Integrating Nutrition Into HIV/AIDS Care and Support Programs - URC

Integrating Nutrition Into HIV/AIDS
Care and Support Programs
Training References for Trainers of Community Volunteers

Integrating Nutrition into Community
HIV /AIDS Care and Support Programs
A Trainers Manual for Training Community Volunteers,

Financial support for this training manual was provided by USAID, Cooperative Agreement number
617-A-00-08-00006-00. The views expressed in this document do not necessarily reflect those of USAID.
NuLife Project supports the Uganda Ministry of Health and partners to integrate Nutrition in
HIV/AIDS Care and Treatment Programs.
NuLife is implemented by University Research Co., LLC, (URC) in collaboration with Save the Children U.S.A.
and ACDI/VOCA.

Table of
Contents
Acronyms
ii
Topic Outline
How To Use This Manual
Start-Up Activities:
Volunteering
Effective Communication Skills
iv
vi
xiii
xvii
xix
Theme 1. Basic Nutrition Care And Support For People Living With Hiv/Aids.
Topic 1: Basics Of Community Nutrition 1
Topic 2: The Relationship Between Nutrition And Hiv/Aids 20
Topic 3: Management Of Some Hiv-Related Symptoms And Illnesses 29
Topic 4: Important Behaviors To Improve And Maintain Good Nutrition 37
And Health For Plhiv
Theme 2. Role Of Community In The Care Of MalnuriShed Individuals.
Topic 5 : Dentifying Malnutrition In The Community 43
Topic 6: Treatment And Care For Malnourished Individuals 53
Topic 7: Other Roles Of Community Volunteers And Other Stakeholders 64
Appendix 93
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | i

Acronyms
AFASS
Acceptable, Feasible, Affordable, Sustainable and Safe
AIDS
Acquired Immune Deficiency Syndrome
AL
Adult Learning
ART
Antiretroviral Therapy
ARV
Antiretroviral
ANC
Ante Natal Care
BCC
Behavior Change Communication
CBO
Community Based Organization
CC
Counseling Card
CNP
Critical Nutrition Practices
CRS
Catholic Relief Services
CV
Community Volunteer
ECS
Effective Communication Skills (Topic)
EGPAF
Elizabeth Glaser Pediatric Aids Foundation
EPI
Expanded Program on Immunization
ETC
Etcetera
FANTA
Food and Nutrition Technical Assistance
FATVAH
Frequency, Amount, Thickness, Variety, Active feeding, Hygiene
FBO
Faith Based Organisation
F&N
Food and Nutrition
FP
Family Planning
GATHER
Greet, Ask, Tell, Help, Explain, Reassure
GPM
Growth Promotion and Monitoring
HCI/MOH-QoC Health Care Improvement / Ministry of Health-Quality of Care
HIV
Human Immune Deficiency Virus
HW
Health Worker
IMAM
Integrated Management of Acute Malnutrition
IYCF
Infant and Young Child Feeding
ITC
In patient Therapeutic Care
LC1 Local Council 1
LAM
Lactation Amenorrhea Method
LBW
Low Birth Weight
ii |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Acronyms
MAM
Moderate Acute Malnutrition
MUAC
Mid Upper Arm Circumference
MOH
Ministry of Health
NGO
Non-Governmental Organization
OTC
Outpatient Therapeutic Care
OVC
Orphans and other Vulnerable Children
PHA
People living with HIV/AIDS
PLHIV
People Living with HIV
PMTCT
Prevention of Mother to Child transmission
RUTF
Ready to Use Therapeutic Food
S1 Session 1
SAM
Severe Acute Malnutrition
SFP
Supplementary Feeding Program
SU
Start-up Activities (topic)
T1 Topic 1
T13.S3.1 Topic 13, Session 3, Activity 1
TB
Tuberculosis
TOT
Training of Trainers
UNICEF
United Nations Children’s Fund
URC
University Research Co. LLC
USAID
United States Agency for International Development
V
Volunteering (topic)
VCT
Voluntary Counseling and Testing
WHO
World Health Organization
WFP
World Food Program
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | iii

Topic Outline
TOPIC
Start-up activities
Session 1
Session 2
Session 3
Session 4
Session 5
TIME ALLOCATED
(Minutes)
15
50
20
10
30
Volunteering 30
Effective communication skills
Session 1
Session 2
Session 3
Session 4
60
40
40
60
BASIC NUTRITION CARE AND SUPPORT PEOPLE LIVING
WITH HIV/AIDS.
TOPIC 1: BASICS OF COMMUNITY NUTRITION
Session 1
Session 2
Session 3
Session 4
Session 5
Session 6
Session 7
Session 8
15
15
50
30
25
50
25
30
80
TOPIC 2: THE RELATIONSHIP BETWEEN NUTRITION AND HIV/AIDS
Session 1
Session 2
Session 3
25
40
40
TOPIC 3: MANAGEMENT OF SOME HIV RELATED SYMPTOMS
AND ILLNESSES
Introduction
Session 1
Session 2
15
40
40
iv |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

TOPIC 4: IMPORTANT BEHAVIORS TO IMPROVE AND MAINTAIN
GOOD NUTRITION AND HEALTH FOR PLHIV
Session 1
Session 2
50
60
TOPIC 5 : IDENTIFYING MALNUTRITION IN THE COMMUNITY
Session 1
Session 2
Session 3
Session 4
15
30
40
60
TOPIC 6: treatment and care for MALNOURISHED
INDIVIDUALS
Session 1
Session 2
Session 3
Session 4
30
40
15
15
TOPIC 7: roleS of community volunteers IN IMAM
Introduction
Session 1
Session 2
Session 3
Session 4
Session 5
Session 6
Session 7
Session 8
Session 9
Session 10
15
35
45
45
30
50
55
10
120
60
15
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | v

How to use this Manual
“Integrating nutrition into Community HIV/AIDS care and support: A trainer manual for
community volunteers” is part of a training package to train community volunteers to help
People Living with HIV/AIDS (PLHIV) and caregivers to improve nutrition practices. The manual
contains 7 topics, divided in two main themes:
THEME 1:
THEME 2:
Basic nutrition care and support for PLHIV
6 topics
23 sessions
The role of community in the Care of Malnourished Individuals
1 topics
10 sessions
The training of community volunteers is four days however, the two themes can be conducted
at one or two separate periods depending on programme planning and availability of resource.
This modular approach allows for flexibility in scheduling training sessions, and also allows for
practice between the teaching segments.
About the Manual
The training manual is accompanied by training references that guides the participants as also
serves as a take home reference. The participants should also receive the relevant counselling
materials and background information (see training preparation below).
It is important to plan the training ahead of time and prepare all the training materials needed
in a training kit. The training kit should have the necessary training aids and demonstration
materials organised by topic and session. These kits are available and can be borrowed from
partners like NuLife.
Alternatively, the training aids can also be printed or photocopied (see annexes 3 and 5)
.Community volunteers are also supposed to receive a bag containing the relevant counselling
materials, all the MUAC tapes, and referral cards, a pen, a notebook etc.
Training methodology
The competence-based participatory training approach used in this guide reflects key
principles of behaviour change communication (BCC) with a focus on the promotion of small
doable actions, a recognition of the widely accepted theory that adults learn best by reflecting
on their own personal experiences.
The approach uses the experiential learning cycle method and prepares participants for handson
performance of skills. The course employs a variety of low-tech training methods and aids,
including the use of MUAC tapes, counselling materials, visual aids, demonstrations, practice,
discussions, case studies, group discussion, recall situations, role plays, brainstorms etc. The use
of flipchart paper is recommended but not in all sessions. e.g. Not all information brought up
during brainstorming sessions should be written down, especially not in the low literate group
of community volunteers. Participants act as resource persons for each other, and benefit from
community practice.
vi |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

It is highly recommended that trainers use their creativity while using this manual, e.g.
a) organise a visit to a health facility or nearby community to practice how to measure
MUAC of clients
b) use two ripe bananas to demonstrate in class how to check for swelling of feet
(oedema) etc.
Manual outline
Each theme has topics and each topic has sessions. Each topic has specific learning objectives,
and contents showing the sessions and time allocated for each session.
The session objectives
These should be introduced to the participants at the beginning of each session to stimulate
their interest, raise curiosity. It will also enable them appreciate the relevance and importance
of the session, link the session to the preceding ones and to the training context.
The session duration
The estimated timing is given for each session considering the participant’s experiences and
their profile, very long sessions are avoided.
The training methods
For each session, the interactive techniques to be used are mentioned.
The required materials
For each session, the needed materials are mentioned. Examples are markers, flipchart
(masking tape and flipchart stands are not mentioned but are indispensable), images, specific
counselling materials etc.
The activities
These are step-by-step instructions to the trainer in order for him or her to carry out the session.
The trainers are asked to use these instructions with creativity, taking into consideration the
participants experience and their skills.
The References
Throughout the training manual, codes (e.g. ECS.S1) will be encountered. The codes refer
to references which can be found in the Community Volunteers’ Handbook.. They contain
information like technical information, instruction sheets, definitions, images, figures, case
studies etc.
The codes in the training manual are the same as the ones of the community volunteers’
handbook. They follow the numbering of the topics and the relevant session (and activity),
and can be decoded as follows:
AL: Adult Learning
ECS: Effective Communication Skills
SU: Start-up Activities
T1: Topic 1
S1: Session 1
T13.S3.1: Topic 13, Session 3, Activity 1
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The Notes to the Trainer.
This is information for the trainer, to equip him or her with additional information in order to be
able to answer questions. This information is not intended to be shared with the participants if
no additional questions on the session arise.
Training Location
Wherever training is planned, a community-based site should be readily available to support
the practicum for measuring Mid Upper Arm Circumference (MUAC), for counselling and
“reaching-an-agreement” skills with mothers/caregivers on small doable practices. Prepare
the practicum site by coordinating with the community before arrival of participants and
arranging for space to practice the skills.
The training preparation
The training preparation starts as soon as one is selected for conducting the training. Each
trainer should:
• Refresh his or her knowledge of the training themes;
• Review his or her sessions;
• Get mentally ready;
• Ensure perfection of his or her technical skills for conducting demonstrations;
• Ascertain sufficiency of training aids such as flipcharts, masking tape, markers, manila
paper, scissors, images, etc. (see national counselling cards under “training methodology”)
• Besides the bag for community volunteers, observe a handbook for each participant and:
• Themes 1 & 2: the “Nutrition Care and Support” national counselling cards, sufficient
MUAC tapes and the community–level job aids.
• Get some information on the participants. Among others, their experiences, particularly in
training; their profiles etc.
• Visit the training venue and make all logistical arrangements the day before.
The co-training
Co - training is an activity that involves several persons in conducting training. It allows cotrainers
to complement each other and to provide required guidance to participants.
Training is more interesting, less stressful and more effective when it is conducted by more
than one trainer.
If the training is conducted by a team, the team members need to prepare and clarify the
following:
• Who is responsible for the overall training coordination?
• Who is responsible for which theme?
• Which of the co-trainers will be responsible for logistics issues that arise?
• What does each trainer expect from the others?
Participants
It’s very important that the choice of participants is done according to the established criteria:
community volunteers formerly trained in community mobilization, HIV infection and progress,
HIV management with ARVs, support of PLHIV/OVCs and monitoring of activities.
viii |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

It is important for the trainers to create and maintain a good training ambiance and relationship
with the participants. This includes:
• Activities to create a good ambiance (e.g. start-up exercise);
• Utilization of humour (e.g. jokes, funny stories, energizers, ice breakers);
• Informal activities (e.g. chats with participants during breaks and meals);
• Good verbal and non-verbal communication.
The trainers should be interested in participants’ concerns and contribute to their problem
solving.
The trainers’ meeting
In order to ensure the quality of the training and to build a strong and efficient training team,
the trainers should support each other mutually, work together and have regular constructive
feedbacks. At the end of each day, the trainers should have a meeting to review the daily
evaluations and to discuss the course of the day. Participants’ views are taken into consideration
and strategies for the coming day are defined.
Examples of Energizers
The following are descriptions of several review energizers that trainers can select from at the
end of each session to reinforce knowledge and skills acquired.
• Participants and trainers form a circle. One trainer has a ball which he or she throws
to one participant. The trainer asks a question to the participant who catches the ball
who responds. When the participant has answered correctly to the satisfaction of the
group, that participant throws the ball to another participant. The participant who
throws the ball asks a new question, the participant who catches the ball answers it.
• Form two rows facing each other, each row represents a team. A participant from one
team/row asks a question to a participant opposite him in the facing team/row. That
participant can seek the help of his or her team in responding to the question. When
the question is answered correctly, the responding team earns a point and then asks
a question of the other team. If the question is not answered correctly, the team that
asked the question responds and earns the point. Questions and answers are proposed
back and forth from team to team.
• Form two teams. Each person receives counselling cards and other images. These visual
aids are answers to questions that will be asked by a trainer. When a question is asked,
the participant who believes s/he has the correct answer will show her counselling
card or visual image. If correct, s/he scores a point for her/his team. The team with the
most correct answers wins the game.
• From a basket, a participant selects a counselling card or visual image and is asked
to share the practices/messages which suit the image(s); feedback is given by other
participants. The process is repeated for other participants.
• Divide the group into smaller subgroups of about 10 participants. Place a set of
Counselling Cards “face down” on a mat in the middle of the circle. A participant is
asked to choose a counselling card and tell the other participants during whom
opportunities a community volunteer can share the practices/messages the counselling
card represents. Feedback is given by other participants. One trainer is present in each
circle to assist in responding.
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | ix

Examples of How to Form Small Groups
• Depending on the number of participants (for example 20), and the number of groups
to be formed (for example 5), ask participants to count off numbers from 1 to 5.
Begin to count in a clockwise direction. On another occasion begin to count counterclockwise.
• Depending on the number of participants (for example 16), and the number of groups
to be formed (for example 4), collect 16 bottle caps (or colored cards) of 4 different
colors: 4 of red, 4 of green, 4 of orange, and 4 of black. Ask participants to select a bottle
cap. Once selected ask participants to form groups according to the colour selected.
• Sinking ship: ask participants to walk around as if they were on a ship. Announce that
the ship is sinking and life boats are being lowered. The life boats will hold a certain
number of participants only. Call out the number of persons the life boats will hold
and ask participants to group themselves in the number called-out. Repeat several
times and finish with the number of participants you wish each group to contain (for
example, 15 participants in groups of 3, the last “life boat” called will be the number
3).
Training assessment and Evaluation
Assessment of participants’ knowledge
Participants’ knowledge evaluation is done at two different times:
1. In the beginning of the training, called the pre-assessment. This will give the trainers an
idea of the participants’ needs.
2. At the end of the training, called a post-assessment. If individuals are scoring badly on
many of the questions, the trainer should take time with those participants, find out what
was not captured fully and go through the relevant information again.
3. As the learning objectives of the two first main themes, it is suggested to do a pre-and
post-assessment before and after both themes.
4. To keep the evaluation informal and anonymous, a short exercise (20 mins) is proposed
during which participants are seated or standing in a circle, facing outwards. Following are
instructions to use for the assessment:
• Ask participants to form a circle and sit/stand so that their backs are facing the centre.
• Explain that questions will be asked and ask participants to raise one hand (with open
palm) if they think the answer is “True”, to raise one hand (with closed fist) if they think
the answer is “False”, and to raise one hand (pointing 2 fingers) if they “Don’t know”.
• Ask participants to close their eyes.
5. One trainer reads the statement and other trainers record the answers on the preassessment
guide and notes which topics (if any) present confusion, and in some cases
who seemed to have difficulties.
x |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

6. Blank assessment guides can be found in “The participants’ Handbook” and are supposed
to be filled out in group after the post-assessment. Assessment guides with correct answers
can be found in annex 2.
Daily Evaluations
The following are descriptions of daily evaluations that trainers can select from at the end
of each day (or topic) to assess the knowledge and skills that have been acquired and/or to
obtain feedback from participants.
A. Form buzz groups of 3 and ask participants to answer one, two, or all of the
following questions in a group*:
• What did you learn today that will be useful in your work?
• What was something that you liked?
• Give a suggestion for improving today’s sessions.
Ask a participant from each buzz group to respond to the whole group
B. “Happy faces” measuring participants’ moods. Images of the following faces (smiling, neutral,
frowning; see Annex 1 for cut out) are placed on a bench or the floor cap on the “face” which
best represents their level of satisfaction (satisfied, mildly satisfied and unsatisfied).
If there were many neutral and frowning faces, trainers should ask the group (the next day)
what was less satisfying to them, and re-explain any sessions if necessary. If participants feel
uncomfortable to be honest about certain issues, they can also write them on a piece of paper
and put them in the parking lot.
Training Evaluation
It is useful for the trainers to have a feed-back on the training itself: the trainers’ skills, the
methodologies used, the logistics etc. Following exercise can be used to evaluate the
training:
1. Ask participants to form buzz groups of 3.
2. Explain that their suggestions will be used to improve future trainings.
3. Explain that questions will be asked and that each group should discuss among
4. Themselves what they think.
5. Have one trainer read the questions below, one by one, allowing groups to share their
comments in the whole group in between. Another trainer records the answers:
• What did you like about the teaching methods?
• What did you dislike about the teaching methods?
• How will you use the information provided?
• How will you use the MUAC tapes?
• How will you use the Counselling Cards?
• What did you learn in the practice in the community?
• Do you feel ready to counsel PLHIV / caregivers?
• What suggestions do you have to improve the training?
• Do you have any other comments? Please share.
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | xi

Start-Up Activities
Learning objectives
By the end of the topic, participants will be able to:
• Name fellow participants and trainers
• Discuss expectations
• Understand the purpose of the training
• Obey the ground rules of the training
Content
Start-up activities
Session 1
Session 2
Session 3
Session 4
Session 5
15
50
20
10
30
Duration:
2 hours, 15 mins
Session 1: Participants’ welcome and registration (15 mins)
Activity:
• GET to the training venue 30 mins before participants’ arrival in order to receive them
• MAKE SURE that everything is clean, and that chairs and tables are arranged in a U shape
• WELCOME participants, register and offer them seats as they come in
• MAKE SURE that all the participants are seated comfortably.
xii |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Session 2: Opening remarks and participants’ introduction
(50 mins)
Note to the trainer:
Present an overview of objectives (listed below) and the time allocated for the topic.
Method: Speech, get to know the person next to you, on your right side.
Material:
• Flipchart, markers
• A prepared flipchart saying: name, expectations, opportunities to talk to community
members about nutrition.
Activities
• GREET and welcome participants.
• ASK an already notified person to give a welcome address and to officially open the
workshop. If this person is not available, refer to the handbook (SU.S1) to introduce the
NuLife program.
• TAP every other person on his or her shoulder and ask him or her to turn to their right
neighbour.
• Explain that each pair will get 5 mins to get to know each other; with a special interest in
his or her name, expectations and personal opportunities to talk to community members.
Hang the prepared flipchart as support.
• Start the exercise.
• After 5 minutes
• Ask each participant to present his or her partner in about a minute, focusing on the
discussion points on the flipchart.
• WRITE the participants’ expectations on a flipchart when they are presented.
• After all participants have been presented
• Thank them
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | xiii

Session 3: Presentation of the training’s learning objectives,
compare with expectations (20 minutes)
Method: Presentation on flipchart, comparison
Material:
• Marker, Prepared flipchart with learning objectives found in the note to the trainer.
• A training agenda for each participant.
Activity
• POST the learning objectives on the prepared flipchart and ASK a volunteer to read them
• GIVE the participants time to ask questions of clarification and reply to questions asked
• REVIEW the participants’ expectations, identify those which cannot be met during the
workshop and give the reasons why not (if they will be met later, explain when)
• HAND OUT and PRESENT the workshop agenda.
• ANSWER questions.
Note to the trainer:
Present the objectives which are relevant for the training you are carrying out: Themes 1 & 2
THEME 1 and 2
Training and learning objectives for community volunteers :
By the end of this training, community volunteers should be able to:
1. Understand and appreciate the role of nutrition support in the care of people living with
and affected by HIV/AIDS
2. Describe their role in integrating nutrition support activities in their daily routines at
community level
3. To implement nutrition support activities which include:
• health education
• nutrition counselling
• nutrition assessment
• referral of clients to health facilities
• follow-up and home visiting of clients in the community
• supporting adherence to RUTF in the community
• networking with other services providers, and reporting
xiv |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Session 4: Discuss administration, logistics and ground rules
(10 mins)
Method: Explanation, Brainstorm
Material:
• Marker, Prepared flipchart with learning objectives found in the note to the trainer.
• A training agenda for each participant.
Activity
• EXPLAIN any administration and logistics arrangements.
• GIVE the participants time to ask questions of clarification and reply to questions asked.
• BRAINSTORM with participants on the ground rules of the training.
• Add any missing rules.
• ANSWER any questions.
Note to the trainer:
Ground rules of a training
1.
2.
3.
4.
5.
6.
7.
8.
9.
Respect for each other
No whispering
Good listening
Actively participate in all activities
Talk one by one
Come in time, do not run away during training
Cell-phones on silent mode
Minimize unnecessary movements
No newspapers
Session 5: Pre- Assesment (30 mins) (See Introduction)
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | xv

Volunteering
Note to the trainer:
Present an overview of objectives (listed below) and time allocated for the topic. At the end of
each topic, refer back to these to make sure they are met.
Learning objectives
By the end of the topic, participants will be able to:
1. Realise that volunteering is part of life
2. List the benefits and challenges of volunteering
3. Think about the qualities of a good volunteer
Content:
Session 1: Volunteering (30 minutes)
Duration:
30 minutes
Session 1: Volunteering (30 minutes)
Method: Brainstorm
Material: Flipchart and markers.
Activity
• BRAINSTORM with participants about occasions or events in their community when
people are involved in volunteering.
• CAPTURE answers on a flipchart.
• ADD missing examples; from the notes to the trainer.
• SUMMARISE by saying ”Volunteerism is part of life and has always existed in communities.
It is a normal and useful activity.”
• ASK participants about the benefits of volunteering, one by one. Everybody should get a
chance to mention a benefit.
• WRITE new answers on a flipchart, complete the list using the notes to the trainer.
• If challenges are mentioned, write them on a separate flipchart.
• ASK participants (to add) challenges of volunteering. WRITE new answers on the flipchart.
When the list is complete, ask the participants to mention some ways to overcome the
challenges just mentioned, without writing these down.
• BRAINSTORM with participants about what qualities a good volunteer needs.
• WRITE the answers on a flipchart.
• ADD missing examples; from the notes to the trainer.
xvi |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Note to the trainer (VSI):
Some examples of volunteering in Africa are:
• “Bulungi bwansi” – Helping to improve the environment in the community
• Weddings – volunteer to carry out a task
• Rotational digging
• Burial groups (twezikye, muno mukabbi) digging graves, cooking at burials
• Looking after orphans – concept – children belong to the community
• Immunization exercises
• Volunteering at church
Some benefits of volunteering are:
• Gives people a chance to gain work experience or learn new skills
• Makes the community a better place to live
• Often includes training, which will be useful both to the project later in life
• Volunteering is a fun and fulfilling experience. It helps people to access opportunities not
usually available to them
• Gives a chance to meet and interact with people from all walks of life – people one might
not normally come across
• Makes use of one’s talents and abilities
• Improves communication skills
• Develops greater knowledge and understanding for people in one’s own community
• Learn how to appreciate the blessings in life
• Feel great about helping those in need
• People become more confident in their abilities
• Gives one the opportunity to make a difference in people’s lives. By using their skills and
experiences to help and enrich their communities.
Some challenges of volunteering:
• Not receiving a payment
• Community members thinking that the volunteering is receiving payment
• Community members receiving contradicting advice by other people
• Community members not trusting the volunteer
• Community members not following the advise of the volunteer
• Covering a large community
• Not having a bicycle, or having a bicycle which brakes down all the time
• Not having enough time to do all the work
• Not receiving support supervision
• Receiving support supervision of poor quality
• Not receiving additional training
Some qualities needed by a volunteer:
• Willingness to volunteer
• Loving his or her community
• Understanding and executing his or her duties
• Well trained to be able to perform his or her duties
• Team approach
• Good monitoring and reporting
• Exchanges information and influences decision making
• Commitment and hard work
• Able to build trust and rapport with community members
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | xvii

Effective Communication Skills
Note to the trainer:
Present an overview of learning objectives (listed below) and time allocated for the topic. Inform
participants that this is not a training on counselling, but a session to equip participants with
simple skills, knowledge and attitudes to enable them integrate nutrition into their activities.
At the end of this topic, refer back to the objectives and ensure that they have been met.
Purpose:
Participants will learn the basic communication skills which will enable them to effectively
negotiate with PLHIV and their home-based caregivers to undertake do-able actions to
improve their nutrition and eating practices.
Participants will also improve their skills in planning, conducting and evaluating a health
education session.
Learning objectives:
By the end of this session, participants should be able to:
• Define Communication
• Understand the importance of the basic communication skills
• Appreciate the importance of counselling to community volunteers
• Identify 6 important steps of counselling (GATHER method)
• Practice using GATHER
• Identify basic communication skills (listening and learning skills)
• Plan, conduct and evaluate a health education session
Contents:
Effective communication skills
Session 1: Basic communication skills
Session 2: The importance of counselling for community volunteers?
Activity 1: Why community volunteers should learn basic counselling skills
Activity 2: 6 important steps in counselling (GATHER method )
Session 3 Reaching an agreement
Session 4 Planning and conducting a health education session)
Activity 1: What is health education?
Activity 2: What to do before, during and after a health education session?
Activity 3: Simulating a health education session
Minutes
60
40
20
20
40
60
15
25
20
xviii |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Duration:
3 hours, 20 minutes.
Session 1: Basic communication skills (60 mins)
Session objective: By the end of this session participants should be able to:
• define Communication
• differentiate between verbal and non-verbal communication skills
Methodology: Brainstorm, demonstration
Materials needed:
1. Prepared flipchart with the “Meaning of communication” (see notes to the trainer)
2. Prepared flipchart with the definitions of “Verbal and Non-veral communication” (see
notes to the trainer)
3. Flipcharts, markers
Activity
• EXPLAIN to the participants that communication and helping skills are important in order to
pass on information to individuals, families and communities. Therefore community volunteers
need to be equipped with basic communication skills
• ASK participants what they think communication means
• WRITE their responses on a flipchart
• SHOW participants the previously prepared flipchart with the “Meaning of communication”
and MAKE sure they understand what communication is
• ASK them to identify key comunication skills.
• EXPLAIN to them that there are two types of communication: verbal communication and
non-verbal communication
• ASK them what they understand by the terms: “verbal communication and non-verbal
communication”, without writing responses down.
• SHOW them a flipchart with the explanation of these terms.
• EXPLAIN to participants that they are now going to look at some effective and noneffective
communication skills
• DEMONSTRATE with a co-trainer each one of the skits with the examples of non-verbal
communication very briefly (see below,each skit should not take more than 5-10 minutes,
make sure the one with the open and closed question follow each other immediately)
Note to the trainer Definitions of communication (ECS.S1):
Meaning of communication:
The process of sharing ideas and experences with other people using verbal and non-verbal
language.
The exchange of information from one person to another with appropriate feedback from
both ends
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | xix

Types of communication:
Verbal communication: Face to face with short words to encourage the client to talk. (Where
speech is involved.)
Non- verbal communication: Usually uses body language (like facial expressions, using hands,
sitting or standing postures, movement of the eyes) and signs.
Important Communication Skills a Community Volunteer must
have:
This also implies qualities of a good counselor and they could include:
Active Listening
Is the art of engaging meaningfully with someone who is trying to communicate with you.
It includes conveying open and welcoming body language, asking follow up questions, rephrasing
key points to ensure that you are understanding, and providing feeddback.
Body Language
This is a set of expressions that we make using our bodies. The expressions include eye contact,
smiling, nodding and other gestures and signals. They communicate how we are feeling and
what we are thinking. For example, if one crosses h/her arms in front of h/her body, it usually
means that person is reserved about something and need to warm up to the issues at hand.
Asking Questions
A useful technique for asking questions is using ope-ended questions . These are questions
that cannot be answered with a “yes” or “no”. They usually start with “how” or “why”, like “ Why
do PLHIV need to eat well?”. Open – ended questions are more usefull than closed questions
because they require reflection. They are a great way to start a discussion, increase participation,
and get more information from community members/ target audience.
Empathetic understanding
This is the ability for the community volunteer in course of communicating, tries to put h/
herself in the situation of the client, and help them cope and be able to stand up on their own
feet as soon as possible.
Genuine/ Sincerity
Ability and willingness to be open, real and consistent in the relationship with the client. To be
prepared to give time and attention, to be a “real” person not just some one in a proffefesional
role.
Unconditional Positive Regard
The ability to communicate with the client without blame or negative feelings, expelling all
fear from the client and making h/her feel h/she is accepted the way h/she is and wanted
despite the weeknesses one may have.
xx |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Warmth
The Counselor cares and respects the clients:
• This conveys love and care
• Breaks down resistance from the clients
• Brings about healing.
Note to the trainer: Skits for Demonstration (ECS.S1):
Demonstration 1: Examples of non-verbal communication
With each demonstration say exactly the same few words, and try to say them in the same way,
for example: “Good morning, Kato. How are you feeling today?”
A: Taking time:
Helps: make him feel that you have time. Sit down and greet him without hurrying;
then just stay quietly smiling at him, waiting for him to answer
Hinders: be in a hurry. Greet him quickly, show signs of impatience, and look at your
watch
B. Posture:
Hinders: stand with your head higher than the other person’s
Helps: sit so that your head is level with him
C. Eye Contact:
Helps: look at her and pay attention as he speaks
Hinders: look away at something else, or down at your notes
D. Barriers:
Hinders: sit behind a table, or write notes while you talk
Helps: remove the table or the notes
Demonstration 2: Closed questions that can only be answered “Yes” or “No” and also
give specific short answers .
CHW: Good morning, (name). I am (name), the community health worker. Are you well?
Client: Yes, thank you.
CHW: Are you eating?
Client: Yes.
CHW: Are you having any difficulties?
Client: No.
CHW: Are you taking your medicines?
Client: Yes.
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | xxi

Demonstration 3: Open questions
CHW: Good morning, (name). I am (name), the community health worker. How are you
feeling today?
Client: I’m well, but I don’t have much appetite.
CHW: Tell me, what have you been eating?
Client: I’ve had some porridge this morning. I’m not sure what I will have later on.
CHW: What foods do you have at home?
Client: Let me see … I know there is some rice and beans.
Demonstration 4: Reflecting back and showing interest
CHW: Good morning (name). How are you feeling today?
Client: All right, but I’ve noticed some sores in my mouth, and I don’t feel like eating.
CHW: Oh dear, are the sores in your mouth keeping you from eating?
Client: Yes. The sores just started this week.
CHW: Aah, you’ve noticed these sores for about a week?
Client: Yes, and my sister is telling me that there’s some food I shouldn’t eat.
CHW: Mmm, your sister says that you should avoid some food?
Client: Yes. Which foods should I avoid?
Demonstration 5: Not using judging words
CHW: Good morning, may I see your chart?
Client: Here you are.
CHW: You are losing weight. Why, are you not eating?”
Client: I don’t know … I hope so, but may be not ... (looks worried) I’m trying.
Demonstration 6: Empathy
CHW: Good morning, how have you been feeling lately?
Client: I have been having nausea and am not eating much and also losing weight.
CHW: I understand. Nausea can make you really feel like not eating. Is there anything you have
been able to eat or drink?
Client: Yes, some cups of juice.
CHW: That’s good. I can help you manage the nausea so you can eat a little more and gain
weight
Note to the trainer :
Refer participants to the notes in their handbooks on Basic Counselling Skills.
xxii |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Session 2: The importance of counselling for community
volunteers? (40 mins)
Session objective:
By the end of this session participants should be able to:
• understand what counseling is
•
•
•
explain the basic communication skills
understand why community volunteers should learn basic counselling skills
identify 6 important steps in counselling (GATHER method)
Methodology: Brainstorm
Materials needed: Flipcharts , markers
Activities:
Activity 1: Why community volunteers should learn basic counselling skills (20 minutes)
• ASK participants to tell you what they understand by ‘counselling’.
• WRITE the responses down on the flipchart
• CORRECT or GIVE additional information
• EXPLAIN that counselling is not the same as teaching or giving advice/ guidance, it is
much broader.
• ASK participants the Basic Communication skills used in counselling
• ASK them ‘why is it important for community volunteers to learn counselling skills?’
• DISCUSS and SHOW participants the previously prepared flipchart on why community
volunteers should learn counselling skills
• MAKE any corrections or changes and SUMMARISE the session
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | xxiii

Note to the trainer (ECS.S2.1):
Definition of counselling:
• The act of providing a safe and secure environment for a client to talk over h/her
problem(s) so as to figure the way out or accept the problem and learn to live with it
and be able to cope with appropriate interventions.
Specifically:
COUNSELLING is a relationship in which a client is helped to make decisions and plan
appropriate actions.
Basic Communication Skills in Counselling
• Active Listening, Asking questions, Answering questions and Checking understanding
and offering support where necessary
Why community volunteers should learn counselling skills:
• In order to effectively communicate the behaviours to improve nutrition
• In order to help clients try the small do-able actions
• In order to help clients look at the different options
• To be able to determine when it might be necessary to refer clients to a more
experienced counsellor and/or other support services
xxiv |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Activity 2: The 6 important steps of counselling (GATHER method) (15 minutes)
Objective: By the end of this activity participants will be able to:
•
know the six important steps in counselling using the GATHER approach.
Materials: Instructions for group work, flipcharts, markers
Activity
• INTRODUCE this activity telling participants that there are some important steps
to consider when counselling clients. (Some of them might have heard of different
methods).
• This activity will focus on 6 simple steps which community volunteers should recall and
use when they counsel clients in the community
• HANG the flipchart with the letters G, A, T, H, E, and R on a wall or stand
• ASK participants to think about each letter and mention what they think each letter
means
• WRITE their responses down on a flipchart and mark with the corresponding letter
• SHOW participants an already prepared flipchart showing GATHER and the explanation
for each letter
Note to the trainer (ECS.S2.2):
G =Greet the client (create rapport,)
A = Ask ( ask how they are feeling, how you can help, etc.)
T = Tell (tell client about alternative choices to address problems, use counselling cards if
available, get client to think what is done differently in their community)
H=Help (help the client to make informed choices, develop small do-able actions)
E =Explain (explain the choice the client has made fully, discuss any barriers)
R= Reassure/ Remind participant about next appointment/
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Energizer: Bad/ Good listening skills in pairs
• INFORM participants that they are going to demonstrate bad and good listening skills
• DIVIDE participants into pairs. In each pair, ask one person to play the speaker and the
other the listener
• EXPLAIN that the speaker is going to talk for 3 to 4 minutes (on any topic) and that the
listener is to demonstrate ‘bad’ listening techniques-the opposite of the points made in
the presentation
• When this is done, DEBRIEF by ASKING the speaker what it felt like to be with a ‘bad’ listener.
ASK the speakers what the ‘bad’ listeners were doing or not doing.
• Go back into the pairs and swap roles. This time INSTRUCT the listener to practice ‘good’
listening skills. When the speaker has finished, DEBRIEF by ASKING the speaker what it felt
like to have a ‘good’ listener.
• ASK the speakers what the ‘good’ listeners were doing or not doing
• DRAW out the key points about active listening and SUMMARISE
xxvi |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Session 3: Demonstration of “reaching-an-agreement” to
encourage a PLHIV to try increasing energy intake
though small frequent meals: initial visit to the client
(40 mins)
Session objective:
By the end of this session, participants will be able to:
• define the steps used for “reaching-an-agreement” with clients, using the 6 important
steps in counselling
Methodology: Demonstration, discussion
Materials needed: Nutrition care and support national counselling cards, flipchart with
GATHER in full, role plays
Activity
USING the 6 important steps in counselling (GATHER), the trainers (not the participants)
should:
• DEMONSTRATE a counselling session including the initial “reaching-an-agreement” visit
of a community volunteer to Jane, the mother of a 12 year old HIV-positive boy, John
• Jane tells the community volunteer that she gives John 2 meals a day because he does
not have appetite and feels weak.
• Community volunteer praises Jane for looking after John.
• Community volunteer uses the Card 4 in the national counselling cards, explaining
that eating extra food (small frequent meals) gives more energy and “reaches-anagreement”
with Jane.
• DISCUSS what happened in the demonstration visit.
• REPEAT the whole counselling session including “reaching-an-agreement” step with Jane,
stopping after each step, and discussing the step with participants. The questions are
questions to be asked to the mother being counselled – GATHER:
• Greet – Greet Jane
• Ask – Ask questions to find out what is happening, how she and the John are doing
etc.
• Tell: Tell the options. Now is the time to use the cards from the nutrition care and
support national counselling cards and to ask:
• What is happening in Card 4?
• What do people in your community do? What do you agree or disagree with? Why?
• Help – Help to find a do-able action by asking: Would people in your community be
willing to try this same behaviour? Would you be willing to try this practice?
Explain: “This is what is meant with “reaching an agreement” with the person you are
counselling. This is to have her or him try a new or “improved” behaviour), which you will
evaluate during your follow-up visit. Whatever you ask the person to try, make sure it is a small
doable action. You can always ask for further changes during a next visit.”
• Remind / Reassure/Refer – Remind about a follow-up visit
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | xxvii

Note to the trainer: The GATHER approach in counselling
Greet the client and introduce yourselves. Discuss status and well-being at the time of /
since the last visit.
Ask how the client feels today and how you can help them about his/her nutritional status and
food intake.
• Ask about any symptoms, nutritional problems and concerns.
• With the client, identify any nutritional needs. For example, not increasing weight
adequately, not adhering to medicine, needing to use dietary approaches to manage
symptoms.
• Find out what the client has done in the past to address these problems. What was his/
her success?
Tell and discuss with the client alternative choices to address his/her nutritional problem(s).
Use the counselling cards, choosing the appropriate set of cards that relate to the problem
identified above.
Help the client make informed choices. With the client (and family members/caregivers),
develop approaches/actions to attain the nutrition goal the client has set. As much as possible,
let the client come up with choices that are practical and relevant to his/her context.
Explain fully the choice(s) the client has made
• Discuss any barriers the client may have in implementing the choices he/she has
made.
• Ensure the client can explain the actions he/she will take. Do demonstrations if
necessary.
• Summarize what has been agreed and how it will be done (the client can do this).
Reassure and give a return date for the next visit.
xxviii |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Session 4: Planning and facilitating health education sessions
(50 mins)
Session objective:
By the end of this session, participants should be able to:
•
•
plan, conduct and evaluate a health education session
define health education
Materials:
Flipcharts, markers, Brainstorm instructions; reference; flipcharts; markers, a flipchart on how to
plan and conduct a health education
Methodology:
Brainstorming and demonstration
Activities
Activity 1: What is health education? (15 minutes)
Activity 2: How to plan, conduct and evaluate a health education session? (25 minutes)
Activity 3: Simulating a health education session (20 minutes)
Activity 1: What is health education (15 minutes)
• ASK participants:‘what does health education mean to you?’
• COLLECT all the answers on a flipchart and offer to summarize the ideas at the end of this
first brainstorm;
• MAKE SURE at the end that everyone understands that when referring to health
education on : A get together, organized in an interactive manner by a health worker or a
communityvolunteer to talk with a group of individuals in a community on a topic relevant
to the health issues of that community
• ASK participants, “Why is it important to conduct health education sessions in the
community?”
• COLLECT all the answers on a flipchart and summarize using section 2 of reference ECS.
S4.1.
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | xxix

Activity 2: What to do before, during and after a health education session (25 minutes)
Activity
• INFORM the participants that it is time to look in details into to how such health education
sessions should be organized and facilitated and that this task is going to be done in three
groups
• READ the brainstorm instructions out loud for everyone and answer questions of
clarification. (See below for breainstorm instructions)
• BRAINSTORM on the three phases of carrying out a health talk
• SUMMARIZE the discussion using reference ECS.S4.2.
• REPLY to any questions, and announce the coming session.
Brainstorm instructions
The LC1 of your village has learned that you have recently attended training on nutrition and
HIV. He has invited you to a village meeting where you will give a health talk on the benefits of
nutrition for people living with HIV/AIDS.
How are you going to go about it in order to properly conduct the meeting? In order to facilitate
thinking, consider that every meeting has 3 important phases :
• phase 1: Before the meeting
• phase 2: During the meeting
• phase 3: After the meeting
How are you going to proceed with these phases? Be as specific as possible. There are perhaps
people in this group who have never been in such a situation, and they will benefit from a
detailed description of what you will need to do or prepare.
Note to the trainer:
Refer to the reference on “norms and procedures for planning and facilitating a health
education” (Reference ECS.S4.1).
Activity 3: Simulating a health education session (20 mins)
Activity
• INVITE one participant to simulate or demonstrate the actual session to the rest of the
group
• INSTRUCT the remaining participants to observe the health education session
• GIVE time for feedback, SUMMARISE
xxx |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | xxxi

Theme 1
BASIC NUTRITION CARE AND SUPPORT
FOR PEOPLE LIVING WITH HIV/AIDS

1
TOPIC
BASICS OF NUTRITION
Note to the trainer:
Present an overview of learning objectives (listed below) and time allocated for the topic. .
At the end of this topic, refer to the objectives and ensure that they have been met.
For session 2 on the food groups, you will need to ask community volunteers to bring some
local food items available in their communities in order to have a food demonstration.
Purpose:
Participants will learn the basics of nutrition needed in the care of PLHIV (infants, children,
adolescents, pregnant and lactating women and adults). This will also make it easier to
understand the relationship between nutrition and HIV.
Learning objectives:
By the end of this session participants will be able to:
• Define nutrition and some key words: e.g. ‘good nutrition’, ‘eating well’
• Describe the importance of food groups
• Identify local foods that belong to each food group
• Explain the other important factors required for eating well: frequency (F), amount (A),
thickness / consistency (T) Variety of different nutrient-dense food groups (V), active
feeding (A) and hygiene (H).
• Understand the role of breastfeeding in the protection against illnesses of babies in
their communities
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 1

• Reflect on how breastfeeding can prevent these common illnesses
• Understand the risks related to the infant feeding options
• Practice choosing foods to make ‘eat well’ meals using seasonally, locally available
foods
Outline
Session 1: Basics of nutrition
Session 2: The food groups and their importance
Session 3: How to improve ways of eating
Session 4: What Breast milk contains
Session 5: What is malnutrition?
Session 6: Causes of malnutrition and how they can be prevented
Session7: The role of breastfeeding in the protection against malnutrition and
illnesses of babies in their communities
Session 8: Breastfeeding practices in the community and recommended practices
Activity1: Discuss infant and young child feeding practices in their communities.
Activity2: Discuss problems related to the different infant feeding practices
Activity3: Learn the recommended feeding practices in Uganda
minutes
15
50
30
25
50
25
30
80
30
30
20
Duration:
5 hours, 5 minutes
2 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Session 1
Basics of Nutrition (15 mins)
Session objective:
By the end of this session participants should be able to define some basic nutrition terms.
Methodology:
Discussion
Materials needed:
markers, flipcharts, prepared reference T1.S1
Activity:
• REFER participants to reference T1.S1 in their handbooks and ASK them to read the text in
the handbook
• DISCUSS the meaning of nutrition and the other key words in the reference and ENSURE
that all the participants are able to define these key words
• ASK participants to go to reference T1.S1 and REQUEST a volunteer to read the reference.
MAKE SURE that all the participants understand this information.
•
•
•
Note to the trainer:
Refer to reference T1.S1 for this session.
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 3

Session 2
The food groups available in the community and their
importance (50 mins)
Session objectives:
By the end of this session participants should be able to:
• identify different foods that belong to the food groups of the Grow, Glow, Go.
• use local foods to make meals
Methodology:
Food demonstration and discussion
Materials
• A variety of foods available in that particular community and some dry food rations
• The laminated cards showing 1) a jogging man 2) a little girl growing into a tall woman 3)
a glowing man
• Card 3 in the national counselling cards (different food groups)
• References T1:S2 (the list of available foods in food groups & the seaonally available foods
table)
Activity
• As participants to form small groups according to their community
• Distribute laminated cards of the different foods to the groups
• ASK each group to divide the foods into foods available during given seasons (months)
• Ask each group to divide the foods into food group (Grow Grow and Glow). Go round and
correct where necessary. Let the group mention other foods available. Write on a VIP card
and let them place in the good group they belong.
• ASK participants to form a circle, bringing their national counselling cards and the food
they brought.
• PUT the laminated card with the jogging man in the middle of the circle and ASK them
to discribe what they see
• PUT the laminated card with the grown woman in the middle of the circle and ASK
them to discribe what they see
• PUT the laminated card with the glowing man in the middle of the circle and ASK them
to discribe what they see
• ASK participant to put the food which they have brought next to the card they think it
belons. (Some participants may not have foods, so you can GIVE them the dried foods
from the training kit).
4 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

• ASK participants to take Card 3 of the national counselling cards and study it.
• ASK participants to correct the foods on the ground, following the GO, GLOW and
GROW grouping
• Once this activity is completed, ASK participants if there are any foods which have
been left out, or are out of season and in which food group would they put them.
• ASK participants to practise making balanced meals using the foods in the middle of
the circle. MAKE SURE that each meal has foods from all the food groups. EMPHASISE
to participants that they can make healthy, balanced and affordable meals using locally
available foods in all seasons.
• To wrap this session up, refer participants to the references T1:S2: the list of available
foods in food groups & the seaonally available foods table. ASK participants to read the
first reference at home, and to fill the table out as their own reference as homework.
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs| 5

Note to the trainer:
The food groups are important for ‘eating well’;
• The foods are grouped according to the major food values they provide
• Almost all foods contain more than one nutrient but they differ in the amount and
quality
• Each food value has a role in the body
• Different amounts are needed for different groups of people and individuals
The food groups
GO FOODS: Energy giving foods: staple foods:
Cereals, roots and tubers: mainly providing carbohydrates and fibre. Examples include rice,
millet, wheat, sorghum, matooke and maize. Also included are cooked foods prepared from
these cereals like posho, bread and porridge. Other foods in this group are yams, cassava, sweet
potatoes and Irish potatoes.
GROW FOODS: Body building foods
1) Animal sources: mainly providing proteins, minerals and vitamins. Examples are rd meat,
chicken, fish, mukene, enkejje, eggs, milk, grasshoppers, and white ants (enswa).
2) Plant sources (legumes): mainly providing proteins, minerals and vitamins. Examples are
different kinds of beans, peas and nuts.
GLOW FOODS: Protective foods
1) Vegetables: mainly providing minerals, some vitamins and fibre. Examples are dark leafy,
green and orange coloured vegetables, such as carrot, pumpkin, sweet potato leaves, spinach,
nakkati, buga, pumpkin leaves (ssunsa), amaranthus (dodo), okra, pumpkin, eggplant, tomato,
onion, green pepper and other local vegetables.
2) Fruits: mainly providing minerals, some vitamins and fibre. Examples are oranges, guava,
mangoes, pawpaw, pineapple, jackfruit, passion fruit, water melon, sweet bananas, avocados
etc. Fresh fruit juices belong in this group, as well as in the water group.
OTHERS:
Extra energy: Fats, oils and sugars: mainly providing energy and taste. Examples are animal
fats e.g. ghee and butter; vegetable fats and oils e.g. margarine, sunflower and palm oil; sugar
e.g. cane sugar, honey
Water: Water is important for life and is necessary every day.
• Water helps in digestion, absorption and transportation of food
• Water regulates body temperature. It is recommended that a person drinks at least 8
glasses (1.5 litres or 1.5 full NICE cups) of water a day. When it is hot, while doing heavy
physical work, sweating or suffering from diarrhoea, vomiting or fever one needs to drink
more water per day.
• One can also get water by drinking soups or fruit juices
• Water for drinking, taking medicines or making juices should always be boiled or treated
to make it safe.
Rest group: Not providing anything else than energy. It is recommended to consume items
from this group in moderation as they interfere with the consumption of healthy foods and
drinks. Examples are artificial juices, sodas, alcoholic drinks, sweets, biscuits etc.
6 | Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Session 3
Other ways of increasing the required food values
(30 mins)
Session objective:
By the end of this session, participants should be able to describe other ways of increasing the
food values.
Methodology:
Question, discussion
Materials needed:
Flipcharts, markers
Activity
• ASK participants: “How how many times families in their community eat every day
• WRITE the responses on the flipchart and PROBE: When, Why, How about children/adults/
pregnant women.
• ASK participants: “How food should be handled and why? PROBE: during preparation,
cooking, serving, eating, storage and eating of left over foods.
• TELL the participants that there are 6 importants ways of increasing food values
(Frequency, Amount, Thickness, Variety, (Actively feed and support), Hygiene (FATVAH)
• DISCUSS each way and ask participants why that particular way is important. GUIDE the
discussion as follows (T1.S3):
Frequency of meals (Number of times meals are eaten per day)
This refers to the number of meals eaten in a day. In order to meet our body’s needs, we must
have frequent meals: 3 main meals and 2 small meals (snacks) each day. The frequency should
increase for those who are sick or recoverying from illness.
Amount of foods
This refers to how much food is eaten at each meal. It is important to eat foods in the appropriate
amounts, again to ensure thatt we are not getting too little or too much food. For example an
adult needs 1 full NICE cup of food at each meal and children would need less.
Thickness of foods
Not too watery as the food values will not be enough and not too thick as the child may have
difficulty in swallowing or chewing). The thickness of foods is an important factor to eating
well, because if food is too thick, it might make it difficult to chew and swallow. However, if food
is too watery, the energy value of the food is reduced.
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 7

Variety
of different foods from each food group. In session 2 we learned about the food groups and
their importance. We now know that each food serves the body differently (GO. GLOW, GROW),
therefore it is important to have a variety of foods from each food group in order to eat well.
Actively feed and support:
Active feeding and support is important, particularly for PLHIV.This is more than just feeding
PLHIV (both adults and children), but involves a number of actions to support PLHIV to have
access to food, grow foods, and prepare these foods.
Hygiene
(washing hands before eating and handling foods, clean utensils, clean water). This is a very
important factor needed for eating well. Good hygiene reduces the risk of diseases such as
diarrhoea, which in turn can lead to malnutrition. It is important to maintain good hygiene
especially for PLHIV.
• GO BACK to the flipchart with the factors which participants mentioned and SEE if these
factors have been covered and discussed under the 6 factors above.
• INTRODUCE the next session by telling participants that in addition to other factors,
some times people may not be ‘eating well’, which could lead to malnutrition.
8 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Session 4
Breast milk and what it contains (25 mins)
Session objective:
By the end of this session, participants should be able to: appreciate the food value of breast
milk
Methodology:
Brainstorm
Materials needed:
images and comparison of breast milk with other animal milks
Activity
• Ask participants: “What breast milk contains
• Put an image of the difference in amount of the food values (Grow, Glow and grow) in
the different milks drawn in chart and posted on the wall.
• Probe until all images are displayed.
• Put the cow’s milk next to the breast milk and let them identify the difference.
• Put the goat’s milk next to the cow’s milk and let them comment on the differences they
see
• Lastly put the porridge next to the milks and let them appreciate the difference
• Let them discuss which type of milk/feed they would give their babies
• Summarise by saying: “Breast milk contains all the food values (Grow, Glow and Grow) in
the right amount for the babies need for the first 6 months of life which are not found in
all the other milks or porridge
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 9

Session 5
What is malnutrition? (50 mins)
Session objective:
By the end of this session, participants will be able to:
• define malnutrition and describe the different types of malnutrition
Methodology:
Brainstorm and interactive lecture
Materials needed:
Illustrations of malnourished adults and children, flipcharts, markers, flipchart with flowdiagram
on types of malnutrition
Activity
• DIVIDE participants into 3 working groups
• GIVE each group illustrations as described below.
• ASK groups to respond to the following questions written on a flipchart:
• Group 1: What are the differences in the 3 illustrations? (well nourished child,
oedematoes and non-oedematous child)
• Group 2: What has caused these differences? (well nourished and undernourished
adult)
• Group 3: What would the “ill looking” man need to reverse his condition? (well
nourished and undernourished adult)
•
After 10 minutes,
• ASK groups to present their group work in plenary, other groups can make additional
comments.
• MAKE sure that all the participants see the key roles of ‘food intake and illness’ as factors
affecting nutrition status.
• make sure they can see and understand the difference between malnutrition with and
without swelling of the feet.
10 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Note to the trainer (T1.S4):
Definition of malnutrition:
‘Mal’ means poor or bad, malnutrition therefore refers to poor nutrition.
Some people will get malnourished because they are ill. But other people will also get
malnourished because the food they eat does not provide foods from all the food groups,
even though they get enough to eat.
In the context of HIV/AIDS, malnutrition refers to the result of a combination of inadequate
dietary intake and infection.
You can be moderately malnourished (bad) and severely malnourished (very bad), the
last one requiring immediate care.
Forms of malnutrition
Severe malnutrition is classified into two categories: with and without swelling. A severely
malnourished individual may also present with a combination of the two.
1. Without swelling
• Outlines of ribs and shoulder blades seen
• Muscle wasting leading to looseness of skin of the upper arm
• Muscle wasting leading to presence of skin folds ‘baggy pants’
2. With swelling
• Presence of swelling of both feet
• The swelling can spread to the whole body including the face
• Skin and hair changes
• Lack of emotion/interest or easility irritated/moody
Reference T1.S4: Picture: Clinical signs of severe malnutrition
Malnutrition with swelling
Malnutrition without swelling
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 11

Session 6
Causes of malnutrition (25 minutes)
Session objective:
By the end of this session participants should be able to:
• identify the factors which lead to malnutrition
Methodology:
Brainstorm and discussion
Materials needed:
Card 5 in national counselling cards (constraints to eating well), flipcharts, markers
Activity
• BRAINSTORM with participants: ‘why do PLHIV become malnourished?‘ (Look for
responses such as: little food available, low food intake, poor digestion and absorption,
etc.)
• WRITE the responses down on the flipchart
• ASK participants to look at card 5 in the the national counselling cards
• ASK participants to describe what they see in the cards. DISCUSS each constraint and
MAKE SURE participants understand how these constraints can lead to malnutrition in
PLHIV
Note to the trainer (T1.S5):
The possible constraints to getting enough food
Poverty and socio-economic conditions (not enough money)
Reduced food production (due to reduced labour because of disease
or other reasons, weather)
Poor storage practices, leading to spoiled food
Lack of enough cooking fuel / firewood
Stigma or other social factors
The possible constraints to “eating well”
Illness and related symptoms
Unavailability of someone to help prepare meals
Lack of support / encouragement during meals
Stigma, depression
Lack of information
Food taboos or other causes of food avoidance
Poor hygiene practices
Lack of access to a variety foods available
12 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Session7
The role of breastfeeding in the protection against
Malnutrition and illnesses of babies in their
communities (30 mins)
Session objective:
By the end of this session, participants should be able to:
• See the link between breastfeeding and its protection against common illnesses in their
community.
• Discuss on Common illnesses of babies in the community and reflect on the relationship
between breastfeeding and common illnesses of babies (10 minutes)
Methodology:
Brainstorm common illnesses of infants and young children
Materials needed:
• Images of common illnesses in the community: diarrhoea, cough/pneumonia (difficulty
breathing), malnutrition (2), vomiting, fever, convulsions
• Images of breastfeeding mother and baby, and healthy mother and baby
Activity
• ASK participants: “What are the common illnesses of infants and young children in your
community?
• PUT an image of each of the illnesses mentioned on the floor or wall so that all can see.
• PROBE until all images are displayed.
• PUT the ‘breastfeeding mother and baby’ in the centre of the other images.
• ASK participants: what is the relationship between “these illnesses” and breastfeeding
(especially respiratory and diarrhoeal infections)?
• PUT the ‘healthy mother and baby’ in the centre as a result of breastfeeding.
• DISCUSS and SUMMARISE by saying: “Breast milk contains a lot of agents that can protect
babies and young children against a lot of diseases.”
• EXPLAIN to them that breastfeeding has other benefits for mother and baby than
protecting against illnesses. These will be discussed later in the training.
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 13

Session 8
Infant and young child feeding practices in the
community and recommended practices (80 mins)
Session objective:
By the end of this session, participants should be able to:
• Discuss infant and young child feeding practices in their communities.
• Discuss problems related to the different infant feeding practices
• Learn about the recommended feeding practices in Uganda
Activity:1
Discuss infant and young child feeding practices in their communities.(30 minutes)
Methodology:
Brainstorm, small group work, observation of Counselling Cards #2 and 4, naming the key and
supporting message(s) demonstrated in the Counselling Cards, Role-play
Materials needed
• Counselling Cards #2 and 4 on optimal breastfeeding practices/messages
Activity
Brainstorm
on the following (do not write down answers), “In your community, …”
• When do mothers in the community initiate breastfeeding?
• For how long do mothers exclusively breastfeed (only breastfeeding with no water,
liquids or solids)?
• How often do mothers breastfeed over a 24 hour period?
• For how long do mothers breastfeed their babies (how many months/years)?
• Divide participants into small groups, asking participants in each group to use their
Counselling Cards for the following exercise.
• Have each group study Counselling Card 2 and name the breastfeeding practice/s and key
message/s the cards represent.
14 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

After 5 minutes,
ASK one small group to share with the whole group and other small groups add additional
points.
• PROBE until the key and supporting messages are mentioned.
Stress that exclusive breastfeeding is the best infant feeding option until around the day the
baby turns 6 months. This is the case for HIV negative women but also for HIV positive women
as will be discussed later in this training.
• HAVE the small groups repeat the process with Counselling Cards 4 IYCF.
• ASK them to form a circle.
• THROW the ball to one participant and ask her/him to name an optimal breastfeeding
practice or message.
When s/he has named an optimal breastfeeding practice or message, s/he in turn throws the
ball to another participant and asks that participant to repeat a different practice or message.
• CONTINUE until all optimal breastfeeding practices and messages have been repeated.
Activity: 2
Discuss problems related to the different infant feeding practices (30 min)
Methodology:
Reading from a flipchart, individual study of a Counselling Card, discussion
Materials needed:
• Counselling Card #15: Infant Feeding Mode and Risk of HIV Transmission.
• Prepared flipchart 1 saying the following (reference T12.S1:1):
• Major problems related to Infant Formula
• It has to be prepared correctly in order to prevent diarrhoea and malnutrition
• It has to be fed with a clean open cup in order to prevent diarrhoea
• It is very expensive
• It does not contain the protective agents against diseases
• Prepared flipchart 2 saying the following:
• Major problems related to Fresh Animal Milk
• Nothing should be added to the milk before it arrives in the baby’s home
• It has to be prepared correctly in order to prevent diarrhoea and malnutrition
• The milk and water have to be boiled very frequently
• A mineral/vitamin mix needs to be added
• It does not contain the protective agents against diseases
• It is expensive
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 15

Activity
• Explain the following to participants: “Even though passing HIV from mother to baby can
be reduced by exclusive breastfeeding and ARVs, there remains a chance of passing the
virus. That is why in some rare cases other infant feeding options than breastfeeding might
be preferable. Only trained health workers can evaluate which infant feeding option is
most appropriate for an individual mother. The health worker will determine so on a case
by case evaluation with strict guidelines.”
• When a child is tested HIV-positive (this can be tested a 6 weeks), exclusive breastfeeding
is always the best infant feeding option.
•
The other two infant feeding options are:
• Infant formula
• Fresh but modified animal milk
• SAY: “The infant formula option is the option which comes the closest to breastfeeding,
without the risk of passing HIV to the baby.”
• HANG prepared flipchart 1 and have a participant read the major problems related to
infant formula feeding including cost.
• MAKE SURE that everybody understands that Animal milk does not contain all food values
a baby needs and is too strong for a younger baby. Hang prepared flipchart 2 and have a
participant read the major problems related to feeding fresh animal milk.
• MAKE SURE that everybody understands.
• BRAINSTORM on the meaning of mixed feeding and write the answers on a flipchart.
• SUMMARISE with the help of the reference. Ensure that everybody understands.
• ASK participants to take Counselling Card #15.
• EXPLAIN that this card shows results of research throughout Africa.
• ASK them to study Counselling Card #15 during 5 minutes.
After the 5 minutes,
• ASK a participant to explain what he or she understands.
• ASK other participants to add on until the Counselling Card is fully understood.
• DISCUSS and SUMMARISE with the help of the key and supporting messages.
16 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Note to the trainer (T12.S1:2):
Mixed Feeding means feeding the baby BOTH breast milk and other foods or liquids, such as
water, glucose water, tea, infant formula, animal milk or other breast milk substitutes, porridge
or rice. Mixed feeding is harmful when a mother has HIV because the virus can pass easily
through the immature intestines. It is therefore NEVER recommended for an infant
before 6 months. An HIV positive mother should choose exclusive breastfeeding or exclusive
replacement feeding.
Note to the trainer (T12.S1:3):
This is for your own information. The community volunteers only need to know that health
workers will do a case by case evaluation to determine what feeding option would be most
appropriate.
What do the terms “acceptable, feasible, affordable, sustainable and safe” (AFASS) mean in
relationship to infant feeding in the context of HIV?
Counselors will use the AFASS criteria to determine which infant feeding option is the best for
a given mother. These criteria are best counseled on with the help of the related Counseling
Card. The AFASS criteria are explained below:
Acceptable: The mother perceives no barrier to choosing the infant feeding option for cultural or
social reasons, or for fear of stigma or discrimination.
Feasible: The mother and family have adequate time, knowledge, skills, and other resources
needed to prepare and serve replacement feeds. They also need support to cope with family,
community, and social pressures.
Affordable: The mother and family, with available community or health system support, can
afford the costs of preparing and using replacement feeding including all ingredients, cooking
fuel, clean water, etc without compromising the health and nutrition of the family.
Sustainable: The mother and family have access to a continuous and uninterrupted supply,
through a dependable system of distribution, of all ingredients and commodities needed to
safely feed the baby using the chosen method, for as long as the infant needs it.
Safe: Replacement milk can be correctly prepared and done so in nutritionally
adequate quantities, and it can be hygienically stored and fed to the baby using
clean utensils.
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 17

Activity 3:
Learn the recommended feeding practices in Uganda
Study the leaflets (20 minutes)
Session objective:
By the end of this session, participants should be familiar with the two leaflets on infant feeding
options (other than exclusive breastfeeding).
Methodology: Working groups
Materials needed
• Leaflet “How to Feed Your Baby Infant Formula”
• Leaflet “How to Feed Your Baby Fresh Animal Milk”
Activity
• EXPLAIN the following to participants: “Community volunteers might encounter the
following leaflets in their communities: “How to Feed Your Baby Infant Formula” and “How
to Feed Your Baby Fresh Animal Milk”. Trained counsellors will give these leaflets only to
caretakers who have been counselled on infant feeding options and who have opted for
infant formula or fresh animal milk. In that case, the role of a community volunteer is to
support these caretakers in their choice. That is the reason why we will go through the
leaflets together, so that you can train them to support and help the caretaker in case of
any problem.”
• Explain the following: “We have already seen that infant formula is very expensive, that is
why this option might not be feasible for many Ugandans. But some caretakers will opt
for feeding their baby with infant formula. In that case they will always be counselled on
the fresh animal milk option too. When caretakers run out of infant formula, they can rely
on the somewhat cheaper animal milk while raising money to buy more infant formula.”
• SEPARATE the participants in two groups, each group having one trainer to lead it.
• GO THROUGH the “How to Feed Your Baby Infant Formula” leaflet by reading the titles of
each panel. After reading a title, ask participants which messages they think are below
the title.
• After the first leaflet, ask participants of the two groups to switch places with the
• other group. After this, everyone except for the trainers will have changed chairs.
• The same process is repeated for the “How to Feed Your Baby Fresh Animal Milk”
• leaflet.
• Ask everyone to go back to their places.
• Discuss and summarise with the help of the flipcharts on the wall.
18 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 19

2
TOPIC
THE RELATIONSHIP BETWEEN NUTRITION
AND HIV/AIDS
Note to the trainer:
Present an overview of learning objectives (listed below) and time allocated for the topic. At
the end of this topic, refer back to the objectives and ensure that they have been met.
Purpose:
Participants will learn the relationship between nutrition and HIV/AIDS and the importance of
good nutrition for PLHIV
Learning objectives:
By the end of the topic, participants should be able to:
• Be familiar with the “Nutrition Care and Support” national counselling cards and the job
aids
• Explain the relationship between nutrition and HIV
• Explain the importance of good nutrition for PLHIV
• Discuss and understand why PLHIV become malnourished
20 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Contents
Session 1: Present and review the “Nutrition Care and Support” National
Counselling Cards and the Community-level Job Aids
Minutes
25
Session 2: Relationship between nutrition and HIV (how HIV/AIDS affects
nutrition and how nutrition affects HIV/AIDS)
40
Session 3: How should PLHIV eat? (40 minutes)
40
Duration:
1 hour, 45 minutes
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs| 21

Session 1
Present and review the “Nutrition Care and Support”
National Counselling Cards and the Community-level
Job Aids (25 mins)
Session objective:
By the end of this session, participants will be able to:
• Have an idea of what cards can be found in the “Nutrition Care and Support” national
counselling cards.
Methodology:
Buzz groups of 3 participants
Materials needed
• One copy of the national counselling cards for each participant
Activity
• DISTRIBUTE the national counselling cards to each participant and then asks the
participants to form buzz groups of 3. EXPLAIN that the national counselling cards is
to be their tools to keep and that they are going to take a few minutes to examine the
content of the cards.
• EXPLAIN that each group is to find the card that shows:
1
• An arm being measure it (job aids CCs #1, 2, 4, 5; NCC CC#15)
• ASK a group to report which card(s) show the item.
• ASK the other groups if they agree disagree or wish to add another card.
• REPEAT the process with the remaining items/characteristics:
• a woman looking in the mirror while wiping her tongue (NCC CC #10)
• a man and a woman fetching water (NCC CCs #14)
• Groundnuts (NCC CCs #3, 4)
• a woman walking to a health centre with a baby on her back (NCC CC #16)
• a woman standing on a scale (NCC CC #15)
• Someone eating (NCC CCs #1, 2, 6, 15; job aids CCs 1, 9, 10)
• a child being breastfed (job aids CC #9)
• Someone with stomach-ache (CC #11)
• different positions of breastfeeding the baby( NCC #17)
• a woman holding a cup giving to a feeding mother (NCC # 18)
• Feeding a sick infant/young child (NCC #19 and 20)
• Hygiene practices (NCC #21)
1 National Counselling Cards
22 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Session 2
The relationship between nutrition and HIV/AIDS (40
mins)
Session objective:
By the end of this session, participants will be able to”
• describe how nutrition affects HIV/AIDS and how HIV/AIDS affects nutritional status
Methodology:
Brainstorm, work in pairs and plenary
Materials needed:
Cards 1 and 2 in the national counselling cards showing the relationship between Nutrition
and HIV /AIDS
Activity
• BRAINSTORM with participants on what HIV and AIDS mean. Do not write during the
brainstorm but share the definition in note to the trainer after the discussion.
• PAIR the participants with their neighbours and ASK each pair to study and discuss:1) the
illustration of the relationship between good nutrition and HIV and 2) the illustration of
the relationship between poor nutrition and HIV/AIDS
• ASK one pair to present their understanding of the first card
• INVITE the rest of the group to give additional information
• ASK another pair to present their understanding of the second card
• SUMMARISE using the key points in the notes to the trainer (Interaction between
nutrition and HIV/AIDS)
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 23

Note to the trainer:
HIV stands for Human immunodeficiency Virus- the organism or virus which weakens a
person’s immune system and causes AIDS. People referred to as having HIV are mostly not
showing any symptoms of the disease yet.
AIDS: Acquired Immuno Deficiency Syndrome is a combination of signs, symptoms,
infections, and cancers which attack an HIV infected person’s body as result of the weakened
immune system. A person with AIDS is showing the symptoms of the disease.
Nutritional status: The state of a person’s health resulting from intake and use of nutrients.
The relationship between nutrition and HIV/AIDS:
• HIV affects nutrition by decreasing food consumption, absorption and causing changes in
metabolism and HIV associated wasting.
• Nutritional status affects HIV disease progression and death
• Improving and maintaining good nutrition may prolong health and delay HIV disease
progression. This needs to start early in the course of the HIV infection, before other
symptoms are observed
• Interventions to prevent and treat malnutrition can have great impact if started early in
the course of the disease.
24 | Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Illustration: The Relationship between nutrition and HIV/AIDS
“Eating Well” Delays HIV Developing to AIDS
Eating Well
Decreased Risk for Disease
Ability to Fight Diseases
Maintaining Healthy
Weight
Card 2
Not “Eating Well” Quickens HIV Progressing to AIDS
Increased Risk
for Disease
Not Eating Well
Loosing Weight
Card 1
Reduced Ability to Fight Diseases
The relationship between nutrition and HIV/AIDS
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs| 25

Session 3
How should PLHIV eat? (40 mins)
Session objective:
By the end of this session, participants will be able to:
• mention at least 3 ways in which PLHIV can eat to meet their requirements
Methodology:
Brainstorm
Materials needed:
flipcharts, markers, card 4 in national counselling cards
Activity
• TELL participants that PLHIV stands for people living with HIV/AIDS, that is, they are
infected with the HIV virus.
• REMIND participants about the importance of good nutrition status in relation to HIV/
AIDS and ASK them to recall the benefits of good nutrtion for PLHIV
• Write the letters F, A, T, V, A, H (back of Card 1) one under the other on a flipchart.
• REMIND participants about these 6 important factors for eating well.
• BRAINSTORM with participants how PLHIV should eat to ensure that all their nutrient
and energy needs are met, write answers next to the relevant letter.
• ADD any missing information guided by the information in the notes to the trainer.
• ASK participants to form buzz groups of 3 and DISCUSS Card 4. After 5 minutes,
• ASK a few groups to share their thoughts.
• SUMMARISE for the group, stressing the importance of frequent and varied meals and
snacks.
• BRAINSTORM on the meaning of a snack,
• SUMMARISE using the notes to the trainer.
Note to the trainer:
Refer participants to reference T2.S3: The benefits of adequate nutrition for PLHIV.
26 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Notes to the trainer (T2.S3):
Benefits of adequate /good nutrition for PLHIV:
• Good nutrition can maintain and promote health weight, normal growth and
development
• PLHIV with good nutrition have a stronger body for fighting other illnesses and are able
to recover quickly from infections
• Adequate nutrition reduces the effects of HIV symptoms such as diarrhoea and vomiting
• PLHIV with adequate nutrition have increased strength and are able to carry on working
• Good nutrition helps medicines like ARV to work properly
How should PLHIV eat to ensure that all nutrient and energy requirements are met?
• Eat at least 3 main meals and at least 2 snacks each day
• Increase the variety and amount of food eaten at meals and snacks
• Increase consumption of foods from all food groups
• Add a little oil or sugar to food or drinks (but use foods with refined sugar very
moderately, including sodas, quenchers and other sweet drinks)
What is a snack?
• extra foods between meals that are easy to prepare
• these extra foods are in addition to the meals—they do not replace meals
• good snacks provide energy and nutrients (not to be confused with sweets)
• most snacks can be eaten as finger foods such as pieces of ripe mango, pawpaw, banana
and vegetables
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs| 27

28 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

3
TOPIC
MANAGEMENT OF SOME HIV-RELATED
SYMPTOMS AND ILLNESSES
Note to the trainer:
Present an overview of learning objectives (listed below) and time allocated for the
topic. At the end of this topic, refer back to the objectives and ensure that they have
been met.
Purpose:
Participants will learn the importance of nutrition in managing some HIV and ART related
symptoms and how to manage common HIV-related symptoms and complications using
nutrition and dietary methods
Learning objectives:
By the end of this session participants should be able to:
• Identify the common nutrition-related problems associated with HIV/AIDS and the use of
ARV’s or other medicines.
• Describe how these illnesses and symptoms can be managed
• Counsel on management of these symptoms using the nutrition care and support national
counselling cards
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 29

Note to the trainer: Introduction to this topic: (10 minutes)
Introduce this topic to the participants by explaining to them that PLHIV often develop certain
symptoms and illnesses which can prevent them from ‘eating well’ and getting enough food.
These symptoms and illnesses can be as a result of the HIV itself or can be caused by the ARV’s
a PLHIV is taking.
Therefore it is very important that these symptoms and illnesses are managed fast because
they can affect a person’s nutritional status and adherence to ARV’s. (Adherence to ART
means: Sticking to taking anti-retroviral (ARV’s) medicines every day in the right amount (dose), at
the right time and following the health worker’s instructions on how to use ART.
This is meant to be a short introduction to the topic. Community volunteers are not
expected to know the key interactions between nutrition and ARV, it is important for
them to be aware that ARV can affect the way food works, food can affect how ARV’s
work and certain effects of the ARV’s can prevent a PLHIV from eating well, thus leading
to malnutrition.
Refer participants to Card 6 of the Nutrition care and support national counselling cards and
explain to them that this card shows the importance of nutrition in increasing adherence
to ART. READ out the notes on the interactions between ARVS and food and make sure that
participants understand the relationship between ARV’s and food
The community volunteer should always refer clients to the health facility/ health workers if
these sympotoms and illnesses are severe or if they know that a PLHIV is not adhering to their
ARV treatment.
Contents
Introduction:
Session 1: The common symptoms and illnesses associated with HIV/
AIDS and ARV’s, which can affect nutritional status
Session 2: Reachings an agreement using nutrition care and support
national counselling cards
10
40
40
Duration:
1 hour, 30 minutes
30 | Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Session 1
The common symptoms and illnesses associated
with HIV/AIDS and ARV’s, which can affect nutritional
status
(40 mins)
Session objective:
By the end of this session participants should be able to identify common symptoms and
illnesses associated with HIV/AIDS which can affect nutritional status of PLHIV.
Methodology:
Brainstorm and studying cards in groups Role –Play
Materials needed:
Prepared flipchart with the common symptoms and illnesses written out, markers, cards in
nutrition care and support national counselling cards on managing symptoms, a ball
(The most common symptoms/ illnesses can be found in the national counselling cards #7-12)
Activity
INTRODUCE this session by EXPLAINING to participants that although there are many HIV
related illnesses and symptoms, the focus of this session is on the particular symptoms and
illnesses which can affect the nutritional status of a PLHIV
BRAINSTORM on illnesses and symptoms. After 5 minutes of brainstorming, HANG a prepared
flipchart with the 9 symptoms written on it and compare these with the results of the
brainstorm:
• TELL participants that these are the most common illnesses which can affect nutritional
status of PLHIV.
• ASK participants to refer to their Nutrition care and support national counselling cardss
• MAKE SURE they have the cards in the national counselling cards on how to manage
common symptoms
• GO THROUGH each card and ASK a participant to interprete the images on the card.
READ the text on the back of each card and MAKE SURE that the volunteers understand
how to manage the common illnesess and symptoms.
• DISCUSS any issues that may arise from reading the cards
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 31

When all the cards are discussed, ASK participants to stand up and gather in a circle.
• THROW a ball to one participant and ASK him or her to mention one way of managing
one of the symptoms or illnesses discussed.
• ASK the participant to THROW the ball to another participant and CONTINUE the same
way until all messages have been mentioned.
• SUMMARISE the session by TELLING participants that they will now practise reaching an
agreement using the cards in the national counselling cards
32 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Session 2
Practise reaching an agreement on managing HIV
related symptoms and illnesses? (40 mins)
Session objective:
By the end of this session, participants should be able to:
• help clients on how to manage common symptoms and illnesses related to HIV using
basic communication skills
Methodology:
Practise listening and learning skills, case studies
Materials needed:
case studies, cards in national counselling cards on managing symptoms (Cards 7-12)
Activity
• ASK participants to form buzz groups of three
• READ the first case study and INSTRUCT a pair from each group to role play a client and
a community volunteer using the national counselling cards. The third person acts as an
observer and provides feed-back to the pair.
• MOVE round and observe the exercise amongst the groups, the other trainers should
also move round. There is no need to do a plenary presentation. After the first role play,
• READ the second role play and REPEAT the excise.
• MAKE SURE that group members shift roles. After the second role play
• READ the third role play and REPEAT the excise. MAKE SURE that group members shift
roles so that every member has played the three roles.
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 33

Case studies (T3.S2)
Case Study 1
John is a 40 year old brick maker in his village. He often does not like eating breakfast or
lunch because the ARV’s which were given to him make him feel like vomiting. John says
that when he does eat, he vomits some of his food and this is worrying him. You further
discover that sometimes John drinks alcohol when he is depressed.
Activity:
Demonstrate how you are going to help John through reaching-an-agreement
Guide for the trainers:
• What food is John eating?
• Are there any food interactions with the foods the client is eating and the
medication he is taking?
• Discuss ARVs and food interaction
• Explain need for increased energy intake and ways to increase energy
• Reach-an-agreement on the use of alcohol
• Manage symptoms of feeling like vomiting, decreased appetite
Case Study 2:
Ann is a 20 year old woman who lives with her mother and sister in a small 2 bedroom
house. The family collects their water from a village tap. Ann was started on ARV’s 5
days ago and has since had diarrhoea. She also noticed that she has pain in her mouth
when she is eating food.
Activity:
Demonstrate how you are going to help Ann through reaching-an-agreement
Guide for the trainers:
• What foods is Ann eating?
• Explain the need for increased energy intake
• Reach-an-agreement on importance of hygiene and clean water and help Ann to
manage her symptoms of diarrhoea and pain on swallowing
Case Study 3:
Christine is a 15 years old orphan, taking care of her 3 brothers and sisters. Since one
month whe feels very tired which makes her life more difficult. She also does not have
interest in food.
34 | Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Activity:
Demonstrate how you are going to help Christine through reaching-anagreement
Guide for the trainers:
• What foods is Ann eating?
• Explain the need for increased energy intake
• Reach-an-agreement on importance of hygiene and clean water and help Ann to
manage her symptoms of diarrhoea and pain on swallowing
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs| 35

36 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

4
TOPIC
IMPORTANT BEHAVIORS TO IMPROVE AND
MAINTAIN GOOD NUTRITION AND HEALTH
FOR PLHIV
Note to the trainer:
Present an overview of learning objectives (listed below) and time allocated for the topic. At
the end of each topic, refer back to these to make sure they are met. At the end of each topic,
refer back to these to make sure they are met.
Purpose:
Participants will identify the key nutrition practices and messages for improving and
maintaining good nutrition for PLHIV
Learning objectives
By the end of this session participants will be able to:
• Identify the important behaviors to improve and maintain good nutrition and healthfor
PLHIV
• Identify key messages to communicate important behaviors for PLHIV using the nutrition
care and support national counselling cards
• Reach-an-agreement on the important behaviors using the cards in the nutrition care
and support national counselling cards
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 37

Contents
Session 1: Important behaviors for PLHIV to improve and maintain good
nutrition
Session 2: Key messages for communicating the important behaviors for PLHIV
Minutes
50
60
Duration:
1 hour, 50 minutes
38 | Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Session 1
Important behaviors for PLHIV to improve and maintain
good nutrition and health (50 minutes)
Session objective:
By the end of this session participants should be able to:
• mention at least 5 of the 8 important behaviors for PLHIV
• Identify key messages to communicate important behaviours for PLHIV.
Methodology:
Brainstorm, discussion
Materials needed:
Prepared flipchart with the 8 important behaviors, markers, counseling Cards.
Activity
INTRODUCE this session by EXPLAINING to participants that the Ministry of Health recommends
8 important behaviours which can enable PLHIV to improve and maintain good nutrition and
health.
• HANG the flipchart with the 8 important behaviors where all the participants can see it
• BRAINSTORM for each important behavior: “what does it mean?” and “why is it an
important practice for PLHIV?” DO NOT write the responses, this is a quick brainstorm.
• POINT OUT that a good message addresses the benefits and/or barriers of implementing
the behaviour and why
• INFORM participants that in the following session, they will learn the key messages for
communicating these behaviours to PLHIV using the cards in the national counselling
cards.
•
THE 8 IMPORTANT BEHAVIORS (T4.S1)
1.
2.
3.
4.
5.
6.
7.
8.
Have periodic nutrition status assessments
Increase energy intake through a balanced diet
Drink plenty of clean, safe water
Practise positive living behaviours
Maintain high levels of sanitation and food hygiene
Carry out physical activities or exercise
Seek prompt treatment for all opportunistic infections and manage diet-related
symptoms
Manage HIV and ART related symtpoms and illnesses
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 39

Session 2
Key messages for communicating the important
behaviors for PLHIV (60 mins)
Session objective:
By the end of this session participants should be able to give key messages for communicating
the important behaviors and identify different cards in the national counselling cards on the
important behaviors.
Methodology:
Studying cards in nutrition care and support national counselling cards
Materials needed:
cards in nutrition care and support national counselling cards
Activity
• INTRODUCE this session by TELLING participants that they are going to look at the key
messages for communicating the 8 important behaviours for PLHIV using the cards in
the nutrition care and support national counselling cards.
• EXPLAIN to participants that some cards communicate more than one message or
behaviour.
• ASK participants to refer to the cards in their nutrition care and support national
counselling cards and look for a card which shows Number 1 of the important
behaviours. When they find the appropriate card,
• ASK one participant to read the key messages on the back of the card.
• CLARIFY any questions.
• REPEAT the exercise until all the 8 important behaviours have been identified and key
messages discussed.
• TELL participants that they will now be given a simple exercise whereby the trainer will
read out some case studies. The participants should then determine what important
behaviours they would communicate to the cases in each study.
• READ each of the case studies below on the flip chart and
• ASK the groups to identify the important behaviour related to each case study.
40 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Case Studies for identifying important behaviours for PLHIV (T4.S2):
Case study 1: Maria was weighed 4 months ago, when she went to the health facility for treatment.
She is not sure if her weight has improved. (KEY BEHAVIOUR 1)
Case study 2: John is worried that he is not getting enough energy, yet he eats three meals a day.
He works long hours as a casual labourer and often feels thirsty (KEY BEHAVIOUR 2 & 3)
Case study 3: Kato has been on ARV’s for 3 weeks, when he is depressed he buys some alcohol
and a packet of cigarettes to make himself feel better. Kato also has very little appetite and
complains of sores in the mouth (KEY BEHAVIOUR 4 & 8)
Case study 4: When you visit Maria at home, you notice her son throwing rubbish behind the
house where there a lot of flies. Also Maria serves both herself and her son food and proceeds to
eat without washing hands (KEY BEHAVIOUR 5)
Case study 5: Jane spent a few days in bed when she was ill and weak. She only went to the
health facility when she felt worse and was diagnosed with Malaria. Now Jane is better but feels
tired and does not like to do much round the house (KEY BEHAVIOUR 6 and 7)
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs| 41

42 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

5
TOPIC
IDENTIFYING MALNUTRITION IN THE COMMUNITY
Note to the trainer:
Present an overview of, learning objectives (listed below) and time allocated for the topic. At
the end of each topic, refer back to these to make sure they are met.
Purpose:
Partciants will learn how to identify malnutrition using MUAC and checking for oedema
(swelling of both feet).
Learning objective
By the end of this topic participants should be able to:
• Identify people with malnoutrition in the community
• Assess swelling on both feet
• Measure using MUAC tapes .
Contents
Session 1: Identifying malnutrition in the community
Session 2: Checking for swelling of both feet
Session 3: Demonstration of using MUAC tapes
Session 4: Practise measuring MUAC
Minutes
15
30
40
60
Duration:
2 hours, 25 minute
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 43

Session 1
Identifying malnutrition in the community (15 mins)
Session objective:
By the end of this session participants will be able to:
• summarise the signs of malnutrition (as identified earlier) and to describe the importance
of identifying malnutrition for PLHIV
Methodology:
studying pictures, brainstorm, Role-Play
Materials:
Pictures of malnourished individuals, 2 ripe Bananas if available (used in topic 1)
Activity
• HANG up the pictures on a wall or hold them high for participants to study for a few
minutes
• RE-CAP signs of malnutrition with a quick BRAINSTORM and showing the pictures of
malnourished individuals
• ASK participants to recall the first important behaviour for PLHIV to improve and
maintain good health and nutrition (Have periodic nutrition status assessments)
.
• ASK ‘Why do we need to identify who is malnourished?”
• SAY “In the community there are two ways of identifying malnutrition: “measurement of
MUAC and checking for swelling of both feet”
• BRAINSTORM with the participants what opportunities they would use in the
community to identify malnoursihed individuals, to find malnourished children,
adolescents, adults, pregnant and lactating women.
• REMIND participants to ALWAYS seek permission from clients to measure MUAC and
check for swelling of both feet. It is better not to go into a separate room, and rather
measure MUAC in the open.
• EXPLAIN to participants that they will now learn how to determine the nutritional status
of community members using a simple tool called a MUAC tape as well as how to check
for swelling of both feet
44 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Note to the trainer :Importance of nutritional assessment in
the care and support of PLHIV (T6.S1)::
Importance of identifying malnourished people
• dentification of malnutrition aids in the detection of potential health and nutrition
problems
• Identification of malnutrition provides information on the current nutritional status of
the client. If assessment is done periodically, the weight changes of the client can be
tracked
• Identification enables one to identify any risky behaviours or factors that might
contribute to the development of ill health or poor nutritional status
• Identification of malnutrition provides opportunities for providing correct and
appropriate nutrition information
Different methods of identifying malnourished people in the community
• Measurement of MUAC
• Checking for swelling of both feet
Opportunities for identiying malnourished children, adolescents, adults, pregnant and
lactating women:
• During home- and follow- up visits
• During mass campaign days
• Child health days
• Outreach clinics
• Schools and community programmes.
• During community gatherings
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs| 45

Session 2
Checking for swelling of both feet (30 minutes)
Note to the trainer:
Besides practising on each other, it is very important that participants practise checking for
swelling of both feet on a person with swollen feet. Therefore try to arrange a visit to the
nearest health center (preferrably with a nutrition unit), or for an oedematous adult or child
to come to the place of training. If this is not possible, ask participants to practise cheking for
swelling of both feet on a roasted plantain.
Objective:
By the end of this activity participants will be able to”
• identify swelling of both feet in malnourished individuals
Materials:
Picture of patient with swelling of both feet, the 2 cards showing the pressing and the pitting
of feet
Activity
REMIND participants that they have already looked at malnutiriton with and without swelling
under topic 1.
EXPLAIN to participants that swelling of both feet is a sign of severe malnutrition and that
patients with swelling of both feet should ALWAYS be referred to the health facility for care.
(Note that for adults pregnant and post partum women, it is hard to determine if it is nutrition
related therefore ALL cases of swelling should be referred to the health facility)
SHOW participants the images of oedema assessment
ASK them to describe what they see. Explain them that they have the same images on Card 7
in their job aids.
ASK for a volunteer from the participants
DEMONSTRATE how to check for swelling of both feet as follows:
Hold both feet with your thumbs on top.
PRESS gently and count ‘one thousand one, one thousand two, one thousand three’ (3
seconds). The patient has swelling if dents (pits) remain when you lift your thumbs
Use two ripe bananas to demonstrate pitting
ASK participants to practise the “checking for swelling of both feet” with their neighbor.
46 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Reference T6.S2: Illustrations on how to check for oedema
How to Check for Swelling of Both Feet
Swelling of the feet caused by malnutrition occurs on both feet:
• it starts on both feet and can spread to the rest of the body
• when the feet are firmly pressed with the thumbs for 3 seconds, and then
removed, pits are left in the skin as shown below
Card 7
Notes to the trainer on oedema (T6.S2):
Recognising oedema:
Swelling usually occurs first in both feet and then in the lower legs. If a patient has been lying
down, you may see swelling over the back. Oedema can quickly spread to the hands, lower
arms and face.
It may be mistaken for ‘fatness’
Malnourished children with oedema often have:
• Skin changes over swollen limbs. Changes include abnormally dark, cracked, peeling
patches (like flaky paint), with pale skin underneath which is easily damaged and
infected.
• Thin hair that can be easily puled out. It may be paler and less curly than normal
• A poor appetite and are miserable
Source: Ashworth and Burgess (2007), Caring for Severely malnourished children
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs| 47

Session 3
Demonstration of using MUAC tapes (40 minutes)
Session Objectives:
By the end of this activity participants should be able to
• recognise the different MUAC tapes to be used for each category
• use the instructions in the job aids to measure MUAC
• interpret the MUAC measurements and colours in order to determine what action to take
Methodology:
Study MUAC tapes and cards in job aids, individual exercise Role-paly
Materials needed:
• Job aids
• 4 MUAC tapes for adults, pregnant/lactating women, children and adolescents (pregnant
adolescents will use the tape for pregnant women)
• Simple tool for interpreting MUAC and actions to be taken
Activity
• ASK participants to individually study all the MUAC tapes for 5 minutes, and to compare
them with Card 3 of the job aids.
• EXPLAIN the numbers, colours and window on the tape
• ASK the participants to form buzz groups of 2, and to study and read Card 5 showing
how to use a MUAC tape After 5 minutes
• ASK a few participants to describe what they see on the card
• MAKE SURE that they see how the length of the upper-arm is measured and the Midpoint
is determined by folding the tape in half
• The MUAC is measured and the result is written down
• MAKE SURE that you TELL the participants that the left arm is used for measuring MUAC
• DEMONSTRATE the measurement of MUAC on one volunteer
• EXPLAIN all the steps aloud (e.g. I am now feeling the tip of the shoulder, which is a bone
and placing the 0-point of the tape on that tip…..etc.)
• ASK if there are any questions
• ASK what they think the colours on the MUAC tapes mean
• EXPLAIN that only individuals who have a yellow (bad malnutrition) or red MUAC (very
bad malnutrition) will be referred to the health facility for nutrition care and treatment
• ASK the categories of people who can be measured with MUAC
• EXPLAIN that the following group of people :
• children from 6 months up to 18 years,
• adolescents and adults (Both men and women)
• pregnant and lactating and women with infnats up to 6 months old;
• women with infants up to can be measured with MUAC. Refer them to Card 4
showing all categories.
48 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

• EXPLAIN the meaning of the cut-off using the flipchart as well as the colour–coding.
• GIVE each participant a task sheet and
• EXPLAIN that this is individual work.
• REFER them to their reference on MUAC category and action to take (see reference
T6.S3.3,
• EXPLAIN that the table on the task sheet shows each category of person measured for
MUAC, what the colour of the tape was when measured. Participants’ task is to:
• decide whether to refer the person to the facility or not and action to take
• TELL the group that they have 5 minutes to complete the task
• MOVE round to provide guidance, using reference T6.S3.3 as a reference
• ASK a few members if they expercienced any problems filling out the task sheet
• ASK if there are any questions
Notes to the trainer: use of MUAC tapes (T6.S3:1):
• Mid-upper arm circumference (MUAC) is the circumference of the middle of the left
upper arm using a special circumference measuring tape. The point of measurement is
between the tip of the shoulder and the elbow.
• MUAC is measured in centimetres. MUAC is recommended for assessing malnutrition
in adults and children more than six months old. Because it is easy to measure MUAC,
it is used to assess the nutritional status of people whose weight can not be taken, e.g.
because they are bed ridden.
Steps for taking MUAC:
Step 1:
1. Bend left arm at angle of 90 degrees
2.
3.
4.
5.
Step 2:
6.
7.
Step 3:
8.
9.
Locate the tip of the shoulder
Locate the tip of the elbow
Place tape measure at 0 cam at tip of shoulder
Pull tape past tip of bent elbow and read length of upper arm
Determine mid-point by:
-Folding the tape in half from ‘0’ to the measured length OR
-Calculating
Mark the mid-point using your finger or a pen
Straighten the arm and place the MUAC tape around the mid-point
Place the MUAC tape through the window of the tape
10. Make sure the tape is neither too loose nor too tight
11. Read the cm measurement in the window at arrow
12. Record the measurement and the colour zone observed
Note to the trainer: Refer participants to their handbooks for further reading on identifying
malnutrition using MUAC and oedema (reference T6.S3).Note to the trainer: The community
volunteer is not expected to know the cut-off points in terms of cm, rather emphasis should be
put on interpreting the colours on the tape and the action to be taken.
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs| 49

Task sheet (T6.S3:2): MUAC category and action to take
Category
Colour of
MUAC tape
Refer
Do not
refer
Action taken
Pregnant woman, 20 years old
Boy, 15 months old
Girl, 14 years old
Girl, 6 years old, has swelling of
both feet
Man, 40 years old
Woman, has swelling of both
feet
Boy, 7 months
Yellow
Red
Green
Yellow
Red
Yellow
Green
Reference T6.S3:3: MUAC criteria to identify malnutrition in the community and action taken
INDIVIDUALS ASSESSED
COLOUR OF
TAPE
ACTION TO TAKE
• Children from 6 months
old
• Adolescents
• Adult men and women
aged 18 years and older
• pregnant and lactating
women
• Women with children up
to 6 months old.
GREEN
YELLOW
RED
Counsel on eating well and importance
of maintaining good nutrition.
Refer for treatment if he/ she has
infections or any complications.
Counsel on preventing infections
through food and water hygiene.
Refer to health facility for nutrition care.
Counsel on importance of eating well.
Refer urgently to health facility for
nutrition care.
Counsel on importance of eating well.
Notes to the trainer:
Refer participants to reference T6:S3:3: Interpreting MUAC and action to take.
50 | Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Session 4
Practise measuring MUAC (60 mins)
Notes to the trainer:
Besides practising on each other, it is very important that participants practise measuring
MUAC on less well-nourished adults and/or children. Therefore try to arrange a visit to the
nearest health center (preferrably with a nutrition unit), or for some people/children to come
to the place of training. If this is not possible, ask participants to measure some community
members as homework, and share their expericnces the following day.
Objective:
By the end of this activity participants should be able to measure MUAC using the coloured
MUAC tapes
Materials:
MUAC tapes, sticks for measuring (if the sticks are not available, make sure to have some
children present on who you can practise measuring MUAC)
Activity
• SHOW the participants s set of MUAC tapes with 4 tapes.
• EXPLAIN to them the different MUAC tapes are for the for the different age groups and
MUST not be interchanged else they will give wrong readings.
• DIVIDE the participants into groups of 3
• GIVE each group a MUAC tape for adults
• ASK each participant to measure the MUAC of a fellow group member and to write the
results in their notebooks
• Have 3 group members first measure the MUAC of one individual while the rest of the
group observe
• MOVE around and to check if they are following correct procedures.
• RE-DO the measurement and correct the measurements If measurements between 2
participants are more than 0.2 cm apart,
• MAKE SURE that all the participants are conversant with the procedure
• GIVE each participant a stick (to represent children’s arms) and EXPLAIN that the marks
on the stick represent the elbow and shoulder (E- elbow, S-shoulder)
• ASK the participants to measure these “children’s” arms.
• ASK them to share their results and COMPARE with the trainer’s measurements
• DISCUSS the exercise
• SUMMARIZE by stressing the importance of doing this exercise accurately as people will
be referred to the health facility based on these measurements.
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 51

52 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

6
TOPIC
TREATMENT AND CARE FOR MALNOURISHED
INDIVIDUALS
Notes to the trainer:
Present an overview of, learning objectives (listed below) and time allocated for the topic. At
the end of each topic, refer back to these to make sure they are met.
Purpose:
Participants will learn the use, storage of RUTF for malnourished people. And their role in
ensuring that they use it as prescribed by health workers
Learning objectives:
By the end of this topic participants should be able to:
• Describe what RUTF is and what it is made up of.
• Explain the benefits/ importance of RUTF
• Explain how to use and store RUTF at home
• Know their role as community volunteers in monitoring use of RUTF by the individual (
adherence)
• Describe the feeding practices for specific illnesses. infants and young children
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 53

Contents:
Session 1: RUTF and its benefits
Session 2: How to use and store RUTF at home
Session 3: Ensuring that RUTF is used as advised by the health worker
Session 4: Feeding Practices for Specific Illnesses in sick infant and young child
Minutes
15
30
35
60
Duration:
2 hours, 40 minutes
54 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Session 1
RUTF and its benefits (30 minutes)
Session objective:
By the end of this session participants should know what RUTF is and what its benefits
Methodology:
Brainstorm, participatory lecture, demonstration
Materials needed:
Job aids, packets of RUTF, flipcharts, markers
Activity:
• BRAINSTORM “What is your understanding of ready-to-use food (RUTF)?”
• Read Card 8 of the job aids together.
• PASS around packets of RUTF for participants to have a look at and feel
• ASK participants to describe the packet they are looking at
• ALLOW time for answers
• ENCOURAGE participants to open the packet and taste the RUTF
• ASK them what it tastes like or if they recognise any of the ingredients
• EXPLAIN to the participants that a Ready-to-Use-Therapeutic-Food (RUTF) is a food
which has more energy-giving, body-building and protective substances which are
needed to treat malnutrition in both adults and children
• TELL participants that the aim of using RUTF is to treat malnutrition
• EXPLAIN further that RUTF is made of peanut butter,powdered milk, oil, sugar and a
mixture of protective and body-building substances
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 55

Session 2
How to use and store RUTF at home (40 minutes)
Session objective:
By the end of this session partcipants will be able to:
• describe how to use and store RUTF at home
Methodology:
Interactive lecture & Brainstorm and role play, small working groups
Materials needed:
Flipcharts, markers, RUTF packets, role play, job aids, OTC ration cards
Activity:
Activity 1:
Storage, disposal and use of RUTF at home (20 minutes)
Objective:
By the end of this activity participants should be able to describe how to store RUTF at home
Materials:
Job aids
Activity
• ASK participants to study Card 11 in the job aids: on storage and disposal
• REFER to Cards 9 and 10 in the job aids showing how to use RUTF, stressing the
importance not to share the RUTF with other family members because this is a special
medicine for the malnourished
• Explain that these cards will be used in the following session, to help a client who is on
RUTF.
Notes to the trainer:
The RUTF packet should be put out of reach of people, rodents, insects and sun. This could be
in a covered basket hanging on the beams of the roof, in a covered pot, in a covered bucket or
in a closed cupboard.
56 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

SHOW card 11 in the job aids and explain that these can be used to help clients
TELL them that RUTF should be kept :
• in a secure place.
• out of reach of others.
• in a clean place, safe from cockroaches and rats
• out of the sun to keep the nutrients.
Activity 2:
Role play with the OTC ration card (20 minutes)
Objective:
By the end of this activity participants should be able to use the cards in the job aids on RUTF
to help clients use and store the RUTF
Materials: J
ob aids (cards on use and storage of RUTF), example OTC ration cards
Activity
• Go through the two example OTC ration cards with the whole group
• MAKE SURE everybody understands
• ASK two other trainers to prepare for the role play. One trainer will take on the role of
community volunteer and the other the role of a caregiver with a malnourished child.
• USE the listening and learning skills we learned in the earlier session, demonstrate to the
caregiver about how to use RUTF using the appropriate card(s) from the job aids
• ASK participants to give feedback on the listening and learning skills.
• CORRECT any information that has to be corrected and SUMMARISE the session
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs| 57

Instructions for role play (T5.S3.2):
To the community volunteer: You are doing a home visit in your community to a mother
whose child has malnutrition. They were previously referred to the health facility and given
RUTF for the young child. The mother is not sure how to use this RUTF. Your role is to help the
mother understand how to use the RUTF. Demonstrate using the listening and learning skills we
learned.
Be sure to include the following information in your session:
Teach the caregiver how to open the packet of RUTF—(tear at one corner and eat paste from
packet or on a spoon)
How to use RUTF
• Describe to caregiver the dosing of RUTF. Define how much should be given to the patient
every day and at each dose (ask to look at the patient card).
• The RUTF should be given in small amounts and frequently (e.g. ½ packet * 8 times per
day), provided that the daily amount is according to the instructions from the health
worker.
• Always have safe drinking water nearby whenever the patient is eating RUTF. Provide at
least a cup of safe drinking water while or after giving RUTF. If the patient wants more, let
him/ her drink as much clean water as he/she wants
• Make sure that all severely malnourished patients, including older children, pregnant
women and other adults, consume and finish the RUTF before eating anything else.
• If a child is breastfeeding, the caregiver must first breastfeed and give RUTF immediately
after breastfeeding.
• Individuals should be supervised while they consume their RUTF and meals.
• RUTF must not be shared with other members of the family or community who may be
hungry. RUTF is a special food for the malnourished patient.
How to store RUTF
• The RUTF packet should be rolled after every use.
• Remaining RUTF in the packet should be put in sealed plastic bag until next dosing.
• The RUTF packet should be put out of reach of people, rodents, insects and sun. This could
be in a covered basket hanging on the beams of the roof, or in a covered pot or bucket.
How to dispose of RUTF
• Always dispose of the empty packets of RUTF safely, either by putting them in a latrine or
by burning them.
• Always counsel on hygiene and sanitation
Notes to the trainer:
Refer participants to the notes on key messages for using RUTF in their handbooks.
58 | Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Session 3
Ensuring that RUTF is used as prescribed by the health
worker (15 min)
Session objective:
By the end of this session participants should be able to:
• identify ways of monitoring adherence to RUTF in the community
• mention at least 5 signs that require referral to the health facility for care
Methodology:
Brainstorm, participatory lecture
Materials needed:
Flipcharts, markers, prepared flipchart showing the roles of the volunteer written on it, flipchart
with signs that require referral, reference on the signs requiring referral
Activity
• BRAINSTORM on how they would monitor adherence to RUTF in their communities
WRITE their responses.
• EXPLAIN that treating malnourished individuals requires adherence
• TELL them that possible ways of monitoring adherence include:
• Ask the caregiver to show you the number of packets remaining, calculate to know
whether it amount left correct
• Ask the caregiver to give the patient some RUTF while you are there (observe if hand
washing, secure place, patient likes it, safe drinking water)
• ASK participants to brainstorm about possible reasons why clients do not adhere to
prescribed RUTF.
• MAKE a note of these responses on a flipchart
• EXPLAIN that certain symptoms like diarrhoea and vomiting can cause clients not to
follow advice on how to use RUTF.
• TELL participants that if they are doing a home visit they must ask for syptoms the client
relates to the eating of the RUTF and advice them to go back for review or to the nearest
health facility.
Notes to the trainer:
Refer participants to reference T5:S4:1 (Signs requiring referral) and reference T5:S4:2 (The Role
of the Community volunteer in ensuring that RUTF is used as advised by the health worker).
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 59

Session 4
Feeding Practices for Specific Illnesses in sick infant
and young child (15 minutes)
Session objective:
By the end of this session, participants should be able to:
•
describe feeding practices for specific illnesses.
Methodology:
Observe/reflect on practices/messages on Feeding the Sick Infant and Young Child using
Counselling Cards #11 and 12 and the “How to Feed a Sick Child” leaflet.
Materials needed: Leaflet “How to Feed a Sick Child”
Activity:
• Ask participants to take their leaflet “How to Feed a Sick Child”.
• Let participants describe the image they see on the “back 1” of leaflet.
• Sore mouth and throat
• Difficulty breathing and cough
• Fever
• Vomiting and Diarrhoea
• Read the feeding messages on “back 1” together.
• Discuss and summarise.
• Explain that the other messages in the leaflet have been discussed when looking at the
Counselling Cards.
60 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 61

Theme 2
ROLE OF COMMUNITY VOLUNTEERS IN
THE CARE & SUPPORT OF MALNOURISHED
INDIVIDUALS IN THE COMMUNITY

Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 63

7
TOPIC
THE ROLES OF COMMUNITY VOLUNTEERS
Notes to the trainer:
Present an overview of, learning objectives (listed below) and time allocated for the topic.
This topic covers all the roles and responsibilities of the communiy volunteers in the care of
malnourished individuals and nutrition care and support for PLHIV.
Because this is a very long topic, with various sessions, at the end of each session refer back to
each session’s objectives make sure they have been met.
Purpose
Participants will learn their roles in the care and support of malnourished individuals in the
community.
Learning objectives:
By the end of this topic participants should be able to:
• Explain the importance of involving the community in the care of malnourished
individuals and nutrition support activities
• Describe the specific roles of community volunteers in the IMAM, and nutrition support
• Identify other stakeholders in their community /catchment area who are involved in
nutrition care and support activties
• Describe the roles and responsibilities of the various stakeholders in the care and support
of malnourished individuals
• Describe the link between community and facility in the care for manourished
individuals
• Prepare an activity plan
• Learn how to fill the regester and reporting tools
64 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Contents:
Introduction
Session 1: Why and how should the community be involved in nutrition care and
support for PLHIV?
Session 2: Describe the specific roles of community volunteers in the nutrition Care
and support
Session 3: Identifying other support services in the community
Activity 1: The Networking model
Activity 2: Case studies and mapping support services
Session 4: The roles and responsibilities of stakeholders in the community
Session 5: Planning your activities as a community volunteer and mobiliser
Session 6: Practice filling the community register and reporting tool
Session 8: Referral of malnourished individuals to the health facility
Activity 1: What is referral to the health facility?
Activity 2: Using referral tools
Minutes
15
35
40
45
15
30
30
50
55
60
30
30
Session 9: Follow-up and support of individuals referred from the health facility back
to the community
60
Session 10: The Link between the community and facility and other stakeholders
in the care and support of malnourished clients
30
Duration:
7 hours
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 65

Note to the trainer: Introduction to this topic: (15 mins)
Introduce this topic to the participants by explaining the following: “Besides identifying
malnutrition, community volunteers have many other roles in the care of malnourished
individuals. All these roles will be discussed in this topic, which will take many hours. To be able
to follow where we are in the topic, we will hang two cards from the job aids on the wall (now
hang Cards 1 and 2 showing “Your role as a community volunteer”, preferably enlarged cards).
Ask the participants to study the cards individually and describe what they see. Discuss briefly,
explaining that the details will be discussed in the following sessions.
During this topic, make sure to frequently refer to the card hanging on the wall, showing which
role is being discussed.
66 | Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Session 1
Why and how should the community be involved in
nutrition care and support for PLHIV? (35 minutes)
Session objectives:
By the end of this session participants should be able to:
• explain the importance of involving the community in the care of malnourished
individuals and nutrition support for PLHIV
Methodology:
Small group work and brainstorm
Materials needed:
Flipcharts, markers
Activity
• EXPLAIN to participants that you will read a task which they will have to think about.
• READ the task (see below) and ASK each group to focus on the following points:
• -What is the role of the community in improving nutrition for PLHIV?
• -How can community and health facility be linked in order to integrate nutrition
services into HIV/AIDS care?
• GIVE participants 5 minutes to think about how to defend their case
Task: Defend your case:
A local NGO has just received some funds to be used in improving the nutritional status of
people living with HIV in your community and in the care of malnourished individuals. The new
project manager feels that it is a waste of money and time to involve the community in the
project and would rather spend the money equiping the health facilties and training only health
workers.
If you were to make a presentation to the project manager, making a case for involving your
community in the care of malnourished individuals and nutrition care for people living with HIV,
what would you present to him.
• ASK a few participants for ideas on how they would defend their case
• FACILITATE a DISCUSSION and SUMMARISE a presentation on a flipchart. The notes to
the trainer can be used as guidance.
1 Uganda HIV/AIDS Sero-Behavioural Survey, 2004-2005. Ministry of Health, STD/AIDS Control Program
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs | 67

Notes to the trainer: The Role of the Community in
improving nutrition for PLHIV (T7.S1):
Some of the roles of the community in improving nutrition for PLHIV
• Identify PLHIV who may be ill or malnourished and take/ refer them to a health facility
• Participate in activities which can lead to improved nutrition status for PLHIV such as
community gardening, attending health education sessions and implement other nutrition
activities
• Support PLHIV at household and community levels through psycho-social support
• Support adherence to RUTF and ARV’s
• Giving nutrition messages
How should the community and health facility be linked:
• Through community awareness raising activities on how to identify and manage
malnutrition (which creates understanding and awareness about the need for care)
• Through referral of malnourished individuals from the community to the health facility
for care and treatment
• Through referral of malnourished individuals from the health facility to the community
for support and care by trained community volunteers
• Through the use of trained community volunteers to identify malnutrition, referral, follow
up and reporting
• Through the outreach teams doing health education and counselling, and sometimes
providing other nutrition services.
• Through supporting malnourished individuals who have been given ready-to usetherapeutic
food at the health facility to adhere and use it according to the instructions
68 | Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Session 2
Describe specific roles of a community volunteer in
nutrition care and support
Session objectives:
By the end of this session participants should be able to the specific roles of community
volunteers in the IMAM, and nutrition support
Methodology:
Small group work and brainstorm
Materials needed:
Flipcharts, markers
Activity
• EXPLAIN to participants that they have to think of specific roles as community
volunteers in nutrtion care
• -What is the role of the community in improving nutrition of PLHIV?
Ask participants to read from their handbook what their roles are
Note to the trainer:
The roles of the a community volunteer
1. Community mobilisatiion
2. Counseling on nutrition
3. Identification of malnourished individuals in the community
4. Referral of malnourished indivdiuals to health facility
5. Follow up of malnourished individuals on RUTF
6. Link individuals who have completed treatment to sustainable livelihood and
other services
7. Record and report cases of malnutrition.
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Activity 1:
Ways to raise awareness of community members (15 minutes)
Session objective:
By the end of this session participants will be able to:
identify some ways to raise awareness of community members about the nutrition program
Methodology:
Brainstorm
Materials needed:
Flipcharts, markers
Activity
• ASK participants whether it would be appropriate to go to the community and start
identifying for malnutrition, without first informing the community about the program
• BRAINSTORM with participants about ways of raising awareness about the nutrition
program
• WRITE down the answers. ADD any missing information using the notes to the trainer
• EXPLAIN that creating awareness is a very important role of the communtiy volunteers. This
will prevent misunderstanding and enable full participation of the community members
Note to the trainer:
Ways to raise awareness in the community:
• Talking about the program to community leaders
• Talking about the program to other community members
• Talking about the program in public meetings and gatherings
• Health education
• Home visits
70 | Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Session 3
Identifying other support services in the community
(45 minutes)
Session objective:
By the end of this session participants should be able to:
• understand the importance of networking with other support services in their
communities
• describe available networking support for PLHIV
• map the support services in their communities, guided by the case studies
Methodology:
Brainstorm, case studies and mapping, participatory lecture
Materials needed:
Case studies, flipcharts, markers, prepared flipchart with reference T7.S2:1.
Activity 1: The Networking model (15 minutes)
• ASK participants whether PLHIV require additional support besides the community and
the health facility, especially if they are on treatment or at risk of malnutrition.
• ASK: “Why do they need further support?”
• ASK them what kind of support they think that PLHIV may need
• EXPLAIN to to them that through partnership and networking different organisations
are able to provide support for PLHIV, therefore it is important for community volunteers
to be aware of the organisations which offer support services in their communities
• USE the diagram below to EXPLAIN that the networking model plays a key role in
supporting health facilities and community volunteers whilst putting malnourished
clients at the centre of the networking model
• BRAINSTORM on the roles that all sides can play in ensuring that formerly and currently
malnourished people will not be malnourished again.
• INTRODUCE the next activity by SAYING “we are going to explore the support systems
present in your own community through case studies and mapping”
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Note to the trainer:
• Transitioning clients off RUTF is made more difficult by poverty, reduced productivity,
and dependency on RUTF.
• Clients who have been on RUTF should be referred to or linked to existing incomegeneration
or other sustainable livelihood programmes for PHA and OVC in their
communities.
Therefore it is important for community volunteers and health workers to be aware of other
stakeholders in their community and catchment area who provide or are involved in the HIV/
AIDS prevention, care and mitigation
Reference T7.S2:1: Figure: The Networking Model
Community
volunteers
Malnourished PLHIV in
your community
NGO’s, CBO’S & FBO’s
which offer further
support services
Government
departments, health
facilities etc.
72 | Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Activity 2: Case studies and mapping support services (30 minutes)
Activity
• DIVIDE the participants into as many groups as we have regions or communities, and GIVE
each group the group work references for this activity. 2 groups will work on case study 1
and the other 2 groups will work on case study 2.
• ASK each group member to read their case study for 5 minutes and then the group should
DISCUSS the appropriate responses for each case study for 10 minutes.
• GO from time to time round the groups to provide assistance and follow-up;
• ASK one member from one group doing case study 1 to PRESENT their group work for 5
minutes
• GIVE participants time after each presentation to comment and enrich the work
• ASK one member from one group doing case study 2 to PRESENT their group work for 5
minutes
• GIVE participants time after each presentation to comment and enrich the work
RESPOND
• to any questions and THANK the participants for their collaboration and
announce the coming session.
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Case studies for discussion (T7.S2.2)
Note to the trainer:
Use local names for the individuals in the case studies.
Case Study 1:
Paul is a 45 year old man, married with 6 children. 4 months ago he developed constant fevers
and a persistent cough but never went to see a health worker. He has had diarrhoea on and off
for the past year and has lost a lot of weight. Paul has no stable job or source of income but has
a small garden, 2 goats and some hens. He and his wife get very little money from selling some
of the food they grow in the small garden and from selling some of eggs from the hens. Only 2
of Paul’s children are in school as he has no money for school fees for the other 4 children. Paul
is very worried about his illness but will not seek help from a health worker.
Activity:
In your small groups, think about and discuss Paul’s problems and how you think you
could help him.
Also think about the other service providers in your community and catchment area
who may be able to support Paul. Generate a list of these stakeholders showing their
target beneficiaries and draw a map showing where these services are located
Case Study 2:
Maria is a 35 year old woman whose husband died after being bed ridden for 6 months. He left
Maria with a 3 month old baby. However, during her pregnancy, Maria did not attend any ante
natal care (ANC) and therefore did not receive routine counselling and testing for HIV. Maria
breastfeeds her baby, but when she goes to the garden, she leaves the baby at home with a
caretaker who gives her some milk and soft-mashed foods. Maria noticed that her baby only
gained very little weight in the last few months.
Activity:
Discuss amongst yourselves how best you can support Maria
What kind of support might Maria need?
Are there any organisations or service providers in your community or catchment area
to whom you could refer Maria for some form of support?
How are you going to put Maria in contact with these service providers?
Note to the trainer:
Refer participants to Reference T7.S2:1: Figure: The Networking Model.
74 | Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Note to the trainer:
At the end of the case studies, INFORM participants that they are going to generate or update
a list of all the service providers in their respective communities to whom they can refer PLHIV
for support.
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Session 4
Roles and Responsibilities of stakeholders in the
community (30 minutes)
Session objective:
By the end of this session participants will be able to:
identify the main stakeholders in their community as well as their roles and responsibilities
Methodology:
Small group work
Materials needed:
Prepared flipchart; markers; group work instruction; reference, a flipchart with the following
instructions: list the roles of community volunteers, CBO’s and NGO’s and health workers in
integrating nutrition into HIV/AIDS care
Activity:
• ASK participants to mention the community based intervention key actors;
• TELL them that they are going to work in 4 groups in order to identify some key actors’
roles and responsibilities;
• DIVIDE the participants into 4 groups. Group 1) community volunteers, Group 2) health
workers, Group 3) community leaders and Group 4) CBOs and NGOs
• GIVE each group 3 cards and INSTRUCT them to come up with 3 roles and
responsibiliities of their stakeholder and write them on their cards.
• GIVE them time to ask for clarifications before working in respective groups
• GO from time to time, in the groups to provide assistance. After 5 minutes
• INVITE one participant from the first group in turn to present the group findings in
plenary
• GIVE them time after each presentation for comments to enrich their work.
• SUMMARISE and REFER participants to the reference (T7:S3) on the roles and
responsibilities of the stakeholders
Note to the trainer:
Refer participants to reference T7:S3: The roles and responsibilities of stakeholders in the
community. These roles are not exhaustive and can be expanded further.
76 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Session 5
Planning your activities as a community volunteer and
mobiliser (50 minutes)
Session objectives:
By the end of this session, participants should be able to:
prepare a work plan for creating community awareness, reaching-an-agreement and health
education in their communities
Methodology:
Small working groups
Materials needed:
Flipcharts, markers, sample activity plan (reference T7.S5)
Activity
• Group the participants by their community/ catchment area (if a person is alone, he/she
works individually)
• ASK them to plan the following using the reference:
1.
2.
3.
Community awareness activities
Home visits/ group visits
Health education sessions
• MOVE round the groups and OBSERVE their work. The plan will not be shared in plenary,
therfore it is important that all trainers go round to the groups.
Note to the trainer:
Refer participants to reference T7.S5: Sample activity plan.
If time is limited, the activity plans can be drawn as homework, and revised by the trainers on
an individual basis the following day.
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Session 6
Getting acquainted with the adapted/new reporting
tool(s) (55 minutes)
Session objective:
By the end of this session participants will be able to:
• Identify the community reporting tools
• correctly fill the reporting tools
Methodology:
Practise using reporting tools
Materials needed:
Enough samples of community client Register, Referral Form, Monthly reporting forms. also to
be found in references T7.S6.1 and T7.S6.2),
flipchart, markers
Activity
• EXPLAIN that each organisation has its own reporting system and tools and therefore
participants will be grouped by organization
• INTRODUCE (in turn) the three tools: the register book and the monthly register
books and show them how they look.
• ORGANIZE the participants in groups. A trainer should be assigned to each group
during the exercise.
• DISTRIBUTE leaflets of the reporting register and monthly reporting tool to each
participant
• GIVE all participants 5 minutes:
-
to study the tool(s), individually.
• Go through each tool with them
• ASK if there are any questions and EXPLAIN where necessary.
• EXPLAIN that, any person with swelling of both feet must be referred for nutrition
care, regardless of the MUAC measurement. SHOW in the tool where this information is
captured.
• EXPLAIN that you will read 10 case studies and that all participants should fill out the
relevant information on their tool (s). Explain that this is an individual exercise and that
they are allowed to ask questions if there are any problems.
• READ the first case study completely. Then read it again, line by line, allowing
participants to fill out their tool(s).
78 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

• ASK if there are any questions. MAKE SURE each tool is checked (by the trainer in the
groups). If there are any people with difficulties, assist them.
• REPEAT the process for the other 9 case studies.
• DISCUSS AND SUMMARIZE, keeping the participants grouped for the next activity.
Case Studies:
Note to the trainer:
Use local names for the individuals in the case studies.
Case study1:
John is 28 years old and part of a support group. He looks very thin and his MUAC
measurement falls in the yellow part. You reach-an-agreement on good important behaviors
and refer him to the health facility.
Case study 2:
Sara is a 25 month old baby girl with swelling on both her feet. You refer her immediately to
the health facility as it is still morning.
Case study 3:
Maria is about 5 months pregnant. She is 40 years old. When you measure her MUAC she falls
in the red zone. You counsel her on maternal nutrition and refer her to the health facility.
Case study 4:
Jane is a 14 year old girl and looks very thin. She lost both of her parents two years ago.
Her MUAC falls in the red zone. You counsel her about nutrition and refer her to the health
facility.
Case study 5:
Ruth is a 35 year old mother of 8 children , 3 of whom died. She is very weak and unable to
walk well because her feet are swollen. Counsel her on nutrition and refer her to the health
facility.
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs| 79

Case study 6:
Moses is a 10 year old boy who looks very skinny. You measure his MUAC which falls in the
green zone.
Case study 7:
Juma is a 45 month old boy, not very active for his age. His MUAC falls in the yellow part. Talk
to the mother to find out what is wrong. Reach-an-agreement with her on complementary
feeding and hygiene, and refer the boy to the health facility.
Note: 45 months is about 3.5 years. Have participants calculate themselves if they need the age in
years.
Case study 8:
Jen is a 6 years old girl and thin. Her MUAC falls in the red part. Refer her to the health
facility.
Case study 9:
Mary is 25 and breastfeeding her third baby. She is thin and her MUAC falls in the yellow part.
Reach-an-agreement with her on maternal nutrition and family planning. Refer her to the
health facility.
Case study 10:
Anne is a 16 years old girl and very thin. Her MUAC falls in the green part.
Note to the trainer:
If participants wonder why someone can look very thin and still have a green MUAC explain
that, especially children, sometimes grow very fast and therefore look thin but are actually
healthy.
Note to the trainer:
Refer the participants to their handbooks for the following figure.
Reference T5.S1: Figure: The Role of Community in the care of malnourished individuals
80 | Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Community Level Nutrition Monthly Report
Organization: _________________________
District:___________________ Subcounty:_____________
Name of Health Facility Attached to:____________________________
Month: __________Year: _______
Number assessed for Malnutrition
MUAC
Green Yellow Red
Oedema (Swelling
on both legs)
Total
Number
referred
to Health
Facility
Male
Children 6 months to less than 18 years
Female
Pregnant / mothers with children up to 6 months
Adults
Male
Female
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs| 81

Food and Nutrition Interventions for Uganda Community Assessment for Malnutrition Client’s Register
Name of Volunteer: ___________________ Year: ___________ Month_________
No. Names
Name of Health Facility____________________
Address
(Village)
Sex
(M/F)
Age
Client Category
(Tick the category of the client) Identify Nutrition Status
(Tick the correct colour of MUAC and check
for swelling of both legs) Referred
by you
Child
(6mth
-18yr)
Adult Pregnant/
mother
with child
up to 6
mths
MUAC
Green Yellow Red
Oedema
(Swelling
on Both
legs) (Y/N)
to Health
Facility
(Y/N)
Comments
(What
happened?)
Total
82 | Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Session 7
Information on the frequency of reporting
(10 minutes)
Session objective:
By the end of this session, participants should understand the reporting system and the
frequency with which they will be required to make reports
Methodology:
Case studies
Materials needed:
samples of reporting tools, flipcharts
Activity
• EXPLAIN that each organisation has its reporting system and data flow. Some require
community volunteers to report monthly while others quarterly.
• EXPLAIN that NuLife is expect to receive the monitoring information from each
implementing partner on a quarterly basis, i.e. every three months.
• INFORM participants that NuLife will work with each organization to develop a mechanism
for reporting on nutrition indicators from the community.
• DISCUSS and SUMMARIZE stressing:
• The importance of reporting in time
• The importance of each single piece of information
Note to the trainer:
The following information is the minimum information organisations need to report on. This
information will be collected in the organisation-specific tools which will be adapted to collect
this information.
Refer participants to Reference T7:S6: The Sample Reporting tool
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Session 8
Referral of malnourished individuals to the health
facility for care and treatment (60 minutes)
Session objective:
By the end of this session, participants should be able to:
• understand the importance of referral and the two-way referral system
• use the referral FORM to refer malnourished clients to the health facility
Material:
Flipcharts, markers
Methodology:
Brainstorm, role play, small group work
Materials needed:
Task cards, flipcharts, markers, sample of referral form
Activity
Activity 1: What is referral to the health facility? (30 minutes)
• DIVIDE participants into small working groups of 4-5
• ASK each group to discuss one of the following:
• Group 1: what does the term ‘referral’ in the context of nutrition care for PLHIV in the
community mean
• Group 2: why is referral important in nutrition care for PLHIV
• Group 3: what are some reasons for referral
• Group 4: at what levels are referrals carried out?
Once the group work is done,
• INVITE a participant from one group to present the group’s discussion
• ASK the other groups to make any contributions, WRITE these on responses on a flipchart
• REPEAT the procedure for the other groups
84 |Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Referral:
Notes to the trainer on referral (T7.S8.1):
Referral links malnourished individuals and those at risk of malnutrition in the community to:
• The health facility for treatment and care of malnutrition and any related illnesses
• Other services or service-providers with more skills, experience or better equipment who
are in a position to support PLHIV and improve their quality of life
Referral can be carried out at two levels:
The community level, whereby trained community volunteers, using specific nutrition
assessment tool (e.g. MUAC, observation of swelling of both feet) screen individuals in their
community and then refer those who are malnourished to the health facility for nutrition
care.
The facility level where the trained health workers who do further nutrition assessment
and determine wheter or not the referred individual can be enrolled into the RUTF/ nutrition
support programme, and then refer individuals back to the community to be supported by
volunteers through follow-up and home visits.
Both the facility and community levels can refer individuals to other support services in the
community for more support (see one of the next sessions).
Two-way referral whereby the individuals are referred from the community to the health
facility for nutrition care and treatment and then referred back to the community for continues
support is important because it:
• Enables early detection of individuals who are malnourished or at risk of malnutrition in
the community, thereby encouraging timely intervention.
• Enables health facilities to keep track of individual clients’ adherence to ART, RUTF and to
provide them with tailored health and nutrition messages
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Activity 2: Using referral tools (30 minutes)
Materials:
Referral tool (this should be the organisation/district-specific tool. If these are not available,
then use the generic one displayed in T7.S8.2)
Activity:
• TELL the participants that they will now learn how to use the referral tools to refer
individuals to the health facility
• DIVIDE the participants into small working groups of 4-5
• DISTRIBUTE a sample of the referral tool and ASK participants to study it
• GO THROUGH the tool together to ensure everybody uderstands it.
• Explain that the upper part of the tool will be filled by the community volunteers about
the client being referred. While, the lower part will be filled by the health worker and will
contain information that the health worker wants to share with the community volunteer.
When the community volunteer visits the client, he or she should ask for this referral
form.
When everybody is clear on the tool
• READ the task sheet for the whole group.
• MOVE round the groups to ensure that they are all filling out the tool correctly
At the end of the group work
ASK • for 2 participants to demonstrate the referral process using the role play instructions
below
86 | Integrating Nutrition Into Community Hiv /Aids Care And Support Programs

Task sheet for Role play:
Instructions: One participant takes on the role of community volunteer and the other the role
of patient. The community volunteer gives relevant information and refers the client who then
goes to the health facility with the referral form.
The client takes the referral form back to the community volunteer who will then support the
client in the most appropriate way.
Community volunteer: You do a home-visit in your community and assess 24 year old John’s
nutrition status using MUAC and find that he has a MUAC in the yellow zone of the MUAC tape.
John’s mother tells you that John has not been taking his ARV’s as he is supposed to because he
vomits every time he swallows the ARV’s.
Instructions:
Discuss as a group what sort of support John requires. If you think that he needs to be referred
to the health facility, then fill out the referral tool.
When making a referral:
• Fill the slip for the community volunteer but also the general information on the slip for
the health worker
• Always remember to counsel the client using the listening and learning skills you have
learned
• Inform the client that you will be referring him to the health facility and explain the
reason for referral (for further nutritional care and treatment )
• Inform the client about where to take the referral form
Integrating Nutrition Into Community Hiv /Aids Care And Support Programs| 87

Generic Referral Form (T7.S8.2)
Section Retained by Community Volunteer
Client Ref. No:___________________
Date ____/_____/_______
Client Name _______________________
Sex (F/M)______
Sub County _________________________
Parish: _____________________________
Village _____________________________
MUAC:
(Tick the correct colour of MUAC )
Green ____ Yellow _____ Red _____
Oedema (Swelling on Both legs): Yes___No___
(Tick “Yes” if the client has swelling of both legs and
“No” if there is no swelling of both legs)
Feedback from Health Worker to Community Volunteer
(Fill and return to the client)
Client Ref. No:___________________ Date ____/_____/_______
Client Name ________________________Sex (F/M)______
Sub County ___________________________Parish: _________________
Village __________________________________________
Health Facility Client is referred to: ____________________________
MUAC: (Tick the correct colour of MUAC )
Green ____ Yellow _____ Red ______
Oedema (Swelling on Both legs): Yes_____ No_____
(Tick “Yes” if the client has swelling of both legs and “No” if there is no swelling of both legs)
Volunteer’s Name: ________________________
To be filled by Community Volunteer
(Fill and give to the client)
Date client was received _____/_____/_______
Client admitted to: (Tick as appropriate)
[ ] Outpatient Therapeutic Care (OTC) (follow up on RUTF adherence)
[ ] Inpatient Therapeutic Care (ITC)
[ ] Supplementary Feeding Program
[ ] Does not qualify for admission (Counsel on eating well and hygiene)
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Session 9
Follow-up and support of individuals referred from the
health facility back to the community (60 min)
Session objective:
By the end of this session participants should be able to:
• carry out follow-up and support visits using the community volunteers’ guidelines and the
home visit checklist.
Methodology:
Brainstorm, role play in groups of 3
Materials needed:
Prepared flipchart with the 2 case studies, “The home-visit follow-up guide” (reference T7.S9:1
or Card 12 in the job aids), flipcharts, markers, group instructions, nutrition care and support
national counselling cards, OTC card, referral form
Activity
• ASK the participants what they understand by ‘follow-up” of clients and why it is
important in nutrition care and support, especially for PLHIV
• ASK them to read “The home-visit follow-up guide” (reference T7.S9:1 or Card 12 in the
job aids)
• CLARIFY any issues that may arise from reading these references
• DIVIDE the them into groups of 3 (triads) and ask them to READ their respective case
study on the prepared flipchart
• ASK each group to role-play a follow-up home visit session (one participant acts as the
client, another as the community volunteer, and the 3 rd and 4 th ones as observers. The
community volunteer should use the home-visit guide.
• After 10 minutes
• ASK each group to switch roles and READ the second case study
• ASK two groups to present their experiences (do not role play) and allow for comments
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Notes to the Trainer: Follow-up (T7.S9:2):
Follow-up is usually done to monitor a client’s well-being
• Done continuously both in the facility and community
• The frequency of follow-up home visits depends on the severity of the problem
• Follow-up will be of benefit if nutrition issues are integrated into other care and
support activities
• Include monitoring of health, nutrition and assessment of dietary intake during
follow-up visits
• Include reaching-an-agreement to address barriers to good nutrition (i.e.
implementing the important behaviors)
• Follow up helps to increase adherence to treatment such as RUTF and ARV’s
• Offer support and encouragement
• During follow-up, review some of the following:
• Meal plans
• Exercise and physical activity regimens
• Use of RUTF if prescribed by health facility, etc.
-
CASE STUDY 1:
When you first visited Maria, she had poor eating habits and was not ‘eating well’. She had
lost so much weight and you referred her to the health facility for treatment. You also noticed
that Maria was depressed, had general body weakness and is on ARV’s. Maria came back
from the facility with RUTF.
Do a follow-up home visit, use the home-visit guide and appropriate cards from the nutrition
care and support national counselling cards.
CASE STUDY 2:
At your initial visit, 6 year old Kato was severely ill, had no appetite and refused the food
given to him. His mother told you that he had lost a lot of weight in the last 2 weeks. You
assessed him with MUAC, it was red. So you helped the mother and referred her to the health
facility where she took Kato. Kato was given 20 bags of RUTF.
Do a follow-up home visit, use the home-visit guide and appropriate cards from the nutrition
care and support national counselling cards.
Notes to the Trainer: Follow-up (T7.S9:2):
Refer participants to reference T7: S8:1: Home-visit follow-up guide
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Session 10
The link between community and facility in the care
for manourished individuals (30 minutes)
Session objective:
By the end of this session participants be able to:
• Know the role of the community in the care of malnourished individuals and have an
overview of the care of malnourished individuals
Methodology:
Brainstorm, lecture
Materials needed:
Diagram on the role of community in the care of malnourished individuals
Activity
• SHOW participants the simple diagram on the roles of community in the care of
malnourished individuals and EXPLAIN to them the role of the community in the care of
malnourished individuals
• EXPLAIN to the participants the various components of the care of malnourished
individuals such as outpatient care, special care and supplementary feeding:
• TELL the assess, identify malnourished individual and refer to the health facility:
• The malnourished, found with serious medical conditions, will be referred for admission
to receive both nutritional and medical treatment till he/she is out of danger.
• Malnourished individuals if found with no life threatening condition, and only
malnutrition, will be managed from home using the RUTF and be required to report to
the health facility on dates written on the clients card.
How can community and health facility be linked in order to integrate nutrition services
into HIV/AIDS care?
• GIVE participants 5 minutes to think about how to defend their case
• ASK participants to refer to card 1 and 2 in the job aids explaining their roles as
community volunteers
• INTRODUCE the next session which is using RUTF in the community
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Health Facility
• Re-assess
• Categorize
• Prescribe RUTF
• Counsel
• Document
• Counter-refer
Community Volunteers
Mobilize community
Counsel on Nutrition
Identify Malnourished cases
refer malnourished cases to health facility
Follow-up
Link to sustainable livelihood and other services
Document
Partner organizations
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Appendix
REFFERENCE TOOLS & JOB AIDES
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THEMES 1&2: Basic nutrition care and support for PLHIV & the role of community in IMAM
Agenda: 4 Day Training on integrating nutrition into HIV/AIDS Care and support Programmes: A training of community volunteers
DAY 1 DAY 2 DAY 3 DAY 4
8:30- 8:45: RE-CAP DAY 2
8:30- 10:05 START UP ACTIVITIES
Session 1: (15 minutes)
Session 2: ( 50 Minutes)
Session 3: ( 20 Minutes)
Session 4: ( 10 Minutes)
8:30- 10.05: RE-CAP DAY 1 (5 TOPIC 1
CONT’D
8:30-10:05
Session 3 (30 minutes)
Session 4 (25 minutes)
Session 5 (50 minutes)
TOPIC 4: IMPORTANT BEHAVIOURS TO IMPROVE AND
MAINTAIN GOOD NUTRITION & HEALTH FOR PLHIV
8.45 – 10.05
Session 1: (50 minutes)
Session 2: (30 minutes)
8:30- 8:45: RE-CAP DAY 3
8:45- 10:15 TOPIC 7 continued
Session 2 (45 minutes)
Session 3. (45 minutes)
TEA BREAK
10:35 – 11:05: START-UP continued
Session 5: ( 30 Minutes)
11:05-11:35: VOLUNTEERING
11:35- 1:15: EFFECTIVE COMMUNICATION
SKILLS
Session 1: (60 minutes)
1Session 2: (40 minutes)
10:45- 1.00
Session 6 (25 minutes)
Session 7 (30 minutes)
Session 8 (80 minutes)
10.30-11.00
Session 2 Cont’d (30 minutes)
11.00- 1:00 TOPIC 5: IDENTIFYING MALNUTRITION IN
THE COMMUNITY
Session 1 (15 minutes)
Session 2 (30 minutes)
Session 3 (40 minutes)
Session 4: (25 minutes)
LUNCH BREAK
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8 0
2:15 – 3:55
Session 3: (40 minutes)
Session 4 (60 minutes)
TOPIC 1
BASICS OF NUTRITION
3:55 – 5:00
Session 1 (15 minutes)
Session 2 (50 minutes)
TOPIC 2: THE RELATIONSHIP
BETWEEN NUTRITION & HIV/AIDS
2.00 – 3:45
Session 1: (25 minutes)
Session 2: (40 minutes)
Session 3: (40 minutes)
3:45- 5:15: TOPIC 3:
MANAGEMENT OF SOME HIV
RELATED SYMPTOMS & ILLNESSES
Introduction (10 minutes)
Session 1 (40 minutes)
Session 2 (40 minutes)
2: 00 – 2:35
Session 4 – Cont’d (35 minutes)
2:35 – 4:15 TOPIC 6: TREATMENT AND CARE FOR
MALNURISHED INDIVIDUALS
Session 1 (30minutes)
Session 2 (40 minutes)
Session 3(15 minutes)
Session 4 (15 minutes)
4:15 - 5:05 TOPIC 7: ROLES OF THE
COMMUNITY IN THE CARE OF MALNURISHED
INDIVIDUALS.
Introduction (15 minutes)
Session 1 ( 35 minutes)
TEA BREAK AND DAILY EVALUATION
10:45 – 1:10
Session 4 (30 minutes)
Session 5 (50 minutes)
Session 6 (55 minutes )
Session 7 (10 minutes)
LUNCH
2.00 – 5:15
Session 8 (120 minutes)
Session 9 (60 minutes)
Session 10 (15 minutes)
5:15- 5:45 POST TEST & TRAINING
EVALUATION
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