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BUILDING BLOCKS:
Comprehensive Care Guidelines
for Persons Living with HIV/AIDS
in the Americas

SUMMARY REPORT
June 2000
PAHO/WHO in
collaboration with
UNAIDS and IAPAC

Acknowledgements
The text of this document was prepared by the Regional Program on AIDS/STI, Pan American Health Organization (PAHO), Regional Office of the World Health Organization. It is a summary report of the document, Building Blocks: Proceedings of the Consultations on Standards of Care for Persons Living with HIV/AIDS in the Americas, PAHO/WHO, 2000.
Comments and suggestions were provided by a group of experts during two consultations on standards of care for persons with HIV/AIDS; the first held in Cancun, Mexico (November 1998) and the second held in Guatemala City, Guatemala (May 1999). The Regional Program would like to thank all participants for their time and thoughtful comments.
FOREWORD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Work team:
COMPREHENSIVE CARE FOR PERSONS LIVING
WITH HIV/AIDS IN THE AMERICAS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HIV/AIDS Comprehensive Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HIV/AIDS Care Continuum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HIV/AIDS Care Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Pan American Health Organization welcomes requests for permission to reproduce or trans- late its publications, in part or in full. Applications and inquiries should be addressed to the Standards of Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Publications Program, Pan American Health Organization, Regional Office of the World Health Appropriate HIV/AIDS Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Organization, 525 Twenty-third Street, NW, Washington, DC, 20037, USA, which will be glad to Building Block Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
provide the latest information on any changes made to the text, plans for new editions and reprints Monitoring and Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Publications of the Pan American Health Organization have full copyright protections in accor- Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
dance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights are reserved.
Recommended Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Regional Program on AIDS/STI
Division of Disease Prevention and Control ANNEX A: APPROPRIATE SERVICES TO MEET
HIV/AIDS CARE NEEDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Directly Observed Treatment, Short-course The Regional Program on AIDS/STI of the Pan American Health Organization (PAHO), Regional Office of the World Health Organization, in collaboration with the World Health Organization (WHO) Headquarters, the United Nations Joint Global Program on AIDS/World Health Organization Programme on HIV/AIDS (UNAIDS) and the International Association of Physicians in AIDS Care (IAPAC), convened a series of consultations with national experts to identify the "build- ing blocks", or core components, of HIV/AIDS comprehensive care.1 These consultations were held in response to numerous requests from health authorities in the Region of the Americas International Association of Physicians in AIDS Care Information, Education and Communication on how they can ensure improved care and, specifically, wider access to antiretroviral therapies This resulted in the development of a Building Block Framework for HIV/AIDS comprehensive
care that depicts three different scenarios for providing HIV/AIDS care. These scenarios out- line a series of steps that can be followed in accordance with available resources and skills to achieve the development of a comprehensive care network for persons living with HIV/AIDS (PLHAs), their families and caregivers.
United Nations Joint Programme on HIV/AIDS Voluntary and Confidential Counseling and Testing 1 The complete summary can be found in the reference, Proceedings of the Consultation on Standards of Care for Persons living with HIV/AIDS in the Americas, PAHO/WHO (2000).
BUILDING BLOCKS
It is a widespread belief that the majority of health care needs of PLHAs could
be fully addressed by ensuring access to medications, in particular antiretroviral therapy. However, this idea falls short of effectively meeting the complete range of PLHAs’ medical, emotional, social and economic needs.
Access to medicines should be viewed as one part of providing appropriate clinical management for PLHAs. It must be ensured that the elements that
constitute the foundation of health care (skilled health providers, laboratory facilities, treatment units, access to counseling and testing, emotional and social support) are firmly in place before concentrating all the efforts and resources to ensuring access to pharmaceuticals.
INTRODUCTION
also serve to improve the emotional condition of affected individuals and ensure they have the care, primary care, secondary care and tertiary means to live a life of dignity and self-respect.
care. Each of these levels should be points with- This document provides an operational definition of HIV/AIDS comprehensive care and outlines the core components of HIV/AIDS care. It presents a care model, outlined in a Building Block Framework, that is meant to provide guidance in the development of poli-
in a continuum of care for PLHAs and togeth-
cies and strategies and promote discussion about the full spectrum of care required to meet the The development of HIV/AIDS comprehensive er integrate a comprehensive care network. To needs of PLHAs, their families and caregivers. It is anticipated that this document will serve as an
care programs should not be considered as a information base from which viable HIV/AIDS comprehensive care programs may be developed.
diversion of resources from prevention activities,but as a strategy to widen their impact. These HIV/AIDS COMPREHENSIVE CARE
programs should enhance primary prevention each of the elements of the HIV/AIDS care efforts and also have preventive effects in and of HIV/AIDS comprehensive care consists of four interrelated elements (van Praag & Tarantola, 1999): themselves (secondary and tertiary prevention).
Establishment of the appropriate services As a primary prevention strategy, they should and mobilization of the necessary resources Clinical management (early and accurate diagnosis, including testing, rational treatment
ensure that (1) people who are not infected do not get HIV, (2) those who are already infected Construction of bridges between each of the Nursing care (promotion of adequate hygiene practices and nutrition, palliative care, home
do not transmit HIV to others, and (3) those care and education to care providers at home and family, promoting observance of univer- who are already infected do not get re-infected.
If these requisites are in place, it will be possi- HIV/AIDS Care Continuum
ble to meet the individual needs of PLHAs at
Counseling and emotional support (psychosocial and spiritual support, including stress and
any point in the evolution of HIV infection by anxiety reduction, risk reduction planning and enabling coping, accepting HIV serostatus2 providing the most appropriate and timely and disclosure to others, positive living and planning of the future for the family) prehensive care should serve to provide guidance responses and referrals to services.
Social support (information, provision or referral to peer support, welfare services, spiritual
on a logical sequence of events that may be used to prioritize actions and establish bridges forinterventions of increasing complexity to be car- HIV/AIDS CARE MODELS
Comprehensive care programs for PLHAs and their support system(s) should encompass services rang-
ried out at different levels of the health system.
ing from counseling to medical interventions, to case management of social service needs, to nutrition- As described previously, HIV/AIDS compre- al support, as well as palliative care, bereavement support and caregiver support. These programs should HIV/AIDS comprehensive care should be avail- hensive care involves providing a wide range of able and provided at all levels of the health sys- interventions throughout the entire health 2 Serostatus refers to whether a person has antibodies to HIV in her blood. Seronegative, or HIV negative, is when antibodies to HIV are not found in a person’s blood. Seropositive, or HIV positive, is when antibodies toHIV are found in the blood.
Summary Report
BUILDING BLOCKS
BUILDING BLOCKS
system. However, the majority of countries Efficiency and Effectiveness: Efficacious
ties, health clinics, hospitals, tertiary refer- can not provide all of the services in all of effectiveness of the specific interventions. their local health systems. At best they may The second dimension is determined by the develop these services through a phased-in The standards and norms of care should be efficacious interventions functional under defined in each country, for each level of serv- may have sufficient resources to permit an Standards of Care
ices, and for each population affected.
expansion of the available responses within The third dimension involves the setting of Although there may be universal standards, it each level of care. The complexity and sophis- standards and is determined by the level of is important to emphasize that local stan- tication of the services will vary as a result of programs to be effective and sustainable, dards should reflect the best care obtainable
the availability of financial, technical and in current local circumstances.
human resources and health infrastructure.
upon and applied. Standards need to reflect However, even in areas where resources are the optimal and desired levels of the quality, Appropriate HIV/AIDS Care
limited, it should be possible to provide a access and coverage of HIV/AIDS care (van standard of care that ensures the mainte- Praag & Tarantola, 1999). Once established, The following table outlines appropriate services to meet the basic needs of PLHAs, their family
nance and improvement of the quality of life standards have to be translated into indica- members and caregivers (refer to Consultation Proceedings, 1999). The specific components are out- and productivity of PLHAs.
tors for monitoring and evaluation purposes. lined in Annex A and should be adapted according to specific situations and resources.
Principles
In theory, standards should be formulated for Appropriate HIV/AIDS Care
minimum and optimum levels of care, taking The following principles were outlined during into account possible variations in the resources the Consultation on Standards of Care for and skills available, development of new and Persons with HIV/AIDS,3 organized by WHO/ cheaper technologies, ease of access and afford- PAHO, as essential guidelines in the develop- ability in different areas within a particular Prophylaxis and Treatment of Opportunistic Infections and other Infections ment and provision of HIV/AIDS comprehensive country (Ibid). However, as one of the principles care systems. To meet the physical, emotional, of HIV/AIDS comprehensive care programs is Management of Sexually Transmitted Infections social and economic needs of PLHAs, care
to achieve equity in the provision of care, the
Management of HIV in Obstetrical/Gynecological (Obs/Gyn) Practice should be governed by the following principles: design of HIV/AIDS care programs and their monitoring and evaluation elements should be Respect: For human rights and individual
based on minimum standards which all imple- menting participants are expected to abide by Accessibility and Availability: Appropriate
and use as a reference to evaluate performance. Equity: Care is provided to all persons liv-
To determine the standards of care in any Management of Sexual Complaints and Dysfunctions particular setting, three different dimensions age, race, ethnicity, sexual identity, income that influence the choice of standards must In determining access to antiretroviral ther-
resources, individuals should not be treated with apy it is advisable to have consensus meetings
substandard antiretroviral regimes (e.g. AZT Coordination and Integration: To ensure a
of national experts in each country, in order monotherapy). If there is insufficient money to The first dimension deals with the technical to establish guidelines for setting priorities of treat all the eligible patients, the threshold for aspects of the intervention to be provided treatment initiation should be determined. Inthis way, fewer patients would be treated but all 3 Consultation on Standards of Care for Persons with HIV/AIDS, Cancun, Mexico, November 1998.
In a setting where there are less than optimal Comprehensive Care Guidelines for Persons Living with HIV/AIDS in the Americas
Summary Report
BUILDING BLOCKS
BUILDING BLOCKS
BUILDING BLOCK FRAMEWORK
MONITORING AND EVALUATION
tion (adequacy of supplies, appropriatenessof training). In order to foster further discussion on what care can be provided in relation to resource avail- ability, three different scenarios are proposed. Appropriate and feasible care alternatives that cor- Evaluation focuses on determining the
respond to the different levels of the health system are outlined in a Building Block Framework
component to refine, adapt and strengthen degree of progress in meeting set goals or pro- (refer to pages 8-9). The minimum standard of care that countries should strive to achieve is existing and new services. Services will only gram performance. It involves an assessment delineated in Scenario I and the increasing range and specialization of services that are possible
be effective if they are consistently evaluated of inputs (human and capital resources avail- with an increase in resources (physical/infrastructure resources, financial resources, technical to measure effectiveness, efficiency, quality, able for program implementation) and pro- resources, support services) and skills (trained health providers) are presented in Scenario II and
usage and acceptability in the community.
gram operation variables (who is to do what, Scenario III.
Programs should seek to collect, analyze and where, when and how). It also involves an use data that reflect the extent to which qual- ity care is provided at all levels of the health may include changes in knowledge, attitudes, behavior, risk factors, disease and disability.
Scenario I: In this setting, testing and basic medications (e. g. tuberculosis (TB)
potential gaps requiring remedial actions. prophylaxis, palliative care) are available in a limited amount at all levels of the health Appropriate indicators for the above moni- system (primary, secondary, tertiary). Interventions are focused on secondary The purpose of monitoring is to ensure that
prevention activities (i.e. prophylaxis of opportunistic infections, avoidance of work is progressing as planned and to antici- potentially harmful behaviors) to avoid further physical deterioration and provide pate or detect any problems in implementa- stage. Indicators need to be established that symptomatic relief. Antiretroviral (ARV) therapy is available for the prevention of mother to child transmission (MTCT) at the secondary level of the health system.
Scenario II: In this setting, testing and drugs are available at all levels, including some
The monitoring and evaluation process should answer the following
ARVs at the secondary level of the health system. All Scenario I services are
questions:
provided plus the etiologic treatment of opportunistic infections. Some excessively Appropriateness: Does the HIV/AIDS comprehensive care system as a
expensive drugs, such as antitumoral medications, are not available at the primary whole respond to the main health needs of the target population? and secondary levels of the health system.
Acceptability: Are the services provided in a manner that is acceptable to
the population and encourages their appropriate utilization? Accessibility: Are the services provided so that problems of access
Scenario III: In this setting, all of the above services are provided plus ARV therapies
(geographical, economic and social barriers) are minimized and equity is Effectiveness: Do the services provide satisfactory outcomes both from the
clinicians’ point of view and that of the clients and their families? In each building block, elements should be read from top to bottom i. e. the elements are arranged Efficiency: Is each service provided so that the maximum output is obtained
in a sequential fashion with the first illustrating the initial care component that needs to be from the resources expended, and does the mix of services represent the addressed. Ideally, all components should be provided within each level of the health system. best value for money with regard to the health needs of the target The core foundation of services in Scenario I should be in place before moving to the next level.
Equity: Are the health needs of different sectors of the target population
The achievement of all services within a particular scenario should be a stimulus to move to the next scenario level. The ultimate goal is to obtain the standard of care presented in Scenario III.
Comprehensive Care Guidelines for Persons Living with HIV/AIDS in the Americas
Summary Report
BUILDING BLOCKS
BUILDING BLOCKS
BUILDING BLOCK FRAMEWORK
Scenario I
Scenario II
Scenario III
As per Scenario I
Scenario III:
As per Scenario II
As per Scenario II
As per Scenario I
As per Scenario I
As per Scenario I
As per Scenario II
As per Scenario I
As per Scenario II
As per Scenario II
SCENARIOS
As per Scenario I
Scenario II:
As per Scenario I
As per Scenario I
As per Scenario I
As per Scenario I
Scenario I:
TERTIARY
COMMUNITY
HOME CARE
SECONDARY
* In countries where transfusional services are available at the primary level, this component should be available at the primary level.
LEVEL OF HEALTH SYSTEM
Comprehensive Care Guidelines for Persons Living with HIV/AIDS in the Americas
Summary Report
BUILDING BLOCKS
measure the quality of care as well as the achievement of program objectives. For example, if one objective of a HIV/AIDS comprehensive care program is to increase the coverage of vol-untary and confidential counseling, possible indicators include: Proportion of primary health clinics that offer voluntary and confidential counseling and testing: Number of primary health clinics that offer voluntary and confidential counseling andtesting / Number of primary health clinics in a given area AIDSCAP/FHI (1997). Introduction to AIDSCAP Evaluation: Module 1. Series of AIDSCAP EvaluationTools. AIDSCAP/FHI, Arlington.
Proportion of individuals who accept HIV testing: Aggleton, P., Moody, D., & Young, A. (1992). Evaluating HIV/AIDS Health Promotion. Health Education Number of individuals who accept HIV testing/Number of individuals who receive pre- test counseling and information on HIV testing.
Bartlett J. (1998). Medical Management of HIV Infection. Johns Hopkins University, Department ofInfectious Disease, Baltimore.
Proportion of individuals who return for HIV test results: Bartlett J., & Finkbeiner, A. (1991). The Guide to Living with HIV Infection. John Hopkins University Press,Baltimore.
Number of individuals who return for HIV test results/Number of individuals tested Broder S., Merigan T.C., & Bolognesi, D. (1994). Textbook of AIDS Medicine. Williams and Wilkins, Baltimore.
CDC/UNAIDS/WHO (1996, Noviembre). Pautas para la Prevención de Infecciones Oportunistas en Proportion of individuals who bring in their partner for HIV counseling and testing: Personas con VIH o SIDA en América Latina y el Caribe. Boletín de la OPS, 121 (5).
Number of individuals who bring in partner for HIV counseling and testing/ Number of Donahue, J. (1998, June). Community-Based Economic Support for Households Affected by HIV/AIDS.
individuals who receive pre-test counseling and information on HIV testing Discussion Paper on HIV/AIDS Care, No. 6. Arlington, Health Technical Services (HTS) Project for USAID.
Fahey, J.L., & Fleming, D.S. (1997). AIDS/HIV Reference Guide for Medical Professionals (4th Ed.). Center for CONCLUSION
Interdisciplinary Research in Immunology and Disease (CIRID) at UCLA, Williams and Wilkins, LosAngeles.
Gilks, C., Floyd, K., Haran, D., Kemp, J., Squire, B., & Wilkinson, D. (1998, June). Sexual Health and As discussed in this document, HIV/AIDS comprehensive care programs consist of a wide Health Care: Care and Support for People with HIV/AIDS in Resource-Poor Settings. Health and range of activities and services that meet the medical, emotional, social and economic needs of Population Occasional Paper. Report for Department for International Development (DIFID), London.
PLHAs, their family members and caregivers. Comprehensive care programs assist PLHAs to
Girma, M., & Schietinger, H. (1998, June). Integrating HIV/AIDS Prevention, Care, and Support: A live longer and more dignified lives, provide family members and caregivers with invaluable Rationale. Discussion Paper on HIV/AIDS Care, No. 1. Health Technical Services (HTS) Project for USAID,Arlington. support, and offer society a greater understanding and acceptance of HIV/AIDS. In addition, Green, L., & Kreuter, M. (1999). Health Promotion Planning: An Educational and Ecological Approach.
these programs support and strengthen already established HIV/AIDS prevention programs Mayfield Publishing Company, Mountain View.
thereby enhancing the efforts to avert the spread of HIV.
Guay, L., Musoke, P., Fleming, T., Bagenda, D., Allen, M., Nakabiito, C., Sherman, J., Bakaki, P. et al. (1999).
Intrapartum and Neonatal Single-dose Nevirapine Compared with Zidovudine for Prevention of Mother-to-child Transmission of HIV-1 in Kampala, Uganda: HIVNET 012 Randomized Trial. Lancet, 354, 795-802. Hunter, S., & Williamson, J. (1998, June). Responding to the Needs of Children Orphaned by HIV/AIDS.
Discussion Paper on HIV/AIDS Care, No. 7. Health Technical Services (HTS) Project for USAID, Arlington.
IMPACT/FHI/UNAIDS (1998). Meeting the Behavioral Data Collection Needs of National HIV/AIDS and STDProgrammes: Workshop Report and Conclusions. IMPACT/FHI/UNAIDS.
Kaplan, J.E., Hu, D.J., Holmes, K., Jaffe, H.W., Masur, H., & DeCock, K.M. (1998, June). PreventingOpportunistic Infections in Human Immunodeficiency Virus-Infected Persons: Implications for theDeveloping World. Discussion Paper on HIV/AIDS Care, No. 4. Health Technical Services (HTS) Project forUSAID, Arlington.
Lazzarini, Z. (1998, June). Human Rights and HIV/AIDS. Discussion Paper on HIV/AIDS Care, No. 2.
Health Technical Services (HTS) Project for USAID, Arlington.
Mazin, R., & Zacarias, F. (1998, October). Eye on Latin America and the Caribbean. Antiretrovirals:Reality or Illusion? Journal of the International Association of Physicians in AIDS Care, 4 (10), 28-29. Comprehensive Care Guidelines for Persons Living with HIV/AIDS in the Americas
Summary Report
BUILDING BLOCKS
Meredith, K., Larson, T., Soons, K.R., Grace, C., Fraser, V., Mundy, L., Melchior, L., & Huba, G.J. (1998).
Building Comprehensive HIV/AIDS Care Services. AIDS Patient Care, 12 (5), 379-392.
Morrondo, R.N., &. González Lahoz, J. (1996). Reuniones de Consenso sobre la Infección por VIH. Sociedad Española Interdisciplinaria del SIDA, Spain.
Nájera, R., & González Lahoz, J. (1996). Curso De Formación Médica Continuada Sobre La Infección Por El Virus De La Inmunodeficiencia Humana. Sociedad Española Interdisciplinaria del SIDA, Spain. Office of Evaluation and Strategic Planning (OESP) (1997). Results-oriented Monitoring and Evaluation: AHandbook for Programme Managers. UNDP, New York.
Office of the United Nations High Commissioner for Human Rights and the Joint United NationsProgramme on HIV/AIDS (1998). HIV/AIDS and Human Rights: International Guidelines. United Nations,New York and Geneva.
OPS (1998, March). Cuidados Paliativos: Guías para el Manejo Clínico. OPS, Washington DC.
OPS (1999, February). Guía para la atención domiciliaria de personas que viven con VIH/SIDA. OPS,Washington DC.
1. Screening and Diagnostic Services
Osborne, C.M., van Praag, E., & Jackson, H. (1997). Models of Care for Patients with HIV/AIDS. AIDS,11 (B), S135-S141.
Laboratory capacity for detection and diagnosis (dependable tests, confirmatory testing) Sanei, L. (1998, June). Palliative Care for HIV/AIDS in Less Developed Countries. Discussion Paper on HIV/AIDS Care and Support, No. 3. Health Technical Services (HTS) Project for USAID, Arlington.
Voluntary and confidential counseling and testing (VCCT) services (confidential testing Schietinger, H., & Sanei, L. (1998, June). Systems for Delivering HIV/AIDS Care. Discussion Paper on that is undertaken with the informed consent of the individual and ensured access to HIV/AIDS Care, No. 8. Health Technical Services (HTS) Project for USAID, Arlington.
Schietinger, H. (1998, June). Psychosocial Support for People Living with HIV/AIDS. Discussion Paper on Laboratory capacity to identify indicators of progression of infection/immune impair- HIV/AIDS Care, No. 5. Health Technical Services (HTS) Project for USAID, Arlington.
US Department of Health and Human Services (1982). Coping with Cancer. Prepared by Office of Cancer Communications, National Cancer Institute. National Institute of Health, Bethesda. Capacity to assess the quality level of laboratory results (identify false positive tests, false UK AIDS Consortium (1997). Access to HIV Treatments in Developing Countries: Interim Report. UK AIDS Capacity to recognize alerting signs and clinical manifestations (physical, mental, oral) UNAIDS/WHO (1998, December). Report on the Global HIV/AIDS Epidemic. UNAIDS, Geneva.
van Praag, E., Fernyak, S., & Katz, A.M. (1997, April). The Implications of Antiretroviral Treatments.
related to HIV infection developed among primary health care providers UNAIDS/WHO Informal Consultation. UNAIDS, Geneva.
Capacity for providing results and supporting development of individual plans of action van Praag, E., & Tarantola, D. (1999, Draft). Operational Approaches to the Evaluation of Major Program in place (support to identify alternatives/options) Components in Care Programs for People Living with HIV/AIDS. WHO, Geneva. Settings for providing results and counseling in a confidential, private manner available WHO (1995). Provision of HIV/AIDS Care in Resource--Constrained Settings. WHO, Geneva.
WHO (1995). Testing Strategy for HIV. WHO Weekly Epidemiological Record. WHO, Geneva.
WHO (1998). HIV/AIDS and Health Care Personnel: Policies and Practices. Sixth Consultation with LeadingMedical Practitioners. WHO, Geneva.
2. Counseling, Psychological and Social Support
WHO (1998, October 9). Recommendations on the Safe and Effective Use of Short-course ZDV forPrevention of Mother-to-Child Transmission of HIV. WHO Weekly Epidemiological Record, 73 (41), WHO,Geneva.
(a) Counseling and Psychological Support
WHO (1998, October 16). The Importance of Simple/Rapid Assays in HIV Testing. WHO Weekly Psychological interventions for coping with diagnosis Epidemiological Record, (41), WHO, Geneva. Counseling to support development of individual plans of action WHO/UNAIDS (1998). The Use of Antiretroviral Drugs to Reduce Mother to Child Transmission ofHIV (Module 6). Guidance Modules on Antiretroviral Treatments, WHO/UNAIDS, Geneva.
Counseling after diagnosis (post-test counseling) WHO (1999). The World Health Report 1999. Making a Difference. WHO, Geneva.
Secondary prevention (counseling and education to delay onset of clinical manifesta- Wilson, S.E., & Williams, R. (1994). Surgical Problems in the AIDS Patient. IGAKU-SHOIN Medical Support groups (e. g. peer facilitated groups) World Bank (1997). Confronting AIDS: Public Priorities in a Global Epidemic. Oxford University Press, New York. Professional interventions for coping with severe emotional disturbance Comprehensive Care Guidelines for Persons Living with HIV/AIDS in the Americas
Summary Report
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9. Antiretroviral Therapy
sionate) sources of spiritual support ■ Distribution programs for condoms and (b) Social Support
4. Prophylaxis and Treatment of
Opportunistic Infections and other
Infections
7. Management of HIV in Obstetrical/
Laboratory capacity to monitor the effect Gynecological (Obs/Gyn) Practice
Prophylaxis planned according to local sit- Surveillance systems to monitor resistance uation (most common health problems, e.
reproductive health counseling, provision of antiretroviral therapy, among others) 10. Antitumoral Therapy
3. Community Education and
5. Nutritional Interventions
Alternatives to breastfeeding (e. g. breast- Participation
milk substitutes, heat treated breastmilk, tion (IEC) strategies (e.g. distribution of 8. Management of Pain and Palliative Care
Plan of action to prevent weight and mus- 11. Neurological and Psychiatric Care
Provision of supplements, if needed (vita- Education for personnel officers in private 6. Management of Sexually Transmitted
Infections
Drug-induced neuropathies (lesions/impair- ments are a result of secondary effects of Comprehensive Care Guidelines for Persons Living with HIV/AIDS in the Americas – Summary Report
ANNEX A: Appropriate Services to Meet HIV/AIDS Care Needs
BUILDING BLOCKS
13. Surgical Procedures
(paralysis, cognitive impairment, speechproblems) Central lines (intravenous (IV) catheters placed in large veins for maintaining long- Emergency procedures (e. g. appendicitis) Elective surgery (e. g. removal of cysts, hipreplacement) 12. Management of Addictions
Cosmetic surgery to manage disfiguringconditions (e. g. Molluscum, warts) Assessment of nature of addiction andsocial environment 14. Management of Sexual Complaints
and Dysfunctions
important infections (Hepatitis B Virus(HBV), Hepatitis C Virus (HCV), bacteria) Pharmaceutical management of erectiledysfunction Guilt, anger and anxiety as obstacles tosafe sex practices Diagnosis and management of dyspareu-nia and orgasmic dysfunctions Sex counseling and therapy for serodis-cordant/seroconcordant couples Comprehensive Care Guidelines for Persons Living with HIV/AIDS in the Americas – Summary Report

Source: http://www.rei-ki.info/WHO-Comprehensive_Care_Guidelines.pdf

111402 dexamethasone in adults with bacterial meningitis

C o py r ig ht © 2 0 0 2 by t he Ma s s ac h u s e t t s Me d ic a l S o c ie t y V O L U M E 3 4 7 N U M B E R 2 0 DEXAMETHASONE IN ADULTS WITH BACTERIAL MENINGITIS JAN DE GANS, PH.D., AND DIEDERIK VAN DE BEEK, M.D., FOR THE EUROPEAN DEXAMETHASONE IN ADULTHOOD BACTERIAL MENINGITIS STUDY INVESTIGATORS* ABSTRACT HE mortality rate among adults with acute Bac

Molecular cells & protein synthesis.cdr

UNRAVELLING THE STRUCTURE OF DNA QUESTIONS DNA MODEL An important milestone in the history of genetics was the purification of DNA by Oswald Avery and his co-workers in 1945. 2. Name the structure / substance that carries genetic material. The realisation by the scientific community that the principle carrier of genetic information and the blueprint for life was DNA led to a 3

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