSING CARE

Nursing care of the person with HIV-related illness is the same as the nursing care for any person who is ill. Consequently, all trained nurses/midwives are competent to care for patients with HIV-related illness as the same principles of nursing practice apply. In addition, many of the health care problems people will have as a result of HIV infection will be familiar to nurses because of their knowledge and experience of caring for people with other chronic, progressive diseases. The use of universal precautions for infection control are critical in the care and prevention of HIV

Almost all (if not all) HIV-infected people will ultimately develop HIV-related disease and AIDS. This progression depends on the type and strain of the virus and certain host characteristics. HIV infects both the central and the peripheral nervous system early in the course of infection, often causing a variety of neurological and psychiatric problems. As HIV infection progresses and immunity declines, people become more prone to opportunistic infection and other conditions. Opportunistic infections are those that can invade the body when the immune system is not working adequately.

Basic nursing care for opportunistic infections

Infection control:
Maintain good hygiene. Always wash hands before and after caring for the PLHA. Make sure linen and other supplies are well washed with soap and water. Burn rubbish or dispose of it in leakproof containers. Avoid contact with blood and other body fluids and wash hands immediately after handling soiled articles
Skin problems:
Wash open sores with soap and water, and keep the area dry. Use the medical treatment, and prescribed ointment or salve. Local remedies, oils and calamine lotion might also be helpful.

Sore mouth and throat: Rinse mouth with warm water mixed with a pinch of salt at least three times a day. Eat soft foods that are not too spicy.

Fevers and pain: Rinse body in cool water with a clean cloth or wipe skin with wet cloths. Encourage the person to drink more fluids than usual e.g. water, tea, broth or juice. Remove thick clothing or too many blankets. Use antipyretics and analgesics such as aspirin, paracetamol etc.

Cough: Lift head and upper body on pillows to assist with breathing, or assist the person to sit up. Place the patient where he/she can get fresh air. Vaporisers, humidifiers, and oxygen might be helpful.

Diarrhoea: Treat immediately to avoid dehydration, either using oral rehydration or intravenous therapy if necessary. Ensure that the person drinks more than usual, and continues to take easily digestible nourishment. Cleanse the anus and buttocks after each bowel movement with warm soap and water and keep the skin dry and clean. Antibiotics used to treat other infections can worsen the diarrhoea. Always wash hands and, where possible, wear gloves when handling faecal or soiled materials

Nutrition: Where available, encourage foods that are high in fat and protein as they will help reduce weight loss.

Local Remedies: There are often local remedies that alleviate fevers, pains, coughs, cleanse sores and abscesses. These local remedies can be very helpful in alleviating many of the symptoms associated with opportunistic infections. In many countries, traditional healers and women's associations or home care programs are collecting information about remedies which alleviated symptoms and discomfort.

Antenatal care

Voluntary HIV testing and counselling (VCT) should be available in antenatal clinics. Many HIV-positive women will be diagnosed for the first time during pregnancy, therefore, this service is critical to the ongoing treatment, care and support for the mother, her family and new born child. The benefits of VCT in antenatal care include:

Access to VCT is important in antenatal clinics because there are ways to prevent transmission, such as:

· termination of pregnancy,

· antiretroviral therapy (ARV),

· modifying midwifery and obstetrical practices, and

· modifying infant feeding.

However, prevention of MTCT is dependent upon the identification of the HIV-positive woman.

Termination of pregnancy
Where termination of pregnancy is both legal and acceptable, the HIV-positive woman can be offered this option. However, many women learn of their HIV status during pregnancy, and will not be diagnosed in time to be offered termination. If termination is an option, the woman, or preferably the couple, should be provided with the information to make an informed decision without undue influence from health care workers and counsellors.

Antiretroviral therapy (ARV)
A recent study showed that the administration of zidovudine (AZT) during pregnancy, labour, delivery and to the new born reduced the risk of MTCT by 67%. This regimen has become standard practice for HIV-positive women in most industrialized countries and many women are receiving a combination of ARV treatments. This long-course regimen is often not available for women in developing countries because of cost and lack of adequate infrastructure. However, there is a concerted effort to provide short term AZT to all HIV-positive pregnant women. Short course AZT is taken orally from 36 weeks of pregnancy through labour and delivery. This treatment does not prolong the life of the mother, but has been found to be effective in reducing transmission of HIV to the infant.

Nevirapine is a much cheaper antiviral drug than AZT, costing about $4 per mother and baby treated. Recent studies have shown it to be effective in reducing MTCT if a single dose is given to mothers just prior to delivery and to newborns immediately afterwards. In terms of both cost and infrastructure requirements Nevirapine offers a more optimistic and realistic alternative for ARV for developing countries. Many countries are in the process of developing guidelines and an effective infrastructure to support ARV. Because ARV treatments vary considerably throughout the world and are still in the experimental stages, nurses/midwives are encouraged to learn more about the ARV treatments and protocols available within their community and country.

 Post-natal care of the HIV-infected mother and her infant

In many instances, the basic post natal care of the HIV-infected woman and her infant will be no different from routine postnatal care. However, the mother (and possibly partner/family) might need additional counselling and support. Such counselling might include decisions on infant feeding (although this decision should have been made in the antenatal period), and advice on birth control. It is important that the woman and her family are involved in a continuum of care, so that comprehensive linking of resources and services can be provided where and when they are most necessary and effective. HIV-infected women are more prone to medical complications such as urinary tract infections, chest infections, episiotomy sepsis, and uterine and Caesarian section wound sepsis. Nurses/midwives should be alert for signs of infection such as fever, rapid pulse, episiotomy or lower abdominal pain, and foul smelling lochia (vaginal discharge). HIV infected women should be taught about perineal care and safe handling of blood and lochia.

Care for infants and children with HIV-related illness

Most HIV-related illness is caused by common infections which can be prevented or treated at home or in a health centre. However, the illnesses often last longer in HIV infected children, and are slower to respond to standard treatments. The standard treatments are nevertheless the most appropriate treatments. The following general recommendations should be used in the management of HIV infected infants/children and in teaching/counselling mothers and other care-givers.

Maintain good nutritional status in weight loss and failure to thrive

In most countries of the developing world, HIV-infected mothers are still breast-feeding their infants. However, with the knowledge that HIV can be passed through breast milk ( approximately 30% risk), this practice might be changing. In some countries, substitutes for breast milk may be recommended for infants of HIV-infected mothers. However there needs to be a safe and adequate supply of affordable breast milk substitutes, access to a clean water supply and adequate means to boil water and to sterilize equipment. In some communities, where supplies and equipment are limited or unavailable, the risk of babies dying if not breastfed will be greater than the risk of passing on HIV. In countries where ARV is available, breast milk substitutes will probably be recommended. Nurses and midwives are encouraged to refer to local policies and practices on nutritional counselling and breast feeding. Regular growth monitoring (preferably every month) is an appropriate way to monitor nutritional status. If growth falters, additional investigations should be done to determine the cause.

Provide early and vigorous therapy for common paediatric infections as early as possible

All infants with HIV antibodies should be treated vigorously for common paediatric infections such as measles and otitis media. (see Table below) Because the immune systems of children with HIV infection are often impaired, these diseases may be more persistent and severe, and the children may respond poorly to therapy and develop severe complications. Consequently, the mothers of all HIV-positive infants should be encouraged to take their infants for examination and treatment as soon as possible whenever symptoms of common paediatric infections develop.

OTHER ISSUES

Fear of death
Fear is a normal reaction and can make people angry, depressed, or aggressive. Caregivers should not give false reassurances, but should encourage the person to talk about their fears. Spiritual support might also be helpful.

Loneliness and depression
Sometimes when someone is dying, people stop coming to visit because they fear death, or do not know how to react. Such isolation can lead to a sense of loneliness and depression. People should be encouraged to visit (if the PLHA wishes). In some cultures, people will also need an opportunity to discuss their feelings about being with someone who is dying.

Feelings of guilt and regret
The PLHA may feel responsible for exposing his/her partner to infection, or may feel guilty for having brought shame to their family or friends. Failure to settle debts, fulfill ambitions, or attend to their responsibilities to children can all cause feelings of guilt, sorrow, and regret. A person may seek forgiveness or wish to discuss ways of resolving problems for which he/she feels responsible.

Spiritual support
This support can come either through an organized religion, or through the exploration of the PLHA's own spirituality, beliefs and values is very important. The PLHA might have been cut off (whether by him/herself or by their community) from his/her religion. Caregivers should acknowledge a person's spiritual needs, respect their religious beliefs (or lack of them), identify an appropriate person who can provide spiritual support, and discuss whether the person wants any religious observances to be performed, including funeral arrangements, in the event of their death.

Making a will
A will helps to make clear what a person wishes to happen after his/her death. The surviving women and children are often left impoverished and unprovided for unless a will is made.

When death comes it is important not to leave the dying person alone.
Many people are very afraid of dying alone. Respect should be given to rituals, observances, and customs related to laying out the body. Mourners can be given time alone with the body if they wish. However, all persons should be warned about the risk of contamination

Risk of HIV transmission in the health care setting

HIV can be transmitted in the following ways:

To patients
through contaminated instruments that are re-used without adequate disinfection and sterilization; transfusion of HIV-infected blood, skin grafts, organ transplants; HIV-infected donated semen; and contact with blood or other body fluids from an HIV-infected health care worker.

To health care workers
skin piercing with a needle or any other sharp instrument which has been contaminated with blood or other body fluids from an HIV infected person; exposure of broken skin, open cuts or wounds to blood or other body fluids from an HIV infected person; and splashes from infected blood or body fluids onto the mucous membranes (mouth or eyes).

Creating a safe work environment

The context and environment in which health care is provided influence not only the quality of care delivered, but also the safety and well being of care providers. Measures that promote a safe and supportive work environment include:

In many resource poor situations, it might not be possible to meet all of the above requirements. However, working toward these goals should be the responsibility of nurses and midwives, other health care workers and their employers. Preventive measures are difficult to practice when supplies and protective equipment are not always available. Priorities must be set and low-cost alternatives sought. Yet, even when supplies are available, the use of Universal Precautions may be influenced by management policy, personal practices, attitude and complacency of staff.

Prevention of occupational exposure to HIV also includes risk assessment and risk reduction activities such as:

Universal Precautions

Universal Precautions are simple standards of infection control practices to be used in the care of all patients, at all times, to reduce the risk of transmission of blood borne infections. They include:

Safe handling and disposal of "sharps"
The greatest hazard of HIV transmission in health care settings is through skin puncture with contaminated needles or "sharps". Most "sharps" injuries involving HIV transmission are through deep injuries with hollow-bore needles. Such injuries frequently occur when needles are recapped, cleaned, disposed of, or inappropriately discarded.

Although recapping needles is to be avoided whenever possible, sometimes recapping is necessary. When this is the case, a single-handed scooping method should be used. To do this, place the needle cap on a hard, flat surface and remove your hand. With one hand, hold the syringe and use the needle to scoop up the cap. When the cap completely covers the needle, use the other hand to place the cap firmly on the hub of the needle.

Puncture-resistant disposal containers must be available and readily accessible for the disposal of "sharps". Many easily available objects, such as a tin with a lid, a thick plastic bottle, or a heavy plastic or cardboard box, can work as suitable "sharps" containers. These can be burned in a closed incinerator, or can be used to transport the "sharps" to an incinerator. It is important to empty containers when they are 3/4 full, to wear heavy-duty gloves when transporting "sharps" containers, to incinerate used equipment at a hot enough temperature to melt the needles. Where the sharp container is not burned, bury it in a deep pit. Added precautions to prevent "sharp" injuries include wearing gloves, having an adequate light source when treating patients, locating sharps containers directly at the point of use, never discarding "sharps" in general waste, and keeping "sharps" out of the reach of children. Whenever possible, needle holders should be used when suturing.

"Sharps" accidents
Each health care facility should develop standards, policies and procedures to be followed in case of "sharps" injury or other exposure. Many health care workers neglect to report such injuries. This can lead to inaccurate data on health care worker exposure and more importantly, to a lack of follow-up counselling, testing, treatment and care (Fact Sheet 7). Following a "sharps" injury, immediate first aid should be given, such as flushing the site with running water, hand washing with soap and water, and, where there is bleeding, allowing the site to bleed briefly. Any exposed mucous membranes should be flushed with large amounts of water. Antiseptic solutions can have a caustic effect and have not been proven to be effective. However, in the absence of water, antiseptic solutions should be used. Following exposure, the type of exposure and the actions taken should be recorded and the appropriate authorities notified. Accident forms should be completed including information about the type of injury, any witnesses and the name of the patient if known. The accident victim should then report to the accident or emergency department for further care and advice. Voluntary confidential counselling should be available immediately, and HIV testing and follow up counselling made available (Fact Sheet 7). Post exposure prophylaxis (PEP) with antiretroviral treatments (ARV) can reduce the risk of becoming infected. PEP should be guided by local policies and is dependent upon the availability of drugs. If available, a combination of ARV should be taken as soon as possible after the accident (within 24 hours) and for four weeks following exposure. Many health care workers find reporting and undergoing voluntary testing and counselling stressful, and some chose to remain silent. This silence is often due to the fear, stigma and discrimination associated with HIV (Fact Sheet 6).

Evaluating "sharps" practices
If the same accident occurs more than twice, "sharps" practices must be evaluated. Methods for avoiding "sharps" use should be considered, for example, drugs might be given by methods other than injection; stapling rather than suturing; using adhesive tape or skin closure strips; and avoiding unnecessary incisions such as episiotomies.

Safe decontamination of equipment

Efficient cleaning with soap and hot water removes a high proportion of any microorganisms. All equipment should be dismantled before cleaning. Heavy gloves should be worn for cleaning equipment and if splashing with body fluid is likely, then additional protective clothing such as aprons, gowns, and goggles should be worn. The following table helps in selecting the method for decontamination:

Sterilization and disinfection

All forms of sterilization will destroy HIV.
Recommended methods of sterilization include steam under pressure (e.g.. autoclave or pressure cooker), or dry heat such as an oven. Disinfection will usually inactivate HIV. Two commonly used disinfection methods are boiling and chemical disinfection. If boiling, equipment should be cleaned and boiled for 20 minutes at sea level, and longer at higher altitudes. Chemical disinfection is not as reliable as sterilizing or boiling. However, chemical disinfection can be used on heat sensitive equipment, or when other methods of decontamination are not available. Equipment should be dismantled, thoroughly cleaned and rinsed after disinfection. Chemicals that have been found to inactivate HIV include chlorine-based agents (for example, bleach), 2% glutaraldehyde, and 70% ethyl and isoproyl alcohol.

Cleaning
Detergents and hot water are adequate for the routine cleaning of floors, beds, toilets, walls, and rubber draw sheets. Following a spillage of body fluids, heavy-duty rubber gloves should be worn and as much body fluid removed with an absorbent material. This can then be discarded in a leak proof container and later incinerated or buried in a deep pit. The area of spillage should be cleaned with a chlorine-based disinfectant and the area thoroughly washed with hot soap and water.

All soiled linen should be handled as little as possible, bagged at the point of collection and not sorted or rinsed in patient care areas. If possible, linen with large amounts of body fluid should be transported in leakproof bags. If leakproof bags are not available, the linen should be folded with the soiled parts inside and handled carefully, with gloves.

Safe disposal of waste contaminated with body fluids
Solid waste that is contaminated with blood, body fluids, laboratory specimens or body tissue all should be placed in leak proof containers and incinerated, or buried in a 7 foot deep pit, at least 30 feet away from a water source. Liquid waste such as blood or body fluid should be poured down a drain connected to an adequately treated sewer or pit latrine.

Planning and management

Proper planning and management of supplies and other resources are essential in reducing the occupational risk of HIV infection. Such measures should include risk assessment, setting of standards and protocols that address safety, risk reduction, post-exposure follow-up and first-aid. In addition, occupational risks can be reduced by introducing measures to prevent or reduce stress, maintain an optimum workload, orientate new staff and provide education and supervision. Staff burnout, characterized by feelings of depletion, loss of vitality, energy, and motivation is a major occupational hazard and can lead to increased risk for occupational exposure to HIV. In addition, fear of occupational exposure to HIV in health care settings may discourage potential recruits from pursuing nursing and midwifery as a career, thus reducing the future supply of trained professionals. Strategies that address these concerns include:

Gaining and maintaining adequate supplies and resources

Nurses/midwives need to explore different approaches to meet their resource needs, such as:

Developing creative strategies
In resource poor settings, some supplies may not be available. In such cases, nurses/midwives must creatively about how to manage care. Can plastic bags or condoms be used instead of gloves; can cooking utensils be used for boiling equipment; are there herbal and traditional alternatives to detergents and soaps? Can leaves, thimbles, or plastic wrap be used instead of bandaids to protect cuts? Are the resources that are available being used appropriately? For example, if gloves are in short supply, prioritize -- they are less necessary for giving routine injections and making beds than for deliveries and suturing.

One way to assign priorities is to classify the commonly performed procedures into low, medium and high risk, and allocate resources accordingly. Consideration should be given to cost effectiveness as opposed to cost containment noting that the cheapest equipment is not always the safest or most cost effective in the long run. In home care settings, nurses/midwives will need to be even more creative in finding solutions to infection control. Wherever possible, a home care kit should be available to all health care personnel working in the community and in homes. This kit should include disinfectants, soap, utensils for boiling, gloves, protective garments, and containers for safe disposal of equipment and waste.

Setting and maintaining standards, and political action
Nurses and midwives should be active in developing and maintaining quality assurance programs, and in developing and participating in infection control committees. Nurses and midwives must also develop, maintain, and evaluate standards, procedures and protocols for safe, adequate and effective control of infections. In addition, nurse managers should exert political pressure upon employers and upon national and international agencies to provide funds for essential supplies and equipment for providing safe quality care.

Care for the care giver
Understandably, many nurses and midwives fear becoming infected with HIV. Stigma, prejudice and discrimination surrounding HIV and its life threatening effect may compromise their ability to provide quality care, and even their commitment to remain in the profession. There should be adequate insurance and compensation for HIV-infected health workers. However, such compensation will depend upon the country's ability to pay, the place of employment and the employer. Particular attention should be given to:

Continued employment
Being HIV-infected is not a cause for termination of employment, regardless of whether HIV was acquired on the job or not. As with any other illness, HIV-infected nurses/midwives should be allowed to work as long as they are fit, provided they practice universal precautions. HIV infected health care workers can make considerable contributions to care by helping to educate others, reducing the stigma and discrimination associated with HIV, and providing sensitivity training, support and counselling. Employers should provide work assignments that both support the HIV infected worker's ability to perform tasks and enable them to avoid infections (particularly TB).

Workplace issues
Health care workers, like the general population, may feel fear, stigma and discrimination towards HIV-infected individual (see Fact Sheet 6). In fact, HIV- infected health care workers are often subjected to severe sanctions from their colleagues. As a result, many careworkers are reluctant to be tested and to enter into counselling, treatment and care. This is problematic, because if nurses/midwives do not know their HIV status, they can put themselves and others in the health care setting at risk. Therefore, employers should develop policies that:

Initiating a package of services

Depending on the stage of the disease and the resources that are available, HIV positive nursing/midwifery personnel require a package of services that might include: