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AIDS action  >  Issue 24 - Counselling
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AIDS action  -  Issue 24 - Counselling

Keys to counselling

Issue Contents
 

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Counselling and HIV

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What leads to good counselling?

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Support for safer behaviour

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Dealing with difficult issues

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Confidentiality versus secrecy

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Working with couples

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Practical Guidelines

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Care for the dying

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Practical issues

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Patient care

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Emotional stress

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Caring for the carers

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When death is near

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News

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Resources

 

 

 

AIDS action  Issue 1         Page 1   2  top of page

  Issue 24 March-May 1994

Key to counselling

Counselling aims to enable a person to cope better with stress, find realistic ways to solve problems and make informed decisions. A counsellor's role is to listen and ask questions, and to provide relevant information, practical suggestions and emotional support. Counselling is not about giving advice or telling people what they should do. The rapid spread of HIV means that demand for counselling services is increasing. Counselling is an essential part of voluntary and confidential HIV antibody testing programmes. It also plays a very valuable role in HIV prevention and care on its own, without testing. Issues such as reducing the risk of infection, family planning, relationships, sexuality and sexual problems, are all important areas for discussion. And, as described on pages 6 and 7, counselling is a vital part of caring for people who are dying, and supporting their carers.
 
Voluntary and confidential HIV testing, with counselling, can help someone who wants to find out if they are infected, although it does not necessarily lead to safer sex - behaviour change depends on many other factors too. Testing can be very risky for people who are vulnerable to discrimination or if confidentiality cannot be guaranteed.

Practising new skills: counsellors need training and support.

Anyone who is considering an HIV test for whatever reason should always have pre-test counselling, to help them assess if they have been at risk, learn about the test and its implications, decide whether or not to be tested and think about how they can prevent infection. Counselling should mean that a person's consent or refusal to be tested is an informed choice - made freely without pressure, and based on their own feelings about the disadvantages and advantages of knowing their HIV status. Counselling after an HIV test is equally important, whether or not someone is infected with HIV, or if they do not want to know the result. One post-test counselling session is often not enough. A person may need ongoing support and to be able to return for more sessions if they wish. 

 

HIV affects everyone 
The impact of HIV goes far beyond HIV-positive individuals. It has great implications for their sexual partners and family members - including future children. Articles on pages 4 and 5 show how coping with HIV can be easier if people choose to share counselling sessions with those close to them. People with HIV have an important role in providing support to others, as their experience of living with the virus can help them to understand people's feelings and reactions. They should not be seen as just 'clients' or passive recipients of care, but should have the same opportunities as others to train as counsellors or educators. Many counselling services are now setting up self-help or discussion groups run by and for people who are HIV-positive.

AIDS Action would like to hear from readers about problems they are experiencing in counselling, and ways in which they are trying to solve these.

 

In this Issue

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Counselling and HIV Page 2

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Dealing with difficulties Page 4

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Caring for people who are dying at home Page 6



AIDS action  Issue 24    1   Page 2   3  top of page

  Counselling and HIV

What leads to good counselling

AIDS Action describes the personal qualities, skills and support needed by counsellors.

HIV counselling means working with people who are, or could be, confronted by an incurable, infectious and often stigmatised disease. This can be a challenging and often emotionally draining task.
 
Personal qualities such as respect for the rights and dignity of other people, and a degree of emotional stability are very important. Counsellors need to be non-judgemental and able to keep confidentiality, to listen, and to express ideas clearly.

Poor counselling - with no privacy or confidentiality, and given advice without listening -  does not help anyone!


Institutional support is valuable. Counsellors need to have time and privacy in which to counsel, and contact with people who will use the service, through referrals for example. Although some medical staff may not have the time to counsel patients, it is important for them to support increased access to counselling. Some practical support, such as condoms, soap, bleach, plastic sheets, home care visits and travel expenses can also be provided to people who are counselled.
 
Training in counselling skills is an essential step towards becoming a good counsellor, although it is possible to be one without having advanced training in counselling, psychology or family therapy, for example. Training in counselling skills is very useful for anyone who provides care and support - from doctors and nurses to volunteers working on AIDS telephone helplines. In most communities there are also certain individuals who are respected and looked to for advice and emotional support, and they also may be interested in learning counselling skills. 
 
Counselling skills enable a person to:

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explain the facts clearly and simply, and provide appropriate information - for example, facts about the HIV test, HIV/STDs prevention and family planning methods 

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talk about sexuality and sex in a non-judgemental and open way that encourages someone to talk freely about what they do, including stigmatised acts such as anal sex or sex before marriage

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listen and give them time to talk

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ask questions that do not encourage a particular response but prompt someone to say more about what they feel, giving them the opportunity to think about their own life and relationships with others 

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empathise, which means understanding how someone else feels about their situation, without imposing personal values and thoughts

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give psychological support, enabling someone to identify and explore their reactions, feelings and emotions

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help someone to make realistic decisions and to find ways to adjust to change, by drawing upon their own

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resources (and those around them in the form of people and services) 

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establish trust and keep confidentiality.

 
What does training involve?
A training course in basic counselling skills should involve at most 20 people, who participate in several workshops spread over a few months. People often concentrate best during work-shops of a few days. It is best to set realistic objectives, and include ways to evaluate the course through discussion, supervision and questionnaires. 

Training sessions should enable participants to practise the skills needed for good counselling, including exercises to help them explore their own values, fears and prejudices. Training should be practical and participatory, using a mixture of group exercises, demonstrations, role-plays, short talks and visual aids such as videos. 

For example, one objective of the course would be improving participants' knowledge of AIDS. This could be achieved with a group exercise followed by a discussion. Participants could then do role-plays in groups of three or four. One person plays the role of the client asking questions, and a second person acts as the counsellor. The other member(s) watch and give positive and negative comments at the end of the role-play. 

During and after training, regular supervision, and the opportunity to work together with an experienced counsellor are essential to help the trainees practise their new skills, and to deal with their emotional reactions to counselling. A follow-up workshop should be held a few months after the course, where trainees role-play difficult situations they have experienced. In the long term, regular meetings with colleagues, supervision and further training are important.

Dr Robert Bar (City University, London, UK) and Karla Meursing (Matabeleland AIDS Council and Mpilo Hospital, Zimbabwe).



AIDS action  Issue 24    2   Page 3   4  top of page

  Counselling and HIV

Support for safer behaviour

Can counselling help people to reduce their risk of HIV/STDs? Aids Action reports on an initiative in India.
 
'A young man who had tested HIV-positive two years previously was very distressed because his parents were putting great pressure on him to get married. He came for counselling, and decided to invite his parents to join a session with him. He was able to tell them about being HIV-positive, that he needed their care and support, and that he felt that not marrying was the most responsible way to behave. After talking through the issues, his parents were more willing to accept his decision.'

Can counselling help people to reduce their risk of HIV/STDs?


This man is just one of the many people who have visited our AIDS counselling centre in Pune, India. Counselling is a very important way to provide support to people who are HIV-positive. How ever, there are very few counselling services in India. We know that some people have committed suicide once  they have found out they are HIV- positive, and often they have had no access to counselling or other help. Our centre provides pre-and post-test counselling and follow-up sessions, and runs groups for people who are HIV-positive. Men make up the majority of clients, although we are trying to make our services available to women too. For the sake of privacy, the centre does not advertise its services, but relies on word-of-mouth, and referrals from doctors, STD clinics and other health care institutions. 

In the past, some blood banks were referring donors whose blood had tested HIV-positive, but who had received no counselling. Confirmatory testing had not been carried out on these samples, and we found that up to 30 per cent were in fact HIV-negative. We feel that this is an opportunity to counsel people who may be HIV-positive about prevention and offer them an HIV test if they want it.

In co-operation with the blood banks, we now contact all the donors whose blood has tested HIV-positive. We give them pre-test counselling, and carry out a confirmatory test if they agree to this. If people decide that they do not want to know their status, we respect their wishes. 

While we do encourage people to tell their partners about their HIV status, we do not put pressure on them. Breaking confidentiality can increase people's distress. For example, it does not help a woman to be told that her husband is HIV-positive without his consent. She may be unable to insist on safe sex or support herself if she leaves home.

We feel that counselling, without HIV testing, can help some people to make changes in their behaviour, and thus protect themselves and others from HIV/STDs. As well as running the centre's services, we also counsel patients - who are mostly male - at the  local government STD clinic. 

All patients are asked to have a one-to-one session after their diagnosis. After telling them why we are there, and reassuring them of privacy and confidentiality, we ask them about their sexual practices and condom use. We then discuss prevention and ways to reduce risk, and show them how to use condoms. They are invited to come back if necessary, and to bring their friends too.

'A migrant labourer was diagnosed as having syphilis. He had just got married, but was living away from his wife and having unprotected sex with other partners. After counselling about HIV and STDs, he became more aware of the risk to his wife and future children. He agreed to try condoms but was concerned about services, but relies on word-of-mouth, his need to have sex. Various options were and referrals from doctors, STD clinics discussed, and he decided to arrange for and other health care institutions. his wife to stay in the city with him. He has In the past, some blood banks were kept in touch with the counsellor, and has referring donors whose blood had test-had no more STDs.' 

Discussing sex is not easy in our culture. We always start with discussing neutral topics, such as work or children, before talking about sexual behaviour. During one-to-one sessions we find that men are willing to talk about sex, and the problems they have in changing their lifestyles or sexual practices. We try to discuss all the reasons why they have unprotected sex or multiple partners. For example, they may be unable to suggest anal or oral sex to their wives, or do not feel they have satisfying sex, or live away from home. After this discussion, addressing the issues becomes easier, and we can talk about practical solutions. We feel that counselling in STD clinics is an effective way to reach men, and, indirectly, their wives and other sex partners (mostly sex workers) who may have less power to protect themselves. 

Dr Sanjay Pujari, AIDS Counselling Centre, Health Plus, 1730 Sadashiv Peth, Pune 411030, India.





AIDS action  Issue 24    3   Page 4   5  top of page

  Counselling and HIV

Dealing with difficult issues

There are many challenges in HIV counselling - AIDS Action suggests some approaches which can also be used during training for role-plays or discussion.
 

  There are many challenges in HIV counselling - AIDS Action suggests some approaches which can also be used during training for role-plays or discussion.


An HIV-positive person has been referred for counselling, but does not know that their blood has been tested.

HIV testing without counselling and consent is an abuse of a person's rights. However, in some workplaces, hospitals and clinics, people are tested in this way. Those who test HIV-positive are often referred for counselling. Some people may suspect or know they have been tested, while others may not be aware of the situation.

Possible approaches 
 

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It is very important for senior staff to try to stop the practice of testing without proper counselling. 

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If the person does not know they are HIV-positive, it may be possible to start the process again. First, the counsellor can give proper pre-test counselling. If they decide not to have a test, or not to be told the results, then their wishes should be respected. 

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If someone already knows or suspects that they have been tested, counsellors should avoid using only one session to tell the client that they are HIV-positive. Instead, the counsellor could begin by explaining the test and its implications, and why their blood has been tested. The discussion could then cover whether the person wants to know the results, giving them enough time in which to mentally prepare themselves to learn that their suspicions are correct.


A person is anxious about telling their sexual partner that they are HIV-positive.
Deciding whether or not to tell a partner is very difficult. Many HIV-positive people - particularly women - fear being rejected, abandoned or losing their children. They are also afraid of being blamed for what has happened, or that their partner will tell others. Not telling a partner poses practical and ethical problems. The couple will not be able to fully discuss whether to have children, or how to cope with possible illness and death. Unprotected sex may result in the partner becoming infected. Keeping silent makes adopting safer sex more difficult - a partner may not see the need to use condoms for penetrative sex. Alternatively, the partner may already be infected, and may want counselling.

Possible approaches
 

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If someone is in a stable sexual relationship, the counsellor should try to introduce the idea of 'shared confidentiality' right from the beginning. People who come for pre-test counselling alone can be invited to come back with their partner, so that the decision about testing can be made together.

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If a person feels unable to disclose the news, and if resources are available, the counsellor can suggest that they have counselling and testing again, this time with their partner. The person encourages their partner to accompany them, behaving as though they have not already had the first test. 

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A person may not be ready to tell anyone very soon after the test, or if he or she is still healthy. Their counsellor can offer more counselling sessions, and suggest they meet other people who are HIV-positive.

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If someone does not see the need to protect others from infection, the  counsellor should emphasise that their partner may not yet be infected, and that safer sex will prevent transmission. Using a condom also helps to keep the person themselves healthy by reducing the risk of STDs (which can be more severe in people who are HIV-infected) and re-infection with HIV.


A person is reluctant to tell close family members or carers that they are HIV-positive.
There are no ethical reasons why someone should tell friends or family members, because there is no risk of infection through casual contact. But deciding not to tell anyone can result in loneliness and depression, and make it difficult to get help and support.

Possible approaches 
 

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Some people over-estimate the likelihood of rejection, and counselling can help them to assess the situation more realistically.

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The counsellor can encourage someone to think of others they could trust, such as members of a self-help group for HIV-positive people or their doctor. 

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The counsellor can suggest that they ask close family members or friends to share a session with them, if this helps them to disclose the news.





AIDS action  Issue 24    4   Page 5   6  top of page

  Counselling and HIV

 

A person may have HIV infection, but after counselling does not want to be tested or to know their status. It is important to remember that HIV testing is not the aim of counselling.

Possible approaches
 

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The counsellor should always accept the person's decision, and never put pressure on someone to have the test. The discussion could focus on the ways in which someone can live their life without knowing whether they are infected with HIV. Safer sex is advised whether or not someone is infected with HIV.


A person doesn't seem to under-stand what being HIV-positive means, or denies the test result.

Possible approaches
 

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It may be difficult for someone who is unfamiliar with Western theories of illness to understand what HIV infection is. Counsellors need to find out the best way to explain the issues in a particular culture. 

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If someone has severe physical or mental health problems, or is very upset, counselling about AIDS may not be possible. The caregivers themselves may benefit from support, and opportunities to discuss the issues. The family should not be told that the person has HIV, without the person's permission. However, if the person is very confused or ill and nearing death, the counsellor may consider telling key family members. 

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Denial is often linked with feelings of extreme anxiety and helplessness, and fears that life is finished. Over time and with continued counselling this may change. The counsellor can help the client to view HIV infection as something that can be managed, and develop a positive attitude about their life with HIV. 

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Denial may make it impossible for the client to explore what they feel. The counsellor can try to discuss being HIV-positive as an imaginary situation: 'Let's pretend it's true, and look at what it would mean for your life.'


Karla Meursing was a counsellor at the Matabeleland AIDS Council and Mpilo Hospital, Zimbabwe. Thanks also to Thandi Nhlengethwa (TASC, Swaziland) and Kgomotso More (counselling coordinator, NACp; Botswana) for sharing their experience.

Confidentiality versus secrecy

Confidentiality is an important aspect of a counselling relationship. People are better able to discuss their feelings if they know that the counsellor will not tell anyone else without their permission. Breaking confidentiality can destroy a person's confidence in their counsellor, and expose someone to discrimination at work, or to prejudice from health workers. While it is vital not to discuss a person's situation without their permission, too much stress on secrecy can make it more difficult for them to cope, and for the most appropriate support to be given. Promoting 'shared confidentiality' means encouraging someone to identify a few others whom they trust, especially their doctor, sexual partner, close friends or family members. It can help some people to have counselling (if they agree) with a partner; close friend, or family members. Counselling with larger groups can be successful, but it may be very difficult for individuals to discuss their personal concerns with others present.

Working with couples
A counselling centre to provide pre-and post-test counselling for out-patients was set up in 1989 at a large hospital in Zimbabwe. Most people are referred by doctors working in local clinics and district hospitals. 

At first most patients were counselled alone. But in many cases, they were afraid or unwilling to tell their partner about their HIV status. This problem affects women particularly, because they depend on their husbands or regular sexual partners for security. Some of the reasons for not telling their partners were lack of understanding about transmission; difficulty in discussing sexual issues and introducing the use of condoms; and fear of being found to be having sex outside marriage.

Many clients said they wanted to bring their partners to the counselling session because they felt that it would be a safe place to bring up difficult issues. Some also wanted to have the HIV test at the same time. So, since 1991 the centre has been encouraging couples to come for counselling and testing together, if they agree. We ask doctors to explain to people why it may be useful to be counselled together, and to refer them as a couple if they wish.


During 1992, 56 couples chose to have counselling together (14 per cent of total referrals). Of the 40 couples who chose to have HIV tests, all were counselled together after the test results too. Most had the same HIV status. Where one was HIV-positive and one negative, counselling helped them to: 
 

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accept the partner who had HIV, rather than blame them

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be more open and understanding about HIV/AIDS

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discuss contraception and sexual issues, agree to try and use condoms. and plan for coping with possible or current illness and its impact on the family.


Odette Coutinho and Dorothy Mhlanga. Mpilo Hospital, PO Box 2096, Bulawayo, Zimbabwe



AIDS action  Issue 24    5   Page 6   7  top of page

  Practical guideline

Care for the dying

In AIDS Action highlights key issues for health workers who are supporting someone who is very sick and dying at home.

 


Many people with AIDS are being cared for at home because hospitals with very limited resources cannot cope with growing numbers of patients. People often prefer to be in a familiar environment with those they are close to.

At some point in a person's illness, little can be done to enable them to live longer. The decision to stop trying to prolong life must be made by the person (if they are conscious), with their carers and health worker. After this, terminal or palliative care is given. This is care that helps the dying person to be as comfortable as possible, and to prepare emotionally and spiritually for death. Even where resources are limited, good palliative care can be given.

Practical issues

Choosing a suitable place
Choose a convenient room in consultation with all those involved. The person's bedroom may not always be suitable, as it may be too small or shared with others. The room needs to have good light and ventilation and be quiet and comfortable, but also enable the person to remain involved in family life.

Health services support
The local health centre should be briefed about the person's condition, so that staff can provide them or their carers with advice and appropriate drugs.

Community and family support  Reducing the pressures on the carers - usually the women in the family - is important. Relatives and friends can help in household or other work, and provide companionship for the sick person. The health worker should discuss how to mobilise support with the family and the local community leaders, perhaps by involving neighbours or members of community or religious associations.


Patient care

The health worker can give advice to enable the sick person to be as comfortable as possible.

Severe pain in the form of headaches, and in the chest, hands or feet, is very common. Sores and ulcers in the mouth or around the genitals and anus can also be very painful. 

Painkillers should be taken before the pain becomes very bad, and regularly while it lasts. Mild painkillers such as aspirin may have no effect. Instead, the health worker can prescribe morphine or pethidine if available, without worrying about possible addiction. Alternatively valium can be given to sedate the person. However, the sick person and their carers should be aware that sedation may cause their condition to worsen.

Other methods to relieve pain include putting a cool, clean, moist cloth over the painful site, pouring clean water over it, or massaging it gently with oil or vaseline. Carers should respond to the person's requests to lie or sit in a particular position or for changes in their environment. Deep and regular breathing may help them to relax.

Diarrhoea
can be a major problem, sometimes persisting for several months, with stools that may be watery, mucoid or foul smelling with pus. The person may be very depressed, sometimes refusing to eat or drink for fear of making the diarrhoea worse. Encourage them to eat frequent, small and nutritious meals. 

Dehydration can be prevented by giving plenty of fluids, such as water, unsweetened fruit juices, soup, rice water or weak tea. If the patient is vomiting, they should take fluids in small amounts but more frequently. Foods and fluids containing too much sugar can make the diarrhoea worse. The health worker can also consider prescribing adsorbents for a short time such as kaolin or pectin, or anti-motility drugs such as loperamide, which may succeed in stopping persistent diarrhoea (although they do not cure the infection). 

Oral rehydration therapy should be given if there are any signs of dehydration, such as having a dry tongue or feeling thirsty. Oral rehydration salts (ORS) solution made from a packet, or home-made sugar and salt solution are the best methods. Sometimes intravenous rehydration can be carried out at home, if a trained health worker is able to monitor the procedure very closely. 

The sick person should be kept as clean, dry and comfortable as possible, with frequent changes of bed sheets. Plastic covering can be used to protect the mattress or blankets, and a bed pan provided if necessary. Smells can be dispersed with good ventilation, air freshener sprays (if available) or by burning herbs used locally.



AIDS action  Issue 24    6   Page 7   8  top of page

  

 

Mental confusion (dementia) affects many people with HIV-related illness. They may become unaware of what is happening around them, be forgetful, unable to think clearly, or move clumsily. Their awareness of being confused may come and go, and this can be very upsetting.

A person who is confused needs constant attention and reassurance, and sometimes one or two people may be needed to restrain them from hurting themselves. Dangerous objects should be removed from within their reach, and medication needs to be supervised.

Severe dementia can cause very rest less or aggressive behaviour, and a sedative may help calm them. However, carers need to be aware that this is likely to make the person drowsy and worsen their overall condition. Looking after a confused person is exhausting and distressing. Carers need to be encouraged to have enough rest, and to take turns in nursing and being with the person. Health workers should explain to the family that the person's behaviour is not intentional but caused by the effect of the virus on the brain. Some drugs can also cause confusion. The medication list should be reviewed, and it may be appropriate to stop all drugs.

Severe skin abscesses or ulcers can become infected. This infection - sepsis - can affect the rest of the body, making the person feverish, with low blood pressure and a fast pulse rate. They may be in great pain and discomfort.

Ulcers need to be cleaned regularly with antiseptic (if available) or salty water (one teaspoonful in a cup of water). The health worker should lance any unburst abscesses, and drain and dress the wounds. This helps greatly in relieving pain and fever. Attempts should be made to disperse the bad smell associated with severe sepsis.

Fever can be lowered by removing unnecessary coverings, and the skin cooled by fanning and using moist cloths. To prevent skin problems, the skin should be kept clean and dry. If the sick person is bedridden, their legs and arms should be moved gently several times a day, and their body turned every few hours to prevent bed sores developing.

Emotional stress 
Someone who is dying may suffer from great psychological stress. Appropriate emotional and spiritual help should be offered. Counselling can help someone understand and explore their reactions to death and dying, and accept the fact that death is near. It also enables a person to make decisions about issues such as how children will be cared for, making a will, informing other relatives, and arranging for burial. It is important for family members to give the person opportunities to talk about their feelings, enabling them to cope better with anxiety, fear, loneliness and guilt - feelings that often worsen as someone becomes weaker.

Fear of death is a normal reaction. Carers should not give false reassurances, but can help the person to talk about their fears. Spiritual support should be provided if the person wishes. Fear can make people angry about their situation, and aggressive towards people they are close to. It may be helpful to explain to the sick person what can happen physically as someone dies (for example, they may have difficulty in breathing or move in and out of consciousness).

Loneliness is very depressing for the sick person. Friends and relatives often stop coming to see them, or, when they do visit, they act like strangers. People should be encouraged to visit, but need to be given opportunities to discuss their feelings about being with someone who is dying.

Feelings of guilt and regret are very common, in part because of the stigma often associated with AIDS. People may feel responsible for exposing their partner to infection, or guilty because they feel they have brought shame to their families or friends. Failure to settle debts, fulfill ambitions or responsibilities to children, can cause feelings of guilt, sorrow and regret. A person may want forgiveness or to discuss ways of resolving problems they feel responsible for.

Caring for the carers
Looking after a partner, friend or family member who is dying is stressful and upsetting. It also adds enormously to the burden of household work - particularly for women. Counselling can help people to cope with the strain, and to solve problems, such as identifying someone else to look after the children or cook.

If the issue has not already been discussed. it is important to encourage the sick person to discuss the implications of their HIV status with their partner (or other close and trusted relatives). Alternatively, if the person is very ill or near death, the health worker should try to talk with the close family. Family members need to be encouraged to talk about their feelings with each other, as well as the sick person. It also helps to talk with friends who may be having, or have had similar experiences. Community and health workers themselves also need support and counselling.

When death is near
The family often needs more emotional support than the person themselves, because they find it difficult to accept what is happening. If the sick person is very weak or unconscious, a decision should be made with the relatives to stop trying to rehydrate or give food to them. The health worker should explain that the end has come, and attempts to try and revive the person should not be made.

When death comes, the health worker should calmly and quietly organise the preparation of the body for burial, making sure that there is no skin contact with blood or other body fluids. They should also make sure that, for example, the death certificate is signed, and that arrangements for the funeral have been made. 

Unless invited to stay, the health worker should then leave the family to contact other relatives and to mourn the dead person according to their cultural traditions. Family members should be offered counselling to help them cope with grief and other feelings, as well as support for practical problems.

Dr Elly Katabira, Dept of Medicine, Makerere University Medical School, PO Box 7072, Kampala, Uganda. 

WHO's new AIDS Home Care Handbook covers nursing care, medical treatments and other practical issues. Single copies are available free from WHO/GPA, 1211 Geneva 27, Switzerland.





AIDS action  Issue 24    7   Page 8       top of page

  News / Resources

 

Human rights and sex work
This year's international AIDS conference is taking place in the Asia-Pacific region for the first time, in Japan. It will be a valuable opportunity for people working in HIV/AIDS in the region, as well as from the rest of the world, to learn from each other. For this process of information exchange to be most effective, the conference is open to as many delegates as possible - people with HIV, activists, educators, scientists, and health and outreach workers. 

However, some people will be unable to attend legally. Japanese law states that: 'Any person who engages in or has engaged in prostitution shall be denied permission for entry to Japan...even if he or she wishes to enter as a non-working visitor.'

Many current and former sex workers are actively involved in HIV/STD outreach work, and have an essential contribution to make to discussions about effective prevention approaches. Requests to make provision for sex workers to enter legally and openly as conference delegates have been unsuccessful.

This situation raises very important human rights issues, especially in the context of HIV. Denial of the right to travel freely is just one of the many human rights abuses that increase discrimination against sex workers, and  their vulnerability to HIV/STDs. 

If you feel that this is an important issue, please write to the Community Liaison Committee, Ministry of Health and Welfare 2-2, Kasumigaseki I-chome Chiyoda-ku, Tokyo 100-45, Japan.

 

Attention all readers! 
Every year hundreds of newsletters are returned to AHRTAG because readers have changed their addresses and have not informed us. 

To check that current addresses are up to date, we have sent questionnaires to people who receive over 19 copies of the newsletter, or who have been on our mailing list for more than three years.

If you have received either a yellow card or a letter asking you to complete a distribution survey, please send replies and completed cards to AHRTAG as soon as possible. These questionnaires also give you the opportunity to tell us about your occupation, workplace, and how you use AIDS Action.

If other readers have not been in touch with us recently, please write in and tell us about yourselves and your work, beginning your letter with the heading: Mailing list information appeal. Thank you.

Resources

Practical issues in HIV testing is a new publication providing information about when, how and why testing for HIV antibodies is ethical and helpful, and including details about new technologies.
Available free from AHRTAG to readers in developing countries and £2.50 elsewhere.

Challenges in AIDS counselling is a video and manual for use during counselling training, covering topics such as talking about sex and telling a client they have HIV infection.
Produced in co-operation with the Ministry of Health, Zambia and available in VHS in PAL or NTSC for US$59 (plus postage) from DSR, 9650 Santiago Rd #10, Columbia, MD 21045, USA. 

Primary AIDS Care is a practical hand-book for primary health care staff involved in managing AIDS-related infections, HIV counselling and testing.
Available far R60.00 (£12.00, plus postage) from Jacana Education, PO Box 2004, Houghton, Johannesburg 2041, South Africa. Reductions for readers in developing countries will be considered on special request.

Statement from the consultation on testing and counselling for HIV infection, 1992.
Guidelines for the clinical management of HIV infection in children, 1993. 
Single copies of the above two resources are free from WHO/GPA, 1211 Geneva 27, Switzerland.

Updated slide sets and handbooks useful for training medical staff in managing STDs, and HIV infection in children and in adults (in Africa and the Asia-Pacific) are available from TALC.
Write to PO Box 49, St Albans, Herts, AL1 4AX, UK for a 1994 catalogue.

 

Executive editor Nel Druce
Managing editor Kathy Attawell
Design and production Ingrid Emsden
 
Editorial advisory group Calle Almedal, Nina Castillo, Professor E M Essien, Dr Sam Kalibala, Ashok Row Kavi, Dr Ute Küpper, Professor Keith MacAdam, Dr Tuti Parwati Merati, Dr Claudia Garcia Moreno, Dr Chandra Mouli, Dr Anthony Pinching, Dr Peter Poore, Barbara Wallace, Dr Michael Wolff
 
Publishing partners ABIA (Brazil) Colectivo Sol (Mexico) ENDA (Senegal) HAIN (the Philippines) Consultants based at University Eduardo Mondlane (Mozambique)
 
AHRTAG's AIDS programme is supported by CAFOD, Christian Aid, FINNIDA, HIVOS, ICCO, Memisa Medicus Mundi, Misereor, Norwegian Red Cross, Oxfam, Redd Barna, Save the Children Fund, SIDA and WHO/GPA.

 

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AIDS Action
The International Newsletter on AIDS Prevention and Care


This English edition of AIDS action was produced and distributed by Healthlink Worldwide.

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