Issue Contents    Breaking the silence Health education Ze Cabra-Macho does it safely... Life on the building sites Convincing the companies Creating a visual impression Avoiding panic Health and safety at work Country report The face of AIDS in Brazil Mythical face of AIDS Looking at the reality Finding a response Counselling What to tell someone who has AIDS... What every patient needs to know Help, but don't over-help Be reliable and consistent Try to maintain regular contact with the patient's physician Let patients discuss their feelings Be sensitive to the patient's social unit Encourage group support Remember you, too, have feelings A basic guide to safer sex Questions and answers WHO Report - AIDS: a worldwide effort will stop it World AIDS Day World Health Organisation adopts anti-discrimination resolution on AIDS Counselling in HIV infection and disease AIDS can be prevented The role of counselling Counselling for whom? Who provides counselling? Risk reduction Risk reduction needs to emphasise that: What needs to be done now Cases Reported by Continent as of 31/07/1988

Breaking Silence

Dr Walter Almeida, General Secretary of the Brazilian Interdisciplinary AIDS Association (ABIA) believes that our most effective resource in the fight against AIDS, is our ability to recognise a common goal, and to work together to achieve that goal. Alone, we can achieve very little, but together, we can ensure that our voices are heard and changes happen - in areas ranging from individual sexual behaviour to ensuring the safety of blood and blood products on a national level. In many countries, such changes will only occur through the organised demands of popular groups.

Ending discrimination
 

Solidarity also means combining efforts to end discrimination against people infected with the AIDS virus and individuals who are seen to practice 'risky' behaviour. This means struggling against widespread ignorance, fear and prejudice. AIDS discrimination can take many 3 forms, but is usually based on the same false assumption - that the disease only affects 'marginal' or 'minority' groups - or the sexually promiscuous, or intravenous drug-users. But as Dr Almeida points out: 'In any form, discrimination is designed to impose silence on the sufferer.' Those discriminated against are thus denied a voice expressing their rights - medical, legal and economic rights, as well as rights to emotional and practical support. Solidarity - through the development of effective health education campaigns and the humane care of those already infected - can help break this silence. This process necessarily involves the direct participation of members of the communities concerned, as well as giving those who suffer prejudice a chance to speak out. In her paper African People in the Struggle against AIDS - the Need for a New Approach, Sue laver from Zimbabwe stresses the importance of information sharing, rather than information giving, approaches which 'activate discussion .. and encourage greater participation by people at all levels - where, for example, the once abused down-town Social Lady becomes Group Advisor, and the misinformed Factory Worker becomes AIDS Educator...'

Finding a voice

Communities should be encouraged to find their own voice in learning about the disease. The article on pp. 2-3 illustrates a pioneering Brazilian health education campaign built around the needs and experiences of a special group at risk from AIDS - immigrant labourers working on construction sites. The campaign illustrates effective health education methods that have international relevance. With the coordination and advice of ABIA, the project uses the skills and experiences of the labourers themselves, as well as company' managers, health professionals, community educationalists and popular artists. The messages and visuals reflect the language and experiences of the workers, and the creative use of popular art helps to avoid taboos as well as expressing clear messages about safer sexual behaviour. Further information on the work of ABIA is given on page 4. 

A similar process of participatory health education is happening worldwide. In Zambia, secondary school children have formed AIDS education clubs - one example being the David Kaunda School Anti-AIDS Club, which has the support of the ministries of Health and Education and the school headmaster. A doctor working in primary health care acts as its patron. Student members organise their own activities, such as producing a newsletter, writing poems, stories and songs, organising rallies and public talks. One of the students, on graduating from school, started a job as Schools Worker with an AIDS Home Care Team at Chikankata hospital. The hospital has established a home-visit, community-based support scheme for AIDS patients living in the surrounding rural communities. The policy of non-segregation of patients, and the direct participation of family members in patient care, has created the opportunity for more effective, practically based health education.

Cultural exchange 
To contribute to the development of community-based solidarity, AIDS Action aims to share information in three main ways: 
 

	providing the relevant facts about HIV infection and AIDS, and its treatment
	outlining guidelines for action for health education and patient care
	describing successful 'case studies' to give readers concrete ideas for future action.

 
Issues in the near future will include information on the correct use of condoms, and the treatment of opportunistic infections, (issue 5 beginning with respiratory infections, such as tuberculosis and pneumonia). Articles do not set out to provide all the answers - many, in fact, will pose additional questions and problems. In particular, the guidelines published here on counselling people with AIDS and giving advice about safer sex are not intended to be comprehensive - they are the first in a series of practical guidelines, each with specific aims, appropriate to different cultural circumstances. The guidelines on safer sex, in particular, have been researched largely from a Western perspective. If readers feel that some of the advice published here is culturally inappropriate, they are encouraged to write in with comments based on their own experiences, or with suggestions for future articles.

However, we hope all readers will find the factual information contained in the safer sex guidelines useful. Everyone has the right to know what forms of intimate contact are safe, and what are not. It is up to readers to find appropriate ways of using this information. Sex is often a taboo, or difficult, subject - we hope that this newsletter can help to break the silence. But in the end, it is community-based solidarity that will help turn silence into action.

Other language editions will be out as from September 1988: to be produced in collaboration with non-governmental organisations working on AIDS and/or other primary health care issues in developing countries. French, Portuguese and Spanish editions will be produced respectively by ENDA (Environment and Development in the Third World) in Senegal; ABIA in Brazil and collaborators in Mozambique; and Grupo CID (Communicaciones Intemacionales para el Desarrollo) in USA.

The international newsletter for information exchange on AIDS prevention and control

Ze Cabra-Macho does it safely...
building an AIDS awareness campaign among Brazil's construction workers

Some months ago, Silvia Ramos - Executive Secretary of the Brazilian Interdisciplinary AIDS Association (ABIA) - was invited by a small construction company in Rio de Janeiro, to give a lunch-time talk to over 400 builders. It was to be the beginning of a major health awareness campaign - among a group of workers whose social and economic circumstances put them at special risk from AIDS.
 
Before I started the talk, the company engineers warmed me: "If some of the men leave half way through - don't worry, just carry on talking. None of them are obliged to stay". As soon as I stood up in front of these 400 men - I knew this talk had to be different. It was obvious that they were living under much poorer conditions than other workers I'd talked to. The men were crowded together along wooden benches in the site canteen, still wearing their safety helmets and boots. Over half of them couldn't read or write. I began to speak as clearly and as openly as I could - some of the men appeared very shy to begin with, but they became more and more interested. I spoke for half an hour and nobody left at all. Everybody stayed for questions.

The engineers said: "This has never happened before - we didn't think they'd be so interested in AIDS." 

These men have a very real interest in AIDS. Silvia was speaking to workers at a small company (about 800 employees) where five of them had already developed the disease.

Life on the building sites

Life on the building sites There are 350,000 construction workers in Rio alone. They are part of a major national industry - but they are also among the poorest of the country's workforce. ABIA believes that construction workers are at special risk from AIDS, largely because of their poverty and isolation. Most are immigrants from the poor, agricultural areas of the Northeast. The majority are aged between 20 and 30 years, and are either single, or separated for months at a time from their wives and children. They come to Rio in search of a job to support their families. The easiest place to find work is on a building site, where they are hired for three to twelve months at a time. They are paid very low wages - it can take months to save a small amount of money. Most construction workers can only afford to rent bunk-beds in over-crowded dormitories on site; sometimes hundreds of men live, work and sleep on the same building site. Occasionally, workers will visit the surrounding favelas (slum districts) to pay for sexual favours from prostitutes. 'Some workers will also have sex with each other,' Silvia explains, 'it's called "Solidarity sex", because they don' t pay for it.'

Being separated from their homes and families, and traveling from one job to the next, means that the personal lives of workers are disrupted. This affects opportunities for developing long-term sexual relationships - and it is through sexual activity with many partners that the workers are most at risk from AIDS. Developing clear educational materials on safer sex was particularly important; the most effective way of doing this had to be carefully researched. 

'One of the things ABIA learned early on,' Silvia explains, 'was that if we talked about "homosexuality" in our health education materials, none of the men would think this applied to them. Having sex is simply part of being "macho", whether it is sex with another man or with a woman.'

Convincing the companies 

ABIA was alerted to the special need for AIDS education among construction workers both by worker representatives and by some companies; although most companies still refuse to admit publicly that AIDS is a problem among their workforce. 'We organised a meeting of all the major construction companies in Rio, to try to persuade them to support AIDS awareness campaigns in the workplace. Some 20 companies became actively involved. We then set up a working party, including employers and active representatives of the workers. We met every week, for four months, to develop the script and pictures for an audiovisual.' Posters and a cartoon book were also planned.  'We had to research the best way of explaining how AIDS is spread, and how it is not. We completed a survey that told us more about who the workers were, where they were from, their age etc., and we asked organised groups of workers and company managers to go back to the sites and find out what words the men used to describe different types of sexual activity, such as "anal sex" or "oral sex". They would come back and tell us: "In my company, the workers use this word or that..."'

 

Creating a visual impression
Since the majority of the workers do not know how to read and write, the materials had to make good use of clear pictures - such as photographs and cartoons. But using photographs of real people to illustrate the use of a condom, or anal and vaginal sex, was a problem. 

One of the members of the working party, Jorge Guidacci, a political cartoonist and graphic artist, suggested using models. He began sculpting a character based on the traditional bonecos - small, clay figures used as a form of popular communication in the northeast, an art form very familiar to the immigrant workers. Bonecos represent figures from everyday life - such as agricultural labourers or city workers - even dentists pulling out patients' teeth!

'Our boneco is called Ze Cabra-Macho - which means "brave heroic man",' explains Guidacci; 'He is a, construction worker and usually  dressed in a typical helmet and boots. He is a fun hero, who has an active sex life. We use photographs of him to illustrate safer sex.'

Around 60 photographic slides have been developed for the audio visual, which, clearly explains about AIDS, and about the Human Immunodeficiency Virus (HIV - the virus that causes AIDS), and how HIV is spread (through infected blood and blood products, needles and syringes, as well as through sex) and how HIV is not spread. The high risk involved in having sex without a condom is stressed, and Ze Cabra-Macho warns: 'the more people you have sex with, the more danger you put yourself in.'

Avoiding panic
Describing how the virus is not transmitted is crucial. 'On the one hand, we know these workers are at risk and we had to develop a special campaign to deal with that,' explains Silvia, 'but on the other hand, we need to avoid unnecessary panic and discrimination. When we are talking about how the virus is not spread, we are talking about solidarity - about not being afraid of a friend or workmate who has AIDS, or is infected with HI\/; about knowing you can share the same cup or spoon, that you can share the same dormitory or even sleep in the same bed. Other workers we talked to - such as office workers - could at least leave the work place and go to their own homes at the end of the day, but it was essential that these workers knew they could live and work safely with someone who is infected with the AIDS virus.'

Health and safety at work 
The audio visuals on AIDS will be used in a similar way to existing videos on health and safety at work. Accident levels on site are alarmingly high (many workers falloff scaffolding, for example) and some companies now use videos on basic safety precautions which are shown in the work-place. This practice will be developed and adapted to put across the message about AIDS. 

Although this health campaign is specifically aimed at construction workers, its methods and approach have a wider significance. Its success so far is due to a practical commitment to the equal sharing of information. This means that everyone has a right to know the facts about this disease; messages must be clear, as well as culturally and socially appropriate. This can only be achieved by building a campaign based on the active participation and direct experiences of the intended audience.

As a product of this process, Ze Cabra-Macho is an effective campaigning tool. Guidacci explains: 'In one of the slides Ze Cabra-Macho appears without his safety helmet or his boots - he is ready for sex, but he is not wearing a condom... in the next slide he appears with a big grin on his face; he is wearing his safety helmet and boots, and he is ready for sex, wearing a condom...' Guidacci smiles and continues: 'a builder knows he must protect himself from accidents at work, he now also knows he must protect himself from accidents in his love-making!'

Hilary Hughes Executive Editor

What to tell someone who has AIDS...

Telling someone they have AIDS, and then providing the support they need, is not easy. Patients must not only understand this new disease - including how to avoid its spread to others - they must also learn to live with it. The following provides some basic advice for those involved in counselling AIDS patients.

Providing counselling support for someone who has AIDS, means being prepared to build an on-going, trusting relationship. This involves 'being with' the patient, listening to him or her, and understanding what the patient is saying, as well as giving practical advice, and emotional support. Good listening skills are essential - as well as an accepting, understanding personality.

What every patient needs to know
It is essential that the patient fully understands the basic facts about the disease, particularly the ways in which the Human Immunodeficiency Virus (HIV) is, and is not, spread. A person who has very recently been told they have AIDS will be in a state of shock and initially will not be able to take in much of what you say: it is important that you arrange to see the patient again a few days after giving them the news. You can then repeat information and answer their specific questions.
 

	Go through all the relevant practical implications of preventing blood to blood and body fluid transmission (see AIDS Action issue 1) - such as reminding the patient that they should never donate blood, or discussing maternal to child transmission with women of child-bearing age.
	Since the most common method of HIV infection is through penetrative sexual intercourse, good counselling on safer sex is essential (see following pages). This should be discussed in a very open, sensitive and positive way.
	Make sure that the patient is reassured about the ways in which the virus is not spread, so that they do not develop anxieties that result in unnecessary, self-imposed isolation.
	Find out what medical resources are available in your area (and at what cost) so that you can give realistic advice about available treatment of opportunistic infections. The patient will find it reassuring to know that most opportunistic infections con be treated successfully.
	Avoid giving the patient a long list of the symptoms and signs of AIDS - some patients may become over-anxious about what illnesses they might develop.

Help, but don't over-help

Patients who feel that there is 'nothing that can be done' to stop the progression of the disease, or that their health is now in the hands of others, can develop a deep sense of dependency and helplessness. It is important to encourage the patient to feel in control of their own health as far as possible, and to take an active role in their own treatment. You can do this by encouraging him/her to:   eat a healthy diet  avoid anxiety and over-work, if possible  seek early medical attention for the treatment of opportunistic infections wherever possible (for signs or symptoms, see AIDS Action/Who Report issues 1 and 3) continue to participate in social, recreational and occupational activities as normal.

Be reliable and consistent
Once you have offered support to a patient, make it clear what kind of support you can offer in the long term and stick to what you have promised. Wherever possible, counselling support should be consistent, reliable and on-going. Even if a patient is referred to a different physician, or medical department, this does not imply a change in the counsellor-patient relationship.

Try to maintain regular contact with the patient's physician
A patient who is feeling profoundly anxious or stressed, may not under-stand the medical advice they are given, and may misunderstand what doctors or nurses are saying. If you are not the patient's medical advisor, ask the patient if you can consult with their physician, about recommendations for treatment, rest, work, sexual practices etc.

Let patients discuss their feelings
Allow the patient to express grief or anger. Try to be understanding and accepting; do not 'judge' or criticise. The patient may not be able to talk openly about his/her feelings with families and friends, who may find talking about illness, death and dying too painful. Let patients talk about these issues if and when they want to - but let them guide you into these topics.

Many patients will experience profound depression, and/or an emotional 'void', during their illness; the patient will often want someone simply to be there, sharing their feelings, listening to them and showing care and affection - touching the patient is an important part of this support.

Be sensitive to the patient's social unit
Someone with AIDS will often experience as much stress from their personal relationships (when the partner and/or family find out about their illness) as from the disease itself. If you can, obtain the patient's permission to discuss problems with relevant individuals; partners and families will often need counselling support.

Some patients refuse to tell partners, or members of their family about their illness, and will often feel worried or guilty as a result. If possible, find out why a patient is hiding the nature of their illness: they may change their mind if underlying problems/anxieties are discussed.

Encourage group support
Groups of people with similar problems and fears can be a safe and supportive way of sharing information and discussing better ways of coping. Group therapy allows patients to see how others are coping with AIDS, and this can reduce feelings of isolation. Group support may also be found in a broader social context - such as within women's organisations or religious groups.

Remember you, too, have feelings
Working with people with AIDS is stressful. Patients will find many reasons to become angry, and may direct this anger towards you, as well as others. Do not take this personally - allow the patient to discuss their feelings with you. 

Carers and health personnel also need support. Try to coordinate a support network amongst colleagues working with AIDS patients - such as regular, interdisciplinary meetings with other professionals and/or community volunteers.
 
Adapted from unpublished materials produced by counselling advisors at the Terrence Higgins Trust (THT) - a UK based charity, involved in AIDS health education, and working in support of people with AIDS, their lovers, families and friends. 

For further information please write to: The THT, 52-54 Gray's Inn Road, London WC1X 8JU, England.

A basic guide to safer sex

Safer sex does not simply mean using a condom, and reducing the number of sexual partners. It means being able to express sexuality in ways that prevent the transmission of HIV. This article provides some practical guidelines for those giving advice about safer sex, especially health care workers and others involved in counselling people with AIDS or HIV infection, and their sexual partners.

Find out what the client (person seeking help or advice) has already heard about safer sexual behaviour 

Be prepared far false ideas or misconceptions, for example, that having sex with just one new person, instead of many, is safe sex.

'Safer sex is not just about using a condom, or reducing the number of sexual partners. It's not how many people you have sex with that counts, it's what you do with them. You could have safer sex with a lot of people and never catch anything. Or you could have "unsafe" sex with just one person and get/pass on HIV infection.'

Explain about HIV transmission
'Between adults, there are only two ways of transmitting the virus that causes AIDS:
 

Blood to blood contact - where blood from an infected person (including menstrual blood in an infected woman) gets into somebody else's bloodstream or comes into contact with certain body tissues. Splashes on the body skin are not a risk, because blood cannot pass through unbroken skin. But splashing infected blood on broken skin, or in your mouth, nose, eyes, on the penis or in the anus or vagina, should be avoided.

Other body fluids - HIV can be transmitted in an infected mans semen (white fluid produced by sexual excitement), or in an infected woman's vaginal fluid. The virus in these body fluids has to get into another persons bloodstream to be passed on. So, like blood to blood contact, there is no risk if these fluids are splashed onto unbroken skin. But the virus can get in through broken or cut skin, or through the sensitive lining of the vagina, anus or the urethra.'

Discuss what this actually means in practical, sexual terms - what it is safer to do... 
'It is safe to kiss and cuddle with an infected person - including kissing your partner on the mouth, so long as you both have healthy mouths (i.e. there are no cuts, lesions ulcers or bleeding gums inside the mouth). There is no medical evidence to suggest that saliva in the mouth of an infected person can transmit HIV infection. The virus has been found in the saliva of infected individuals, but it is present in very small quantities - too small to be infectious. There is a very small theoretical risk of transmitting the virus from an infected person to an uninfected person through mouth to mouth kissing, only where there are cuts, lesions, ulcers or bleeding gums in both mouths. This, of course, is highly unlikely.

'If the skin on your hands is unbroken and healthy; there is no risk involved in touching and caressing the skin on the body and face touching and caressing the penis or a woman's clitoris, or inserting fingers inside the vagina or anus.' 

... and what is not safe to do
  

'Penetrative sexual intercourse (putting the penis inside a woman's vagina, or inside a man or woman's anus) carries the greatest risk of HIV transmission. Penetrative sex means that the virus can get out of an infected body (via body fluids) and into someone else's bloodstream. Infection can pass both ways between sexual partners. If you are infected with HIV and your sexual partner is not/might not be, then you should not have penetrative sex.'

What does this mean for the client?
Find out how he/she feels about this:
 

	'Do you think you could have a sexual relationship without penetration?'
	''What exactly gives you the most pleasure?'
	'Are there other ways you could get a similar feeling?'

Explain the use of condoms
If the client feels that their sexual relationships must involve penetrative sex, talk about the use of condoms for protection.
 

'Condoms are not safe sex; but they reduce the risks of HIV transmission. You still run the risk of transmitting the virus because condoms can break or slip off: but the risk is much less if you use them properly...'

When condoms fail, it is usually because they are used carelessly or incorrectly. Clear advice on the correct use of condoms is therefore essential.* Try to get the client, and the client's sexual partner, to discuss their sexual behaviour and desires in the light of the above information. Listen to your client's language when talking about his/her sexuality and reflect it where possible - taking care over your choice of words, as well as what you focus on.

Explain the risk involved in oral sex
Find out what the client understands by oral sex (putting the penis inside the mouth, or kissing a woman's genital area). If it has been part of the client's sex life, explain the risks involved.

Current epidemiological evidence suggests that HIV infection is not passed on through oral sex alone. It is difficult for the virus to get from infected semen or vaginal fluids into the bloodstream through the lining of a healthy mouth. Semen, however, should not be swallowed.

'The safest way of having oral sex, is to kiss around the genital area, avoiding direct contact with the tip of the penis, or with semen or vaginal fluid.'

Discuss safer alternatives to penetrative sex
Help the client to discover that sexual relationships can consist of more than just penetrative sexual intercourse; in some cases, you may meet a lot of resistance to this, initially. But it should be possible for individuals to adapt their sexual desires and fantasies to some extent, within existing cultures and traditions.

Sexual behaviour is a kind of 'language' that is learnt during adolescence (or earlier). It is a form of personal communication. The threat of AIDS now means that it is necessary to communicate slightly differently. We can all do this by learning to 'extend' our sexual 'vocabulary': saving lives and learning more about ourselves in the process.

Adapted from National AIDS Manual, produced in the UK as a resource for volunteers and professionals giving advice on AIDS/HIV infection. Further information: Peter Scott, NAM Publications, PO Box 99, London SW2 1EL, UK.

* The December 1988 issue of AIDS Action will include a detailed article on the correct use of condoms.

WHO Report - Global Programme on AIDS

WORLD AIDS DAY draws overwhelming response

Plans for World AIDS Day are accelerating as the 1 December 1988 day of communication about AIDS continues to draw an enthusiastic response around the globe. 

During the course of five days at last month's IVth International Conference on AIDS in Stockholm, Sweden, nearly 400 organisations, communities and groups involved in AIDS prevention and control, in over 60 countries, expressed strong interest in World Aids Day. Since then, reports of new organising efforts, from Africa to Asia, North America to Latin America, and Europe to Oceania have continued to arrive at WHO headquarters in Geneva.

'The response has been nothing short of overwhelming', said Dr Jonathan Mann, Director of the WHO Global Programme on AIDS which launched the World AIDS Day project at the London Summit of Health Ministers in January. 'It's the kind of response that will show people around the world that in the fight against AIDS, we are united, rather than divided and alone'. 

Over 250 organisations, including several major international organisations, television networks and national groups working on AIDS prevention programmes have already indicated they are planning events for World AIDS Day, including films, broadcasts, public events, concerts, meetings and youth activities.

World AIDS Day support from GPA will include:
 

	'Action Kits' with ideas for World AIDS Day events
	A World AIDS Day newsletter providing regular updates on developing activities
	Images suitable for decorating T-shirts, bags, posters or any other suitable display items with the World AIDS Day symbol
	A global mailing list for those wishing to receive World AIDS Day materials and updates
	Distribution of World AIDS Day fact sheets and brochures.

The objectives of World AIDS Day are to:

	Tell people everywhere that AIDS can be stopped worldwide
	Convince people that their responsible behaviour can protect them and stop the spread of AIDS
	Encourage compassion and understanding towards those who have AIDS or are infected with the virus
	Highlight the extraordinary range and scope of the fight against AIDS allover the world
	Support AIDS prevention and control programmes everywhere.

Information on World AIDS Day is available by contacting the WHO Global Programme on AIDS, Public Information in Geneva.

World Health Organisation adopts anti-discrimination resolution on AIDS Protecting the rights and dignity of people infected with the human immunodeficiency virus (HIV, or who have AIDS, is vital to the success of the national AIDS programmes and the Global AIDS Strategy. This is the message in a resolution adopted by consensus at the 41st World Health Assembly held in Geneva May 2-13. The resolution urges 166 member states of WHO to:   Foster a spirit of understanding and compassion for HIV-infected people with AIDS through information, education and social support programmes;  Protect the human rights and dignity of HIV-infected people and people with AIDS, and of members of population groups, and to avoid discriminatory action and stigmatisation of them in the provision of services, employment and travel;  Ensure the confidentiality of HIV testing and to promote the availability of confidential counselling and other support services to HIV-infected people and people with AIDS.  Dr Jonathan Mann, director of GPA said the World Health Assembly action has made avoiding discrimination in relation to HIV-infected people and people with AIDS a central part of the global AIDS strategy.

AIDS: a worldwide effort will stop it 

Counselling in HIV infection and disease

The world is facing an epidemic for which there is presently no cure and no early prospect of a vaccine. The epidemic thrives on human ignorance, fear and resistance to change. The disease is acquired immunodeficiency syndrome (AIDS). AIDS can be prevented, however.

Programmes for preventing the spread of HIV focus on changing attitudes and behaviour; counselling is a critical part of such programmes. Counselling not only provides information and education in a personal manner, but it helps HIV-infected persons and those associated with them to come to terms with their situation and accept and carry through their responsibilities.

AIDS can be prevented
On the basis of available information, The World Health Organisation estimates that between five and ten million people are infected with the virus that causes AIDS - the human immunodeficiency virus (HIV). Most of them do not know they are infected. Between 500,000 and three million of them are expected to develop AIDS by the early 1990s. This means that during the next five years there may be 5 to 20 times more AIDS cases than there have been over the last five years. 

Several features of HIV infection and AIDS should be noted:
 

	Infection with the virus is life-long. Once a person is infected, the virus remains in the body and the risk of developing AIDS or other conditions related to HIV increases with time.
	A person who is infected with the virus may have no symptoms for years and may be quite unaware of the infection. However, such a person can pass the virus on to others - the main route of spread is through sexual contact.
	People infected with HIV can continue to be fully functioning members of society. They should be helped to do so and to behave responsibly so as to prevent further spread of HIV.
	HIV infection can be prevented even without a vaccine. It is spread by well recognised and specific behaviours, mainly involving sexual relations and the sharing of contaminated needles. These behaviours are amenable to the exercise of individual responsibility and control. Avoidance of risk behaviour can stop the spread of the infection.
	The AIDS epidemic has provoked fear and misunderstanding about what HIV infection and AIDS mean for social relationships and society. Policy-makers, health workers, the public, and those most directly affected have all been influenced by this fear and misunderstanding.

The role of counselling
Counselling is a process that can help people understand better, and deal with, their problems, and communicate better with those with whom they are emotionally involved. It can improve and reinforce motivation to change behaviour. Counselling helps people learn to deal with fear and anxiety. It can provide support at times of crisis. It helps them face up to their problems and to reduce or solve them.

Counselling may help people solve problems arising out of HIV infection in themselves, their families, or others to whom they are close. It is a means of ensuring that information on AIDS is correct and consistent, and of assessing life-styles, personal expectations, and willingness and capacity to change behaviour.

Counselling can be used to make sure that individuals considering being tested for HIV infection are well informed and appreciate the technical, social, ethical and legal implications of testing.

Counselling as a service should ensure continuing access to the counsellor and consistent support from the health and social system. It must ensure adequate time for discussion and problem-solving. Ensuring time for discussion has on important symbolic value: it signifies society's willingness to provide support and care.

Counselling as a process respects the individual regardless of sexual preference, socio-economic background, state of health or national, religious or ethnic origin.

Counselling is a means of helping people avoid discrimination against HIV-infected persons and of ensuring their continued integration in society.

AIDS: a worldwide effort will stop it 

Counselling for whom?
The need for counselling arises in many circumstances related to HIV and AIDS.

 

	Individuals considering being tested or screened for HIV infection need to be carefully prepared and supported. They need to know the facts about testing and its implications. Their decisions should be founded on correct information.
	Counselling is vital when a test shows HIV infection. It helps deal with the resultant fear and anxiety and often hostile attitudes on the part of both the patient and the patient's family, friends and other loved ones.
	HIV-infected persons who are otherwise healthy may experience more stress than those who already have AIDS. They will often need special care and support. Counselling is needed as an integral part of the management of stress and as a means of motivating them towards positive behavioral change.
	As HIV-related diseases develop, medical needs must be met quickly and efficiently. A function of a counselling service will be to mobilise support and refer patients to medical care and other services that can help maintain hope, dignity and quality of life.
	AIDS and other HIV-related diseases can result in unemployment, loss of educational possibilities, and other social handicaps. Counselling can help to reduce such effects. It can help to mobilise the continuing medical and emotional support that patients and those who are caring for them need.
	Sometimes a person may be infected but cannot, or will not, be tested. People with risk behaviour, such as intravenous drug users and prostitutes, need to be counseled and helped to behave in ways that will reduce their risk of contracting HIV infection or passing it on to others.
	Counselling is also useful for those who are tested and found not to be infected. They too need to be advised about what they should do to avoid HIV infection.
	Health workers, family, friends and all who come into regular social, or professional contact with HIV - infected persons and AIDS patients, can benefit from counselling and the support it provides.

Who provides counselling?

In different circumstances different people can undertake counselling. A counsellor should be able:
 

 

	to communicate information about HIV infection and AIDS in an accurate, consistent and objective manner;
	to gain the trust of people who need help with their psychological and social difficulties;
	to listen sympathetically to people who ore afraid, anxious, distressed, and possibly hostile;
	to understand other person's feelings, to accept these feelings and their expression without criticism or censure, and to respond to them in such a way that the other persons can feel free to express their feelings;
	to help HIV-infected people understand their problems and those of other people in their lives who are affected;
	to help people reduce or resolve their problems.

Many people already have some experience as counsellors. With additional training in the skills needed to work with people affected by AIDS and related problems they can provide valuable care and support.

AIDS: a worldwide effort will stop it 

Risk reduction
In all countries there are people whose behaviour increases their risk of becoming infected with HIV Homosexual and bisexual men, male and female prostitutes, men and women with many sexual partners, intravenous drug users and their sexual partners, for example, are at such increased risk. It is particularly important that education and counselling services are provided for such persons. They need to learn accurately the nature of the disease, how it is transmitted and how HIV infection can be prevented.

Risk reduction needs to emphasise that:
 

	the main route of HIV transmission is sexual contact; HIV is spread through vaginal, anal or oral sex; the sexual spread of HIV can be prevented.
	intravenous drug users are at high risk because they often share needles and syringes; support for stopping the use of intravenous drugs must be provided; methods to reduce the risk of infection and transmission of infection need to be made clear; sexual partners of drug users should be told of the risks they run even though they themselves may not be using drugs.
	any skin-piercing (including injections, ear-piercing, tattooing, acupuncture or scarification) can transmit the virus if the instruments used have not been sterilised and have previously been used on an infected person; people who provide any skin-piercing service should know of this danger and learn how to sterilise their instruments; the public should understand the risk of infection, keep skin-piercing to a minimum, and insist it is done with sterile instruments.
	women who are pregnant and infected with the AIDS virus can transmit HIV infection to their unborn children; women who run the risk of becoming pregnant and contracting HIV infection need counselling.

What needs to be done now 

1. Counselling is a vital part of all strategies for preventing and controlling AIDS. It not only helps those who are already infected adapt to their problem but also helps prevent the further spread of HIV infection.

2. Counselling needs to be integrated with all HIV testing, screening, and medical care programmes. Counselling has to be recognised as an integral part of all health care programmes and activities for HIV control and prevention.

3. Large numbers of people need to be trained in the skills of counselling. New training programmes should be instituted. Existing programmes in counselling will need to include training on HIV infection and AIDS.

4. Counselling services should be readily available and accessible.
   

For further information on establishing a counselling service for HIV infection and AIDS, please contact the Global Programme on AIDS, World Health Organisation, 1211 Geneva 27, Switzerland.
 
 
CASES REPORTED BY CONTINENT AS OF: 31/07/1988
 

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