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AIDS action  >  Issue 38 - Health workers 
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AIDS action  -  Issue 38 - Health workers

HIV and its impact on health workers

Issue Contents
 

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HIV and its impact on health workers

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Health worker stress

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Coping with the burden

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Getting together to talk about stress

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Reducing risk at work

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Steps to making the workplace safer

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Our fears about HIV

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Health workers with HIV

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Health workers need support

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District management

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Allocating resources

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Community treatment for patients with TB

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Caring for children

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Support for home carers

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Drugs for dealing with HIV

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News

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Letter

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New publications

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Resources

 

 

 

AIDS action  Issue 38         Page 1   2  top of page

  Issue 38 September - November 1997

HIV and its impact on health workers

Sharing their concerns helps AIDS community workers to keep up morale.

In countries with high HIV rates, health workers, auxiliary staff and managers are all under pressure to cope with the impact of HIV.

HIV has led to more patients requiring treatment and care, but often with lower budgets and staff shortages due to HIV-related illness. HIV creates its own emotional stresses for health sector staff - the sadness of seeing people die, the fear of getting HIV, and the stigma attached to HIV. Patients often have expectations that health workers cannot meet. As one health worker said: 'Sometimes there is uncontrollable pain, yet a patient is sure that I am able to help'. It is not surprising that health workers sometimes feel exhausted and helpless.

However, steps can be taken to improve the situation, even where resources are scarce. This special joint issue of AIDS Action and Health Action aims to help health sector staff responsible for providing HIV treatment and care to identify key problems and find ways to overcome them. It contains examples of how staff have got together to discuss their concerns and seek solutions. It includes guidelines on reducing occupational risk of HIV transmission, and a section for district health managers on how to plan the most effective use of existing resources. 

Several key points emerge. Most important is the need for good support to health workers and carers, including training and supervision, and access to confidential counselling. Support from other sectors and the community is also very important. AIDS affects all areas of life - it is not the responsibility of the health sector alone. 

Demand for care and treatment of people with HIV will continue to rise, especially in areas where people have HIV but are not yet sick. Resources will continue to be in short supply, and dealing with HIV will never be easy. But by following the strategies outlined in this issue, some of the worst problems can be alleviated, and health workers will be better placed to cope.

 

In this special joint issue with Health Action
 

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Coping with the burden Page 2

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Talking about stress Page 3

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Making the workplace safer Page 4  

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Our fear about HIV - Training activities Page 6 

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Health workers with HIV Page 7

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Allocating resources Page 8

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Support for home carers Page 10

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Drugs for dealing with HIV Page 11

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News and resources Page 12



AIDS action  Issue 38    1   Page 2   3  top of page

  Health worker stress

Coping with the burden 

Alan Whiteside assesses the burden that HIV has placed on health services and suggests ways to reduce the pressure.

The need for care and treatment of people with HIV-related illnesses is rising rapidly. According to UNAIDS, 2.3 million people died of AIDS in 1997 - a fifth of the total since the epidemic began. More people also need treatment for illnesses that have become widespread because of HIV, such as tuberculosis (TB). Additional care is required for children of HIV-positive parents, who become ill more often because of poverty resulting from their parents' HIV status, and who are likely to be orphaned. 

Yet health services in many countries are under pressure from policies such as structural adjustment and health sector reform, which have reduced their budgets.

More patients, fewer staff and lower budgets put huge pressures on health services.


Illness and death of health workers also adds to the pressure. In one Southern African country, about one in 40 health care staff are predicted to die from AIDS in three years. 

In some countries, public sector employees are entitled to up to a year's paid sick leave. Some countries face the problem of 'ghost workers' - staff on long-term sick leave who cannot be replaced. The result is more stress on remaining staff and fewer staff to care for patients.

When resources are low, sometimes all health workers can offer is compassion. But when staff are stressed, even this is difficult. Stress can build up to a feeling of burn-out - complete exhaustion and helplessness. Causes include:

 

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having to treat HIV-related problems with inadequate knowledge or support 

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having to provide treatment and care that is less than ideal, such as using unscreened blood for blood transfusions

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making decisions about treatment and referral with limited knowledge about HIV 

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talking to patients every day about illness and death 

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being unable to cure patients

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becoming involved in non-health care activities such as income generation projects, without the necessary knowledge 

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discussing difficult issues around sexual behaviour without training 

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suffering stigma attached to HIV 

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worrying about friends and family who might have HIV

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fear of getting HIV.


The way ahead 
Demand for services will continue to rise. Training local health centre staff, providing support for health workers, and obtaining support from other sectors can help reduce the pressure.

Local health centres People with HIV should receive good care at an early stage of their illness from their local health centre. Health centre staff need the skills and resources to treat HIV-related illnesses, so that people are referred to hospital only when absolutely necessary. 

Home-based care Care and support are often best provided at home. Families require the support of local health centre staff, who may need additional training.

Support to staff Health workers need training and supervision to provide the best care available. Their skills and experience need to be valued and they should be involved in decisions about their work. Their own concerns must be recognised and action taken to reduce them.

Reducing HIV transmission to staff Health workers' main risk of HIV infection is from their own or their partner's sexual behaviour. They also face a small risk at work. They need information and support to minimise the risk of transmission in their personal and professional lives.

Support from other sectors Most national AIDS programmes were originally staffed by health workers, because HIV was seen as a health issue. However, AIDS affects all areas of life. It requires a coordinated response from health, education and social services, legal institutions, and religious and community groups.

Alan Whiteside, Economic Research Unit, University of Natal, King George V Avenue, Durban 4001, South Africa.

Thanks also to Sam Kalibala, UNAIDS, CH-1211 Geneva 27, Switzerland. 

AIDS Briefs: integrating HIV/AIDS into sectoral planning, by Tony Barnett, Erik BIas & Alan Whiteside (eds), 1996, Global Programme on AIDS

The effect of HIV on health care in sub-Saharan Africa, Development Southern Africa, Vol 13 No I, February 1996, Decosas Josef and Alan Whiteside.



AIDS action  Issue 38    2   Page 3   4  top of page

  Health worker stress

Getting together to talk about stress

Hospital staff and outreach workers at Kitovu Hospital in rural Uganda worked with a facilitator to analyse the stresses they faced and how to improve the situation.

About 80-90 per cent of people in adult medical wards have an HIV-related disease. Staff felt stressed because: 

We cannot cure HIV Some people feel that without a cure for AIDS, little can be done to help. Stigma leads to some of our patients being neglected at home.

The pain experienced by AIDS patients 'I feel touched when I counsel a client in pain. Sometimes there is uncontrollable pain, yet a patient is sure that I am able to help.'

Heavy workload and burn-out 'I have to talk to many people with HIV with limited time. Sometimes I am hungry, tired and anxious. By the end of the day I may be burnt out. The death of someone to whom I have been close leads to frustration.'

Fears of having HIV 'Sometimes I feel sad and tired, thinking that one day I may be like one of the patients.'

Behaviour change is slow We have to educate people about preventing HIV and positive living and care. Change can take a long time, or does not happen. 

Some staff felt that they were drinking or smoking too much, over-reacting to patients, developing nagging behaviour and keeping away from friends.

Managers felt stressed by staff illnesses:

Being fair Staff who are sick with HIV fear losing their salary, so they continue to work, even when they are too ill. It is problematic to be compassionate to them, fair to other staff and fair to the hospital.

Planning work It is hard to plan work because staff are often off due to illness, burials or other family needs. 

'I feel touched when I counsel a client in pain. Sometimes there is uncontrollable pain, yet a patient is sure that I am able to help.'


Losing skills
We want to train staff to improve their skills. but we know that many staff who are being trained are likely to become ill.

Personal issues Staff have problems at home which are the same as those they see in hospital. so there is no place for them to relax. Bringing their emotional burdens to work affects their performance.

Low morale Staff have a sense of helplessness in situations that do not seem to resolve themselves. It is hard to motivate them or get them to take initiative.


All staff noticed the stresses on the hospital:

Other health problems These seem to be getting worse. For example, there was a measles outbreak, despite local immunisation campaigns.

Expensive care People are attending hospital when their illness is already at an advanced stage. If the illness is HIV-related, it often takes a long time for the patients to recover.

Action plan 
After we had identified our concerns, the facilitator helped us to make recommendations. Some needs could be met through incentives, salaries or performance appraisal, but these are expensive. We came up with other ideas. As carers we need:

Time for reflection and recreation to refuel ourselves.

Training, updating and supervision. 

Confidential counselling to discuss our fears about HIV and help us cope with demoralising work. Many nurses said that their training had not prepared them for coping, so frequently, with young people with HIV and with dying patients. 

Group support among patients and carers to make expectations more realistic, make sure that patients can air their grievances about staff, and help staff feel appreciated.

A holistic approach to healing, incorporating spiritual and emotional issues into our training programmes. 

Recognition from managers that staff are affected and may be infected. They may be experiencing the same problems as patients.

Information on how to protect ourselves against HIV/AIDS and more knowledge about the infection.

We realised that health workers shouldn't take on the responsibility of others, just because the challenge is there. We need to start working with others who can do this better than we can. 

Mrs Robina Ssentongo, Programme Manager, Kitovu Hospital, PO Box 413, Masaka, Uganda.





AIDS action  Issue 38    3   Page 4   5  top of page

  Reducing risk at work

Steps to making the workplace safer

AIDS Action explains how to reduce the risk of spreading HIV at work and what to do if an accident occurs.
 

The risk of HIV transmission during health care work is very low. Fewer than 200 cases have been proved worldwide. However, health workers (and other carers) can be exposed to HIV and other serious infectious diseases such as hepatitis B and C, and TB.

Like anyone else, health workers can also be at risk from their own or their partner's sexual behaviour. This is likely to be a much greater risk, yet is often the most difficult to accept. 

Health workers need to know what the risks are in their professional and personal lives and how to minimise them.

Take care to prevent injuries when handling sharps. Hollow needles are the most risky.


Risks at work
HIV is present in large enough amounts to cause infection to others in blood and some body fluids: lymphatic fluid, semen, vaginal and cervical secretions, colostrum, breastmilk and cerebro-spinal fluid. 

HIV is not present in large enough amounts to cause infection to others in saliva, sweat, tears, vomit, urine or faeces, unless blood is visibly present.
 

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Splashes of HIV-infected blood or body fluid on intact skin present almost no risk of HIV transmission.

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HIV-infected blood or body fluid on cuts or grazes, or in the eye, presents a possible risk if much blood or fluid is in contact with the cut, graze or eye for a significant length of time. 

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Needlestick injuries involving HIV-infected blood, where the skin is punctured by a sharp (needle, scalpel or other sharp instrument), present a higher risk, especially if the injury is caused by a hollow needle.


Preventing accidents
Accidents normally happen during emergencies, when health workers are stressed. Poor working conditions, such as bad lighting or long working hours, also make accidents more likely. Both individual health workers and managers have responsibility for preventing accidents at work. 

Health workers
 

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Take care to prevent injuries when handling sharps. Hollow needles are the most risky. 

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Do not recap used needles. Do not remove them from syringes by hand. Do not bend or break them by hand.

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Handle sharps carefully, especially in emergencies. Dispose of them carefully with thought for others. Place used sharps in puncture-resistant containers with lids (sharps boxes). Keep these as close to the place of use as possible. Sharps boxes can be made from large drug tins, tablet bottles or buckets with a lid.

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Use protective barriers such as gloves to prevent contact with blood and other body fluids. If necessary, re-use gloves carefully after rinsing in water (not alcohol or disinfectant) and leaving to dry out of direct sunlight.

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Avoid unnecessary injections, episiotomies (cutting the perineum during labour) or laboratory tests.

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Avoid direct contact with patients' blood or body fluids if you have an open cut or sore.

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Cover broken skin, sores or cuts with a waterproof dressing.


Managers
 

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Try to ensure reasonable working conditions.

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Do not let inexperienced staff carry out difficult or stressful procedures.

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Assess where the greatest risk is - injecting rooms, operating theatres, delivery rooms, laboratories, clean-up departments and mortuaries - and ensure that infection control procedures are followed in these areas.

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If resources are limited, use them rationally. For example, keep gloves for activities with the greatest risk of exposure, such as delivery. 

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Promote a 'safety ethos'. If no one seems to care about safety, everyone is at increased risk. If health workers believe that infection at work is unavoidable, they may take unnecessary risks, both at work and in their private lives. Some health facilities have set up infection control committees with authority to take action, or developed a procedure for reporting and monitoring accidents. These have reduced the number of accidents. They can help to maintain morale by showing that staff health is taken seriously. 


Midwives, birth attendants and surgical staff may be at higher risk than other health workers because of the large amount of blood present after delivery and during operations. They should be provided with gloves and cover any open wounds, sores and cuts on their hands and arms.

Health workers making home visits need to take special care because of the stresses involved. Poor housing often means that they have to see patients in dark rooms with little fresh air. They are at increased risk of getting TB. They also have additional responsibilities, such as training family members to care for someone with HIV while protecting themselves.





AIDS action  Issue 38    4   Page 5   6  top of page

  Reducing risk at work

 

After an accident 
Despite following precautions, most health workers will have an accident at some time in their work. Health workers need to know what to do after an accident and where to go for confidential counselling. It may be useful to have a poster on the wall of the clinic or ward outlining the procedures. 

  1. If infectious body fluids have been spilled, clean them up immediately using soap and water, or a chemical disinfectant if available.

  2. If eyes or skin have been splashed with blood or body fluid, wash them as soon as possible with water (for eyes) and soap (for skin). Do not scrub skin or use disinfectant chemicals. as this may cause cuts or grazes. 

  3. If skin has been cut or pricked, let the wound bleed for two minutes. Then clean with alcohol disinfectant if available (which will burn) for 3-4 minutes. Try to assess the risk of transmission. Unless a lot of blood is involved, such as with a hollow needle, there is no need to do any more.

  4. Report the accident to the manager, so that steps can be taken to avoid similar exposures in the future.


Policies vary about what to do if a health worker has been exposed to a significant amount of blood from a patient. The World Health Organization advises that the patient and health worker be tested soon after exposure, and the health worker tested again six months later.

However, HIV antibodies cannot be detected until three months after infection, so a blood test soon after exposure might not confirm that a person had HIV. 

Health workers who have possibly been exposed to HIV need time to think about the implications of having an HIV test. They need access to trained, confidential counselling and support in making decisions. 

anti-viral treatment after exposure to HIV (post-exposure prophylaxis or PEP) can reduce the risk of infection. PEP using zidovudine alone has been proved to reduce HIV transmission from an average of 3 in 1,000 injuries that involve puncturing the skin with HIV-infected blood, by 79 per cent; but it is expensive. Combination therapy (using two or three anti-viral drugs) may be even more effective, but it is even more expensive. 

PEP needs to be guided by local policy and depends on availability of drugs. If available, a combination of antiviral drugs should be taken as soon as possible within 24 hours after exposure for four weeks. However, there is still a risk of infection, and long-term side-effects are unknown. 

PEP needs to be carried out by trained health workers who can assess the risk of possible transmission; provide counselling. including assessing the risk of HIV transmission from previous activities if the health worker's HIV status is unknown; diagnose HIV in the patient and health worker quickly and accurately; and ensure a month's supply of anti-viral drugs, starting immediately.

In most countries, anti-viral drugs are not accessible to health workers. However, it is important for managers to know about them, as it may be possible to purchase them privately. Taking anti-viral drugs incorrectly is dangerous.

Health planners also need to realise that, although the costs of PEP are very high, they are much lower than training a new health worker. They can also help to maintain health workers' morale by showing that health workers' health is important.

WHO, Preventing HIV transmission in health facilities, 1995.

Provisional Public Health Services Recommendations for Chemoprophylaxis After Occupational Exposure to HIV Morbidity and Mortality Weekly Report, Vol 45, No 42. 1996.
 

Reducing risk at work
 

 

Hepatitis and TB

Hepatitis B and C
, which are also transmitted via blood, are much more infectious than HIV. They can cause chronic disease and death.

Hepatitis can be transmitted the same way as HIV. The risk of acquiring hepatitis B at work is up to 100 times greater than HIV. Health workers should follow the same infection control procedures for hepatitis Band C as for HIV. There is a vaccination against hepatitis B.

Tuberculosis (TB) is infectious. It is transmitted by air-borne particles from TB bacilli in the lungs. TB stops being infectious two weeks after the start of treatment.
 

To minimise the risk of TB:
 

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Isolate people suspected of, or diagnosed with TB, from other patients, and, during the early stage of treatment, from people with HIV. 

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Ventilate rooms - keep windows to the outside open and uncurtained, if possible. Keep doors closed. 

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Encourage infectious patients with uncontrolled cough to wear masks or a clean cloth over their nose and mouth. 

 



AIDS action  Issue 38    5   Page 6   7  top of page

  Reducing risk at work 

Our fears about HIV

Many health workers are worried about the risk of HIV at work. Health workers in Zambia discussed their fears.

HIV affects every aspect of life in Zambia. The majority of adult medical hospital admissions are HIV-related. We set up small group discussions with nurses, midwives, hospital porters, cleaners, laundry workers, mortuary attendants and medical students to see how HIV affected hospital staff.

Most staff were worried about getting HIV from needlestick injuries. Some nurses also worried that they might transmit HIV to patients this way. 'When you are giving injections, you can infect yourself or the patient. Sometimes the needle pricks you, but you still treat the patient. You can get infected.'

Almost all nurses said that they had had a needlestick injury. They often did not have clear guidelines on what to do when this happened. They often did not report needlestick injuries, as they felt that little could be done. They were usually told to squeeze the wound and then wash it and apply white spirit. Anti-viral treatment is not routinely available in Zambia to medical staff after exposure to HIV. 

Some people were confused about how HIV could be transmitted. For example, they wondered if they could get HIV by washing cloths from the mortuary.

What can we do? 
Staff felt that they were very likely to have HIV because of repeated occupational exposure, but that there was nothing they could do about it. 'We do have a little fear. On the other hand, this is just work. If we are infected, there is nothing we can do.'

About one in three sexually active adults in Lusaka is HIV-positive, so it is likely that many hospital workers have become HIV-positive through unprotected sex. Even though HIV is common, there is fear and stigma attached to it. Few people are open about their HIV status. This may explain why the nurses we talked to were reluctant to have an HIV test following occupational exposure. 'It is better not to know because it's very depressing. There is also the stigma. People will be pointing at me. Who is going to believe that you got HIV from a patient?'

These discussions show how important it is for health workers to have access to accurate information, and how efforts need to be made to reduce the stigma around HIV. 

With thanks to Rachel Baggaley and Zachariah Kasongo, Zambast Project, c/o ASD, WHO, CH-1211 Geneva 27, Switzerland.

 

Activity

Twenty-four hour clock
This activity encourages health workers to consider their risk of acquiring HIV both at work and outside work. It may be best done in single-sex groups. It is important that the facilitator can discuss issues such as sex sensitively. 

In small groups, ask participants to write down what they usually do each hour of the day, both at work and out of work. In the large group, ask the groups to compare their 'twenty-four hour clocks', Ask them to discuss the main points that relate to HIV risk. These may involve out-of-work activities and also risks at work, such as working for a long time without a break.

 

Activity

Accident zones
This activity allows hospital and health centre staff; traditional birth attendants and others to discuss the risks of HIV infection at work. All staff must be represented, including doctors, nurses, auxiliaries, and laundry and cleaning staff.
 

In small groups, ask participants to draw a map of their workplace - wards, operating rooms and kitchens in hospitals, or homes and local services for community-based staff. Then ask them to mark areas where they may face a risk of acquiring HIV.

Ask the groups to feed back to the large group why they think that there is a risk. Make sure that any inaccurate information is corrected.


Then ask the group to identify ways to reduce the risks. It may be useful to list these in order, starting with those that can be implemented immediately at no cost. 

With thanks to CAFOD AIDS team, 2 Romero Close, Stockwell Road, London SW9 9TY, UK. 

 



AIDS action  Issue 38    6   Page 7   8  top of page

  

Health workers need support

It is important that health workers with HIV can continue to work while they are healthy

Many health workers know that they are HIV-positive. Others suspect that they might be. Managers need to provide appropriate support. 

Confidentiality
Many health workers may not want an HIV test if they know the people who will be testing or counselling. They need access to confidential counselling. No health worker should be forced to disclose their HIV status at the request of patients or other staff.

Health workers who think they might have HIV need access to confidential counselling.

Health and safety at work HIV-positive health workers should be allowed to continue their work as long as possible. They (and all other workers) must take precautions to protect themselves against HIV transmission. If possible, managers should enable health workers with HIV to avoid infections such as TB, for example, by ensuring that they do not work in TB wards.

Fears for the future Health workers need to know that they will be able to work as long as they are healthy, without discrimination from colleagues. Managers have a key role in providing information to employers, colleagues, and patients and their families. It is important that health workers with HIV can continue to work while they are healthy. 


Viewpoint

Having HIV makes me less afraid
Francois Lanteigne, a Canadian nurse who has been living with AIDS for nine years, outlines advantages and disadvantages of being an HIV-positive health worker. 

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I can give advice based on my own experiences. That means I emphasise the importance of sleep, nutrition. exercise and emotions. I want patients to understand the importance of informing their families about their health condition. It is amazing how many people wait until the last minute. With few exceptions, the reaction of patients to learning about my condition is good.

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I can clearly understand the physical and psychological problems, such as fatigue, experienced by patients.

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I have a good understanding of potential problems; I can easily recognise the signs of opportunistic infections.

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I give patients a feeling of security by giving them a lot of information. I do not judge the disease. I am convinced that there are still people who say, '‘If only he were not gay ... a drug addict ... a delinquent ...' 

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I learn to become less afraid of death through listening to patients and talking with my friends and family.

 

 Where there are advantages, there are also disadvantages:

 

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I run the risk of getting infectious illnesses. Working with people with AIDS requires a lot of energy, and my energy level is not always at its best.

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There is always the fear of going public - to admit to being HIV positive in front of patients - or the pain of hiding it.

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It is difficult to he present and to comfort patients and my friends during the terminal phase. 


These are my recommendations to all care givers working with AIDS:

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Dissociate work from your private life. Have fun after work. Be strong in your mind, because you must expect to regularly come into contact with death.

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Take steps to prevent burn-out. Don’t do too much. Make time to enjoy life.

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Be professional. Keep an interest in the subject - be curious, scientific, and organised.

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Be aware of the benefits. This can be an enriching experience. 


Extract from a speech at the International Conference on AIDS, Cmada 1996. Source: Canadian Association of Nurses in AIDS Care.


Viewpoint

Positive about my work
A health worker in Uganda talks about fears and hopes connected with being HIV-positive. 

My partner died six years ago. Before he died we talked. and he agreed, on my suggestion, to have an HIV test. We both took the test and were both diagnosed positive. Hell broke loose, but we got counselling and accepted the situation.

I have since faced problems as a human being and as a health worker, Ill-health may lead to me losing my job, which is a major worry. I see patients suffering and it is an indication of what I may face in the future. I always think about what people may say about me.

However, knowing about HIV and AIDS does help me practise positive living.





AIDS action  Issue 38    7   Page 8   9  top of page

  District management

Allocating resources

How should district health managers make the best use of existing resources? Assessing needs and coordinating with other sectors and the community are key strategies.

Many district health managers fear that caring for patients with HIV-related illnesses will result in lower quality care for all patients. Few extra beds, staff or drugs are usually available for patients with HIV. Managers therefore need to find ways of allocating existing resources to benefit the most people. This means making choices about what services to provide and where to provide them. 

Managers need to ask themselves the following questions: 
 

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How can I coordinate efforts with other health care providers and other sectors?

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How can I assess needs, including those at community level? 

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How can I use existing resources more efficiently? 

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How can I strengthen links with the community? 

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What essential drugs do I need?

Coordination 
Activities such as gathering data, supporting home care schemes and running community education programmes can be carried out more efficiently if hospitals coordinate their efforts with: 
 

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other sectors, such as education, transport and agriculture 

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other health care providers, such as religious organisations, private practitioners, pharmacists, and traditional healers

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local and national NGOs working with people with HIV/AIDS

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local communities 

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people with HIV/AIDS.


An example of coordination comes from Magu district, Tanzania. The district AIDS programme was originally set up under the primary health care committee, with representatives from a number of sectors. However, the committee turned out to be too large to meet regularly to plan an AIDS programme. A smaller committee has now been established, called the District AIDS Action Team. Members include the district planning officer, heads of health, education and community development sectors. and representatives of NGOs. The district AIDS control coordinator acts as the committee secretary.

By sharing members' experiences, the committee tries to assess what is needed to deal with HIV what resources are available, and what effect existing services and interventions have had. The aim is to ensure that resources are used effectively and that groups work together. 

Home-based care is often promoted as a way of reducing hospital expenditure, but it has its own costs, such as training of carers.

Some districts have problems when donors or international agencies wish to do AIDS-related work that does not fit in with district priorities. Some agencies may even do harm - providing drugs that are not otherwise available, or employing staff at higher salaries. 

If this happens, managers have to explain their priorities and negotiate with agencies to ensure that these are taken into account. Managers are more likely to be successful if they can show that their programmes are based on sound research, good financial planning and efficient allocation of resources.


Assessing needs Before allocating resources, managers need to assess the need for them. One way to do this is by organising a workshop. 

  1. Invite people who provide support and services. These include representatives of health centres and tuberculosis (TB) services, NGOs of people living with HIV/AIDS, other NGOs and people involved with home care.

  2. Share experiences. Consider the particular problems in your area. Look especially at the range of care services from hospital to home. Where are the links weak and where are there bottlenecks? For example, drugs may be available in the district hospital but not in health centres. The aim is not to lay blame but to recognise strong points and acknowledge weaknesses.

  3. Look for creative solutions. Find ways of shifting people and resources into weaker areas and unblocking bottlenecks. For example, improve drug supply to health centres or give more support as people are discharged from hospital. Again, the aim is not to lay blame or to increase already heavy workloads, but to find ways for people to work together.

  4. Agree how each level can respond. Write down how people and organisations fit into the new arrangements. Agree a trial period and process of monitoring. Remember to promote joint activities. Try to link activities between 'formal' and 'informal' sectors - link home and community with clinic and hospital.

  5. Arrange follow-up meetings to review progress, share solutions and successes, and consider problems.



AIDS action  Issue 38    8   Page 9  10  top of page

  District management

 

Hospital or home?
To allocate resources efficiently, managers need to compare the cost of hospital care (including the time that people are in hospital, drugs and other treatment, and the outcome of treatment) with other types of care. Hospital costs are usually high. 

Home-based care schemes are often promoted as a way of saving hospital costs. However, home-based care has its own costs. Carers need basic information and training before a patient is discharged, and continuing support from trained health workers. Home-based care cannot replace all health facility care. Health services have the main responsibility for diagnosing HIV-related illnesses, carrying out more complicated examinations, such as sputum and X-ray investigations, and treating complex illnesses, such as PCP (a common HIV-related pneumonia) or meningitis.

Some services, such as diagnosis or treatment of common conditions, can be done in health centres, provided that staff are trained in basic procedures and have essential drugs. Managers should find ways to allocate resources to health centres and provide training and supervision to staff.

People who are either terminally ill or recovering from illness may prefer to be at home. However, in some countries, legal requirements concerning death mean that carers prefer people with AIDS to die in hospital. Health managers should press for legal changes to make it easier for people stay at home. Allocating resources away from hospital may be unpopular with some staff. Managers need to work with staff to convince them of longer-term benefits and help them to deal with any problems that result.

 

Community treatment for patients with TB

If a patient is well enough to go home, but has still to complete a course of drugs, should the patient be discharged? Hlabisa health district in South Africa uses a system for ensuring that people continue their treatment at home.

A high proportion of people admitted to hospital in Hlabisa district have HIV-related TB. In the past, they stayed in hospital for at least two months. This was expensive both for the patient and the hospital. 

Since 1991, Hlabisa district has been running a programme of community-based directly observed therapy (DOT). TB patients leave hospital to continue their treatment at home. They take four standard TB drugs twice a week while being observed by a 'supervisor' - a nurse, community health worker or volunteer. The supervisor holds enough drugs for six months' treatment. 
 

Patients with TB can continue their treatment at home if they are observed by a 'supervisor'.


Supervision is carried out equally well by paid health workers and volunteers. However, many more volunteers are available than health workers. A 'TB field worker' - a member of hospital staff - visits supervisors each month. 

There are clear guidelines of what is expected of both supervisors and patients. Accurate record-keeping is important to ensure that drugs are taken correctly. 

The Hlabisa DOT programme is used for 90 per cent of people with TB. Of these, 85 per cent continue with it until they are cured. DOT costs about one-third of hospital-based treatment.

David Wilkinson, Medical Research Council, PO Box 187, Mtubatuba 3935, South Africa. 9

 



AIDS action  Issue 38    9   Page 10  11  top of page

    District management

Caring for children

For the past two years, the Thuthuzela Abantwana project in Cape Town, South Africa has been working with families of children with HI\/.

In the Khayelitsha squatter camp, 8 per cent of people are estimated to have HIV. Children with HIV have been treated at the children's hospital 25 kilometres away. Many have become ill again after being discharged, and have had to return to hospital. Most primary level doctors have not been trained to treat HIV-related illnesses in children, and there has been little support or training for home-based care.

We aim to build links between:
 

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medical advisers and health workers 

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the hospital and primary level health workers 

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project workers and families

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families and community agencies.

Caring for children


The project has an advisory committee consisting of representatives of the hospital, Red Cross Society home-based care staff, and NGOs working in HIV/AIDS and welfare. 

We have four full-time community health workers who advise families on the management of childhood illnesses and HIV. Minor interventions, such as advice on nutrition and food preparation, can make a major difference to the health and wellbeing of children with HIV. Through regular visits, the project workers gain the confidence of carers and families.

Since the project began, we have supported 89 families, trained 30 community health workers, increased the knowledge of primary level doctors and established links with NGO agencies. However, there are huge problems in sustaining the project, including lack of resources, long distances, poor transport and lack of community support structures.

Desiree C Fransman, Project Coordinator, Thuthuzela Abantwana, c/o Child Health Unit, 46 Sawkins Road, Rondebosch, 7700 Cape Town, South Africa.


Support for home carers

Links are being developed between hospital and home in Manipur state, north-east India, where HIV is spreading rapidly, mainly because of the large number of injecting drug users.

We have been looking at practical ways of developing links between our hospital and people with HIV/AIDS, family members, NGOs and other community organisations, to ensure that patients with HIV continue to receive good care after being discharged. Initiatives include:

A directory listing local sources of support for health staff, families and patients. However, the directory is not as widely known about as it could be.

A home care handbook for home carers, in two languages. The hand-book is popular and widely used.

Voluntary community organisations called 'community care groups'. Each group covers a local area. Members include local health workers, people with HIV/AIDS, families, drug user support groups and home care NGOs. The groups aim to ensure minimum standards of home care. A person can contact their community care group for support after being discharged from hospital.

Health workers give their knowledge and services to the groups, not as part of their work, but as members of the community. Their involvement has proved very useful. They also provide useful feedback to the hospital about community needs and activities. However, many areas still have no community care groups.

Voluntary service cells, which are groups of volunteers who visit hospital out-patients to give support and advice. The next step will be to establish protocols in the hospital to include the cells in discussions.

Pre-discharge discussions with patients and families, and with NGOs and volunteers, to consider the options for community care. These discussions are very useful, but do not always take place. We want to ensure that they become standard.

Recognising nurses' role. Nurses are the main link between the hospital and community-based carers, but are often left out of discharge planning, which is still mainly done by doctors. Managers need to allocate extra time to share information with nurses.

Many people are resistant to these new ways of working. Nurses who support new ways of working are trying to persuade other nurses through the All Manipur Nurses Association and by talking to managers and doctors.

Mrs Lhingneilam Kipgen, Health Studies Unit, Centre for Organization Research and Education, Yaiskul Police Line, Imphal 795 001, Manipur, lndia.



AIDS action  Issue 38    10  Page 11  12  top of page

  District management

Drugs for dealing with HIV

Managers need to know what drugs to stock for treating HIV-related infections.

The drugs used for treating HIV-related infections are mainly those used for other illnesses. Managers should follow essential drugs policies when dealing with HIV. 

The World Health Organization Essential Drug List (EDL) contains most of the drugs used for treating HIV/AIDS opportunistic infections and sexually transmitted infections (STIs), according to a survey carried out in 1997. In some African countries, the WHO list gives a wider choice than national treatment guidelines. 


Often the major problem for district health services is ensuring that drugs reach health centres and dispensaries. HIV, STIs and tuberculosis (TB) are all public health problems, so it is particularly important that drugs for treating them are:
 

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available when needed

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available in areas of greatest need

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correctly prescribed 

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used for their intended purpose.


Some drugs are supplied in ready-made kits, as part of an essential drugs programme or specific disease control programme. In either case, drugs arrive in standard quantities without taking local needs into account. District staff have to ensure that kits reach health facilities when needed and that they are used sensibly. 

In some programmes, drugs are supplied according to their rate of use at individual health units. This has the advantage that supply is adjusted to actual needs. District staff have the additional tasks of monitoring consumption, supplying drugs as required, and ordering supplies as needed.

A major challenge for district staff is to get drugs from district head-quarters to health units, particularly those in remote areas. This requires good communication, good planning, and sometimes creative solutions. However, even when supplies are at health centres, they may not reach the people in greatest need or be prescribed or used correctly.

More people are likely to request drugs in areas of high HIV prevalence than in lower prevalence areas. Requests should be monitored to: 
 

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assess needs

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determine patterns of use and distribution 

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consider alternative patterns of use and ways to improve distribution 

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see whether there is a strong case for keeping more drugs.

Most drugs that are useful for treating HIV-related illnesses are included in essential drugs lists.


Most HIV-related illnesses are treated with drugs that should be available at health centres. For example, HIV-related fevers are treated with aspirin. Very few drugs that are useful for treating HIV are not included in essential drugs lists. These vary from one area to another, depending on the national drugs policy and locally common HIV-related illnesses. 

Drugs prescribed for HIV-related illnesses must be considered in relation to those used for other health problems, especially problems likely to occur because of HIV, such as tuberculosis (TB), other respiratory ailments and chronic diarrhoea. 

For example, an HIV-positive patient who is receiving TB treatment should not be prescribed thiacetazone (a TB drug common in some countries), because this can cause a severe reaction in people with HIV.

Anti-viral drugs (if available) may have reactions with other drugs. Pharmacists supplying patients who are taking anti-viral drugs such as zidovudine or DDI should check that these drugs do not react with other drugs that patients are taking.

With thanks to Robin Gray, DAP, WHO, CH-1211 Geneva 27, Switzerland and Mrs E Grace Allen-Young, Pharmaceutical Division, Ministry of Health, Jamaica.

 

Anti-viral drugs 
Anti-viral drugs aim to prevent the HIV virus from reproducing in the body. The hope is that they will help to keep people with HIV healthy for longer. They are expensive, and are not accessible to most people in developing countries. However, in all countries, some people are likely to be using them. Hospitals and pharmacies therefore need to know how they work. 

Ideally, anti-viral drugs should be used only where there are laboratories with enough equipment and trained staff to monitor their use. Otherwise it is difficult to monitor any side-effects or to see if the patient is developing resistance. 



AIDS action  Issue 38    11  Page 12       top of page

  News / Letter / Publications / Resources

News

HIV 'more serious'
The HIV epidemic is more serious than previously thought, according to figures released in late I997 by the joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization.

About 30 million people are now living with HIV, including 1.1 million children aged under 15 years. There are 16,000 new infections each day In very badly affected sub-Saharan African countries, life expectancy has fallen to late 1960s levels. In some countries, a quarter more infants are dying because of HIV. 

However, there is some room for hope. The report highlights the spread of HIV in Latin America and the Caribbean among poorer and less educated people. 'There is an important opportunity to be grasped here to slow the spread of HIV. This can be done if special attention is given to the HIV prevention needs of poor and marginalised communities,' comments UNAIDS executive director Peter Piot. 

In most parts of the world, the majority of new infections are in young people aged 15-24. Girls appear to be especially vulnerable. However, in Uganda, infection rates in parts of some cities have halved among teenage girls since 1990.

Letter

Moments of hope
Our greatest concern is the lack of a national policy on HIV/AIDS for Ethiopia and a real lack of coordinated effort. Still, there are people who are very concerned, and there have been moments of hope.

We have attempted to involve families and neighbours in providing care and support to people with HIV. However, fear and stigma are major constraints. Some family members are reluctant to care for patients because they are afraid of contracting the virus. Sometimes they do not know how to cope with a person who is dying. They are embarrassed and withdraw their help from those who need it. 

Our home visiting team is trying to educate families about the way HIV is transmitted. The home visitors recently completed a one-week workshop in HIV/AIDS education, and are using their knowledge during awareness programmes.

Sister Dehne Mengiste, Programmes Coordinator, Medical Missionaries of Mary, Counselling and Social Service Center, Ethiopian Catholic Church, PO Box 71 27, Addis Ababa, Ethiopia.

New publications

Treatment of tuberculosis: guidelines for national programmes (second edition) provides information for TB programme managers, health policy makers and other health personnel on managing TB control programmes in health facilities and the community.
£2.70 plus postage and packing (£2.75 surface, £3.75 airmail) from TALC, PO Box 49, St Albans AL1 5TX, UK.

Safe childbirth: Child Health Dialogue 8 looks at the basic care that health workers should provide to women having a normal pregnancy and birth, including care in communities.
Free to developing countries, on subscription elsewhere (some rates as AIDS Action) from AHRTAG.

Resources

HIV prevention and AIDS care in Africa: a district level approach is a training manual, based on Tanzanian experience, for district health management team members and NGO project staff, It contains practical guidelines for a comprehensive district AIDS control programme.
D.fl.49 (about US$25) from KIT Press, PO Box 95001, 1090 HA Amsterdam, The Netherlands.

Reducing the impact of HIV/AIDS on nursing/midwifery personnel advises nurse and midwife planners on how to create a safe work environment to protect against HIV transmission and support HIV-positive nurses. 
Free in English, French or Spanish from International Council of Nurses, 3 Placelean Marteau, CH-1201, Geneva, Switzerland.

Practical guidelines for preventing infections transmitted by blood or air in health-care settings provides guidelines for hospital, health centre and home-based carers on protecting against hepatitis, HIV and TB. 
Free to readers in developing countries and £/US$10 elsewhere, from AHRTAG.


Correction
Syphilis is caused by bacteria, not a virus as stated in AIDS Action 36-37. We apologize for any confusion. Thank you to Dr Abdulaziz of San'a.Yemen for pointing this out.

 

Managing editor (AIDS Action) Nel Druce
Commissioning editor
(AIDS Action) Sian Long
Executive editor
(AIDS Action) Celia Till
Principal editors (Health Action) Suzanne Fustukian and Dr John Macdonald 
Executive editor (Health Action) Kaye Stearman
Design and production Ingrid Emsden
 
Special advisers for this joint issue Sandra Anderson, Klemens Ochel, Dr Charles Gilks, Jim Simmons, Tim Martineau, Ann Smith
 
Editorial advisory group (AIDS Action) Calle Almedal, Kathy Attawell, Dr Nina Castilio-Caradang, Nancy Fee, Susie Foster, Peter Gordon, Dr Sam Kalibala, Dr Ute Küpper, Dr Tuti Parwati Merati, Dr Chandra Mouli, Dr Arletty Pinel, Dr Sunanda Ray, Daniel Tarantola, Dr Eric van Praag, Rakesh Rajani, Kate Thomson
 
Aids Action Publishing partners HAIN (the Philippines) SANASO Secretariat (Zimbabwe) ENDA (Senegal) ABIA (Brazil) Colectivo Sol (Mexico) Consultants based at University Eduardo Mondlane (Mozambique)

AHRTAG's AIDS programme is supported by CAFOD, Charity Projects, Christian Aid, DfkF/JFS, Finnish Government, HIVOS, ICCO, Memisa Medicus Mundi, Misereor, Norwegian Red Cross, Oxfam, Save the Children Fund, SIDA.

 

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AIDS Action
The International Newsletter on AIDS Prevention and Care


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