No need to feel helpless
	Becoming more at ease with sexuality
	Safe working practices
	Making the most of limited resources

Health workers can do many things to improve the services they offer, and reduce the spread of HIV among women and their families. This may involve providing information and services or improving their own skills in dealing with the sensitive issues of HIV and sexual health.

No need to feel helpless

If you work in a health service with very little money to spend, it is easy to feel helpless in the face of HIV and AIDS. Even if you cannot provide ARV therapy for the HIV-positive pregnant women in your area, there is still plenty you can do: 
 

	Make sure all young men and women are well informed about HIV and how to keep themselves safe. This may include getting involved in schools or with youth groups and organisations.
	Make condoms available as widely and as cheaply as possible and promote their use through bars, clinics, markets, grocery shops, truck stops and so on. They are still the best way of preventing HIV spreading.
	Improve access to confidential voluntary HIV counselling and testing services for women and their partners.
	Encourage women with HIV to form support groups. Positive women can gain a lot of mutual support and strength from such groups and they can also be powerful agents for change.
	Make links with organisations and groups that are already active in your country. As well as government health services, you can look for support and resources from AIDS organisations, churches and mission hospitals, community-based groups, and many non-governmental organisations (NGOs).
	Strengthen maternity services, Make good-quality antenatal care accessible to more women, particularly the poor and those in rural areas. This could involve running mobile clinics, training traditional birth attendants, making stronger links with the nearest hospital and using their laboratory facilities for testing blood and other specimens.
	Update your own practice by getting together with colleagues who also work in maternity care to look together at the areas of practice which need to change.
	Improve services for STIs and encourage people to practise safer sex.
	Make sure all women are well informed about the risks and benefits of different feeding options for their infants. Where women choose to breastfeed, encourage them to do so exclusively for the first six months of life. Find out what women in your area do, and what they believe, about supplementing breastmilk. Try to find ways to overcome the common fears that a baby will go hungry or thirsty if he or she does not receive other drinks or foods.

Becoming more at ease with HIV and sexuality

You cannot work in the field of HIV and AIDS without coming face-to-face with sexuality and very intimate areas of people's lives. These are things which you would not normally talk to people about. They may make you feel ashamed, embarrassed or angry and you may not know which words to use. Here are some activities to help you become more comfortable discussing these difficult topics.

Activity 1 Giving Things a Name  You can do this exercise alone, but it is better in a group. You might prefer to do it in single sex groups, but everyone will learn more if it is a mixed group. Think of all the words you need for your work with HIV and AIDS which can be difficult or embarrassing. Write up all the 'proper' words for the group to see - you might have words like: sexual intercourse, masturbation, condoms, penis, testicles, kissing, sex worker, anal intercourse, oral sex, breasts, sperm, vagina, homosexual. Now, ask the group to think of other names which might be used for these things. Write them up for everyone to see.  Discuss where, or how, these words would be used and by whom - friends of the same sex, health workers, boyfriend or girlfriend, husbands or wives, children and so on. Decide which words health workers should use in their work to make sure that they are clearly understood without causing offence.

Activity 2 Role Playing  It makes it easier to deal with an embarrassing or difficult situation if you have thought it through ahead of time. One of the best ways of doing this is by role playing a situation with a group of your colleagues. Here are some examples:     Michael, aged 26, is HIV positive. He tells a health worker he has a new girl friend, Angela, who is now pregnant by him. She does not know he is HIV positive. Try acting this out with a health worker and Michael and then with different combinations, for example, Michael and Angela, the health worker and Angela, all three together.  What can the health worker say and do? What works and what doesn't work?    Maria is pregnant and has had an HIV test. Now the health worker has received the result - Maria is HIV positive.  How does the health worker tell Maria? What words should the health worker use? What information should be given? How can the health worker find out Maria's concerns?    Nasiba comes to talk to the health worker. She is an educated woman with two young children. Her husband is expected home soon from the city where he has been away working. Last time he came home Nasiba was frightened that he might have become HIV positive and tried to talk to him about using a condom. He became angry and violent and refused to even discuss it. Now Nasiba is even more afraid; what would become of her children if she became HIV positive? Nasiba asks the health worker for advice.   Try acting this out with just Nasiba and her husband, with the health worker and Maria, and with all three of them together.  What can the health worker say and do? What works and what doesn't work?

Activity 3 Acceptable Behaviour  This exercise can be used for small groups where the .members trust each other and can agree to keep the exercise confidential. The facilitator should make sure that the exercise is used to challenge stigma and discrimination and not to reinforce negative stereotypes about people living with HIV and AIDS. Prepare separate pieces of paper with words describing different kinds of sexual behaviour such as unprotected vaginal sex, vaginal sex with a condom, oral sex with a woman, oral sex with a man, group sex, sex with a prostitute, anal sex, sex outside marriage, sex between two men, sex between two women, a man forcing his wife to have sex with him. Ask the group to sit around a table. Mark one end of the table 'Very Acceptable' and the other end 'Not at all acceptable'. Each person then selects a piece of paper and places it in a position on the table according to how she or he feels about the activity named. The participants should be asked to say what thoughts and feelings made them decide to place the paper at that point. You could also ask people to discuss how some of their attitudes would affect their work and their relationships with HIV-positive people.

Safe working practices

Although the risk of health workers becoming HIV positive through their work is very low, all health workers who care for people with HIV and AIDS need to protect themselves. 

Midwives, birth attendants, obstetricians and anybody else attending births are at higher risk than other health workers, because of the large amount of blood present during and after delivery. As well as being exposed to HIV, they are also exposed to other serious infectious diseases such as hepatitis B and C, and TB. Health workers need to know what the risks are and how to minimise them. 

Like anyone else, health workers can also be at risk from their own or their partner's sexual behaviour. This is likely to put them at much greater risk than their work with HIV-positive patients, yet is often the most difficult to accept.

Risks at work 
HIV can be transmitted from one person to another in blood and other body fluids such as, amniotic fluid (the waters that surround a baby when inside the mother), vaginal and cervical secretions, and breastmilk. HIV cannot be transmitted in saliva, sweat, tears, vomit, urine or faeces, unless blood is visibly present.
 

	Splashes of HIV-infected blood or body fluid on unbroken skin, presents a very low risk of HIV transmission.
	HIV-infected blood or body fluid on cuts or grazes, or in the eye, presents a possible risk if a lot of blood or fluid is in contact with the cut, graze or eye for a significant length of time.
	Needlestick injuries involving HIV-infected blood, where the skin is pierced by a sharp instrument such as a needle or scalpel, 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 working quickly. 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 
Use universal precautions (see below).
 

	Handle sharps carefully, especially in emergencies.
	Use gloves to prevent contact with blood and other body fluids. If necessary, re-use gloves after rinsing in water (not alcohol or disinfectant) and leaving to dry, out of direct sunlight.
	Only give injections or take samples for laboratory tests when it is really necessary.
	Avoid episiotomies (cutting the opening to the vagina during labour).

Health workers working in people's homes need to take special care. Poor housing often means that they have to work in dark and crowded rooms. Home deliveries may be particularly difficult. Health workers will have to think ahead about how they and other family members will stay safe in an environment where there may not be a clean water supply or an easy way of disposing of needles. How will the blood of the delivery be cleared up? Who will dispose of the placenta and how? The best answers to these questions will depend on the circumstances, but preparation is needed.

Health workers also need to explain to family members how to protect themselves - make sure that the person washing any clothes from the delivery or disposing of the placenta knows how to do it safely.

Universal precautions for labour and delivery    Cover open cuts, sores or dermatitis with a waterproof dressing. Wear gloves whenever there is a risk of contact with blood and body fluids, including when caring for women after delivery. If you may come in contact with lochia (the bloody vaginal discharge which is passed for the first few days after delivery). If your skin does come in contact with blood or other body fluids, wash with soap and water straight away. Wear glasses or goggles and a mask if there is a risk of blood or amniotic fluid being splashed and always during a caesarean section. Wear a waterproof apron for delivery. Always wash hands before and after contact with the woman and after removing gloves.   Take care to prevent injuries when handling sharps. Handling them as little as possible and use a needle holder when suturing. Do not recap used needles. Do not remove needles from syringes by hand. Do not bend or break them by hand. Hollow needles are the most risky. Place used sharps in a puncture-resistant container with a lid (sharps boxes). Keep these as close to the place of use as possible. Sharps boxes can be made from large drug tins, or buckets with a lid.   During a Caesarean section: wear eye goggles, use double gloves, pass sharps using a receiver rather than hand-to-hand, use needle holders and avoid using the fingers in needle placement. Avoid using suction on newborns unless really necessary. If essential, use wall suction if available. The De Lee type of suction apparatus (in which the suction is provided by the health worker's mouth) puts health workers at risk. Dispose of solid waste such as blood soaked dressings safely. Handle newborn babies with gloves until they have been washed. Advise women how to handle and dispose of sanitary pads and rags safely.

Managers 
 

	Judge where the greatest risk is: injecting rooms, operating theatres, delivery rooms, laboratories, clean-up departments and mortuaries, and make sure that infection control procedures are followed.
	Use resources rationally. For example, if supplies of gloves are limited, keep them for activities with the greatest risk of exposure, such as delivery.
	Make staff safety a priority. If health workers believe that infection at work is unavoidable, they may take unnecessary risks. Some health units have set up infection control committees to reduce the number of accidents.
	Remember the needs of cleaners, porters and other auxilliary staff and provide them with the protection and information they need too.
	Encourage staff to report all exposure incidents and try to make sure that they are treated in a non-judgemental and supportive way.

After an accident 
Even if they are careful, health workers can be vulnerable to an accident at some time in their work which may put them at risk of infection. All health workers need to know what to do after an accident and where to go for help. It may be useful to have this information on a poster on the wall of the clinic or ward (see box). 

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.

Post-exposure prophylaxis 
Antiretroviral treatment after exposure to HIV can reduce the risk of infection. After a needlestick injury with HIV-infected blood, zidovudine alone reduces the risk of HIV transmission from an average of 3 in 1,000 injuries to less than 1 in 1,000. Combination therapy with zidovudine and lamivudine is recommended for deeper injuries and lacerations but is obviously more expensive. It is recommended that all health facilities, particularly those offering ARV treatment to patients, should make drugs available to staff for this purpose.

The availability of the drugs, even if they are never used, is likely to make health workers feel safer in their work and reduce the likelihood of substandard care for patients known to be HIV positive.

Action after an accident   If body fluids have been spilled, clean them up immediately using soap and water, or a chemical disinfectant if available. Bleach, isopropyl alcohol, povidone iodine and soap will all work to stop the HIV virus. If the 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. If the 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 judge the risk of transmission. Unless quite a lot of blood is involved, such as with a hollow needle, there is no need to do any more. Report the accident to the manager, so that steps can be taken to avoid similar exposures in the future.

Making the most of limited resources

People working in the field of HIV in pregnancy will need to make decisions about the best use of the available resources. The following exercise can help health planners, policy makers, health care providers, community leaders, pregnant women and their partners and people living with HIV, plan effective activities.

Activity HIV Interventions  Get people together in small informal groups and ask them to list, on separate pieces of paper, all the interventions which they believe will reduce the number of pregnant women with HIV within their community or country. These might include:    HIV education in schools  accessibility and promotion of condoms  education activities which focus on men  improved status of women  health services which diagnose and treat STIs  availability of ARV therapy.   Ask each small group to rank the interventions in order of effectiveness, that is, putting the most effective intervention at the top and the least at the bottom. Each group will then present their list to the larger group.   In the large group discuss the lists of each group and discuss which of the interventions would be easiest to achieve and which would be the most difficult. The group should also try to identify:   particular barriers and how these might be overcome resources required and where they might come from.   Repeat the whole exercise looking at the interventions which would reduce the risk of mother-to-child transmission of HIV. This time the interventions might include:   ARV therapy for pregnant women known to be HIV positive increased availability of voluntary counselling and testing HIV education in schools better information for women on the risks and benefits of breastfeeding accessibility and promotion of condoms.    Finally, ask participants to agree:   What are the priority interventions? What can be done now within existing resources? Who will do it? By when?