SEA/AIDS/111
Teaching HIV/AIDS in Medical Schools
Regional Office for South-East Asia
World Health Organization
New Delhi 1999
Teaching HIV/AIDS in Medical Schools
ISBN 92 9022 220 4 © World Health Organization 1999 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation, in part or in toto, of publications issued by the WHO Regional Office for South-East Asia, application should be made to the Regional Office for South-East Asia, World Health House, Indraprastha Estate, New Delhi 110002, India. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The views expressed in this publication are those of the author and do not necessarily reflect the decisions or stated policy of the World Health Organization; however they focus on issues that have been recognized by the Organization and Member States as being of high priority.
Printed in India
Contents Foreword................................................................... vii 1. Introduction ............................................................ 1 2. Objectives ............................................................... 3 3. Integrating and Modifying the Existing Curriculum .... 5 4. Essential Teaching Elements ..................................... 8 5. Proposed HIV/AIDS Content in the Medical Curriculum .............................................. 10 6. Teaching Methods.................................................. 11 7. Assessment ........................................................... 13 8. Staff Development ................................................. 15 9. Programme Evaluation ........................................... 16 Annexes 1. Imparting Knowledge and Skills to Students ............ 19 2. Departmental Groupings ........................................ 33 3. List of Participants ................................................. 39
v
Foreword Today, HIV/AIDS is one of the greatest threats to the health of the community the world over. In the SouthEast Asia Region, with about 5.5 million people already infected, the epidemic is still rising sharply. WHO estimates that by the year 2000 there will be 8 to 10 million persons living with the virus in South Asia. does delay the onset of AIDS but today the cost of this
Treatment with the highly active antiretroviral therapy treatment is more than most individuals in the Region
can afford. The conclusion is unavoidable – more and attention as they develop AIDS and present with a variety of opportunistic infections. Recognizing that HIV/AIDS is a major public health
more people in the Region are going to need medical
problem, the World Health Organization has identified HIV/AIDS as one of its priorities. In pursuance of this decision, the Regional Office for South-East Asia has taken an active role in offering technical assistance to the countries of the Region.
Given this scenario, it is clear that the vast majority of medical practitioners are directly or indirectly going to vii
Teaching HIV/AIDS in Medical Schools
be affected by the epidemic in their professional work. The medical students of today are going to be the who will have to bear the brunt of this anticipated load. medical practitioners of the next thirty years. It is they
not currently a major problem, all health systems need to equip their student doctors to handle the disease in relevant to HIV/AIDS as an integral part of the the future. Medical schools need to include topics curriculum.
Even though in many parts of the Region HIV/AIDS is
To initiate the process of systematic integration of HIV/AIDS in the medical curriculum, the Regional Office has prepared this curriculum in consultation with experts in the Region. I hope it will be widely used as a basis for teaching HIV/AIDS to medical students in the Region. developing a national consensus on the modalities of
Dr Uton Muchtar Rafei Regional Director
viii
1.
INTRODUCTION HIV infection has now spread to almost every country in the world. The current WHO/UNAIDS estimate is that there are about 33.4 million infected persons in the world. Six million HIV-infected persons are reported to are in the WHO South East-Asia Region. Cases of AIDS are increasingly being reported in most countries of the South East Asia Region. By the end of 1999, the Region had reported 134,677 cases of AIDS. Even though very significant advances in the treatment of HIV infection from finding a therapeutic solution to the problem of have been made in the recent past, medical science is far HIV/AIDS. Intensive efforts are being made in the developed world to find a vaccine for HIV infection. Even though several candidate vaccines are on the anvil, it is not likely that there will be an effective vaccine in the be in South and South-East Asia, out of which 5.5 million
near future, and when a vaccine is developed, it is masses in the developing world.
another question whether it will be affordable for the
be affected by HIV, and that many countries will be affected seriously, it seems inevitable that the medical 1
Given the fact that almost every country is going to
Teaching HIV/AIDS in Medical Schools
as well as promoting its prevention and care. It is the health care providers who will have to treat those with Health care providers, particularly physicians, will also HIV infection and suffering from HIV-related disease. have to learn to protect themselves and those that come to them for medical help. Serious ethical questions will have to be resolved and most doctors will face dilemmas that challenge their own beliefs.
profession is going to be involved in managing HIV/AIDS
almost any site on the body, and affect almost any organ and a sufficient period lapses, most doctors in clinical practice will see cases of opportunistic infection. Many doctors will also have to deal with the trauma and
HIV-related infections and neoplasms could occur at
system. Once HIV infection spreads in the community,
anguish faced by persons who discover or suspect that they are HIV positive. Doctors have to be prepared for this eventuality.
this new condition is a matter of some urgency in the Region. This can be done by refresher and in-service training of doctors already working in the community and in medical institutions. However, it is an urgent necessity that the doctors of tomorrow are prepared to deal with the many outcomes of the spread of HIV infection in the community. 2
The provision of skills and knowledge to deal with
Teaching HIV/AIDS in Medical Schools
acquire the virus through the sexual route. It has been found that the efficiency of transmission of HIV from the in the presence of sexually transmitted infections (STIs). genital ulcer disease but also if there is an infection infected to the non-infected partner is greatly enhanced This is not only true when the non-infected partner has without ulceration. The presence of inflammation has the same effect as ulceration. What is interesting to note is that the presence of sexually transmitted infection in the
The vast majority of new HIV-infected persons
infected partner also facilitates the spread of HIV infection. STIs enhance the secretion of the virus in vaginal/cervical fluids and in semen.
of sexually transmitted infections have a marked effect Mwanza (Tanzania) demonstrated a 40% reduction in the
Studies have shown that the detection and treatment
on the incidence of HIV sero-conversion. A study in incidence of HIV infection following early detection and sexually transmitted diseases must therefore be integral package.
treatment of STIs. The early detection and treatment of and essential parts of a complete HIV/AIDS prevention
2.
OBJECTIVES
3
Teaching HIV/AIDS in Medical Schools
The objective of including HIV/AIDS-related education in with: • knowledge about the HIV virus and how it is
the medical school curriculum is to produce a doctor
spread and not spread.
• competence to diagnose and manage persons
with HIV infection and HIV-related disease.
• knowledge of the extent of HIV/AIDS problem –
at global and city levels – and its impact on health. • knowledge about psycho-social and behavioural
aspects.
• communication skills and the ability to counsel
persons with HIV/AIDS as well as their families to • understand the STI and HIV relationship and to
manage STI using the syndromic approach.
• the ability to plan and execute appropriate
preventive measures against HIV infection in the hospital, understanding workplace of the and importance community. of team for An
approach and intersectoral cooperation optimal utilization of resources.
• compassion for individuals living with HIV/AIDS.
4
Teaching HIV/AIDS in Medical Schools
• an awareness of medical ethics; human rights
issues, and costs of medical care.
knowledge and skills are required, besides the allimportant and most difficult inculcation of a suitable attitude.
To meet the above objectives a wide array of
3.
INTEGRATING AND MODIFYING THE EXISTING CURRICULUM
3.1 Evaluation of present curriculum The medical education curriculum is already very full
and puts a heavy burden on medical students. Hence, it may not be practical or even useful to have a fresh and committed curriculum. self-contained module introduced into an already heavily
achieved is already being taught in almost every medical school; what is needed is merely a change in emphasis and a judicious use of examples drawn from HIV/AIDS.
Fortunately, a major portion of what is sought to be
justification to integrate this segment into the existing HIV/AIDS has several important facets, each of which 5
There also are significant technical reasons and
curriculum. The provision of care in the context of
Teaching HIV/AIDS in Medical Schools
relates to the ideals of medical practice in general. First a chronic HIV disease with a gamut of associated
is the understanding of and skills in the management of opportunistic infections; second is the need to overcome and third is the development of skills in coping with the
prejudicial attitudes that can impede high quality care, psychological demands of certain types of care of patients. Running right through the curriculum is the serious concern for ethics and the rights of the patient. All these could best be developed in the milieu of an otherwise disparate teaching and learning elements. However, if the existing curriculum in a medical
educational programme that tends to integrate the
school is subject or discipline-based, it is unwise to first teaching programme begins. In such
attempt to bring about a degree of integration before the integration could be a medium-term objective. The teaching of HIV/AIDS must begin right now within the existing HIV/AIDS-related topics into the existing curriculum in immediately, as it would not necessitate finding educational programme. By introducing instances,
this manner the programme can be implemented almost extensive teaching time or the creation of special staff for the purpose. This would make the proposition eminently feasible. 3.2 Initiating changes in the Teaching Content 6
Teaching HIV/AIDS in Medical Schools
One of the urgent initiatives each medical school should take is to set up a multi-disciplinary committee or task force. The committee’ s responsibility would be to look at
the present curriculum, assess the essential knowledge
and skills needed and advise on the course content and
the system of evaluation. The committee should be
composed of members from the following departments:
public health, microbiology, internal medicine, sexually transmitted infections, paediatrics, psychiatry and a representative of medical students.
3.3 Process of bringing about change The Educational Spiral provided a simple way of integrated into the medical curriculum. identifying how HIV and AIDS could be incorporated or identification, and determination of the specific tasks Needs
that a medical graduate needed to undertake formed the starting points for curriculum design. The educational objectives would then be determined on the basis of and learning methods and the assessment would follow. Finally, it was considered essential to conduct regular
these tasks. The selection of relevant content, teaching
programme evaluations in order to improve the medical curriculum over time. This is particularly important during the early stages of implementation.
7
Teaching HIV/AIDS in Medical Schools
4.
ESSENTIAL TEACHING ELEMENTS The following elements in the curriculum are considered essential compassionate and sensitive doctors competent to and community. to meet the objective of producing
manage HIV infection (and AIDS) in the individual, family • Epidemiology and transmission of HIV • Signs, symptoms and natural history of HIV
infection
• Testing: Elisa, Rapid Tests, Simple tests, Western
Blot, CD4, Viral load etc.
• Diagnosis of HIV infection/AIDS • Prevention of HIV transmission including health
care settings.
• Psycho-social impact of HIV/AIDS • Counselling Skills • Patient, family and community education • Nursing care (adult, infant, child) • Home care • Support and care including palliative care • Terminal care • Human Rights and Ethical issues 8
Teaching HIV/AIDS in Medical Schools
• Gender issues • Legal implications
If all the above topics are to be adequately covered, it is necessary that the essential minimum be clearly delineated. Today there is such a wealth of knowledge and experience about the virus, its manifestations and it all. The aim of most medical schools is to produce a doctor capable of functioning effectively in institutions and the community at the level of the first doctor foundation for reasoned action and the ability to that in HIV medicine, as in other aspects, it is not required to train each medical student in every detail of medicine. increase his knowledge and skills. It therefore follows
management that no medical student can hope to learn
intervention, and to give the new graduate the scientific
the following :
However, the new graduate must be skilled
to do
1. Recognize, diagnose and treat patients with HIV/AIDS; 2. Provide counselling and appropriate referral services; 3. Diagnose and manage STIs; 4. Manage HIV-related pregnancy; 9
Teaching HIV/AIDS in Medical Schools
5. Discharge planning, referral and follow-up; 6. To use appropriate tests and interpret the results; 7. To encourage family and social support; 8. To promote and protect patient’ s rights; 9. To produce behaviour change; 10. To know and use Universal Precautions, and 11. To use blood appropriately
5.
PROPOSED HIV/AIDS CONTENT IN THE MEDICAL CURRICULUM It will be noted that most of the elements can be fitted into the existing teaching of various medical school departments. What is needed is a conscious decision to focus and stress those aspects that are important to HIV general principles. The teaching of the
medicine and to use examples from HIV when teaching
elements of the core curriculum would then permeate through the entire course, with almost every department taking an important responsibility. By involving all the teaching departments in meeting
different
the objectives defined for the overall course in HIV
medicine for undergraduate medical students, the course 10
Teaching HIV/AIDS in Medical Schools
can be smoothly incorporated into the curriculum with such a change can be implemented at the medical school Council, and Universities or Boards of Studies.
no apparent extra burden on the student. Best of all, level with minimal procedural hassles with the Medical
6.
TEACHING METHODS Most medical schools in the Region are still dependant portion of the teaching, though there are some schools upon conventional uni-disciplinary lectures for the major that have begun to use more innovative and interactive teaching – learning situations. HIV medicine has thrown most other branches of medicine, training a doctor to manage persons suffering from HIV disease with up a new challenge to medical education. More than
understanding and compassion needs the inculcation of a sympathetic and non-judgemental attitude in the medical student. Schools entirely dependant conventional teaching methods may find it difficult to upon
influence the attitude and thinking of student doctors. STI, HIV and AIDS, their teaching should be integrated carried and out jointly by teachers from many
Experience shows that while dealing with subjects like and
social
disciplines, e.g. medicine, preventive medicine, and behavioural sciences. Moreover,
institutions have found that innovative teaching-learning 11
many
Teaching HIV/AIDS in Medical Schools
methods are better at influencing attitudes. It may
therefore be worthwhile focusing on the use of learning sessions, games, role-play and similar methods that can situations such as structured case studies, tutorial
help students to learn to understand and cope with the HIV/AIDS the attitudes learnt during training are the most important part of the training. The sensitivities surrounding the ways in which HIV
emotional dimension. It is often said that in an area like
is transmitted and the current role of education and the importance of physician-patient communication
counselling in reducing the risk of infection emphasize skills. Effective communication skills in emotionally sensitive areas depends as much on the personal comfort and emotional development of the physician as on counselling the experience techniques. with specific Teaching interviewing and
experiences that allow medical students to explore their feelings about various emotional aspects of patient care,
learning
and
such as human sexual behaviour, death and dying, or patient characteristics and lifestyles different from their own, are important to develop communication skills. All conventional learning experiences, such this calls for introducing different types of nonmultidisciplinary seminars highlighting the various
as
aspects of the HIV/AIDS problem.
12
Teaching HIV/AIDS in Medical Schools
and learning methods would be most effective concerns being a role-model for the student cannot
Another crucial and related aspect of what teaching
the teacher. Here, the cardinal importance of the teacher overemphasized and the truth of the old adage that, to it. In order to facilitate teaching of HIV/AIDS in
be
“ attitudes are not taught but caught”has much meaning medical schools, the teachers should have access to and make use of teaching aids such as visuals, overhead developed by national programmes and made available materials. to all medical schools as standardized and pre-tested projectors and slides. Such materials should be
7.
ASSESSMENT Appropriate assessment of students is important for at least three reasons: 1. It is essential to make sure that the medical students, at the time of graduation (and at the objectives of the course, in this case related to HIV/AIDS. 2. Assessments will encourage students to work harder, thereby motivating them. different phases of their learning), have achieved
13
Teaching HIV/AIDS in Medical Schools
3. Particularly in the case of a newer subject of learning such as HIV/AIDS, assessments can guide the teachers as well as the students about parts which need to be improved. parts of the course that have been successful and Naturally, no single assessment during the course
can achieve all of these. Also, in view of the need to assess the attitudes and the ability of young doctors to trauma of being diagnosed as suffering from handle persons who are suffering from the intense stigmatizing, incurable disease, a range of student essays, multiple choice questions (MCQs) and MEQs all a
assessment methods will have to be used. Conventional have a role but they alone will not suffice. It is important
to ensure that questions on HIV/AIDS are asked both in skills and attitudes, a variety of appropriate assessment methods need to be selected.
theory as well as practical examinations. For testing The selection of such
methods need to be based on the cardinal principles of evaluation which would ensure their validity, reliability and, of course equally importantly, their feasibility. The Objective Structured Objective Clinical
(OSCE),
Examination (OSPE) have many features that will help teachers to determine students’ skills (including
and
the
Structured
Examination
Practical
14
Teaching HIV/AIDS in Medical Schools
communication skills), and attitudes. Also possible are patient management problems, projects and checklists.
day-to-day evaluation (with appropriate feedback) of
Another method that has found favour is a constant
students as they face real and contrived experiences assessment could be best used as a method of formative assessment and thereby motivate the students to learn. Finally, it is necessary to bear in mind that no method is perfect. Each has some
during the course of their training. Such continuous
assessment
advantages and disadvantages. Therefore it is always
necessary for the teacher to use a variety of methods whenever feasible. Such selection should be based on the objectives of the course, economy of time and expense, reliability and validity of the instruments, and their value as learning tools for the students.
8.
STAFF DEVELOPMENT In any new educational initiative, the development of the faculty in both content and process of education is of the faculty hold positive attitudes and are motivated to staff should not feel that additional workload is being critical importance. There is also the need to ensure that engage in the new teaching and learning activities. The imposed on an already overburdened work schedule. 15
Teaching HIV/AIDS in Medical Schools
This is particularly important among a traditionally-
oriented faculty. Nowadays, many medical schools have their own medical education units or equivalent bodies, In those medical schools where the which have staff development as their primary mandate. educational expertise already exists, what is required
necessary
may only be some orientation to the new tasks. Such units should be oriented and encouraged to conduct the necessary staff development work to introduce the new curriculum. Indeed, it is essential that such units be represented in the curriculum committee that established. It is useful to have an ongoing series of seminars, workshops and orientation sessions in the initial period of transition.
is
9.
PROGRAMME EVALUATION One of the tasks of the committee that will steer the new curriculum segment on HIV/AIDS and STI will be to set up the mechanisms to determine how the new training programme is fulfilling its objectives. It is also useful to identify the secondary and unforeseen effects of the programme on students and the institution. Such evaluation will require the collection of some baseline data (for comparison later), periodic student
assessments, and both quantitative and qualitative measurements. Programme evaluation, usually (and 16
Teaching HIV/AIDS in Medical Schools
understandably), takes a much lower priority in planning consumed by the day-to-day activities. Rarely is budget allocated to programme evaluation. However, in those institutions in which regular mechanisms are in place for
and implementation, the attention of the staff being
programme evaluation, the evaluation of this teaching evaluation exercises. The point to bear in mind is that the absence of any type of evaluation, after establishing the programme may have later on the institution.
and learning component could form part of the larger
a new programme, could severely compromise the effect
17
Annex 1
Imparting Knowledge and Skills to Students The report is the outcome of an informal consultation the specific topics to be covered and as it may be of help to those who try and implement the curriculum, the details are given below. held in Bangkok. The group went into great detail about proposed
A.
Recognize, diagnose and treat patients with HIV/AIDS Knowledge required: • General morbidity patterns in the community and
country
• HIV prevalence by area, age, sex etc. • HIV virology and immunology • Pathogenesis • Staging –CD4, Virus load • Clinical manifestations and profile 19
Teaching HIV/AIDS in Medical Schools
− − − − −
pulmonary dermal oral neurological neoplastic
• Diagnosis
−
criteria (CDC, WHO, Bangui, National etc.) treatment national policy opportunistic infections education nutrition condoms psychosocial aspects
• Management
− − − − − − −
• Common opportunistic infections
− − − −
TB PCP Diarrhoea Fungal infections
• Drugs
−
for opportunistic infections and regimen 20
Teaching HIV/AIDS in Medical Schools
− − −
anti-retrovirals adverse reactions costs
• Preventive therapy and its usefulness
− − − −
TB PCP Post-exposure Prophylaxis Role of cotrimoxazole or antimicrobials
• Paediatric AIDS • HIV and Pregnancy • Universal Precautions • Psychosocial Aspects and Quality of Life issues
recognizing, diagnosing and treating patients with HIV/AIDS are the following: • Communication • History-taking
The skills needed to carry out the objective of
interpersonal communication examination with a
skills,
especially
relating
to
complete
physical
• To make appropriate laboratory tests requests
and to interpret the reports
• Practise Universal Precautions 21
Teaching HIV/AIDS in Medical Schools
• Sexual history-taking • Problem-solving and analytical skills • Team-building skills • Developing non-judgemental attitudes • Practising Universal Precautions
B.
Provide Counselling and appropriate referral services Knowledge required: • HIV infection and treatment • Implication
consent
of
a
diagnostic
test,
informed
• Culture and beliefs • Patient’ s rights • Concept of counselling; purpose and process • Implications of a test • Counselling facilities and services available in the
Region
• Ethical issues
22
Teaching HIV/AIDS in Medical Schools
providing
The skills needed to carry out the objective of counselling and appropriate referral to
HIV/AIDS cases are the following: • Practice of counselling • Communication skill • Writing referral notes
C.
Diagnose and manage STIs Knowledge required: • Modes of transmission and prevention • Common STIs
− − −
what they are manifestations laboratory tests and procedures
• Drugs used • Syndromic management, its components, impact • HIV –STI interactions • STIs in women • Partner notification issues
− −
partner examination partner referral 23
Teaching HIV/AIDS in Medical Schools
−
contact tracing
diagnosing and managing STIs are the following: • Examination skill
The skills needed to carry out the objective of
− − −
detecting discharges and ulcers collection of smear light microscopy
• Demonstration of the correct use of a condom • Counselling for partners • Communication skill
D.
Manage HIV-related pregnancy Knowledge required: • Vertical transmission
− − − −
mechanism risk role of breastfeeding and of milk substitutes costs AZT –short-term vs long-term Anti-retrovirals in combination therapy
• Role of various interventions
− −
24
Teaching HIV/AIDS in Medical Schools
• Decisions in HIV+ women
− − −
regarding contraception conception terminating pregnancy
• Diagnosis of neonatal HIV infection • Prognosis in neonatal HIV infections • Treatment of neonatal HIV infection • Management of HIV+ pregnancy
managing HIV-related pregnancy are the following: • History-taking • Communication/education • Counselling • Manage delivery with Universal Precautions • Postpartum care
The skills needed to carry out the objective of
E.
Discharge planning, referral and follow-up Knowledge required: To understand: • Concept of need for continuum of care
25
Teaching HIV/AIDS in Medical Schools
• Community and home care • Role of health care worker and other agencies,
programmes − − PLWHA
legal aid agencies
• Importance of follow-up visits • Criteria of referral • Financial aspects
managing discharge planning, referral and follow-up are the following: • Communication skills • Training skills • Ability to mobilize the support of NGOs for
The skills needed to carry out the objective of
community and home care
F.
To use appropriate tests and interpret the results Knowledge required: • National Policy for HIV testing • Testing strategies • Common tests available
26
Teaching HIV/AIDS in Medical Schools
− − − − −
ELISA Rapid tests Simple tests Western Blot Virus load
• Sensitivity, specificity, predictive value • Interpretation of test results • Voluntary Counselling and Testing • Informed consent • Unlinked anonymous tests • Screening of blood and organs • Pre- and post-test counselling
following:
appropriate tests and interpreting the results are the • When to request HIV tests • Interpret results • Maintain confidentiality
The skills needed to carry out the objective of using
G.
To encourage family and social support Knowledge required: 27
Teaching HIV/AIDS in Medical Schools
• Epidemiology of AIDS • Patient needs for health and other types of
care/support • Role of family and community in providing care
and social support • Role of different sectors • Understanding of the culture and resources that
can be mobilized for support
encouraging family and social support are the following: • To mobilize community support • To
The skills needed to carry out the objective of
providing legal, financial and educational support
mobilize
NGOs
and
other
sectors
for
H.
To promote and protect patient’ s rights Knowledge required: To understand • Human rights, access to care • Discrimination and rejection
− −
isolation quarantine
• Confidentiality and informed consent 28
Teaching HIV/AIDS in Medical Schools
• Empowerment and gender issues • Obligation to treat / nurse • Ethics and law
− − −
access to care access to schooling employment
promoting and protecting patient’ s rights are the following: • Interpersonal communication • Maintain confidentiality • Carry out advocacy
The skills needed to carry out the objective of
attitudes have to be inculcated: • Respect for all persons • Compassion
To carry out the above objective, the following
I.
To produce behaviour change Knowledge needed: • Epidemiology
−
magnitude of problem 29
Teaching HIV/AIDS in Medical Schools
− − −
trends community prevalence national policy for prevention and care, including the ethical issue
• Mode of transmission
− − −
horizontal – sharing of needles, unprotected sex, unsafe blood vertical –mother to foetus, breastfeeding accidental –needle stick
• How HIV is not transmitted? • Consequences of diseases related to HIV
− −
tuberculosis other opportunistic infections
• Risk and risk behaviour
− − − − −
vulnerability of women, youth risk associated with sexual activities pattern of risk-taking in the community safer sex accidental exposure to infection
• Condom promotion
−
Skills needed to meet the objective of producing following: behaviour change are the
30
Teaching HIV/AIDS in Medical Schools
• • • • • • •
Communication skills Managerial skills Diagnostic skills Team work skills History-taking skills Use of appropriate language Demonstration of correct condom use
J.
Universal Precautions Knowledge required: • Universal precautions and the concept that all
patients are assumed HIV-positive
• Conduct normal delivery taking precautions • Manage accidental injuries • Disinfection and sterilization • Post-exposure prophylaxis
and promoting Universal Precautions is the following:
The skill needed to meet the objective of practising • Demonstrate and practise universal precautions
31
Teaching HIV/AIDS in Medical Schools
K.
Use blood appropriately Knowledge required: • National policy regarding blood transfusions • Rational blood use • Blood safety measures • Use of blood components • Autologous transfusions •
donors donors
Screening donated blood v/s testing blood
• Favourable donors – voluntary non-remunerative
Skills needed to meet the objective of using blood rationally and safely are the following: • Identify safe and non-safe blood • Encourage voluntary donations • Counsel for autologous transfusions
32
Annex 2
Departmental Groupings (The list given below is just an example taken from one medical school. Not every medical school would have the adapted to meet individual circumstances, but most topics will fit into the following illustrative pattern.) Anatomy Physiology Microbiology The immune system Nutrition and the immune system Virology –The HIV structure and natural listing, and HIV-testing policies and strategies
same departmental structure. Groupings will need to be
Pathology Forensic Medicine Human Rights, Right to get treatment and medical care Confidentiality Partner notification Informed consent Immunology HIV and immune system CD4 count
33
Teaching HIV/AIDS in Medical Schools
Viral load Medicine Clinical Management (diagnosis and treatment of opportunistic infections) • Tuberculosis • Pneumonia • Fungal infections, Candida • Kaposi Sarcoma Counselling of a HIV-positive patient Care of the terminally ill patient Home care Hospital infections and universal precautions Cardiology Dermatology Venereology/ STI Dermal manifestations and their management Common STIs –organisms
Department of
–manifestations –investigations management –syndromic
Counselling and Partner notification STI-HIV interactions Paediatrics Demonstrating the correct use of condoms 34
Teaching HIV/AIDS in Medical Schools
Neonatal HIV infection Infant feeding and HIV including use of breast-milk substitutes (where breastfeeding is contraindicated) Management of Paediatric AIDS Psychiatry Drug use and abuse / HIV Human sexual behaviour Interview techniques Confidentiality Interpersonal communication Counselling Obstetrics and Gyneacology HIV and pregnancy Management of pregnancy in the HIVpositive patient Short-term AZT therapy Conception / contraception in the HIV-positive patient Universal precautions and deliveries Haematology Blood components White cells / CD4 and CD8 cells Transfusion Medicine Blood safety Rational use of blood 35
Teaching HIV/AIDS in Medical Schools
Blood components Donor recruitment and retention, screening donated blood Hospital Management Universal precautions Disposal of Sharps Disposal of contaminated wastes Surgery Universal precautions Rational use of blood / plasma expanders ENT Ophthalmolog y Emergency Medicine Treating a bleeding injury Resuscitation of the HIV-positive person Oral candidiasis
36
Teaching HIV/AIDS in Medical Schools
Preventive and social medicine including epidemiology
Mode of transmission, efficiency of transmission Control of infectious diseases Disinfection and sterilization Medical Ethics Human rights Unlinked anonymous testing Informed consent Testing policy for HIV Testing strategies Home care and community support Communication and the mass media Community education and awareness generation Prevention of HIV infection including safer sex Condoms Validity of tests Sensitivity and specificity Prevalence and predictive value of tests AIDS and STI surveillance HIV sentinel surveillance Epidemic / pandemic
37
Teaching HIV/AIDS in Medical Schools
Social and behavioural sciences
Culture and belief systems Sexual behaviour and other risk factors Community structure and organization NGOs and their role Patients’and doctors’rights Ethics Communication Interview techniques Counselling Rights and needs of a terminally ill patient Community-based care Family-based care Team building Working intersectorally Social support systems Gender issues Care of orphans
38
Annex 3
List of Participants Dr Palitha Abeykoon Regional Adviser, HRH WHO South-East Asia Regional Office IP Estate New Delhi 110 002 India Dr Jai P. Narain Regional Adviser, STI/AIDS and TB WHO South-East Asia Regional Office IP Estate New Delhi 110 002 India Prof. Lalit M. Nath Association for Health, Environment and Development (AHEAD) E-21 Defence Colony New Delhi –110 024 India Prof. Shanker Chowdhury Addl. Professor of Community Medicine Centre for Community Medicine All India Institute of Medical Sciences Ansari Nagar New Delhi 110 024 India Prof. Gopal Acharya Chairman, Department of Internal Medicine and Director, Medical Education Department Institute of Medicine P.O. Box 1524, Kathmandu Nepal Prof. Susheila Dali Institute of Medicine Maharajgunj, Kathmandu KHA2-330 Tahachal Kathmandu, Nepal
39
Teaching HIV/AIDS in Medical Schools Dr Zubairi Djoerban Department of Internal Medicine Faculty of Medicine University of Indonesia 6 Salemba Raya Jakarta pusat Indonesia Dr Verapol Chandeying Prince of Songkla University Faculty of Medicine Department of Obstetrics and Gynaecology Hat Yai, Songkla 90110 Thailand Asst. Prof. Dr Piroon Mootsikapun Department of Medicine Srinagarind Hospital Khon Kaen University Khon Kaen 40002 Thailand Prof. Prasong Tuchinda Faculty of Medicine Rungsit University Phya-Thai Hospital II Hospital 943 Phaholyothin Road, Physthai Bangkok 10400, Thailand Colonel Vanich Vanapruks Phramongkutklao College of Medicine 315 Rajavithee Road Rajathevee, Prayatai Bangkok 10400 Thailand Assoc. Prof. Dr Boonmee Sathapatayavongs Department of Medicine Ramathibodi Hospital Mahidol University Rama 6 Road, Bangkok 10400 Thailand Asst. Prof. Wisut Boonkasemsanti Department of Obstetrics and Gynaecology Chulalongkorn Hospital Rama IV Road Bangkok 10330 Thailand Associate Prof. Dr Nisarat Opartkiattikul Department of Clinical Pathology Faculty of Medicine Siriraj Hospital Mahidol University Bangkok 10700 Thailand
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Teaching HIV/AIDS in Medical Schools Assoc. Prof. Dr Chantapong Wasi Department of Microbiology Faculty of Medicine Siriraj Hospital Mahidol University Bangkok 10700 Thailand Asst. Prof. Dr Prasert Auewarakul Department of Microbiology Faculty of Medicine Siriraj Hospital Mahidol University Bangkok 107 00 Thailand
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