Mzake Ndi Mzake - HIV and AIDS Manual

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Mzake ndimzake

Sourcebook for HIV and AIDSpeer group education

Basic education programme

Prevention Treatment CareSupport Prevent Treat CareSupport Preventing TreatingCaring Supporting PreventTreat Care Support PreventTreating Caring SupportingPrevent Treat Care SupportCare Prevention Treatment

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Mzake ndimzake

Sourcebook for HIV and AIDSpeer group education

Basic education programme

Prevention Treatment CareSupport Prevent Treat CareSupport Preventing TreatingCaring Supporting PreventTreat Care Support PreventTreating Caring SupportingPrevent Treat Care SupportCare Prevention Treatment

Edited byAndy V Byers

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Published by GTZ Basic Education Programme, P O Box 31131, Lilongwe 3, Malawi

© GTZ 2009

The choice, presentation of facts contained and opinions expressed in this manual areresponsibility of the editor and the conributors and do not necessarily represent the views ofGTZ.

Any part of the manual including illustrations may be duplicated, photocopied, reproduced oradapted for non-profit purposes without permission from GTZ, as long as sources areacknowledged.

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DedicationThis manual is dedicated to the thousands of Malawians, who have participated as peerleaders and group members, in the Mzake ndi mzake peer group education for HIV andAIDS prevention project. We have included hundreds of their observations andquotations. Their contributions have greatly enriched this publication.

AcknowledgementsThis book is a complete revision and expansion of the first edition of Mzake ndi mzakeand it would be impossible to name the hundreds of people who have helped to createit, but we must single out a few for special recognition.

We give thanks to the creators of the first edition of Mzake ndi Mzake which wasdeveloped from the work of Kathleen and James Norr and Chrissie Kaponda, withthe assistance of the health professionals of the Kamuzu College of Nursing.

The Mzake ndi mzake peer groups contributed ideas and suggestions for this edition:• Lilongwe Primary Teacher Training College• Blantyre Primary Teacher Training College• Karonga Primary Teacher Training College• Kasungu Primary Teacher Training College• St Joseph Primary Teacher Training College

• Maria Tsvere, GTZ consultant and lecturer in HIV and AIDS at ChinoyiUniversity, Zimbabwe led the first revision workshop.

• Venencia Kabwila, formerly manager of the GTZ HIV and AIDS programme.• Sindisiwe Kabwila, former GTZ HIV and AIDS mainstreaming advisor, planned

and directed and the revision.• Lillian Muyunda Byers, Acting Country Director, International HIV/AIDS

Alliance, Lusaka, Zambia contributed scores of activities and observations.• Andy V Byers, GTZ consultant, redesigned and expanded the original draft of

Mzake ndi mzake by including activities drawn from his publications ExploringReligion and Morality (Oxford University Press) and The Science Teachers Handbook(Heinemann). He illustrated this edition with his own drawings and those ofIsaiah Mphande, Paul Ndunguru, Madalitso Chauluka and Rawlings Demba.

• Wilfried Goertler, former GTZ Team leader who initiated and encouraged therevision process.

• Georg Mades, Malawi GTZ Team leader, whose quiet determination andunflinching support brought this book into being.

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ContentsIntroduction ............................................................................................ 11What it means to be a peer educator ..................................................... 12How to use the manual .......................................................................... 13How to conduct a session ....................................................................... 14

Unit 1 The Importance of HIV and AIDS Prevention..................... 161.1 Meeting for the first time .............................................................. 161.2 Fears and hopes about Mzake ndi Mzake .................................... 161.3 What are the aims of Mzake ndi Mzake ........................................ 171.4 Deciding on expected group norms .............................................. 171.5 How much do you know about HIV and AIDS? .......................... 181.6 What is difference between HIV and AIDS? .................................. 191.7 How does HIV weaken the immune system? ............................... 191.8 Research to stop HIV with different drugs ................................... 201.9 HIV and AIDS worldwide .............................................................. 211.10 HIV and AIDS in Malawi ............................................................... 221.11 Why is HIV/AIDS prevention important to our community?...... 221.12 What is the impact of HIV/AIDS on the individual? .................... 231.13 What is the impact of HIV/AIDS on the family? .......................... 231.14 What is the impact of HIV/AIDS on the community and nation? 231.15 What is the impact of HIV/AIDS on school-age children ............. 24

Unit 2 Preparing for behaviour change ......................................... 252.1 Assignment review .......................................................................... 252.2 What are the most important things in your life? ......................... 252.3 What are the most important things in life for your group? ........ 262.4 How can I build high self-esteem? ................................................. 272.5 Everyone is unique and special ...................................................... 282.6 How can we develop empathy? ..................................................... 282.7 What is happening in Malawi today ? ........................................... 292.8 Which negative behaviours in our society need changing? .......... 302.9 Why should we discuss values, virtues and vices? ........................ 312.10 What is a good person? .................................................................. 322.11 What are the major virtues and vices in society? ........................... 332.12 Do different people need different virtues? ................................... 332.13 The human values in The Millenium Development Goals ........... 342.14 How are virtues and vices developed ? ........................................ 352.15 Why do we behave as we do? ........................................................ 362.16 Rights and responsibilities ............................................................ 372.17 How to make the right decision .................................................... 372.18 Is there a struggle going on within me? ........................................ 382.19 When free will clashes with the golden rule .................................. 382.20 How do I lose self-control or self-discipline? ................................. 392.21 How do I develop and nurture self-control? ................................. 392.22 How can I change negative behaviour into positive behaviour? 402.23 Groups can unite and divide us .................................................... 412.24 How do prejudice, stigma and discrimination divide people?...... 42

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Unit 3 Relationships and human sexuality .................................... 433.1 Assignment review ......................................................................... 433.2 What is love?................................................................................... 433.3 Sex and sexuality ............................................................................ 443.4 Elements of human sexuality ........................................................ 443.5 Sexual development ....................................................................... 453.6 Sex, love and behaviour change..................................................... 463.7 The external features of the female reproductive system ............. 473.8 The internal features of the female reproductive system .............. 473.9 The features of the male reproductive system .............................. 483.10 What should we call the male and female reproductive parts? .... 483.11 Over 30 reasons why people have sexual relationships .............. 493.12 Frequently asked questions about sex .......................................... 503.13 Assignment...................................................................................... 53

Unit 4 Ways of preventing the transmission of STIs .................. 544.1 Assignment review ......................................................................... 544.2 Which body fluids contain the HIV? ............................................. 544.3 How do people get infected with HIV? ......................................... 554.4 How to prevent HIV infection through blood contact .................. 564.5 How is HIV/AIDS not transmitted? .............................................. 574.6 What are some signs or symptoms of an STI ?.............................. 574.7 Complications of sexually transmitted infections ........................ 584.8 Are there other ways for people to get STIs? ................................ 594.9 What would you do if you got an STI? ......................................... 594.10 How can STIs increase our chances of HIV infection? ................. 594.11 How many people will Cecilia share body fluids with? ............... 604.12 How many people have you shared body fluids with? ................ 604.13 What is the ABC of safe sex? ......................................................... 624.14 What is safer sex ? ......................................................................... 624.15 Thinking about sex without a condom? ....................................... 634.16 How fast does HIV spread ? .......................................................... 634.17 What factors put men at risk of STIs and HIV infection? ............ 644.18 What factors put women at risk of STIs and HIV infection? ...... 654.19 Why are young girls vulnerable to HIV infection? ...................... 664.20 Why are young people at high risk of HIV infection? .................. 674.21 Assignment .................................................................................. 67

Unit 5 Condoms .................................................................................... 685.1 Assignment review ......................................................................... 685.2 If a man can carry a condom why can’t a woman?....................... 695.3 How strong is a condom?............................................................... 695.4 Don’t condoms have holes in them that allow HIV through? ..... 695.5 Condoms are not romantic ............................................................ 705.6 Sex with a condom is like eating a sweet inside the wrapper ...... 705.7 Can condoms come off and remain inside a woman? ................. 705.8 But we never use condoms don’t you trust me?........................... 715.9 But I love you, why use a condom? ............................................. 71

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5.10 Condoms can cause impotence, cancer and TB! ........................... 715.11 Semen is necessary to help a baby develop properly ................... 715.12 Condoms are only used by prostitutes and the unfaithful ........... 725.13 Doesn’t promoting condom use encourages promiscuity? .......... 725.14 Can I wash the condom and use it again? ..................................... 725.15 Preparing to demonstrate how to use condoms ........................... 735.16 How to select and store condoms .................................................. 735.17 How to use a male condom correctly ............................................ 745.18 The female condom ...................................................................... 755.19 How to use the female condom correctly ..................................... 765.20 The lifeboat game: values and condoms ....................................... 775.21 Role play: Advising a friend about safer sex ................................. 785.22 Role play: Talking about prevention of STIs ................................ 785.23 Role play: Dispelling false beliefs about condoms ........................ 795.24 Assignment: Discussing condoms with a partner or friend ........ 79

Unit 6 Talking with your partner about HIV .................................. 806.1 Assignment review ......................................................................... 806.2 Barriers to communication about safer sex ................................... 806.3 What is needed to change risky behaviour? .................................. 826.4 Communicating with your partner about safer sex ..................... 826.5 How does an aggressive partner behave? ..................................... 836.6 How does a passive partner behave? ............................................ 836.7 How does an assertive partner behave? ........................................ 836.8 Responding to an aggressive partner ............................................ 846.9 Finding a mutually acceptable solution ......................................... 856.10 Can condoms be an enjoyable part of your love life? ................... 866.11 Role play: Talking about safe sex with a new partner ................... 876.12 Alcohol drinking or drug use and sexuality ................................. 886.13 Assignment ..................................................................................... 89

Unit 7 HIV and AIDS testing and ARV drug treatment ............. 907.1 Assignment review ......................................................................... 907.2 What happens when you go for VCT? .......................................... 917.3 What are some reasons for not going through VCT? ................... 917.4 What are the advantages of going through VCT? ........................ 917.5 Why is counselling an important part of VCT? .......................... 927.6 What is the clinical approach to diagnosing AIDS? ..................... 937.7 What is the laboratory test approach? .......................................... 937.8 What are the advantages of finding out you are HIV negative? .. 947.9 What are the advantages of testing with your partner if

you learn that both of you are HIV positive? ................................ 947.10 What are the advantages of testing with your partner if you

learn that one of you is HIV positive and the other one is not? ... 957.11 Where can I go for a free VCT? ..................................................... 957.12 What are ARVs ? ............................................................................ 96

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7.13 What are the four groups of ARV drugs and why do we needto use four of them? ....................................................................... 96

7.14 What must we know about ARVs if we want to use them? ......... 977.15 When should a person start taking ARVs? .................................... 987.16 What happens before someone starts taking ARVs? .................... 987.17 Where can people get ARVs? ........................................................ 987.18 What is HIV resistance to ARVs? .................................................. 997.19 How can we reduce the rate of resistance to ARVs? ..................... 997.20 What challenges are faced by people taking ARVs? ..................... 100

Unit 8 Things we can do to fight the spread of HIV.................. 1018.1 Assignment review......................................................................... 1018.2 How to carry out a risk assessment .............................................. 1028.3 Ways to protect groups who are at risk of HIV infection ............ 1038.4 Which factors in our society encourage the spread of HIV?........ 1038.5 Cultural practices that increase the risk of HIV infection ............ 1048.6 Do Malawian laws allow nkhanza? ............................................... 1058.7 Malawi’s National HIV/AIDS policy ............................................. 1068.8 Revising: stigma and discrimination? ........................................... 1078.9 Revising: causes of stigma and discrimination ............................. 1078.10 Identifying stigma and discrimination in our communities......... 1088.11 How can we stop discrimination in our communities ................. 1098.12 Role play: Helping to reduce stigma about HIV and AIDS ........ 1108.13 Do humorous cartoons help in the fight against HIV .................. 1108.14 Ways to protect widows from HIV infection ................................ 1118.15 Ways to protect young girls from HIV infection .......................... 1118.16 What can we do to reduce early sexual activity in children? ....... 1128.17 Ways to protect young children from HIV infection .................... 1138.18 Ways to protect women and men from HIV infection ................ 1148.19 More ways a community can protect itself from HIV infection... 1158.20 Teacher networks to fight HIV : T’LIPO ....................................... 1168.21 Networks to fight HIV: MANET ................................................... 1178.22 Malawi’s sex industry and the spread of HIV/AIDS .................... 1188.23 Is there an Education-vaccine against HIV? ................................... 1208.24 Does staying silent on homosexuality help spread HIV/AIDS ?.. 1218.25 Looking closely at a global approach to HIV prevention.............. 1228.26 How are people who spend time in prison put at risk?................ 1238.27 How does trafficking for sexploitation spread HIV and AIDS? .... 1248.28 How does HIV/AIDS affect the elderly? ....................................... 1258.29 Talking to children about sexual and reproductive health........... 1268.30 Role play: Discussing sex education for young children .............. 1278.31 Role play: Talking to a child about sex and HIV/AIDS................. 1288.32 Keeping children safe from sexual abuse and HIV ...................... 128

Unit 9 Living positively with HIV/AIDS ........................................ 1299.1 Assignment review ....................................................................... 1299.2 How do different people react when learning they are HIV+?..... 1299.3 What causes stress for people living positively with HIV?............ 130

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9.4 Living positively with HIV and AIDS ........................................... 1319.5 HIV and nutrition: Eating positively ............................................ 1329.6 Which food groups should be used by PLWHA? ........................ 1339.7 Which medicinal plants can b used by PLWHA?......................... 1349.8 How can foods relieve common symptoms of HIV/AIDS? ......... 1359.9 Which recipes can be used to alleviate diarrhoea?........................ 1369.10 HIV and hygiene: positively clean ................................................ 1379.11 Does spirituality strengthen the immune system?....................... 1389.12 Deep breathing and quiet time ..................................................... 1399.13 Role play: Talking about living positively with HIV and AIDS ... 1399.14 Succession planning ...................................................................... 1409.15 What things should you put in your own will? ........................... 1419.16 What things should you put in your own memory book? .......... 1419.17 What things should you put in your own memory box? ........... 1419.18 Why is home-based care so important? ........................................ 1429.19 When should a family start home-based care for PLWHA?......... 142

Unit 10 Educating caregivers about HIV and AIDS.................... 14310.1 Assignment review: Concerns of PLWHA and their caregivers... 14310.2 Practical ways of preventing HIVcross-infection........................... 14410.3 What is the role of counselling in home based care? ................... 14510.4 What forms of counselling can a person access in Malawi? ........ 14510.5 How can we reduce opportunistic infections? ............................. 14610.6 How can health workers help families with PLWA? .................... 14610.7 What can care givers do in the fight against HIV and AIDS? ..... 14710.8 Living positively: Further ideas for role plays ............................. 147

Unit 11 Preventing Mother-To-Child Transmission (PMTCT).... 14811.1 Assignment review: What is mother-to-child transmission?........ 14811.2 During pregnancy: preventing mother-to-child transmission .... 14811.3 During childbirth: preventing mother-to-child transmission ..... 14911.4 During breatfeeding: preventing mother-to-child transmission . 15011.5 Why is it dangerous for a mother to mix feed a baby? .............. . 15111.6 Role play: Partners talking about having an HIV free baby ........ 152

Appendix ................................................................................................... 153The A to Z against HIV: it’s much more than just ABC .............................. 153Facilitation techniques ................................................................................. 158Planning for your new Mzake ndi mzake peer group ................................. 159The TALULAR Challenge ............................................................................ 160More Talular ideas ....................................................................................... 162Evaluating peer group activities .................................................................. 166Glossary of terms ......................................................................................... 168References and further reading ................................................................... 170Certificate ................................................................................................... 172

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Introduction

Welcome to Mzake ndi mzake, the peer group HIV and AIDS education project.Although this book is aimed at peer educators, we hope that it will also serve as auseful sourcebook for others interested in educating themselves and others.

Today, people’s health is threatened by HIV and AIDS. Worldwide, just 1 in every 5people at risk of being infected with HIV, has access to basic prevention services.This book has been produced to equip peer educators, with knowledge and skills toenable them to disseminate information on STIs, HIV and AIDS. This will help themto develop the attitudes needed to encourage positive behaviour change. We hope itwill assist in going further than the basic messages of ABC for HIV prevention. It isessential to go ‘beyond the ABC of HIV’, because a present many people still don’tabstain from unprotected sex, they aren’t faithful to their partners and rarely if everuse a condom.

After going through the activities, it is hoped that you will be able to:• explain the basic facts about human sexuality, STIs, HIV and AIDS• protect yourself and others from HIV and AIDS by changing any behaviours that

put people at risk• help yourself and others in your community to avoid getting infected by STIs,

HIV and developing AIDS• describe how a wide variety of social factors influence the spread of HIV and AIDS• encourage yourself and others in your community, to live positively with or

without HIV and AIDS

When working in small groups of friends, people feel more comfortable about sensitiveand personal concerns. Many people also trust information that is suggested by theirfriends. They often develop a sense of responsibility and ownership when carrying outan action planned and developed by their peers. It is often easier to contemplate andsupport successful behaviour change within such a group.

Please remember, that this manual is not a substitute for professional medicaladvice. Peer group members and the community members they reach, shouldregularly consult their doctors or qualified medical health practitioners in mattersrelating to their health, particularly in respect to symptoms and treatment whichrequire diagnosis or medical attention. It is essential that people who have beenexposed to the risk of HIV, and their sexual partners, seek professional medicaldiagnosis and treatment.

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How to use the bookThis book has been described as creative mix of ideas contributed byinnumerable people. Many authors have written or suggestedactivities, so you will find a wide variety of styles and a certainamount of repetition. We hope that this variety adds to yourappreciation of the many hands that have so generouslyworked to make this book possible.

There are over 200 activities in the eleven units, which you can combine and cover inwhatever order your group decides. But, we suggest you follow the general order inthe book unless you have important reasons not to do so. The first unit looks at theimportance of HIV and AIDS prevention, and unit two looks at preparing for behaviourchange. Topics in these two units reappear throughout the book, so you should becomefamiliar with the contents, and refer back to them if or when necessary.

All of the activities are listed in the contents pages, so you are strongly advised to keepthe checklist up-to-date, in order to record the activities you have covered. Each unitends with an evaluation activity that the peer group completes. Use the evaluationquestions to help you assess your accomplishments, challenges, including how manymeetings are held and how many people participate.

What is a peer educatorPeers are people who share similar interests and may live or workin the same place. Peer education is a process of sharing informationamongst peers at a place where they feel safe and comfortable.Peer education provides a means of delivering culturally sensitivemessages from within. Mzake ndi mzake peer groups are informalgatherings of people who share a common desire to protectthemselves and their loved ones from HIV. Mzake ndi mzake peereducators are group members who have learnt how to facilitate onthe themes of HIV/AIDS prevention, treatment, care and support.

Peer educators are concerned about their peers and regard themselves as responsibleopinion leaders.

The role of a peer educator is to:• convene meetings and facilitate the activities suggested in the book• act as a role model in the community and influence behaviour change• lead group discussions to identify the activities to be covered in each session• encourage group members to identify activities that they would like to cover• encourage members to keep a record of the activities covered• motivate peers to share experiences and support each other• counsel those who wish to confide in you and those who need your help• distribute condoms and be ready to openly discuss proper use of condoms• manage time wisely, be assertive, remain focused and avoid discussing off topic• evaluate the meetings using the evaluation questions on page 166

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How to conduct a sessionAlways remember that the main aim is to get people to practice safe sex and safer sex.

The following suggestions have been made by peer group members and we hopethat you find them helpful. You do not have to use all of the ideas, but we suggestyou discuss the points with other peer group members.

• Mzake ndi mazake peer groups should be small enough so that everyone canparticipate fully in the chosen activities

• A meeting could last from one to two hours• You do not have to finish a whole unit in one session and

are free to run more shorter sessions if you wish• Facilitation is not lecturing and peer educators need to

learn how to assist the group without taking it over• At the beginning it is helpful to work together with another

peer educator and co-lead the activities• If necessary ask fellow peer educators questions or for support• As you become more experienced, you will gain confidence and be more self-

reliant.• Talking about sexual behaviour may not be easy, because it is a very private subject

and people often do things they would not like to reveal to others.• Help the group find a way to talk honestly and openly about sexual and other

important matters.• Make everyone feel comfortable and free to talk about personal feelings• Be friendly helpful and approachable then your peers will feel free to open up if

you are open and non-judgmental• You need to become self confident and dependable• Show empathy and understanding to group members and they will seek counselling

and talk about sensitive issues• Participants will learn more from you if you are patient and a good communicator• Be mature in the way you handle the individual group members• Encourage members to be supportive of each other• Stop or discourage any judgmental behaviour or laughing at what others say• Respond forcefully to statements that belittle or stigmatise others• Create a climate of trust and openness within the group• Familiarise yourself with the activities via the contents pages of the book• Guide the group to work together to choose a unit or a selection of activities• Check and familiarise yourself with any background information, points for

discussion or specific resources required

You will learn how to become a peer educator by workingthrough the book. By using it as a guide, you will practiceconducting peer group sessions.

Finally, when you have completed the training, you will beawarded a certificate of recognition as a qualified peereducator. After certification, you will be able to work with groups of interested peoplein your institution, workplace or community.

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• Collect the resources you will require and organiseother related logistics.

• If you are going to use a resource persons make surethey are available

• Decide on a simple introduction to the session.• Introductions can be in the form of a song, dance,

poem, quotation (point to ponder), poster oranother art form

• When are you going to work individually, inpairs or larger groups?

• How big will your working groups be and where will they sit?• Consider using an ice breaker to keep groups alive and reduce any tension.• Let group members discuss what they already know about the topic or activity

before reading the list of peers’ suggestions• One of the most satisfying parts of being in a peer group is when one, or more,

people in the group can accurately explain a topic or answer the question, so neverread the points for discussion before ‘opening the floor’ to your group

• Some activities later in the book, do not have a statement asking you to discuss atopic, this is because it is assumed that the group will decide what to do next

• Check all the bullet points mentioned in an activity• Bullet points for discussion are listed to help you make sure that a great variety of

ideas are considered• You may not agree with all the points suggested• Hundreds of points were suggested by previous peer group

members and that is why you will notice that they often readas if spoken by different people

• Admit when you are not sure of something that you may beasked about

• If you are not sure of an answer you can say something like,Does anybody in the group know an answer? then say, Iam not sure about that, but we should try to find outbefore the next session.

• Avoid imposing your own views or beliefs on the group,no matter how valued they may be

• If peer group members have a heated argument on a topicand cannot agree on something, and this is holding up the session, then saysomething like, Well, let’s agree to differ on this particular point and move on.Alright?

• Some discussions are private and sensitive and you may feel uncomfortable at times• Move and talk in a way that makes you feel comfortable.• Some things you will talk about in peer group meetings are confidential so people’s

names and certain topics should never be discussed outside of the meetings• When asking questions, pause long enough to allow people to think, before you

yourself give answers or continue talking• Collect feedback on the session by using the evaluation questions.• Before ending a session, ensure that members are clear about the place and

starting time of the next session.

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PRIVATE STUDY & ASSIGNMENTS: The whole group maydecide to select some activities as assignments or for private study,to be carried out between the meetings. This will mean that moreof the group time is available to cover the issues that are consid-ered particularly important.

USE A VARIETY OF TEACHING/FACILITATING TECHNIQUES: Discussions areimportant, but many activities can be covered by using debate, games, drama,drawing, song, dance, story and poetry. See page 162 for more ideas.

TALULAR IDEAS: Adding TALULAR (Teaching And Learning Using LocallyAvailable Resources) ideas to group activities will enrich the experiences ofperticipants. See page 164 for an introduction to TALULAR.

PICK-AND-MIX ACTIVITIES: Some peer group members will know a great dealabout HIV and AIDS, while others may not. As a group or as individuals, youcan cover the units or activities in any order. The manual is designed so that, ifyou wish to, you can ‘pick-and-mix’ activities that may deal with related topics,which are of particular relevance to you or your group.

Keep track of your individual and group progress. Whenever you com-plete an activity put a tick in the box on the contents page.

TIMING ACTIVITIES: Read through each activity in advance of themeeting. This will help the group to decide the amount of timethat they will spend on each activity. Groups can combine activi-ties, so that more time is available to cover the issues that thewhole group considers particularly important.

The following list of suggestions were considered very important.

More than the ABC of HIV: You are familiar with the ABCmessage for HIV prevention. By the end of the course you willhave created your own A-Z of HIV prevention, treatment, careand support. See page 157 for ideas for your A-Z of HIV.

Create and include messages about protecting vulnerablegroups from HIV. Groups such as pregnant women, unbornbabies, new-born babies and the impoverished. See page 103 fora full list of groups that are at risk and need assistance.

Points to ponder.... Messages..... Log book... Can you work out why certainsuggestions are marked with a while others are marked with a cross

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Unit 1 The Importance of HIV and AIDS preventionIntroductionTens of thousands of Malawians have died from AIDS, probably a million people areinfected with HIV and all of us have been affected in one way or another by the disease.We have over 800,000 children orphaned by AIDS and it is also killing hundreds ofteachers and other government workers every year. If we do not organise effective HIVand AIDS prevention training things will get even more difficult. This training isimportant because it could save your life and the lives of many others close to us.

Learning outcomesBy the end of this unit, you will be able to:• state a few facts about each other• briefly explain the extent of the HIV and AIDS

pandemic• describe the impact of HIV and AIDS• explain the importance of HIV and AIDS prevention• assess your level of knowledge of basic information about HIV and AIDS

Activity 1.1 Meeting for the first timeDivide the group into pairs. If there is an odd number of people, one person should beadded to another pair to make a group of three. Ask them to find out the following:1 Your partner’s name2 Three interesting facts about your partner3 Why your partner wishes to join the Mzake ndi Mzake peer education group4 If they know the meaning of the terms HIV and AIDS

• After a few minutes the group should come together again• Each person should introduce and describe their partner to the group• Summarise (on the chalk board) why people joined the peer group

Activity 1.2 Fears and hopes about Mzake ndi MzakeThis activity should provide you with an opportunity to voice fears and hopes (orexpectations) of the Mzake ndi mzake programme.

What to do next:• divide a piece of A4 paper into four• explain that no names should be put on the papers

which will be displayed later in the session• think about what you expect or hope to learn from

the Mzake ndi mzake programme• write down two things you hope will not happen

during the programme (each answer should bewritten on a separate paper)

• write down two things you hope will happen during the programme (eachanswer should be written on a separate paper)

• ask volunteers to give the meanings of the terms HIV and AIDS• write the meanings on the board (HIV means Human Immmuneodeficiency

Virus and AIDS means Acquired Immune Deficiency Syndrome)

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Activity 1.3 What are the aims of Mzake-ndi-mzake?When all the participants are seated, review the hopes or expectations expressed on thepapers on display. Briefly go through them and explain those likely to be met by thetraining and those which may need further research during or after the course.

Write the aims of Mzake ndi mzake on the board and read them out. The trainingprogramme is designed to enable you to:• explain the basic facts about human sexuality, STIs and HIV and AIDS• carry out a personal risk assessment to discover if your behaviour puts you at

risk of HIV infection• protect yourself from STIs especially HIV and AIDS by changing any behaviours

that put you at risk• promoting positive behaviour change and so help yourself and others in your

community to avoid HIV and AIDS• encourage and support those in the community infected with HIV to live

positively with HIV and/or AIDS

Activity 1.4 Deciding on expected group normsDiscuss what ground rules the group will use during meetings. It is up to the you andthe group, to modify them and add more rules as you may see fit.’

Points for discussion - bring up only if not mentioned - add ideas you discoverWhat have peer group members suggested?• Stay on schedule• One person speaks at a time• Any question asked is a good question• Everyone has a right to change his or her

opinion both during and after a session• Everyone is allowed to express his or her opinion• Respect opinions of everyone• Enjoy the discussions• We are all learners but all of us have something to teach others• If a member of the group consistently breaks group rules then the whole group

will meet to decide what should happen

Point to ponderI know why I would make an excellent group leader, it’s because I have an unshakeableconfidence in my own ability to always make correct decisions. Discuss.

• After everyone has finished, ask participants to put theirpapers in two bags or boxes. One bag labelled for hopesor expectations and one labelled for fears.

• Ask one or two participants to post the fears and anotherone or two to post the hopes or expectations. They mayalso be grouped lying flat on a table top if agreed. Letthe participants view the two sets of papers and talkcasually about their observations.

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Activity 1. 5 How much do you know about HIV and AIDS?This ball game gives everyone an opportunity to assess their level of knowledge onbasic information about HIV and AIDS. It is also an ice-breaker to break the tensionamongst everyone.

Many people are confused about what HIV and AIDS is and how it is spread. Thisgame gives everyone a chance to review some of the things people say about HIV andAIDS. Some of the things you will hear are true while others are false.

How to play the game• Move your chairs into a circle• Ask everyone to stand up• Throw the ball to any participant• As soon as the catch is made the leader should

asks one of the 20 questions shown below• The person catching the ball should respond by saying whether the statement is

true or false.• If the catcher gets the question wrong, they sit down in

their chair and miss a turn• The catcher then throws the ball to another participants

and the leader asks another question• Throw the statements randomly at least twice• The reasons for some answers will become clearer as we

go through the training

Choose the statements from the following list1 HIV is the same as AIDS False2 A person only gets AIDS when HIV destroys the immune system True3 A person will know right away if they have been infected with HIV False4 A blood test will always show that you are infected with HIV False5 You can always tell just by looking whether a person has HIV or AIDS False6 There are many symptoms of AIDS True7 Antiretroviral drugs cure AIDS False8 Faith healing cures AIDS False9 All people who look well are HIV negative False10 People who test HIV negative do not have the virus in their body False11 Some people get HIV from mosquito bites False12 Women are less likely to get HIV than men because their monthly

menstruation washes the virus from their bodies False13 You can get infected with HIV when you donate blood False14 If I have sex with somebody it means I love that person False15 The partner who first shows symptoms of an STI is the one who

brought the infection into the relationship False16 It is easier for a woman to contract STIs and HIV than a man True17 Circumcised men are not infected by STIs or HIV False18 Women who are HIV positive can deliver babies that are HIV negative True19 People living with HIV/AIDS can live a long time if they take ARVs True20 Eating a good balance diet helps to boost immune system True

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Activity 1.6 What is difference between HIV and AIDS?HIV is the virus that causes AIDS. AIDS is not a virus nor a disease. A person only hasAIDS, when HIV has damaged their immune system so much, that their body is tooweak to fight off even ordinary diseases. So, what is HIV? Here is one description.

The Human Immuno-deficiency (=body’s ability to fight infections gets weak) Virus

The diagrams show theoutside of an HIV (left)

and the cross-section throughan HIV (right)

Activity 1.7 How does HIV weaken the immune system?

If HIV keeps killing every CD4 Tcell it enters, eventually our body

is too weak to fight off evenordinary germs and it showssymptoms of many diseases

HIV is powerful. When it gets intoour body it searches for the CD4

T cells and attacks them.It enters the CD4 T cells and

can now control them.

The CD4 T cells are then changedinto HIV copying factories. When

the new HIV copies escape into theblood, they search for more healthy

CD4 T cells to attack

Special white blood cells, calledCD4 T cells, help to protect our

body against infection

When germs enter our bodythe CD4 T cells fightand usually kill them

CD 4T cells help to killthe germs and keep our bodies

strong and healthy

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Acquired = it enters from outside your body and

Immune = your body’s ability to fight infection

Deficiency = gets too weak and

Syndrome = you show symptoms of having not just one illness but many

Points for your discussion, debate, drawing, song, story, play, poem, poster etcWhat have peer group members suggested?• The immune system is a collection of cells which defend our body against infection• When we are HIV free the body’s immune system can cope with most infections• Part of our immune system are the white blood cells, which have the ability to identify

and work together in order to fight off most harmful viruses or bacteria• There are two important types of white blood cells, B-Cells and T-Cells. One type of

T cells called CD4 T cells is important in the fight against HIV. They are often calledhelper T cells

• When HIV enters the blood, our CD4 T cells make HIV antibodies (chemicals), tofight the infection

• Being HIV-positive means that the HIV antibodies are present in your body• There is no way to remove HIV from a body or to kill HIV• Unfortunately the HIV antibodies cannot successfully fight and kill the HIV• A person could be HIV+ for over 10 years before their body starts to weaken and

become unable to fight off most diseases• When HIV gets into the blood of a person, it attacks white blood cells, but it is

especially attracted to CD4 T cells, which it attacks and enters, then it reproduces bymaking many copies of itself. When the HIV copies leave the cell they spread roundthe body attacking and taking over more CD4 T cells

• It is like a defending army losing soldiers while the attacking HIV army is growing• Some HIV infected CD4 T cells are identified as dangerous and killed by B cells• Without enough CD4 T cells, the body is unable to defend itself• As the viral load (the number of HIV copies) increases, the CD4 T cell count decreases• The two types of HIV are called HIV-1 and HIV-2 (Malawi has mainly HIV-1)• Both types cause AIDS although HIV-2 is less virolent than HIV-1• HIV can mutate (change) when it reproduces and it now has at least 9 subtypes• A CD4 (T-cell) count below 350 to 400 cells mm3 marks the onset of opportunistic

infections

Activity 1.8 Research to stop HIV with different drugsScientists know that any drug that can kill HIV will probably be far too strong for ourown human body cells. So, they are developing many different drugs to prevent HIVfrom spreading. They are looking for drugs to stop HIV in at least six ways. Drugs tostop HIV from searching, sticking-to and attacking T cells. Other drugs are to stop HIVfrom entering T cells, while others stop HIV reproducing inside the cells. The last groupof drugs stop the HIV copies getting out of the cells. Each ARV drug stops HIV fromdoing only one of these activities. There is no single drug that can stop all of these HIVactivities by itself. That’s why people take more than one pill when they are on ARVs.

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Activity 1.9 HIV and AIDS Worldwide• Read the following facts about HIV and AIDS• Discuss the implications of the information for HIV

prevention, treatment, support and care• Share you ideas

The term epidemic is the rapid spread of a disease amongmany people in the same place. A pandemic means it occursover a whole continent or the whole world. AIDS is a pandemic.

Points for your discussion, debate, drawing, song, story, play, poem, poster etc• Since the start of the HIV/AIDS pandemic over 25 million people have died due

to AIDS related illnesses.• Sexual transmission accounts for over 85% of all HIV/AIDS infections.• Over 4 million new infections were reported last year with over 2 million of those

in sub-saharan Africa.• Almost 40 million people in the world are living with HIV and over 25 million of

those live in Sub-Sahara Africa.• Africa has over 12 million children who have been orphaned by AIDS.

Anti-retroviral treatment (ART) is prolonging the lives of millions of people whoare HIV+, but not everyone who needs them can get them.

Problems encountered collecting data on HIV and AIDS from around the world• Data collected about HIV and AIDS can give us part of the picture, but may be

inaccurate.• Research shows that many cases of HIV infection are not reported because many

infected people do not go for HIV tests.• An increase in the number of diagnosed cases of HIV in Malawi, does not

necessarily mean that more people are getting infected with HIV. It might meanthat more people are going for HIV tests, because they have become more available,or that stigmatisation of people who are living with HIV has declined, or morepeople are willing to get tested.

• Figures based on gender and age may reflect a group that is more willing to betested than an other. For example more women than men in Malawi undergoVoluntary Counselling and Testing (VCT).

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Roots: family background, whoinfluenced us as wegrew up etc.Trunk and branches: thestructure of our life, things likejob, family, training, and groupswe belong to etc.Leaves: What inspires us. Just asstem and leaves feed the trees.Things like love, compassion,friendship, faith etc.Fallen leaves: struggles andproblems encountered. Thesecould be illness and death offamily and friends. Money usedfor funerals and hospital visits.Not enough food for family;money for school fees etc.Fruits: achievements in life. Yourchildren could be branches orfruits.

Activity 1.10 HIV and AIDS in MalawiAsk the group to review the following information.• Over 11 million Malawians are not infected with HIV. The prevalence rate is just

over 14% this means about 86 out of every 100 Malawians are HIV negative.• Nearly 1,000,000 persons who are infected with HIV, but still look and feel

healthy, 850 000 are adults above 15 years and over 500 000 of these are women.• Because HIV infection is spread mostly through sexual activity, people between

15 and 49 years of age are the most infected.• Malawi has almost 800,000 orphans.• Infection rates are higher in urban areas, where 1 of 5 adults may be infected.• Only 34% female and 41% male adults are aware of how they can prevent

themselves from HIV infection.• In 2008, AIDS -related deaths have dropped by when compared to 2003.• Out of 159,111 people who went onto ARVs in 2004, 106,547 are still alive.• Peer group members should note any new statistics appearing in the media.

Activity 1.11 Why is HIV/AIDS prevention important to our community?• Draw a Life tree with chalk ( on a board/table) and label the parts of the tree• Just as a tree, every human being has different parts to his or her life.• Study the diagram and notes.

Now reflect on your life and complete your Life Tree by examining how HIV andAIDS has affected your life. Share your life tree with the group and summariseunder the following headings: individual, family and community. Adapt this activityfor different audiences.

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Activity 1.12 What is the impact of HIV/AIDS on the individual?Points for your discussion, debate, drawing, song, story, play, poem, poster etcWhat have peer group members suggested?• Shock, stress even anger• Feel betrayed or depressed• Feel unable to cope with life• Lack of income and resources• Sad and pessimistic about the future• Loss of job or school place• Broken relationships• Self-esteem lowered• Decide to live positively with HIV/AIDS• Join support or action group and works to fight HIV• Add any other key points to your list

Activity 1.13 What is the impact of HIV/AIDS on the family?Points for your discussion, debate, drawing, song, story, play, poem, poster etcWhat have peer group members suggested?• Loss of financial resources leading to family stress• Harder to pay any education fees• It is difficult to care for people living with HIV and

AIDS (PLWHA)• Income lost to medical and funeral expenses• Stress due to loss of loved ones (parents, children etc)• Extended family disruption or disintegration• High dependency ratio of children to adults• People have to seek out the best ways to protect family

members from HIV and encourage and assist members livingwith HIV to live positively

Activity 1.14 What is the impact of HIV/AIDS on communities and nation?Points for your discussion, debate, drawing, song, story, play, poem, poster etcWhat have peer group members suggested?• Increase in hospital bed occupancy• Increase in health expenditure straining

national budget• Lower productivity• Pessimistic mood in communities

where some see no future• Loss of skilled workforce• People need training to

replace the sick and the dead• Reduced national income• National development slows• Possible social unrest• Citizens speak out openly about sexual matters that were once taboos• Communities are pro-active by educating all citizens on HIV and AIDS

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Activity 1.16 Assignment: HIV and AIDS and the futureThe assignments are designed to give you an opportunity to share some of theknowledge and skills from the activities you have just completed. They also giveparticipants an opportunity to carry out research and make preparations connectedwith the activities in the next unit or session.

Preparing for behaviour changeRead through the point to ponder and discuss it with friends and family.Point to ponder: If the word development means good change, what changes do youwant to see in your personal life, family life, community life and national life that willhelp.

EvaluationEvaluations can be carried out after each session or at the end of each unit. Use theevaluation questions on page 166 and record the results in an exercise book or on plainpaper for filing. Be sure to indicate the date, unit number, number of members, andyour name in the record. Remember to mention which activities were carried out andyour own feelings about the unit.

Activity 1.15 What is the impact of HIV/AIDS on school-age children?Discuss which of the issues mentioned in activitites 1.12, 1.13 and 1.14, are particularlyrelevant to school-age children.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcWhat points have peer group members suggested?• Orphaned by AIDS or infected with HIV/AIDS• Often need to care for sick parents or siblings• Trauma related to illness and death of family member• The traditional extended family support system is

being over-stretched• Lower motivation due to loss of support from a

disintegrating extended family• Need for children to work• Discrimination and stigma they can suffer in school

due to infection of themselves or death of familymembers

• Early marriage in the case of girl children• Child-headed family and caring for younger siblings• Child is the bread-winner

1 Talk to a friend, neighbour or relative about HIV andAIDS in Malawi.a How concerned are they about HIV and AIDS?b How many people do they think are already

infected?c Let them talk freely about issues that arise.d Tell them that most people in Malawi are HIV

negative.

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Unit 2 Preparing for behaviour changeIntroductionWhy is behaviour change an important part of HIV prevention, treatment, supportand care? It is because HIV and AIDS is destroying the things we value most in life.Our extended families are breaking down. Sickness and funerals are robbing us ofloved ones, hard earned wealth and our traditional lifestyle. Children are orphaned,out of school and many are on the streets. Families and communities are struggling tokeep going. This is why it is important for each one of us to identify what we considerthe most valuable things in our lives and do everything we can to protect them. Theactivities look at the life skills necessary for a person to identify risky behaviours whichneed changing, successfully change the behaviour or support others in the communitywho are trying to do so.

Learning outcomesBy the end of this unit, you will be able to:• list the most important things in your life• identify negative behaviours in society that need

changing• explain why a person’s values play an important

part in behaviour change• describe the character qualities you most value in

a good person• describe how values are acquired and developed• explain how people make choices in life• describe the different stages of behaviour change• explain why making some decisions are not easy• explain how a person can build their self esteem• explain how a person can develop self-control• state the importance of empathy in behaviour change• describe how group identities can unite and divide societies• define and differentiate between a person’s rights and their responsibilities

Activity 2.1 Assignment reviewCarry out a review of the assignment by discussing your findings.

Activity 2.2 What are the most important things in your life?If we asked people around the world this question, what do you think they would say?

Here are some of their suggestions:• You’re only young once. So, you should go out and have fun, fun, and more fun!• I want my share of the good things in life. I want a big car, big house and money!• I want to get to heaven, so my life is lived in order to earn my place in paradise• Seeing my grandchildren growing up and succeeding• Babies. I want to have children, then my life will mean something• I will use any means possible to feed, clothe, shelter and educate my children• I really don’t know, I haven’t thought about it much. I am sure I will think about this

question when I am older• I want to learn absolutely everything I can about this amazing thing called ‘life’• I just don’t care about questions like that, I just need a few drinks

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What are the most important things in your life? When we asked groups of peoplethat question, we got a long list of ideas. Here is the list we compiled. The items arelisted in no particular order of importance.

The most important things in life are:• Marriage • Children• Family • Religion• Own house • Own car• Love • Friends• Enjoyment • Money• Sex• Studying• Being happy• Staying healthy• Career success• Boyfriend or girlfriend• Democracy and freedom• Fashionable clothes• Football and other sports• Travelling abroad• Peace (no conflict or war)• Doing what I want to do• Doing good• My community• My country• The Earth (our environment)..................................................................• Work by yourself• Write the heading The most important things in my life, and then choose the ten

things that you think are the most important in your life• Put a number 1 next to the one you think is the most important• Put a number 2 next to your second choice• Number your other choices until you have put a number next to all of them

Activity 2.3 What are the most important things in life for your group?• Choose someone to read out the list shown above• Write the list on the board before the voting starts• As each item on the list is read out, you should silently raise your hand if that item

is in your top ten• The vote counters should add up the numbers of hands raised for each item and

write the scores on the chalk board• After the whole list of things has been read out, the counters will announce which

are the most important things in life according to the class opinion poll• What are the five most important headings?

Points to ponder• Owning more and more things will never make you completely happy• Sometimes you have to do things that you don’t enjoy• The most enjoyable things that you want to do can damage your body, mind and spirit• We need to develop the strength to make the right choices and stick to them

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Activity 2.4 How can I build high self-esteem?A person who has high self-esteem feels:

uniqueconnectedempowered

What does it mean to be unique, connectedand empowered?

Points for your discussion, debate, drawing, song, story, play, poem, poster etcI am unique (eg. ‘I feel special’)

No two people are the same. Never in the history of the world, has there everbeen anyone exactly like youTo develop high self-esteem you must think of yourself as special or uniqueYou must love yourself, not with an arrogant selfishness, but with the same sortof love you would give a child or partner

I am connected (eg. ‘I feel as if I belong’)To be connected, you must make an effort to form and maintain good relationshipsRelationships can be of many different typesWe should try to form, build and maintain relationships within family, school,community, tribe, nation and/or internationallyAt school or work we belong to different classes, departments, teams and clubsWhen you are connected, you have a sense of belonging. This makes you feelgood about yourselfMembers of groups live or meet together to share this sense of belongingWorship also helps us to stay connected to GodTraditional beliefs say that the community is made up of living people, ancestors,other spirits, animals and plants, air, water, rocks, infact the whole planet anduniverse! God is at the centre of his community and gives everything lifeTraditional believers respect the interaction of everything in the environment andworship in ways that maintain the relationshipsTraditionally, if people work together, and look after living things, the ancestorsand the environment, this strengthens and protects life’s relationships (mwambowa umunthu or mwambo wa umoyo)Muslims and Chrisians believe that every good deed is an act of worship. Gooddeeds therefore strengthen relationships between people and with GodWhen believers meet together for worship or in community service thisstrengthens the connections between all of their believersNon-believers also value relationships but do not consider a God is part of them

I am empowered (eg. ‘I feel that I have talents and can achieve things’)Things that make us feel good about ourselves, can build our self-esteem andempowers usEvery person is born with an special variety of talents, as they develop thesetalents and enjoy the feeling of success, this builds self-esteemIf we leave some talents underdeveloped or unused we can feel depressed andthis lowers self-esteem

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Activity 2.5 Everyone is unique and special

Now we are going to look at ways of strengthening our relationships or connectionswith other people. Malawi’s main religions teach that everyone is unique and special,but we only become fully human when we mix and interact with other human beings.How far do you think that people with no religious beliefs share this viewpoint?

Points for your discussion, debate, drawing, song, story, play, poem, poster etcHere are some suggestions:

If I want to be treated as unique and special I must learn to treat other peopleas unique and special tooUnfortunately, we humans can find it very difficult to live peacefully together fora long timeIf we are to enjoy good relationships we must always consider the thoughts andfeelings of others

Activity 2.6 How can we develop empathy?Empathy is the ability to imagine what another person is feeling and thinking. If youcan imagine what a person is feeling or thinking you might understand why theybehave as they do.


One of the best ways to develop empathy is to imagine that you are standing insomeone else’s shoes or walking a mile in someone’s shoesBy developing empathy we can try to share other people’s feelings such as fear,sadness, joy and happinessIf we learn how to empathise it may help us to become more compassionatetowards other peopleChristianity, Islam and Traditional Religion consider compassion to be one of themost important virtuesLike other virtues empathy to others does not develop straight away and mayneed to be practicedbefore it becomes a habit

You may wish to combine this activity with activity 2.25 on page 42.

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Source: Times

Activity 2.7 What is happening in Malawi today?We love to call our country the warm heart of Africa. As a nation we value the idea of akind and generous heart. Many foreign visitors comment on how much they enjoybeing in the country. Many names that we give children reflect the traditional valueswe would like to see in our children.

But some of the good things that made us the warm heart of Africa are changing.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcLook at what some people are saying about Malawi today:

People are forgetting our traditional values that’s why things are going wrongHIV and AIDS are destroying family and community lifeHIV is harming our efforts to develop into a 21st century nationHIV is spreading because of a decay Malawi’s moral standardsCorruption is playing a part in keeping thousands of Malawians in povertyAIDS is not just about abstinence, faithfulness and condoms. Poverty and genderinequalities are complicating our fight against HIV and AIDSChildren are not getting the right sexual reproductive health lessons they need a new sortwhich includes moral educationTeachers, preachers and politicians are not the role models they used to be

• Which statements do you agree with?• Which ones do you disagree with?• Which ones are you not sure about?• Discuss your answers with the group

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Activity 2.8 Which negative behaviours in our society need changing?

Before we look at behaviour change for action against HIV infection, we need to look atbehaviour in general.

How would you define the terms good behaviourand bad behaviour.Here are two suggestions:

Good behaviours are the actions that webelieve to be right, just, fair, positive,constructive and true.Bad behaviours are the actions that webelieve to be wrong, unjust, unfair,negative, destructive and false

Describe some of the bad behaviours in our society that you would like to change.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcAlcoholism and drink induced negative behaviourIllicit sexual activities like pre-marital sex, adultery, under age sex and spousal rapeSmoking chamba and taking drugs leading to addictionPrejudice and discrimination against minority groups (eg people with disabilities)Using power and position to influence employment interviews, school places etcOver-eating to the point of being overweight or obese, even though many people inthe country go hungry and are under-nourishedPetty stealing of small things from the work placeNot being polite to someone because you believe you have more statusNot speaking out or taking action when a neighbour (male or female) is subjected togender based violenceAllowing boys to play while girls fetch water, wash, cook and clean the houseFavouring a son or boy child over a daughter or girl childLying about where you have been and what you have been doingTelling someone you love them when what you want is sexual intercourseAvoiding doing a very important job by doing a less important taskAccepting bribes in the form of money, gifts or favoursOverspending on luxuries when orphans and street children are struggling nearbyGoing to worship regularly, but not living a truly religious lifestyleStaying silent about girls being sold or given as child bridesExam leakage

Points to ponderWhat we think and believe greatly influences how we behave.• Why do some people behave in a negative way, even though they know and want

to do the right thing?• Think about how all sorts of negative behaviours can affect the spread of HIV.

Source: Headline in The Malawi News, August 9-15, 2008.

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Activity 2.9 Why should we discuss values, virtues and vices?Our values greatly influence our behaviour and may therefore put us at risk of HIVand other dangers. Values also influence how we interact with others in our society.What are values and what is the difference between virtues and vices?

Points for your discussion, debate, drawing, song, story, play, poem, poster etcHere are some suggestions:• Values are the human character qualities that

a person or a group considers valuable• Most societies consider virtues to be the most

important character qualities (values)• Virtues are the types of feelings, thoughts and

behaviour that a society calls right or good• Virtues are important and useful in building

and sustaining a community• Virtues are called good habits, because they can

be practiced over and over again• Vices are the types of feelings, thoughts and

behaviours that society calls bad or wrong• Vices are considered dangerous and destructive to development of a community• Vices are called bad habits, because they can be repeated over and over again• Some vices are considered so bad that they may be called evil or wicked• Many people have vices, bad habits, that they think they cannot stop• When a person’s values contain serious vices, we say they have poor moral

standards or that their personal values are wrong• How we feel and think seriously affects the way we speak and act• All of Malawi’s major religions, teach that few human beings are perfect and that

we all have a mixture of virtues and vices• Strengthening virtues and fighting vices will make us better people and our

families and communities more safe, peaceful, prosperous and happy• Traditional rules of behaviour (mwambo) help a person to become umunthu

(a complete human being) and as the Tumbuka say, this helps towards thecreating and sustaining muzi uweme (good village or village of goodness)

• Christians use Jesus as the perfect role model, individuals work to behave as Jesuswould, so that the local and worldwide church is a living example of Christlikebehaviour

• The Muslim Hadith describes what Muhammed, said, did or approved of. It saysthat the most perfect Muslim, has the best character and that virtue leads toparadise. They use the examples of prophets they consider to be perfect rolemodels, such as Isa (Jesus), Yusuf (Joseph), and especially Muhammed

• Good Muslim behaviour is seen to strengthen the jummah (the local community)as well as the ummah, the world wide community of Muslims

Points to ponderWhat would Jesus, Muhammed or a genuine umunthu (ancestor or living) say and do iffaced with some of the negative situations found in Malawi today? Discuss

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Activity 2.10 What is your idea of a good person?

Here is a list of good character qualities or virtues found in communities all over theworld. Some words have similar or overlapping meanings. Look through the words,choose your own top ten virtues, the ones that a person like yourself should display.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcI am a good person if I am:1 Caring: show affection and concern for other people2 Chaste: do not have sex except with the person to whom I am married3 Compassionate: feel or share the suffering of others and want to help them4 Courteous: show good manners5 Courageous: ready to face and endure great difficulties, danger, pain or suffering6 Forgiving: ready and willing to forgive7 Generous: ready to give freely or share8 Gentle: kind; careful; not rough or violent9 Hard working: works hard to improve personal, family and community life10 Honest and truthful: ready to tell the truth, not lying, cheating or stealing11 Hopeful: confident of future success12 Humble or modest: not openly proud or boastful13 Just: behave in a fair and correct way14 Kind: show concern for the feelings of others in a gentle and friendly way15 Loyal or faithful: true to my religion, partner, family, friends and people16 Loving: feel and show love to one or more (partner, children, family, God etc)17 Merciful: show a forgiving attitude towards someone that I could hurt18 Obedient: obey fair rules and laws19 Patient: accept annoyance, suffering and delays without anger20 Prudent: act wisely or carefully when planning for the future, especially money21 Resourceful: good at finding ways out of difficulties or creative ways to do things22 Respectful: show respect and admiration23 Responsible: reliable or sensible when carrying out a duty or task24 Temperate or self-controlled: able to control excessive behaviour, especially

anger and the amount I eat and drink, drinking little or no alcohol25 Tolerant: accept that people have the right to hold different beliefs to my own26 Trustworthy: able to be trusted, reliableWhich of these values do you think are important in traditional African culture?

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Activity 2.11 What are the major virtues and vices in society?Compare your findings from the last activity with the lists shown below.

Christian virtuesThe seven Christian virtues are:1 Justice. You treat all people fairly2 Courage. You are ready to face and endure pain,

suffering and trouble3 Prudence. You plan carefully and wisely for the

future4 Temperance. You control your desires5 Faith. You are true to your religion6 Hope. You are confident of future success7 Love. Christians consider this the greatest virtue of all

Islamic virtuesΙslam values all of the above virtues, but believes that only by practicing the 5pillars of Islam can a believer develop the right attitude of mind, body and soulinorder to face any moral choice. The five pillar of Islam are:1 Faith. Declare that there is no God but Allah and that Muhammed is his prophet2 Prayer. Pray five times daily3 Charity. Every year Muslims gives at least 2½% of their savings to the poor4 Fasting during the month of Ramadan5 Pilgrimage to Makkah once in a life time if circumstances allow

The seven deadly sins (vices)The seven deadly sins were identified by Christians as the most serious threats tosociety and the chances of a individual getting a place in heaven. For religiousbelievers, a sin is anything that goes against God’s teachings. The 7 deadly sins are:1 Pride. Arrogance; having an inflated opinion of yourself; being big-headed2 Anger. Strong feeling of displeasure which may lead to loud or violent behaviour3 Envy. Jealousy; wanting what someone else has or to be like someone else4 Lust. Greed for sex; sexual desire, but with no love involved5 Gluttony. Greed for food and drink6 Avarice. Greed for power and wealth7 Laziness. Finding excuses and ways to avoid doing important work

Activity 2.12 Do different people need different virtues ?List some of the character qualities that you think the following people should show:• good friend • good teacher • good nurse• good mother • good street child • good father• good religious leader • good parent living in poverty • good sex worker

Point to ponderOur streets are now filled with street kids... smoking, taking drugs, stealing, sleeping intunnels and eating dirty food... it is breeding a generation that will be uncontrollable... theywill have no human heart and will be prepared to kill to get what they want! Discuss.

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Activity 2.13 The major values in the UN Millenium Development GoalsThe United Nations has made a statement about the values shared by over 200 of itsmember states.

Read through the following quotation from theUnited Nations, which outlines the major valuesin the UN’s Millenium Development Goals.

Discuss whether the list fits in with your ownthoughts or those of the group as a whole.

‘’We consider certain fundamental values to be essential to international relations in thetwenty-first century. These include:• Freedom. Men and women have the right to live their lives and raise their children indignity, free from hunger and from the fear of violence, oppression or injustice. Democraticand participatory governance based on the will of the people best assures these rights.

• Equality. No individual and no nation must be denied the opportunity to benefit fromdevelopment. The equal rights and opportunities of women and men must be assured.

• Solidarity. Global challenges must be managed in a way that distributes the costs andburdens fairly in accordance with basic principles of equity and social justice. Those whosuffer or who benefit least deserve help from those who benefit most.

• Tolerance. Human beings must respect one other, in all their diversity of belief, cultureand language. Differences within and between societies should be neither feared nor repressed,but cherished as a precious asset of humanity. A culture of peace and dialogue among allcivilizations should be actively promoted.

• Respect for nature. Prudence must be shown in the management of all living species andnatural resources, in accordance with the precepts of sustainable development. Only in thisway can the immeasurable riches provided to us by nature be preserved and passed on to ourdescendants. The current unsustainable patterns of production and consumption must bechanged in the interest of our future welfare and that of our descendants.

• Shared responsibility. Responsibility for managing worldwide economic and socialdevelopment, as well as threats to international peace and security, must be shared amongthe nations of the world and should be exercised multilaterally. As the most universal andmost representative organization in the world, the United Nations must play the centralrole.

It is important for us to appreciate that the six UN values mentioned here will keepreappearing in the national media and within our local communities.

Later, we will get another opportunity to discuss how far the shared values of the UNmay influence efforts to reduce the prevalence of HIV around the world and moresespecially in Malawi.Point to ponderIt is wrong to assume that the whole world could share the same basic values. Discuss

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Activity 2.14 How are virtues and vices developed ?


Giving people a list of rules to follow works only so far, if other members of acommunity openly break society’s rules in full view of othersIn traditional life, umunthu, is the person showing moyo wangwiro (good spiritualhealth) or moyo wabwino (good living)Traditionally, the ancestors are considered role models and are rememeberedbecause of their good lives, and there is no real afterlife for badly the behavedPeople develop virtues and vices and turn them into habits, by following theexample of role models around them. Not only what these role models say butmore especially what they doTeaching by examples which stress responsibility and self-control (discipline)People, especially children, copy or imitate the actions of older communitymembersMuslims consider Muhammed to be the best role model (Uswatun Hasanah)Christians say that people can see the character of Jesus in the loving actions ofgood Christians and the young should model this sort of behaviourYou may want to possess a virtue but it can only be made a full part of yourlife through practice, practice and more practiceIf you wish to be brave you must practice being brave, starting with small acts ofbravery and building up to greater acts by making bravery part of your characterHow could you help a child to learn to be kind and generous?Try to become wise by making good decisions based on knowledge and experienceIt is said that if you want to become wise you must examine your emotions,thoughts and behaviours in order to discover your personal virtues and vices

Point to pondera) Whoever is granted wisdom has indeed been granted wealth abundant (The Quran)b) Wisdom is more valuable than jewels (The Bible)

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Activity 2.15 Why do we behave as we do?

When we decide what we think is right and what we think is wrong, we have made amoral decision. As we grow up and then grow older, we learn that life is all aboutmaking the right choices or decisions. Every choice we make has one or moreconsequences. Some choices may be very easy to make, while others are very hard.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcPeople all over the world use the same methods when making choices. Here are someof the different ways in which people decide what is the right thing to do:1 I obey God’s laws. Most religions have a set of rules and laws that are believed to

have come from God. Believers are expected to obey the laws of their religion.One rule appears in all the major world religions. Compare the following versionsof what is called the golden rule.

Christianity - Treat other people as you would like them to treat youTraditional - Do for others what you want them to do for youIslam - Nobody truly believes, until he wishes for his brother what he wishes

for himselfBuddhism - Act towards other people as you would act towards yourselfSikhism - What you consider for yourself, so consider for othersHinduism - Do nothing to others, which would cause pain when done to you

2 I am not religious, but I always follow the golden rule3 I am a good citizen and always obey all laws4 I will do anything to avoid punishment or pain5 I follow cultural tradition6 I think about myself first, my pleasure, possessions and position7 I do whatever will please my peers, constitutants and tribe8 I copy older members of my family and community9 I only help those who can help me10 I do it because it feels like the right thing to do11 I rebel, against a society where I am poor, marginalised, without hope

• Discuss whether you use one or more of these reasons when deciding what to do• Can you list any reasons why people find it hard to follow the golden rule?

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Activity 2.16 Rights and responsibilitiesToday, people are talking a lot about human rights. Malawi’s religions and the consti-tution say that as well as human rights you also have human reponsibilities.What is the difference between a human right and a human responsibility?

Human rights are things you are free to do or the things your family,community or nation should do for you.Human responsibilities are the good things you should do to help other peoplesuch as your family, community or nation. To also have a responsibility not to dothings that might be harmful to yourself and others.

What are my responsibilities?There are two types of responsibility:

Legal responsibility - something the law says that you should or should not do.Moral responsibility- somethings that your personal code of conduct (code ofbehaviour) say that you should or should not do. This is also called a moral duty ormoral obligation. For example there is no law that says that Malawians have tocare for their parents when they get old. But most Malawians say they have amoral responsibility to do it.

Activity 2.17 How to make the right decisionIn activity 2.15, we looked at some of the reasons why people behave as they do. Inactivity 2.16 we looked at rights and responsibilities.

In life we face millions of choices and our choices change the world in millions ofdifferent ways. Our choices create our own lives and alter the lives of others. Here is aseven step method, that many people have used to help them make the right choicesin life.

If you have a decision to make, go through the seven steps before you act.1 What is the problem that you are facing?2 List all of the different ways in which you could solve the problem3 List the consequences for each of the different choices4 Do the choices and consequences match up to your personal values?5 What will be the impact on other people of each choice?6 What is the best alternative?7 Act on your decision

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Activity 2.19 When free will clashes with the golden ruleThe major religions in Malawi say that God has given human beings free will. Non-relgious people often believe that they have free will, but it is not a gift from anyone.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcIf I have free will it means that I am the one who has to choose between good and badthoughts, words and deedsI am the only one who can control my feelings, thoughts, words and actionsYou have freedom of choice. In a one-party state or dictatorship choice may belimited, in a developing democracy more and more choices become availableA selfish or self-centred person might say something like, I do what I want to do, myfeelings and needs are the priority. Are there any times when selfishness would bejustified?If I am selfless I think more of other people’s feelings and needs than my ownThe golden rule reminds us that, even if we have to care for others, we must love andcare for ourselves as well, because if we don’t love and care for ourselves we will not beable to care effectively for others!

Activity 2.18 Is there a struggle going on within me?All the major world ideologies, teach that the strength andgoodness of a community, depends upon the decisionsthat individual community members make. If individualsbehaves in positive or constructive ways, the communityis strengthened. But, if an individual chooses to behave ina negative or destructive way the community is weakened.

When we try to decide what to think or do, it can feel as ifthere’s struggle goig on inside us. Some people say that itis as if I am wrestling with my conscience. They mean thatchoosing between good and bad thoughts and actions canmake you feel uneasy inside.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcHere are a few more comments about the feelings and making the right choices.Which of the quotes do you feel expresses your own feelings?• My vices and virtues are competing with each other deep in my head and heart!• It seems as if an angel is whispering in one ear and a devil is whispering in the other• My good side is arguing with my bad side• Sometimes I get some really bad thoughts

and I am glad people can’t read my mind!• I have to fight my selfish thoughts and

urges all the time! Sometimes it’s so veryhard to behave in a good, fair and kind way

• A vice will stay a living, breathing, ugly part of you until you yourself destroy it!Have you ever had the same sort of thoughts and feelings? Describe one occasionwhen you struggled to make a decision.

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Activity 2.20 How do I lose self-control or self-discipline?If you have self-control, you have the ability to control your feelings, thoughts andbehaviours. So, how do we lose self-control?

Points for your discussion, debate, drawing, song, story, play, poster etcHere are some suggestions:• Religions often describe the struggle for self-control as a war!• It is better to win control over yourself than over whole cities (Bible)• The greatest jihad is against the self (Hadith)• You lose self-control when you give in to, or surrender to your vices• The serious vices are the seven deadly sins of pride, anger, envy, lust,

gluttony, avarice and laziness, because they can make you act very selfishly• When you give in to your vices, you may feel uncomfortable inside, have a guilty

conscience and this lowers your self-esteem• ..wrong doing is that which wavers in your soul and which you dislike people finding

out about (Qur’an)• Many Malawians, believe that good and evil forces are at work in the world. These

forces can influence and destroy a person’s self-control• Satan said, I had no power over you except that I called you and you obeyed me. So do

not blame me, but blame yourself (Quran)• Jesus was tempted and had to forcefully repulse his negative thoughts• Many believe evil spirits (mfiti), sorcery and magic are some of the things that can

weaken a person’s self-control

Point to ponderAlcohol and other drugs make us feel, think and act differently. We can be excited anddepressed it can really influence or destroy our self-control. Discuss.

Activity 2.21 How do I develop and nurture self-control?How do we develop and then nurture the life skill of self-control or self-discipline?

Points for your discussion, debate, drawing, song, story, play, poem, poster etcHere are some suggestions, can you think of any others?

All forms of worship try to keep humans connected to God, so that they can askfor help when they need itMuslims believe that life is a test which they must pass inorder to go to paradiseThe five pillars of Islam help Muslims to maintain self-discipline on a daily basisChristians say that the Holy Spirit advises and strengthens self-controlTradional believers appeal to azimu for help with prayers like, mzimu ndirinde(Take my hand my ancestral spirits)Positive thinking, as it always helps to look on the bright side of lifeDon’t continue arguing say, I see your point but think differentlyDon’t continue arguing say, I think we should agree to disagree

Point to ponderIt is so hard to resist temptation! No matter how much I try I seem to be drawn back tobehaving badly. What can I do? Discuss.

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Activity 2.22 How can I change my negative and risky behaviour?How have other people changed their lives around? How can someone change theirnegative or destructive behaviour into positive and constructive actions? Well, behaviourchange involves knowledge, attitudes as well as actions. Your knowledge and attitudeswill probably need to change before anything else. Inorder to successfully stop negativebehaviour a person needs to go through various stages of change.

The 6 stages of behaviour change are :1) Not thinking about changing2) Thinking about changing3) Preparing to change4) Changing5) Making the change a habit6) Trying not to slip back to old habits

Points for your discussion, debate, drawing, song, story, play, poem, poster etcThe stages of behaviour change in more detail are:1 Pre-contemplation....... I am not thinking about changing my behaviour.

I am in denial, because I don’t think I have a problem... I don’t have a problem!2 Contemplation............. I accept that I have a problem and I have identified it!

I am thinking about changing my negative behaviour. But, something has to happento motivate me to change an event or person. The root of behaviour change is in themind and usually requires a complete change of our attitude to something.

3 Preparation ................. I am planning and getting ready to change my attitudeand then to change my behaviour. I have gathered information, learned how tochange, decided when to change, know what the impact will be of my change, I amnow determined to change! I am developing an action plan that I will use to makechange disciplined and easier.

4 Action ........................... I have stopped my negative behaviour by changing topositive actions or avoiding certain risky situations. I am putting my action planinto operation (using all previous information, plans, new skills, experience,decision making).

5 Maintenance ................ I am practicing my behaviour so it becomes a positivehabit that I can call upon when necessary. I have ways to reinforce this newbehaviour, ways to support and sustain my positive living.

6 Relapse (Start-over).... I have slipped back into my old behaviour to one of theother stages. People tend to move back-and-forth between stages, and a relapse to aprior stage is always possible. In fact, people can relapse to any stage, but a return topre-contemplation is least likely. It is important to remember that changing yourbehaviours, especially intimate and private behaviours, is a complex process.

Points to ponderIndividuals, couples, groups, institutions, communities and governments all can and do usethis process to promote development, which is positive change. Discuss.

Pick out some of today’s key issues and discuss how behaviour change has beensuccessfully promoted. Some issues could be gender, democracy, crime, orphans andvulnerable children, malaria, primary education and of course HIV and AIDS.

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Activity 2.23 Groups can unite and divide usPeople all over the world are born into groups like families, tribes and nations. Wehave no choice about some of the groups we belong to, this is because we do notchoose things like our sex, colour of skin or whether our parents are rich or poor. Onthe other hand, we can choose whether or not we want to join some other groups likereligions, political parties, sports or social clubs.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcWhat are some of the things that can be used to unite or divide people?

• Age: between old and young• HIV: between HIV+ and HIV free• Gender: between male and female• Colour: between black and white• Lifestyle: between rich and poor• Education: between educated and

uneducated• Tribe: between your tribe and mine• Region: between north and south• Politics: between UDF and DPP• Religion: between your religion and

mine

• Nationality: between Malawians andother nationalities

• Laws: between criminals and theirvictims

• Sport: between fans of different teams• Disability: between able-bodied and

disabled• Music: between rap and gospel• Fashion: between traditional and

modern• Beauty: between those who are

thought beautiful and those who arenot

Points to ponderIt is not the obvious things that divide human beings. It is not colour nor race nor religion,it is our envyof those who have more than us and our fear of anyone who is different.Discuss.

I just don’t like them, I have never liked them. In fact my father and grandfather hatedthem as well and warned me about them on numerous occasions. Discuss.

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Activity 2.24 How do prejudice, stigma and discrimination divide people?Point to ponderIt is often easier to blame our problems on outsiders like foreigners and the underclass thansee that the solution is in our own hands. Discuss.

Prejudice• We are prejudiced if we prejudge before we know all the facts• We can prejudge individual people and groups of people• Prejudice happens in our minds and involves our feelings and our thoughts

Stigma• In olden times, in different parts of the world, slaves and criminals were often

marked on the skin with a tatoo or branded with a hot iron• The Greeks called this mark stigma. It was like a label that the slave or criminal

carried everywhere and could be seen by everyone they came into contact with.The mark showed they were different, it made them outsiders from society

• When we stigmatise, we are now acting on our prejudice• When we stigmatise ,we are pointing the first finger of our prejudices• When we stigmatise, we are labelling someone as being different to ourselves and

we make them outsiders• Stigmatizing involves feelings, thoughts and behaviour.• Stigmatizing can develop into a serious form of negative discrimination

Negative discrimination is often the end result of stigmatizingDiscrimination is when we put our thoughts and feelings into action. We treat somepeople in different ways than we treat others. Favouritism is a form of positive dis-crimination. The next activity will look at how discrimination may affect others.

Activity 2.25 Assignment: Standing in someone else’s shoesDuring a typical day we meet all sorts of people at markets, in shops, on the roadand at work. It is often easy for people to discriminate against others they meet,especially in a situation where a dangerous disease is preading in our community.

• Observe the different types of people you meet or pass by• Imagine what it would be like to live as some of the people you meet• Choose four people from the list shown and write short notes, a poem or a song

describing the life of each of your choices• You can start each description with the words, What would my life be like if I was a

• rich person• male street child• female street child• unemployed single mother• president of Malawi

Evauation. Use the questions on page 166 and enter the results in your log book.

• refugee or displaced person• person of the opposite sex• prisoner• poor student needing school fees• person of a different race or colour

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HIV

IntroductionThe drawing above is adapted from a well known cartoon. What point do you think itis trying to communicate? The drawing is pointing out that sex and love can makepeople feel, think and act in ways that could be described as crazy. If HIV is now adanger to people forming sexual relationships, then it affects billions of men and womenall over the world - including ourselves and our children - and it is essential to study itin greater detail.

In order to recognise our feelings, thoughts and actions concerning sex and affection,we must understand the relationship between love, sex and sexuality. This will help usto respect our own feelings as well as the feelings of others which may influence howhumans behave.

Learning outcomesBy the end of this unit you should be able to:• explain the terms sex and sexuality• describe elements of human sexuality• describe factors that influence sexuality• discuss some of the physical and psychological

changes which take place during adolescence• explain how sexuality can affect behaviour• describe the features of the female reproductive system• describe the features of the male reproductive system• list some of the reasons why people have sexual relationships• answer some of the most frequently asked questions about sex and sexuality

Activity 3.1 Assignment reviewCarry out a review of the assignment by discussing your findings.

Activity 3.2 What is love?As you work through this unit on sex and sexuality, remember that love is consideredto be a significant part of most sexual relationships. Look at the types of love mentionedbelow and discuss how they may relate to discussions on sex and sexuality.• Love of objects and experiences - I love eating chicken; I love drinking beer; I love dancing• Love of family and friends - I love my grandmother; I love my old friend so much• Love of husband/wife (partner) - My wife/husband has always been my one true love• Love which is unconditional - I try to love other human beings without conditions

Unit 3 Relationships and human sexuality

+

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Activity 3.3 Sex and sexualitySex is a condition of being either male or female. This aspect is genetically and biologicallydetermined and cannot be changed. On the other hand, sexuality deals with thebiological, psychological, socio-cultural as well as ethical aspects of human sexualbehaviour. Biological aspects of sexuality refer to issues of reproductive organs,hormones, nerves and brain centres. The knowledge about biological aspects help usto understand how the body responds to sexual stimulation. However, it is importantto note how people view themselves as males or females constitutes the psychologicalaspects of their sexuality. Therefore, sexuality is associated with all the feelings, thoughtsand behaviours of a person in relation to issues such as love, attractiveness and sexualintimacy.

• Discuss the relationship between sex andsexuality

• Discuss the importance of learning about sexand sexuality

Activity 3.4 Elements of human sexualityHuman sexuality is a broad concept which includes the following elements: sex,sexuality, sexualisation, sexual intimacy and self-identity.

Points for your discussion, debate, drawing, song, story, play, poem, poster etc• Discuss the terms sexuality, sexualisation, sexual intimacy and sexual-identity• Discuss the importance of self-identity in relation to sex and sexuality

Sex is the condition of being male or female.

Sexuality refers to those aspects of gender identity that relatesto sex. These include sexual desires, sexual behaviours andsexual orientations. You need to understand human sexuality,so you can learn how to protect yourself. Sex is frequentlysecret and emotional, so many people have a lot of troubletalking about sex.

Sexualisation is using sex or sexuality to manipulateor control other people. It is manifested through suchbehaviour as flirting, seducing, withholding sex froma partner in order to punish or to get money.

Sexual intimacy is the ability and need to be emotionally close to another humanbeing and have that closeness returned. Sharing intimacy is what makes personalrelationships rich. While sensuality is about physical closeness, sexual intimacy focuseson deeper emotions too.

Sexual identity is a person’s understanding of who she/he is sexually. This includes thesense of being male or female (sexual orientation). Sexual identity can be seen as threeinter-linked factors. These are gender identity; gender role and sexual orientation.

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Activity 3.5 Sexual developmentDuring sexual development children experience many changes in their bodies as theygradually become sexually mature. Sexual development usually starts some timebetween ages 9 and 16. Most girls start their sexual development earlier than mostboys. Ask the group to study the diagrams below. Discuss what aspects mentioned inthe diagams are the most significant aspects of male and female sexual development.

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Activity 3.6 Sex, love and behaviour change in adolescents and adultsAs children grow into teenagers and towards adulthood, parents, relatives, communityleaders, teachers and others become concerned that the young will work hard, stay outof trouble and grow into successful members of society.

The issue of sex before marriage worries adults, and they often sternly warn both boysand particularly girls, against sex that can bring unwanted pregnancy and HIV into thefamily home and the shame that would result. In many societies around the world, thishas meant that sex has often been given a bad name, labelled as dirty or somethingwhispered about, but never freely talked about in any great detail.

Here are some things that people have said about sex and love, that might influenceour view of sex, our sexual behaviour and any possible behaviour change to be madeby ourselves or others. Read the statements through and think about whether youshare the view or disagree with it. Spend only ten minutes or so on the activity andresist the temptation to impose your own ideas on others, agree to differ and move on.

1 Sex is beautiful, special and essential for human survival2 They way I love my wife is completely different to the way I love my children, the

way I love God is so different to the way I love football andeating chicken with nsima.It so gets confusing, having one word for so many feelings!

3 Sex without love is animal lust, rats do it, pigs do it even cockroaches do it4 Sex between two people can be wonderful, exciting and enjoyable experience, but

they don’t need to be married or even love each other5 Sex is just for making babies6 Love making is to make babies from love7 Sex is about giving and sharing rather than taking or having8 Sex should bring loving partners closer together9 Sex should be love-making and love is always more than just sex-making10 Sex should make both partners smile and feel happy11 Sex is to be enjoyed by both men and women12 Sex education films which show enjoyable ways to make love are useful to a society13 Sex in pornographic films is a corrupting influence on society14 Boys talk of love when what they want is sex, while girls use sex because what they

really want is love15 If parents really love their children they would talk to them about sex and not leave

them find out fromtheir possibly misinformed peers

Did you find that this activity created a lot of heated discussion and debate? Well,anything that creates such energy is useful, especially if we can focus efforts on thefight against HIV.

Points to ponder.HIV is passed on by sex, and sex and love are also the most powerful tools we have touse in HIV prevention, treatment, care and support. Discuss

When I make love for the very first time, I want it to be a very special event. I want toremember it for the rest of my life. Or is that too much to ask for? Discuss

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Activity 3.7 The external features of the female reproductive systemThe group may split into male and female groups for this activity. Study the diagramsof the female reproductive organs. Locate the clitoris, labia, urethral opening, vaginaand anus.

Drawing of a woman’s external genitaliaThe clitoris is a small firm organ at the top ofthe inner vaginal lips. The clitoris is a verysensitive part of a women. It provides manypleasurable feelings during sexual activity.The labia or vaginal lips cover the delicate areawhere the openings of the urinary tract andthe vagina are located.The urethral opening is where urine comes out.

The vaginal opening is below the urethral opening. This is the outlet for a baby duringchild birth and through which a penis penetrates into the vagina during sexualintercourse. The anus is the opening where faeces (waste products) come out.

Activity 3.8 The internal features of the female reproductive systemStudy the diagram and locate the ovaries, uterus, and vagina.

The ovaries usually produce one egg every month.The egg travels down a narrow fallopian tube and isfertilised and then moves down to the uterus.The man’s sperm travels from the vagina up the uterusto the tube. If the sperm meets the egg, the egg isfertilized and the woman becomes pregnant.The uterus is the place where a fertilised egg growsduring pregnancy. Each month if she is not pregnant,a woman menstruates: she sheds the blood-rich liningof the uterus. Usually the uterus is only about as bigas a fist. It expands during pregnancy.

The vagina is the passage from the uterus to outside the woman’s body. It producesvaginal fluid and act as a passage for menstrual flow. During sexual relations, the man’spenis goes inside the vagina and releases sperms.

Points to ponderIn female circumcision the clitoris is cut out, usually with a sharp knife, and the vaginal lipsare stitched closer together to make the vaginal opening smaller. During her first sexualintercourse the young woman is very vulnerable to medical problems. Discuss

In male circumcision the loose skin (foreskin) which folds over the head of the penis is cut off.This reduces the chances of being infected with HIV, but may reduce pleasure because themovement of the skin at the base of the penis head. Discuss

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Activity 3.9 The features of the male reproductive systemLook at the diagram of the male sexual anatomy and locate the scrotum and testes,urethra and penis.

The scrotum is a sack, which contains the twotestes and protects them against damage or injury.It controls the temperature around the testesThe testes produce the sperm that can fertilizea woman’s egg. Testes produce a hormone calledtestosterone.

During sexual activity, the sperms travel throughtubes in the testes and the penis and then theyare expelled from the penis. Seminal vesicles arepocket like structures lying around thespermatic cord. Seminal vesicles produceseminal fluid which is important for the survivalof sperms.

The urethra is the small tube that carries urine or the semen, down the penis to theoutside the body. During ejaculation, a special valve closes off the bladder so no urinecan mix with the semen and sperm

When a man is sexually excited, the penisbecomes erect (larger and firmer). It is atthis time that he can push his penis intohis partner’s vagina. Semen containingsperms comes out with force when theman has a climax or comes. Not havingsex or an ejaculation does not cause anyhealth problems, because sperms arere-absorbed into the body.

The anus is the opening where faeces(waste products) come out.

Activity 3.10 What should we call the male and female reproductive parts?This activity contains terms that may be offensive to some people, or be censored frommainstream media. In order for peer groups to be effective they have to discuss whatterms are use for male and female genitalia (private parts).

• What names do you use to for the male and femaleprivate parts?

• When do people use the scientific names?• List all the different names you can think of, that are

used for the male and female genitalia - see page 169• Discuss which terms could be used with different peer

group audiences• What words would you use with children?

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Activity 3.11 Over thirty reasons why people have sexual relationshipsThere are many reasons why people form sexual relationships.• Read the list of reasons why men and women form sexual relationships. If you are in

a group circle let each person read a line each until you finish the list• Decide which of the reasons are good and make you feel happy and which are bad

reasons which make you feel sad or angry?

Points for your discussion, debate, drawing, song, story, play, poem, poster etcI have this sexual relationship because I want to:1 give and receive love in a very special way2 get special treatment and promotion (eg. workplace, school, college, services)3 have a baby4 discover the ’fireworks’ that go with sex that’s in hollywood films and in other media5 fulfil one of God’s purposes for marriage6 obey my husband who says that my duty is to have sex with him whenever he wishes7 prove my manhood (or womanhood)8 get money, fashion clothes and gifts9 get a fresh experience, my wife (or husband) is not as tasty as she was when we met10 show my husband (or wife) that if he can be unfaithful so can I11 please my teacher so he gives me good marks12 get or keep my job13 make good friends with this person who could give me a much better quality of life14 prove my independence and sample what this sex thing is all about15 be released from this police station cell without being charged16 get this influential person to help me afterwards17 release the tensions in my body18 be cleansed after my husbands death (kupita kufa)19 be initiated into womanhood (kuchotsa fumbi)20 have a temporay husband replacement (mbulo)21 have a change of wife (chimwanamaye)22 have a baby and my husband cannot give us one (fisi)23 get accepted...feel loved...become more popular...cure my loneliness and depression24 stay alive after these men have finished raping me25 fulfil my loving same-sex relationship in a special way like mixed-sex couples do26 feed my family, because I am unemployed at the moment27 to be cured from AIDS and I have been told this child virgin will cure me28 have two wives, polygamy is allowed in our culture29 stay in my uncle’s house where he feeds and clothes me because I am an orphan30 hold on to my partner31 be protected from violent people in this prison32 be protected from the other street children who frighten me33 show this person I am the boss and I have the power!

Point to ponderA sexual relationship may have little to do with love and affection, but be more aboutestablishing power within the relationship. It can be almost impossible for some people tosay, ‘No!’ Discuss.

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Activity 3.12 Frequently asked questions about sexDiscuss the following questions. They are written from a health professional’s viewpoint.

1 What exactly is a virgin?The term virgin is used for a woman or man whohas never had sexual intercourse at any time duringtheir life. By sexual intercourse we mean thepenetration of the penis into the vargina.

2 What is a virginity test?A female virgin has a hymen, a thin membrane of skin in the vagina, which is brokenwhen she has sexual intercourse. It tears as soon as it is poked with anything stiff, suchas a finger or a penis. But a few women are born without this membrane and somemembranes are easily torn during physical exercise, such as riding a bike or climbinga steep hill or heavy farmwork. The hymen can also tear during a medical examinationor treatment of the sex organs. So, the existence or non-existence of this membrane isnot a good indicator of virginity. The only way to identify a virgin is to know whetherthe person has or has not had sex. If a woman has had sexual intercourse she has losther virginity and there is no way to get it back.

3 Is it important to be a virgin before marriage?Many people believe that sexual intercourse is a very special gift from God and shouldbe shared only with the person you marry. Others believe it is important for youngpeople to remain virgins until marriage, because it is the very best way to protect them,from unwanted pregnancies, sexually transmitted diseases which may affect fertilityand more especially from HIV.

4 Do adults have to have sex to be completely healthy?If you abstain from sex completely or for a long time, it causes no health problems. Noharm will be done to either your private parts or any other part of your body. Whenpeople who have been celibate (abstained for a long time) have sex they will feelexcitement and enjoyment. Abstaining from sex for a long time, does not cause pimpleson the face or private parts or psychological problems. The causes of these conditionshave their roots elsewhere.

5 Why does a man’s penis become erect when he sees parts of a woman’s body?In Africa, tradition says that men find the hips (thighs) and buttocks of women attractiveand they get sexually excited. In other countries of the world it may be a woman’sbreasts, neck or legs. These are natural, male sexual feelings and just thinking about awoman is often enough to cause the penis to become erect.

6 How often can a person have sexual intercourse?As often as both they and their partner wishes. Having regular, daily sexual relationswill not harm a person as long as they are not being forced against their will, whichwould be a form of sexual abuse or spousal rape. Obviously, as a physical activity ituses energy and can make people tired. Often men need more time to recover andbecome excited between ejaculations than women do.

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7 Who has more enjoyment when having sex, the man or the womanIt is not easy to say who has more enjoyment when having sex, because the extent ofenjoyment a man or woman has depends on both of the people involved. The mostimportant thing about having sex is that both the man and woman try to satisfy eachother to the maximum extent. If both seriously try to satisfy their partner, both will geta lot of enjoyment from having sex. In earlier times, many men thought that it is onlythe women’s task to satisfy the man’s desire, and often women did not get muchenjoyment from having sex. This is not how it should be. Nowadays things havechanged, because men have started to realise that having sex is more enjoyable if bothpartners try to satisfy each other. This is why sexual intercourse is called making love.

8 Do women have orgasms?Yes, women also have orgasms when having sex. A womanreaching an orgasm when having sex feels a very specialexcitement and well-being in her body. Men usually ejaculatewhen they reach their orgasm. Women can have one or moreorgasm while having sex. Some women experience multipleorgasms which do not need to be caused by intercourse, butcan be stimulated by stroking and touching parts of her bodyespecially the clitoris and vagina.

9 What is the easiest way for a man or woman to have an orgasm?The most important things is that both partners are ready to have sex. This means thatthey love and respect each other, and that they are physically and mentally ready tomake love. Not being ready to have sex, for example if you fear pregnancy, or STIs, mayhinder you from reaching an orgasm. If both partners are ready, whether or not youreach an orgasm depends on the way you go about having sex. You should make surethat you have agreed together upon ways of having sex, which bring the most enjoymentand satisfaction to both of you. Indeed, millions of people around the world enjoyforeplay which involves cuddling and touching before full penetrative sex. Every womanand every man has certain parts of the body, which are very sensitive to touching.Foreplay can increase the chances of reaching an orgasm for both women and men.

10 What can be done if someone cannot have an erection or an orgasm?Sometimes a man cannot get an erection or ejaculate when having sex. This can be fordifferent reasons. To have an erection and ejaculate requires energy, therefore anythingwhich reduces the physical energy of a man, such as stress, sickness, alcohol abuse,drug abuse, smoking or feeling hungry can hinder the man ejaculating properly. Actionto reverse these conditions should be taken. Other important reasons could be notbeing ready to have sex or not really being in love. Gentle, loving, sexual foreplay canhelp bring about an erection for the man and assist both partners to an orgasm.

11 Can a penis get stuck when penetrating a vagina?No, because the vagina is made from very elastic skin. The vagina can expand sufficientlyfor giving birth to a child, where it may expand as much as ten to twelve centimetres indiameter. So, even if you have a big penis, it cannot get stuck in a vagina.

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12 Should a woman’s vagina be dry during sexual intercourse?No, a woman’s body naturally produces lubricationduring fore-play. This lubrication makes intercourseeasier and there is less risk of damaging the delicatemembranes. Traditional medicines or herbs shouldnever be put into the vagina to make it dry, becausethey can damage the tissues and increase the risk ofHIV infection.

13 Why do men usually take the initiative towards having sex?Studies have shown that in many places in theworld, boys and men take the initiative to havesex, this is said to be because of social andbiological factors. Men are often the leaders inthe family and community, they are bigger andstronger and they can get sexually excited veryquickly. It is commonly accepted that men oftenhave an orgasm before women do. Today, it isbecoming more acceptable for women to takethe initiative as well as men. The cartoon showsTaxina drawn by late Vic Kasinja.

14 How soon can a couple have sexual relations after a woman has a baby?Usually 4-6 weeks. A woman can have sexual relations as soon as she has no pain ordiscomfort and feels ready to do so. Some women have little desire for sexual relationsjust after giving birth. It is not harmful to the baby’s health to have sexual relationswhile the baby is still nursing. Some local beliefs are the traditional ways of makingsure women do not get pregnant too soon. Sexual intercourse has no harmful effectson a woman’s milk.

15 Is it all right to have sexual intercourse during menstruation?Yes, but it is advisable to use a condom. A woman cannot get pregnant duringmenstruation even if a condom is not used. Sexual relationsduring menstruation can be messy, but it is not physicallyharmful for either men or women, unless one or morepartners is infected with an STI. However, some peoplefind the idea unacceptable.

16 What is masturbation and is it wrong?Orgasms can be achieved through masturbation. Forexample the man can rub his penis, or the woman canrub her clitoris to reach an orgasm. Masturbation is asafe way of satisfying the feeling of wanting to have sex.It has no negative health consequences. It will not cause aperson to have future problems having sex with a partner and it does not cause blindnessnor weaken the sexual organs. Remember, religions often have clear teachings onwhether masturbation is acceptable or not, check with your religious leaders if in doubt.

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Activity 4.12 Assignment: Talking about sexuality• Interview a friend, neighbour or relative about how you each learned about

sexuality and what they would like to know more about• How do you and your friend think

young people should learn aboutsexuality?

• How old should a child be when youfirst introduce the concept of sex tothem?

• Find out how much they know aboutthe way HIV is transmitted

• What sexual practices would they wishto change in order to reduce spread of HIV and STIs in Malawi?

• Collect any interesting or important stories about HIV transmission

Evaluation. Evaluate the unit or your chosen selecton of activities by using thequestions on page 166.

17 Does a woman need semen to improve her health and beauty?Some people believe that women require semen for their health, especially so they willhave beautiful skin. If you look at the diagramof a woman’s body, you will see that semen goesonly into the vagina. It has no way to reach theskin. So putting on lotion will give smooth softskin, but sexual intercourse cannot affect the skin.This question is still being debated by scientists.

18 What are the consequences of anal sexual intercourse?The main problem with having anal sex is that there is an even higher risk of infectingone another with STIs and HIV/AIDS. To have anal sex is dangerous, because their areno fluids to lubricate penetration and the skin in vulnerable. Therefore it is very easy toget small injuries, which do not cause pain but which also enhance the chance oftransmitting diseases. If you decide to have anal sex use a condom. Homosexually isillegal in Malawi and against the teachings of the main faiths.

19 What is oral sex and is it safe?Oral sex is using your mouth to stimulate your partners genitalia. Oral sex on malegenitalia is called falatio. Oral sex on female genitalia is called cunnilingus. If partnershave no STIs, especially HIV, there is no health hazard. While some women enjoyfalatio, others do not like receiving sperm in the mouth, others find it unpleasant.Religions often have clear teachings on whether oral sex is acceptable or not and youshould check with your religious leader if you are concerned.

20 Why should men take on greater responsibility in reducing HIV infection?Men are slow in seeking health care and do not easily cope with illness in the waywomen often do. They take greater risks regarding alcohol abuse and casual sexualintercourse. Men need to take greater responsibility to protect themselves, their partners,and future children.

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Unit 4 Preventing transmission of HIV

IntroductionAn STI is a Sexually Transmitted Infection. STIs are also known as STDs or SexuallyTransmitted Diseases. There are many STIs which can be passed from one person toanother through sexual activity. In this unit you will study how STIs get into the body,what they can do to the body, how they should be treated and ways to protect the bodyfrom future infection. HIV is the most dangerous STI so the unit begins by looking attransmission of HIV.

Learning outcomesBy the end of this unit you should be able to:• identify which body fluids contain the HIV• describe how people get infected with HIV• describe how to prevent HIV infection• explain how HIV/AIDS not transmitted• describe some signs or symptoms of STIs• describe some of the complications resulting from sexually

transmitted infections• describe what you would do if you got an STI• explain how infection by other STIs can increase our chances of HIV infection• calculate how many people you may have shared sexual body fluids with• explain the ABC of HIV prevention• define the terms safe sex and safer sex• list the factors that put men at risk of STIs and especially HIV infection• list the factors that put women at risk of STIs and especially HIV infection• describe why young girls may be vulnerable to HIV infection

Activity 4.1 Assignment reviewReview the assignment as preparation for the activities in this unit.

Activity 4.2 Which human body fluids may contain HIV?Which human body fluids do you think are the most dangerous?

Points for your discussion, debate, drawing etcThe following fluids may contain HIV:• Seminal fluid, vaginal fluids, and blood pose the highest risk• 75% of men secrete a clear fluid called precum from

the penis before they ejaculate and pecum cancontain HIV if the man is HIV+

• Breast milk poses a risk of infecting children, butin Malawi, breast milk is recommended as theonly food for the first 6 months of a baby’s life

• Sweat and tears have very low risk of HIV• Amniotic fluid poses less risk than vomit, faeces, urine and saliva, although all

these have low chances of causing HIV infection

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Activity 4.3 How do people get HIV?We will now look in greater detail at theways in which HIV is spread.

Facts about HIV• Is a parasitic virus which needs to live inside

another living thing (a host) in order to survive• Uses human body cells to reproduce inside• Cannot live and reproduce outside the body• Cannot survive unless it is in human body fluids like blood, semen, urine etc• Can stay alive and dangerous in body fluids such as drops of blood etc• Dies when outside the body when a liquid completely dries up!• Has no brain, cannot think and it does not plan where it will reproduce next• Has millions of humans to help find new bodies for it to reproduce in• Would find it almost impossible to reproduce and survive if humans stopped

moving it to new places• Prevention, treatment, care and support programmes work to stop humans

from passing the virus to new bodies where it can successfully reproduce

People get the HIV virus through1 Sexual contact2 Mother-To-Child-Transmission (MTCT)3 Other ways of body fluid cross-infection

Points for your discussion, debate, drawing, song, story, play, poem, poster etcThe most common way is sexual contact through unprotected sexual intercoursewith an HIV infected person.Why are the vagina, the inside of the foreskin and anus the most vulnerable routes?1 Vagina: the vagina lining is thin especially in young girls and the vagina has

little mucus. The vagina also contains HIV targets such as white blood cells,which may be there as a result of some inflammations not caused by HIV. Youngwomen are biologically more vulnerable to HIV infection. After sex semenremains in the vagina at body temperature long enough for infection, whereasvaginal fluid may dry and stay for a shorter time on a penis

2 Foreskin: The male foreskin easily allows HIV to penetrate the skin and it isliable to tears and ulcerations. Circumcision is recommended for sexuallyactive men and can reduce HIV risk by about 60% in men.

3 Anus: Male and female anus linings are extremely thin. Unprotected anal sexposes a very great risk.

Mother-to-child-transmission. An HIV infected mother can pass on HIV to her babyduring pregnancy, delivery or breast feeding. Doctors recommend that Malawianwomen breast feed exclusively for six months. Which means giving the baby no otherliquids or feeds, not even traditional medicines like dwale. Unit 11 deals with thisimportant topic in greater detail.

Other ways of body fluid cross-infection. See the activity 4.4. You may wish tocombine activities 4.3 and 4.4.

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Activity 4.4 How to prevent HIV infection through body fluid contactWhat strategies would you use to prevent yourself from becoming HIV infected viacontact with blood and other fluids? We have marked the peer group memberssuggestions with symbols ( & ) and we hope that this will help to show the thingsthat are dangerous and the things that are safe to do.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcWhat have peer group members suggested?

The HIV virus can live for only a very brief time outside the human body, so the riskis quite small. But if any HIV contaminated fluids like blood, come into contactwith the blood in your body you are at risk

Sharp objects, like needles for injections orrazor blades, that have been used by aperson with HIV can transmit the virus,because a small amount of blood mayremain on the blade or pointTo prevent the risk of HIV infection fromsharp objects, use only new needles and razorblades or be sure they have been properlysterilized. Health clinics use disposableneedles or sterilize them so that injections atthe clinic and hospitals are safeEar piercing, tattoos, traditional medicalcutting, ritual procedures such ascircumcision and self-injecting drug abuse,should be with new or properly sterilizedequipment for each person

Sharing a toothbrush can also put you at risk, especially if there are cuts, sores orgum bleeds in the mouthDuring violent gender-based disputes there is a danger of HIV infection if bothpeople involved have open wounds or are bleedingViolent contact sports like boxing and wrestling if blood mixes through open cutsTraditional birth attendants, mothers and babies are at risk if one has cuts or soresThere is a risk when the same cloth is used to wipe both bodies after sexual intercourse,this is because both vaginal fluids, semen and possibly blood may be on the clothThere are risks when caring for a person living with AIDS (PLWA) because of openwounds, bleeding and open bowel issues - we will deal with these issues in greaterdetail in unit 9 which starts on page 129The risk of getting HIV from unprotected sexual relations is much greater than therisk of getting HIV while caring for a person living with HIVYou may be at risk of contracting other diseases such as tuberculosis (TB) from aPLWHAIf the person has TB, check with a doctor or clinic about protecting yourself andfamily because TB can be treated effectivelyIn an accident or emergency, where a person has been cut a plastic bag can be usedas a substitute for medical gloves. The risk is not great unless you yourself have openwounds on your body.Blood transfusions are unlikely to give you HIV, because blood is tested before use

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Activity 4.5 How is HIV/AIDS not transmitted?HIV cannot live for long outside the human body and it cannot travel through theair by itself. This is why there are no anti-HIV sprays to kill it in the air. So, can youwork out how HIV is not transmitted?

Points for your discussion, debate, drawing, song, story, play, poem, poster etcYou cannot get HIV from the following activities:

Handshaking or huggingKissing (provided people have no mouth sores)Visiting PLWA’s homes and hospitalsSharing beds and furntiturePreparing food and eating togetherSwimming pools or public showersUsing items previously used by a person with HIV,such as books, clothing or the toilet, telephone,hand washing basins, unless the PLWHA has open wounds or soresDonating or giving blood. When you donate blood you do not get some fromsomeone else. The equipment used is always sterilisedBeing bitten by mosquitoes or other insect bites. This cannot happen because themosquito mouthparts cannot transmit it. If mosquitoes transmitted HIV, thenalmost all people in malaria-prone areas like Salima would be HIV+ by nowCaring properly for people living with HIV and AIDS.

Activity 4.6 What are some signs or symptoms of an STI ?HIV does not have any significant symptoms in the early stages of infection, but aperson may have slight flu symptoms in the first two weeks or so. But, HIV graduallyweakens a person’s immunity to other infections such as STIs, colds etc. You may wishto combined this activity with 4.7.


Having an STI can seriously increase someone’s risk of getting HIVSometimes people have painful symptoms, but sometimes there are no symptomsFor some STIs, women are more likely to be infected without showing any symptoms

Here are some symptoms that may show that a person has an STI and some peoplemay have one or more of these symptoms:

Sores or blisters near sex organs or in and around the mouthBurning pain when passing urineΙtching feeling on private partsSwelling around the sexual organsDischarge from eyes of new born babyRashes (spots) on the bodyPain during sexual intercoursePain in lower belly area or in the vagina or testesBleeding from the vagina other than regular periodsUnusual pus discharge from penis or vagina, that canbe very smelly

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Activity 4.7 Complications from sexually transmitted infectionsHere are some of the complications that can occur if a person has an untreated STI.Which complications would you personally be most afraid of?

Points for your discussion, debate, drawing, song, story, play, poem, poster etcSome STIs cause serious and permanent damage to a the body if left untreated.Increased risk of getting infected with HIV, because the skin in your private partsmay be damaged by STI infection.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcBrain damage which may lead to madness or insanityInfertility in both men and women.Miscarriages by pregnant womenDeath of babies, before, during or after birthBlindness in infants if not treated well in pregnancyPelvic Inflammatory Disease (PID) in women - MbuluNearly all STIs are treatable by clinics, rather than bytraditional healers, who often treat only the symptomand not the cause of the infection

Disease Cause Symptoms in Men Symptoms in Women

Gonorrhea a bacterium • discharge from • bad (foul) smellcalled the penis • vaginal dischargeGonococcus • pain when urinating • pain when urinating

• genital itching • lower abdominal pain• urethra constriction due to pelvic inflamation

• itching of the vulva

Syphilis a bacteria • infectious genital ulcer • infectious genital ulcercalled • fever • feverTreporema • bumps on penis • itching in the vaginapalladium • swollen lymph glands • swollen lymph glands

• bleeding from vagina• pain in pelvic area

Trichomonisasis Micro-organism • no visible signs that • profuse vaginal dischargecalled chlamydia lead to problem called • vaginal paintrichomontis urethritis • vaginal itching

• increased itching • bad smell

Candidacies Fungus • sores and itching • painful sexual intercourseof penis • vaginal discharge

• vulva irritation• reddened vulva

Chancroid A bacterium • genital sores • vaginal swelling(mabomu) Haemophilus • genital swelling • vaginal sores

ducreyi • vaginal discharges

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Activity 4.8 Are there other ways for people get STIs?Like HIV, some of these diseases are also spread by ways other than sexual contact.Look at the list of STIs on the last page and discuss how they could be transmitted.


STIs are caused by different micro-organisms and have different signs and symptomsNewly born babies can be infected whilst in the womb or during birth or duringbreast-feeding by their HIV positive mothersKissing, sharing a toilet, razors, bath cloths and towels can transmit some STIsOpen sores on the genitals and around the mouth are often very highly infectiousSo, it is imperative that people with STIs get immediate treatment and do not passthe disease on to others

Activity 4.9 What would you do if you got an STI?STIs do not go away on their own, they must be treated by medical professionals. Youcan easily spread the STI to others. If you though you had an STI what would you do?


Go to the clinic if you or your partner has any of these symptoms, even if thesymptoms seem to have gone awayDo not stop your treatment early even if thesymptoms seem to have goneUntil both of you finish your treatment, youneed to abstain or use condoms during sexIf either of you has had sex with anotherpartner now or recently, that person alsoneeds to be treatedAttend all follow up medical sessionsBe very hygienically clean and careful so that you do not pass on the STI

Activity 4.10 How can other STIs increase our chances of HIV infection?Review this topic by discussings what you have already learned.


If a person already has another STI, especially an open sore in the genital area,that person can more easily get infected with HIVTo become infected, the HIV virus must enter your bloodstream, if there is anopen sore or cut in the genital area, this is more likely to happen.If one gets infected with HIV, some STIs (genital herpes and warts) becomes morefrequent, some STIs become aggressive and respond poorly to treatment.STIs like genital herpes and syphilis, depress the immune system making it easierfor HIV to attack a person with STI at a single encounter.Prevention of STI infection therefore reduces the spread of HIV in a communityTo reduce the chance of getting HIV have all STIs treated as soon as possibleEncourage others in the community to get tested for STIs and treated

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Activity 4.11 How many people will Cecilia share body fluids with?People sometimes forget that a new partner may have had a previous partner. Discussthe diagram on page 61. Read the following case study and make a list of the peoplementioned. Then create a diagram to work out a possible chain of infection. How manypeople may put Cecilia at risk of HIV infection?

Today is Cecilia’s wedding day. She is a very religious, youngwoman who is marrying George, her first serious boyfriend.She is a virgin who has saved herself for her future husband.George attends the same place of worship as Cecilia and hashad only one serious sexual relationship with Monica. He hasnever been tested for HIV, because he knows Monica is notpromiscuous. This is because Monica has had sex with just oneother man, Kondwani. Kondwani, is very good looking and isvery attractive to girls and older women. Last year, at school hewas seduced by Mrs Mwape, his teacher. They did not use acondom. Mrs Mwape had never done this sort of thing before,she was a virgin when she had married her husband.

Mr Mwape, an accountant, is regularly called to workshops by the lake. He enjoys thepleasures of sex workers. Mr Mwape and his friends at the bar, often joke that he musthave played around with over thirty of the sex workers in the ten years in his job.Mary, one of the prostitutes, had been forced into sex work by her violent husband.She had started three years ago, just after her marriage. Like the other prostitutes Marycould have sex with up to ten men a day, with local men, workshop attenders andforeign tourists. Mary’s husband has never stayed faithful to her for long. He drinksand when drunk he has sex with young and old sexworkers. Locals make fun of himbecause he often has sex with Chikondi, a kind hearted prostitute who is well over 50years old.

When Cecilia and George begin a sexual relationship how many people may be involved?

Activity 4.12 How many people have you shared body fluids with?This is a private activity you may do as an assignment. Look at the picture on the nextpage. Could you represent your sex life in thesame way by using simple little drawings?This is one way of assessing your risk of HIVinfection.• Select a drawing or shape, to represent

people that you have had sex with• You may wish to use boxes or bubbles• Use only initials and dates if you prefer• Put a if you think that person was an

HIV risk to you for any reason• Put a ☺ if you think that person was not

an HIV risk to you for any reason• Finally consider your behaviour and decide

if you should change it at all• Go for VCT if you are at all concerned!

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Point to ponderOnly one person had HIV to start with, but how many could be infected now? Discuss

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Activity 4.13 What is the ABC of safe sex?The ABC of safe sex, or staying safe from HIV is the most popular prevention messagein the world. It calls on people to stick to one or more of the methods, depending upontheir beliefs and the situations they find themselves in:

A = abstain from sexual intercourseB = be faithful to one uninfected life-long partnerC = use condoms correctly and consistently

Activity 4.14 What is safer sex?The term safe sex and safer sex mean different things to different people. Safer sex issaid to involve physical contacts, which do not allow the penetration of the penis intothe vagina. There are many ways in which people can have an enjoyable, sexualrelationship and stay safer from both HIV and an unwantedpregnancy. Read through the statements below and decidewhether the advice may work for you and your partneror other people. They are all sexual activities with nocontact with semen, vaginal fluids or other body fluids.

Points for your discussion, debate, drawing, song, story, play, poem, poster etc1 The safest sex is no sex at all, until after both VCT and marriage2 I play with my partners hair slowly moving my fingers gently over his scalp3 When his fingers move up and down my arms, barely touching my body hairs it

sends ripples of excitement all over me...then our fingers play together4 My fingers trace patterns on his forehead, cheeks and gently explore his ears, followed

by the eyebrows and then I start kissing him starting with his hands5 We like to touch skin with different things like a flower, a feather, our hair, small

stones, coins, drops of water, slices of fruits and sweets...it’s very sexual6 We keep our clothes on and enjoy touching and stroking through our clothes, because

it’s safe and we have barriers up against temptation...we hold hands and hug a a lot7 We keep our clothes on but can press our private areas together and move...it’s safe sex8 We allow ourselves to be naked above the waist, but remove nothing else, apart from

shoes and socks. We can kiss and touch only uncovered places, nowhere else9 I really enjoy doing a strip dance for him. I never remove my pants...I move sensually

and peal off my clothes...I enjoy him looking at my body, but no intercourse until VCT!10 We can stand, sit or lie down in all sorts of different ways...we take turns removing

clothes down to our underwear11 I do masturbate to an orgasm and I think it helps control my behaviour12 I wear shorts and she wears a swimsuit or underwear, which we never take off...

...touching the private parts for long time... I suppose it’s mutual masturbation13 We tell each other sexy stories, including all the exciting details of what is happening14 We shouldn’t talk about this sort of issue as it may encourage people to experiment

Points to ponderSafe sex involves making rules and trust. Trusting that both partners will keep to thoserules. There is sexual freedom up to a limit, but a limit not to be crossed. Discuss

Both safe sex and unsafe sex begin in the mind and that is the best place to stop them bothuntil after both VCT and marriage. Discuss

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Activity 4.15 Thinking about sex without a condomAfter carefully considering the consequences, a couple should consider the followingpoints before having a full sexual relationship.• Your safety depends on both your behaviour and your partner’s behaviour• Βefore having sexual intercourse without a condom, you need to:

1) Use condoms for three months2) both get treatment for any STDs3) both have a blood test that shows you are HIV free4) be completely faithful to each other or use condoms in any outside relationship

You may combine this introduction with Activity 4.14.

Activity 4.16 How fast does HIV spread?You may wish to combine this activity with others. This is a very good ice-breaker orintroductory activity.

You will need• Cups which represent the human body• Water which represents healthy human body fluids• Starch solution which represents infected body fluids

containing HIV• Iodine solution which represents an HIV test• Behaviour cards. These are small pieces of paper with the following five letters on

A (abstain) B (always be faithful) U (unfaithful partner) S (sexually active )

Suggested method• Explain what sort of behaviour each letter represents• Ask each participant to pick a paper at random• Give one or two participants a quarter cup of weak starch solution (HIV+)• Give all others a quarter cup of plain water• Ask participants to mix the contents of their cups according to the behaviour shown

on the paper• To mixing represents sexual intercourse between two people, which mixes body

fluids• To represent sexual intercourse pour the contents of one cup into the another, mix

and then divide the contents equally between the two cups• Stop the activity when most of the participants have mixed body fluids with

others• Represent the HIV test, by putting a few drops of iodine solution into each cup.• If the solution goes dark then it means starch (HIV) is present in the cup• How could you develop this idea further?

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Activity 4.17 What factors put men at risk of STIs and HIV infection?What factors put men at risk of STIs and HIV infection? Ask the group to think aboutthe behaviour of men in their community. The best male role models in a society, whohold firm views about correct behaviour are at lower risk than the poor role models.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcWe have marked the peer group members’ suggestions with the symbol becausethis activity concentrates on identifying dangerous behaviours that can be changed.Which dangerous behaviours put men at risk?

Wanting to prove their manhoodBelief that girls and young women don’t have HIVNot abstaining when a sexual partner ismenstruating or is in latter period of pregnancyMen who abstain from having sex with their wifeduring her menstruation, believes it is culturallyacceptable to go out with other women.Unfaithfulness by wivesCasual sex with multiple partnersHomosexual relationshipsWanting to show off wealth through sexUsing sex as source of powerIf accused of being impotent, men have sex withother women to prove or disprove the allegations.Looking for sex to gain experienceTraditional view of women as sex objects to be usedand then discardedPerforming widow cleansing ritual with a late relative’swidowMen selected to act as fisi during girl-child initiationInfection by blood on an unclean blade during the circumcision of a boy-child

Showing off to peers, by bragging about manhood and conquestsDrinking alcohol in a bar frequented by sex workers

The late Brian Hara’s cartoons often used humour to carry important messages

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Activity 4.18 What factors put women at risk of STIs and HIV infection?What biological and social factors put women at risk of HIV and AIDS?

Points for your discussion, debate, drawing, song, story, play, poem, poster etcWe have marked the peer group members’ suggestions with the symbol becausethis activity concentrates on identifying dangerous behaviours that can be changed.What have peer group members suggested?

Early marriage of primary school-age girls puts them at risk, because theirreproductive organs are not fully developed and smaller than a grown woman

There is a lot of pressure on woman tohave sex with boyfriends to prove theirfaithfulnessOlder men with money (sugar-daddies)tempt young girls to exchange sex forgifts or moneyPoverty can force women to become sexworkers in order to support theirfamilies.Employers can pressure womenemployees to give them sexual favoursSome women use sexual favours to risein an organisation

Sex within marriage is considered as simply a duty and a condition for havingchildren, instead of as a source of mutual pleasure and bondingSome men are sexually unfaithful, they can bring HIV and AIDS into a marriageWomen put herbs and other agents in thevagina to cause dryness, heat and tightness.These substances may cause inflammationand open sores in the vagina making iteasier for HIV to mix with body fluidsWomen are the primary care-givers athomes with people living with HIV andAIDS. This puts them at risk of infectionfrom blood and other body fluidsWife inheritance, where a relative inheritsa dead relative’s wifeWhen an impotent man hires fisi to havesex with his wifeWidow cleansing through sexual intercourseProverbs like Mamuna ndi mwana, whichmeans that a man is a child, so he has anexcuse for any sexual infidelityMen say they love a woman when what theyreally want is sex, a woman will often have sexwith a man when what she really wants is his loveWomen are vulnerable to HIV infection because of gender inequalities and lack ofpower within sexual relationships

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Activity 4.19 Why are young girls vulnerable to HIV infection?We have just discussed the factors which make women vulnerable to HIV. Now, wewill look at factors that make young girls particularly vulnerable to HIV infection.Read the article from the Malawi Daily News.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcHow widespread in your area, are events similar to those described in the article?Peer group members suggested that the following points were very important.

Men often choose younger women as sexual partners and it’s not easy for a youngwoman to talk assertively with an older man.Early marriage, where the older husband controls the sex life of the couple due tothe respect and expected unquestioning obedience of his younger wife

You can combine this activity with the next one if you wish, but group membershave suggested that school age girls are particularly vulnerable.

School girls - their friends beingsold for cows (Source: Nation May 31, 07)

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Activity 4.20 Why are young people at high risk of HIV infection?What are the factors that put young people at particular risk of HIV infection?We have marked the peer group members’ suggestions with the symbol becausethis activity concentrates on identifying dangerous behaviours that can be changed.


Young people can experience rapid mood changes and become very emotional,this can lead to stress, depression, aggression and wild behaviourResearch shows that youth interaction between mental health and HIV/AIDSincreases the risk of them developing mental disordersElders who carry out the initiation may not be well informed about how youngpeople can prevent HIV and AIDS, STIs and early pregnancyAnxiety disorders in youths can lead to reckless sexual behaviour during whichthey are exposed to HIVYouths often don’t want to listen to lectures on behaviour from adults.They experience new strong sexual urges and attraction to the opposite sexThey may have day dreams or sexual fantasies which they want to act outThey need more independence from their parents and this can lead them intounsafe situationsNegative peer pressure can influencethem act in dangerous ways and dothings just to impress the groupInfluenced by negative role modelsthey see on TV or in filmsThey want to try new things and takerisks and this can lead to infection,injury or deathDrinking alcohol and smoking chambaEarly unsafe sexual relationshipsIn some parts of Malawi, young people start having sex at a very young agesHalf of all women have sex before the age 15 and half of all men before 16Unemployment and the lack of community activities that interest them can leaveyouths with lots of time on their handsLack of accurate informationLack of communication with parents or caregivers.Parents may not feel comfortable talking to their children about sex

Activity 4.21 Assignment : Peer pressureCarry out research into the power of peer pressure in your community. Look at bothnegative pressure and positive pressure within different peer groups. How do youthink that peer pressure could be used toencourage people to work to halt theHIV pandemic?

Evaluation. Evaluate the unit oryour chosen activities by usingthe questions on page 166.

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Unit 5 CondomsIntroductionMany doctors and health workers seecondoms as a key weapon in fightingthe pandemic of HIV and AIDS. Otherpeople view the situation in a completelydifferent way. Some religious leaders areopenly opposed to the use of condoms asthey blame them for encouragingpromiscuous behaviour. Others say thatcondoms interfer with the natural processof conception. In your peer group youwill probably have conflicting views, butwe believe it is valuable for all studentsand teachers to know more about condoms.Discussing condom use does not mean thata person is going to use one.

Learning outcomesAt the end of this unit, you should be able to:• explain how condoms protect against HIV and STIs• correctly use and dispose of a female and a male

condom.• be comfortable when discussing and teaching others

about importance of using condoms

Assignment 5.1 Assignment reviewEncourage group members to share their experiences about the assignment from thelast unit.

Assignment 5.2 If a man can carry a condom why can’t a woman carry one?What message do you think the cartoon is sending out?

Points for your discussionStudy the picture and consider the followingquestions.• What is happening in this picture?• Does this happen in Malawi?• Why do you think that the man is surprised?• What do you think of the woman’s statement?• Discuss the situation in pairs and then as a

full peer group• Some peer group members believe that the

woman is perfectly correct in carrying a condom, because she is protecting bothherself and her husband. Do you agree?

• Some peer group members believe that the both partners are correct in carryingcondoms, because they are protecting each other. Do you agree?

• Many activities in this unit will deal with the practical, social and moral issuesrelated to condom use.

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Activity 5.3 How strong is a condom?What can we say to people who say that condoms can break during sex and thereforedo not protect us. In Malawi standards experts would say, Condoms are tested for tensilestrength; freedom from holes; dimensions such as length, width and thickness; air inflationfor bursting pressure and volume; package seal integrity before they are distributed.

DemonstrationChoose one of the two demonstrations below.Say, Let me show you that condoms are very strong.1 Blow up a condom like a balloon until it breaks.

In preparation, before the session open andlightly wash the lubrication from a condom.

2 Fill a condom with water and show that it doesnot break. You can even play a game of catchwith it, but be careful people don’t get wet!

What causes condoms to break?Sharp fingernails; exposure to heat and sunlight for a long time; unrolling condomsbefore putting them on makes it harder to put on without stretching. Don’t put oil-based lubricants such as petroleum jelly, baby oil or lotions on a condom.

Point to ponderPeople say that condoms sometimes fail, but in our community condoms may be the bestchance, because abstinence has failed and being faithful has failed us as well! Discuss.

Activity 5.4 Don’t condoms have tiny holes which allow the HIV through?

Peer group members have suggested that you could say:Condoms, like everything else, do have pores and holes but they are too tiny to seeResearch shows that these pores are too tiny to let the HIV virus go throughUnder normal use there is no leakageIn scientific stress tests, condoms have been filled with over a bucket full of waterbefore showing any signs of leaking - that is a considerably larger volume than theaverage penis - some condom critics fail to mention the fact that scientific testersoften fill condoms with over 4 litres of water

More importantly, there are many couples where one partner is known to be infectedand the other is not infected. Studies show that the HIV negative partner did not contractHIV or other STIs when those couples used condoms consistently. But if couples didnot use condoms at all or used them inconsistently, many of the partners who wereHIV negative became infected. Condoms do not offer 100% protection, but they offerover 98% protection and this greatly reduces the risk of HIV infection by sexual contact.

Points to pondera) If you can’t abstain or be faithful, use a condom to save the life of your partner and

future children. Do not kill your own partner by unsafe sex. Discussb) If condoms give 98% protection against HIV infection that is better than the 0% protection

if you don’t wear one. Discuss

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Activity 5.5 Condoms are not romanticPeer group members have suggested that you could say:

Worrying about HIVand AIDS or STIs is not romantic...with condoms we don’tneed to worry...we can relax and enjoy our loveLet’s try to make it safe and romanticIf we keep the condom close by under thepillow it will be less stressfulLet’s open a packet and examine a condomtogether...it is not just the man’s job to put it on.Many couples find that they enjoy sexualrelations even more when they use a condom,once they get used to using condoms andmake condoms a part of their activities...theyare more relaxed, because they are not worryingabout getting pregnant and infected with HIV orother STIs. For many men condoms help them last longerbefore ejaculation, which is something both the man and his partner appreciateRomantic men always hold their partner after making love...they become veryexperienced at carefully and quietly, removing the condom and putting a knotnear the open end, which seals the semen inside. Keeping a fresh tissue near athand can also make it easier. Learning how to remove, knot and carefully hidethe used condom for later disposal, is more romantic than a noisy performance.

Activity 5.6 Sex with a condom is like eating a sweet inside the wrapperYour partner says, ‘Sex with a condom is no good because there is no skin-to-skin contact, it’slike eating a sweet inside the wrapper or wearing a raincoat in the shower?’

Peer group members have suggested that you could say:If two people have sex without a condom they risk sharing a lot more than a goodtime...how can we enjoy sex when we are worried about AIDS?We can have sex without a condom someday, if we both get tested and find outthat we are both HIV negative and we agree to be completely faithfulI don’t think its time to have a baby right now

Activity 5.7 Can condoms come off and can remain inside the woman?Peer group members have suggested that you could say:

The condom will not usually come off if the man withdraws his penis carefully,holding the top of the condom right after climax so the penis is still erectPeople all over the world have used condoms safely for over 100 yearsCondoms are the safest of all family planning methods for both the man and thewomanIf a condom did come off during intercourse, the woman would be able to reach itwith her finger, and take it out of her vagina. This is because, at the top of a woman’svagina, there is only a very tiny opening to her uterus (womb). A condom cannotenter the womb. When a woman is in labour, this opening gets bigger to let thebaby out. But when a woman is not in labour, this opening is always tiny, a condomcould not possibly get through it.

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Activity 5.8 But we’ve never used condoms before, don’t you trust me?Peer group members have suggested that you could say:

It is not a matter of trust, it is a matter of health.Condoms are important for our health, untilwe both get testedIt is important that we are both protected.Maybe we should be more careful, becausewe haven’t been for VCT yetWe can still prevent infection or re-infection,because if one of us is HIV positive, gettingmore viruses can weaken the person moreI want to protect myself from pregnancyWe should start using condoms now so that wewon’t be at any risk

Activity 5.9 But I love you, why should we use a condom?Peer group members have suggested that you could say:

Show me that you love me and care about my future by using a condom.Being in love cannot protect us against HIV and AIDS.Careful, sound, scientific research shows that condoms are effective. If 100couples use condoms or a year consistently and correctly, only about two or threewill experience a pregnancy.Unless people know they are both faithful, condoms are a safer way for sexuallyactive individuals to reduce the risk that they might give HIV or STIs to a partneror receive HIV and STIs from a partner

Activity 5.10 Condoms can cause impotence, TB and cancerPeer group members have suggested that you could say:

This is not true, condom use does not lead to impotenceDiseases like cancer and TB are not passed on by condomsA few people are allergic to the latex or natural rubber incondoms - those people can use a condom made ofpolyurethaneVery rarely, a person may be allergic to the lubricant on acondom, and will get a mild rash or itching - that personcan use an unlubricated condom, or try a different brandthat they may not be allergic to

Activity 5.11 Semen is necessary to help a baby develop properlyPeer group members have suggested that you could say:

Condoms protect the baby by protecting the woman from HIV or other STIs - thisis very important for the baby’s health.The baby gets all it needs to develop from the single sperm and egg that unite toform life and then from its mother. Women whose partners are away during therest of their pregnancy deliver healthy, fully developed babies.

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Activity 5.12 Condoms are only used by prostitutes and the unfaithfulPeer group members have suggested that you could say:

Condoms protect from pregnancy and HIV orother STIs. Your regular partner or spousedeserves this sort of protection tooMany religious people around the world usecondoms, but many do notProstitutes are fellow human beings - if theyconsider condoms essential for their wellbeingthen others should consider the ideaAbstaining from sexual activity is the only way tobe absolutely safe from getting HIV through sexualcontact

Point to ponderEverytime a prostitute uses a condom she is acting not only to protect herself, but she alsoprotects her client, his family, his community and the economy of the nation! Discuss

Activity 5.13 Doesn’t promoting condom use encourage promiscuity?Peer group members have suggested that you could say:

If two HIV negative people are both completely faithful they can haveunprotected sex, but the reality in Malawi today is that sadly many of uscannot depend on abstinence or faithfulnessCondoms do not promote sex outside marriage. Condoms are not widely used inMalawi, but HIV and AIDS continue to spread. Many people do not use condoms,but they also do not abstain before marriage, nor do they remain faithfulPeople can control their own behaviour but they cannot control their partner’sbehaviour, nor change their own or their partner’s past behaviours. So theyshould be able to use condoms to protect their future healthMost partners have not been tested and many people have had risky relationshipsin the pastMany people who say condoms should not be used do consider using themIn a democracy, people should have full information about family planningThe HIV and AIDS epidemic is so serious that we need to encourage the use ofcondoms as a public health and development issue

Point to ponderI am not prepared to take the risk with my daughter’s life. I shall educate her aboutcondoms and how to use them properly. She will not die from ignorance! Discuss

Activity 5.14 Can I wash the condom and re-use it?What have peer group members suggested?

No, only use the condom once, 1 round 1 condom, 3 rounds 3 condoms

Point to ponderIf you are sitting on the bed with your love, it is may be too late to ask where you can buya condoms. Discuss

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Activity 5.15 Preparing to demonstrate how to use condomsRemind people that learning how to put on a condom does not mean they have to useone. A religious person in an earlier Mzake ndi mzake group said, The sin does not lie withthe condom, its just a piece of rubber! What do you think?

There are 3 parts to the demonstration:• selection and storage• demonstration• practice

1 Show a condom in its packet to the group and talk about how to select and storecondoms (see activity 5.16 below)

2 Show how to put on a condom correctly - use a penis model, a small cucumber, abanana or a maize cob inner pith for the demonstration

3 Divide the group into pairs and have one person demonstrate how to use thecondom - then the other person should do so

4 Be sure everyone in the group has an opportunity to putting on a condom.5 Occasionally, you will encounter a person who is not willing to do this. Let this

person just observe, and make sure that they do not discourage others in thegroup from trying the condom demonstration. Remind people that learninghow to put on a condom does not mean they have to use one.

Activity 5.16 How to select and store condomsHold up a packet of condoms or a condom in its wrapper.

What have peer group members suggested?Check the expiry date before buying and using a condomAlways remember that even an old condom is safer thanno condomStore condoms in a cool and dry place near the bedaway from sunlightDo not store in a hot place like in the glove compartmentor boot of your carDon’t keep condoms in a warm pocket for too many daysit can get very warmSome condom lubricants contain a spermicide (Nonoxyl-9) for added protectionThe spermicide kills sperm and kills the HIV virusUse latex male condoms unless either partner is allergic to latexBefore using check to see if your condom feels hard and decayed or looks driedout or discoloured or damaged - if the condom has any of these defects,throw it awayMany people keep at least two condoms nearby even when they only intend touse one - this is in case you spoil or get one dirty, which is easy to do if excited

Point to ponderI have kept the same condom safely in my inside jacket pocket for six month now. Discuss

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Activity 5.17 How to use a male condom correctlyCondoms offer very good protection if used properly. But, they mustbe put on and used correctly. Pass out packaged condoms and pointout the expiration date. Allow participants to familiarise themselveswith the packaging of the condom before opening it. Check to see ifthere are diagrams on the inside cover of the packaging - if thereare compare the diagrams and instructions with those shown below.

Read the following while putting the condom on the model• Choose a penis model, a small cucumber, a banana or a

maize cob inner pith or similar shape for this practical• Open condom package carefully - be sure you do not

puncture the condom with your fingernails• Hold the top ring of the condom tightly as you remove

it - do not let it unroll yet• Do not test the condom before use - the manufacturer

has already tested it• Do not use two condoms at once - 2 condoms rubbing

against each other makes them more likely to break• A condom should not be unrolled until the penis iserect

and hard• A condom is rolled over the penis starting at the tip• Roll the condom over the erect penis while squeezing

the bubble at the tip to keep out air• Roll it all the way down to the base of the penis and be

careful to leave the bubble at the end - this providesroom for the semen and helps prevent breakage

• Most condoms are pre-lubricated today - never lubricatethe condom with vaseline, oil or lotion

• Lubricants and vaginal foam with Nonoxyl-9 can beused in addition to a condom for extra protection -Nonxyl-9 kills the HIV and AIDS virus

• Soon after ejaculation the penis should be withdrawnand the condom carefully removed - hold index fingerand thumb around the condom at the base of the penisso that it cannot slip off during withdrawal

• Wrap the condom in a tissue if available, and dispose ofit in an appropriate way - if you can learn how toknot the condom it may be easier to carry beforedisposal

Never wash and reuse a condomDo not use the male and female condom together - they will rub against eachother and that sort of friction can damage them both

Point to ponderI learned to use a condom correctly by practicing putting it on in the privacy of my ownroom. At first I made mistakes, but like most things, pratice did make perfect. Discuss

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Activity 5.18 The female condomAlthough many people have seen a male condom, fewer have seen a female condom.

Do the following• Pass a female condom (that is still in the packet) and around the group• Encourage participants to examine the packet and any writing on it• Open the packet and hold up the condom• Read and discuss some of the following information before the group examine it• Pass the condom around - if someone does not wish to hold it do not press them

What is the female Condom?The female condom is a plastic pouch that covers the cervix, the vagina, and part of theexternal genitals. A woman uses the female condom during sexual intercourse to preventpregnancy and STI/HIV infection. Research is still being conducted to determine theeffectiveness of this new product. Malawi has two types of female condoms. The firstgeneration female condom (FC) Care condom and the New generation condom (FC2).The FC condom is made of polyurethane, a colourless and ordourless material thattransmits heat better than latex. Polyurethane can produce noise during sex. The FC2is made of nitrite, which is thinner and almost noiseless. Both condoms are lubricatedwith silicon based non-spermicidal lubricant and expire after 5 years. Advantages of using a female condomWhat have peer group members suggested?

Is safe and effective in protecting against STIs, HIV and pregnancyDoes not require a prescription or medical examinationCan be inserted up to 8 hours before sexual intercourseCan be used by women who were afraid of using or relying on the male condomIs female controlledExcellent option for someone who does not need ongoing contraceptionIt can be used with oil-based lubricants like vaselineDoes not alter the vaginal flow and reduces thechances of irritation from allergic reactions

Disadvantages of using a female condomWhat have peer group members suggested?

Costs more than the male condomHas a slight noiseSometimes negatively associated with sex workersIs female initiated but requires skills to use properlyand to negotiate its use with a partnerCan be difficult to insert - needs practiceLike the male condom it can occasionally break or slip out during intercourseMost women experience no side effects - rarely, someone may experience anallergic reaction or irritation

Point to ponderIt took me some time to get used to using the female condom, but now it takes just a fewseconds to put it in place. Discuss

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Activity 5.19 How to use the female condom correctlyThis may be very difficult to demonstrate unless you have a model, but it is well worththe effort.

• Check the expiration date on the condom package - shelf life is usually 5 years• Find a comfortable position - try standing with one foot on a chair or sit with

knees apart or squat down1 Open the package carefully so that the condom does not get damaged2 Find the inner ring which is at the closed end of the condom3 Squeeze the inner ring together4 Put the inner ring into the vagina5 Push it up into the vagina with a finger, the outer ring stays outside the vagina6 During sex, guide the penis through the outer ring, keeping the ring outside and

against the labia (outer lips)7 Hold the ring as the penis is withdrawn - then remove the condom immediately

after sex, before you stand8 Squeeze and twist the outer ring to keep the sperm inside the pouch and pull the

pouch out gently9 Burn, bury the condom or put into pit latrine, do not flush it down the toilet

1 32

4 5

8

7

6

9

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Activity 5.20 The lifeboat game: values and condomsConduct the life saving boat game. This will let participants critically examine the optionsthey could adopt to save their life and the lives of others.

If I am to stay safe from HIV, I may have to get into a different lifeboat

Do the following• Use chalk to draw three boats and label them as abstinence, be faithful and use a

condom• Ask peers to assume different roles - professional sex workers, truck drivers,

professionals like doctors, newly weds, army personnel, office secretaries, churchbeliever, experimenting youth, a person who drinks, two lovers who have justmet on the ship, a church elder etc

Read the following to the participants• Imagine your character is in a ship which is sinking• There are three life saving boats at your disposal -

the abstinence boat, the be faithful boat and theuse a condom boat

• Move into the boat that you would prefer to save yourcharacter’s life - act quickly before the ship sinks.

• Give time for the participants to move into the boatsof their choice

• Let the participants in each boat defend their choices• Summarise the findings from the game • Adapt or improve the game for different audiences

Point to ponderLook at the advert for condoms on the right.It was used in the United States. Do you thinksuch a message would work in Malawi?Give at least one reason for your decision

Points to PonderIs a person who knows that they are HIV+ but refuses towear a condom guilty of premeditated murder? Discuss

What would you say to a religious person who isHIV+ but refuses to wear a condom? Discuss

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Activity 5.21 Role play: Advising a friend about condom useIntroduce the role play by studying the cartoon and reading the brief background.You can add additional ideas or change the scene if you wish.

BackgroundTwo good friends, George and Kondwani, have known each other since primary schooldays. They meet at the bus stop and start to talk. They were out at a bar, drinkingtogether last night. George had to study for his examinations and returned home early.Kondwani stayed on and got very drunk leaving the bar with a woman who is knownto have had many partners. George wants to help Kondwani avoid getting HIV throughthis behaviour. Continue the conversation between George and Kondwani.

After the role play.The people who play George and Kondwani should stay in role during the discussion.• What other ways could you develop this role play?

Activity 5.22 Role play: Talking about prevention of STIsIntroduce the role play reading the brief background. You can add additional ideasor adapt the scene if you wish.

BackgroundTaona and Nora are two young women who work at the same place.They are sitting together and talking over lunch break. Nora is lookingsad and Taona asks her what is wrong. Nora says she has a smellydischarge and pain when she urinates. Yesterday, she went to theclinic because she thought she might have an STI. The nurse told hershe should change the way she practices birth control. That birthcontrol pills or injections do not protect against HIV or other STIs.She has just returned from the clinic with the results.

Nora: You’ll never guess what I learned at the clinic yesterday.Taona: What did you learn?

After the role playDiscussion points - bring up if not mentioned - add new ideas you discover• What are the advantages of using condoms even if you are already using shots or

the pill to prevent pregnancy?• What should a woman or a couple do if they have already had unprotected sex?• What should Taona and Nora do next?• What other ways could you develop this role play?

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Activity 5.23 Role play: Dispelling false beliefs about condomsIn this activity you will be able to chose from a selection of roleplay topics. They arebased around myths and false beliefs about condoms.

Choose from one of the following1 Sipho and Jane share the same room in the college.

One morning as she is cleaning, Sipho discovers apacket of condoms under Jane’s bed. Sipho hasnever used a condom before. She starts to thinkabout the different things that people say aboutcondoms. She’s worried, because she cannot seem to get answers to the key questionsand decides to ask Jane when she comes in the evening.

2 Yoanus and Charley, unmarried college students are discussing their girlfriends.Yoanus says that he’s upset because his girlfriend, Yamikani, is refusing to have sexwith him. She insists that if they have sex she will become pregnant or get STIs.

3 Yamikani is in Yoanus’ room, they are alone and it is getting late. Yoanus hasdecided to raise the issue of protection with Yamikani. She wishes he would beless bossy when they discuss the issue.

After the role playDiscussion points - bring up if not mentioned - add new ideas you discover•• What are the advantages of using condoms, even if you are already using shots or

pills to prevent pregnancy?• What should a person or a couple do if they have already had unprotected sex?• Is it still beneficial to start using condoms or start abstaining and being faithful?• Please bring up differing points of view in a respectful way, so that everyone is

aware of the differing faith views in our society.

Activity 5.24 Assignment• Review the stages of behaviour change from page 40• Find out what things may stop your peers/friends from

talking about safe sex and condom use with a friend ora partner

• Identify the stages of behaviour change that a personwould pass through in order to reach the point of usingcondoms consistently during a sexual relationship

• Find out what aspects related to alcohol use could hinderconsistent behaviour change

• Prepare to share your findings with the group at the nextmeeting

Evaluation. Use the questions on page 166 to evaluate the activities from this unit.

Point to ponderIt takes courage for couples to actually discuss using a condom. The condom and thediscussion are the easy parts, the barrier is that we are not yet brave enough! Discuss

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Unit 6 Talking with your partner about HIVIntroductionMillions of people know what they can do to keep from getting infected wth HIV, yetmany do not practice abstinence or safer sex. This unit looks at the issues surroundingcommunication between partners on HIV. It will consider some of the barriers toeffective communication and the ways in which these barriers can be removed.

Learning outcomesBy the end of this unit you should be able to:• explain the different stages that people may need to go

through in order to use condoms consistently duringsexual relationships

• identify the barriers to communicating about safer sex• describe how gender affects discussions on preventing

thE spread of STIs• identify what is needed to make people change their

behaviour• practice ways to communicate with a partner about safer sex, sexuality, HIV and

AIDS• explain how condoms may become an enjoyable part of sexual relationship• identify the issues raised by alcohol, drug use and sexuality

Activity 6.1 Assignment review:In order to change your behaviour and begin using condoms consistently, the followingstages may be used:1 Pre-contemplation - You have not considered that you are at risk and need to

use condoms2 Contemplation - You become aware of the risk and subsequent need to use

condoms 3 Preparation - You begin to think about using condoms in the next few

months4 Action - You use condoms consistently for fewer than six months5 Maintenance - You use condoms consistently for six months or more6 Relapse - You may begin to use condoms less consistently or stop

Activity 6.2 Barriers to communicating about safer sexYou may wish to combine this activity with 6.3 and 6.4. Remember that it is notnecessary to hold a lengthy discussion on each of the points raised during this activity.Many of the key issues will be considered in greater detail later in the course.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcAs you talk consider the reasons why people don’t practice safer sex try to group theideas under the following three headingss• Individual reasons• Couple or relationship reasons• Social or cultural reasons

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1 Individual reasonsWhat are some of the reasons an individual finds it hard to change risky behaviour?Look back at pages 64-67 to review some of the earlier activities linked to this topic.How do these reasons create barriers to communication?

Points for your discussion, debate, drawing, song, story, play, poem, poster etcWhich individual reasons can create barriers to communication about safer sex?

Enjoy having unprotected or natural sexual relations.Want to have a baby but have not been for VCTFear they are already infected, so there is nothing to loseDon’t wan to admit that they drink too much or use drugsso they do things they never intend to doLife is short anyway, so they do not want to lose any funBelieve they are not going to have sex, so don’t preparePeer pressure

2 Couple or relationship reasonsWhich relationship reasons can create barriers to communicationabout safer sex or changing risky behaviour?


Cannot communicate openly, especially about sexual mattersToo shy to raise the matter of safe sex with a partnerTalking about safer sex raises difficult issues between you and your partnerFear a partner will think they are not faithful if they talk about HIV preventionHave different goals in life, so they cannot agree on what to do - for example, aman may want to have extra partners while a woman wants him to be faithfulHave unequal power relationships, so that the wife fears physical or emotionalabuseLack of respect from one partner for another - one partner may be the underdog

3 Social and cultural reasonsSexual activities are enjoyable, and many of us don’t like to change activities that giveus pleasure. Many social or cultural factors affect conversationss about sexual matters.

Points to ponderTwo of the barriers to effective communication arethe difficulty of talking openly about sex andgender inequality. Discuss

If I went for VCT without telling my wife, I amnot sure if I would tell her of my visit if I hadbeen found HIV negative. Discuss

If a villager’s wife started talking to her husbandabout using a condom he would suspect that shewas having an affair. Discuss

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Activity 6.3 What is needed to help people to change their behaviour?It may be hard to talk a partner or friend about changing a risky behaviour, especiallyif it involves personal and private issues. We can however provide information, skills,and processes that might help them choose and maintain more positive behaviours.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcWhat do we need to do to help people change risky behaviour?

Couples have to be brave, show courage, inorder to talk about and then challenge arisky behaviour that endangers their livesCommunity elders should encourage couplesto talk to each other about safer sexTalk openly and frankly about how you feeland let the person talk about how they feeland think about HIV preventionTough love is the answer, where a partner rejectssomeone who engages in risky behaviour - thiscan shock them into changing their waysIf a person is depressed because they cannottalk about their behaviour, they must begiven hope and see a better future is possibleEncourage more conversation within the familyand this will make talking about sex easierTalking helps a person take more personalresponsibility for managing their reproductive healthInformation and correct facts must be available to couples to study or talk about,before they take any actionTalking together helps partners to come to an agreement not only over sexualmatters but other aspects of their relationshipConversation empowers couples to fight together against any risky behaviour

Activity 6.4 Communicating with your partner about safer sexYou may wish to combine this activity with 6.5, 6.6, 6.7, 6.8 and 6.9.Communicating is more than just using the correct words, it is also our tone of voice,facial expressions and body language.

In a sexual relationship partners can share personal facts about how they feel, thinkand would like to act. When partners share these special feelings and thoughts it oftenprovides an opportunity to strengthen the relationship, but it can also be a worryingtime for a partner who feels threatened or mis-understood.

In partnerships, relationships can have different power structures. The most commonattitudes/behaviours found within relationships are aggresive, submissive and assertive.

Points for discussion - bring up if not mentioned• If both partners have an aggresive attitude what would you expect to happen?• If both partners have an submissive attitude what would you expect to happen?• If both partners have an assertive attitude what would you expect to happen?

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Activity 6.5 How does an aggressive partner behave?How would you describe the behaviour of an aggressive partner?

Points for discussion - bring up if not mentionedWhat have peer group members suggested?

Use body language that frightens or controls, likes standingstiff and erect using a loud voice and angry gesturesPresent their own ideas forcefullyOften seem to lecturer their partner and other peopleDo not listen to their partner’s ideasCan be domineering by ignoring the partner or butting-inand start discussing something else

Activity 6.6 How does a passive partner behave?How would you describe the behaviour of an passive partner?


Use body language that shows lack of confidenceor fear; like slumping over; a soft voice; notmaking eye contact and submissive gesturesPresent their ideas timidly or keep silentAgree with their partner to end disagreement,even if they don’t like what their partner suggests

If this happens frequently, they can feel resentful, unhappy and they loseconfidence in themselves and their partnerThe work of a person who suffers within a relationship can be affected

Activity 6.7 How does an assertive partner behave?How would you describe the behaviour of assertive (but respectful) partner?


Use body language that shows respect to othersVery rarely lose their temper or get angryStanding relaxed and straight, using a moderatevoice, looking directly at their partner and usingfriendly gesturesPresent their own ideas and feelings confidentlyand clearly without shoutingListen carefully and make sure they know whattheir partner thinks and feelsTry to find a plan that both partners can acceptIdentify people in national and local life whoshow assertiveness and use them a good examplesDo you think that compromise plays an importantpart in a relationship involving two assertive people?

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Activity 6.8 Responding to an aggressive partnerWhether the aggressive partner is male or female, certain characteristics are usuallypresent in a conversation. How could you respond to an aggressive partner?

Points for discussion - bring up if not mentioned - add new ideas you discoverPeer group members have suggested three basic responses to aggressive behaviour.

You could:1 Delay - try to postpone this discussion

to a time when you are both morerelaxed - this is especially useful ifyour partner is drunk or becomingviolent. You may need to leave orget help to protect yourself. Takeyour children with you if they arein any danger.

2 Bargain - try to follow a middle path that gives each of you part of what you want.Even if you don’t get all of what you want - agreeing to a bargain this time shouldmake it easier to bargain again and again in future.

3 Refuse to go along with your partner’s demands - if your partner will not bargainand what he/she suggests is not acceptable to you, you may have to refuse. Refusinga partner can trigger anger, so if you refuse you may also need to leave and go to asafe place while your partner calms down.

• Which of the stragtegies have you used (delaying, bargaining or refusing) duringconversation with a partner?

• Discuss different situations when each of the strategies is most likely to succeed

More ideas for improving bargainingMake your own body language confident and respectfulExplain how you feel about your partner’s ideasand the different ways of saying them - eg. Ifeel (frustrated, sad, angry, embarrassed) whenyou shout at meMake a clear statement of what you wantIf your partner interrupts, point this out andsay you want to finish speaking.Ask your partner how he/she feels

Points to ponderI am the man of the house and must be obeyed. My wife is breaking her marriage vows ifshe asserts herself too much! Discuss

I always obey my husband if he is right, but feel that I have to challenge him if he is inthe wrong. That’s what a good wife should do. Isn’t it? Discuss

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Activity 6.9 Finding a mutually acceptable solutionSometimes it can be difficult to agree when both partners feel very strongly about theiropinions. How can we compromise or find a solution that is acceptable to both?

Points for discussion - bring up if not mentioned - add new ideas you discoverWhat have peer group members suggested?

They can find a middle path that gives each of them someof what is important to themThey can agree that they will follow one of their ideasthis time, and the other person’s idea next timeThey could agree that one of them will make decisionsabout one area of life, and the other will decide aboutanother area of life - for example, the man will decideabout clothes and the woman about furnishings. But itmay be better for both to be involved in both issuesEven if partners do not come up with an ideal solution, knowing that they havetried and have listened to each other makes them feel glad to be togetherMake a list of the statements that could be used during a discussion whichreaches a mutually agreed conclusion - write down the exact words that will bespoken and test them out on peer group membersIf you believe that you personally need to practice making these sort ofstatements, why not find a place where you can be alone. Then speak the wordsout loud - try them at home speaking into a mirror.Study the cartoon shown below and swer the following questions:a) How do you think the message relates to conversations between sexual

partners about HIV and AIDS?b) How do you think its message relates to the fight against the HIV pandemic?

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Activity 6.10 Can condoms be an enjoyable part of your love life? In unit 5, we looked at the condom and some of the mis-conception surrounding itsuse. In this activity we will discuss how condoms can be made an enjoyable part of asexual relationship. Refer back to the activities in unit 5 if you wish to revise the topic.

What could you say to convince your partner to use a condom consistently?Remember, that if you decide to use condoms, you need to use them every time youhave sex in order to stay safe.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcGroup members have suggested that by using a condom I show that I care about:

myselfmy partnermy family and future generationsevery child being a wanted childhelping to stop the spread of HIV and STIs

What other statements have peer groupmembers suggested?

Take control of your lifeYou alone are in charge of your body andonly you can decide what to do with itThe decision to have unprotected sex can seriouslyaffect you and everything in your life forever!It is a modern world, and women should be able tocarry a condom, especially if it will save her life and the life of many othersFind a condom before sex starts, because after beginning sexual activity it may bemore difficult to negotiate safe sex, if you and your partner are excitedLearn how to use a condom before sex - you may need to use condoms a fewtimes before you are really comfortable about putting them on and removingthem as part of, and not an interruption to sexualactivityCouples can make condoms a fun part offoreplay and by calling a condom by a nicknamelike Johnny break the ice a bitThe woman can put Johnny on her partner in anenjoyable wayMany sexually active people who say thay don’t like condoms have not triedthem, or they tried them as teenagers when they were not very experienced -encourage them to try condoms again or try a different brand of condomIf partner does not agree, explain issues about safe sex and if s/he still does notagree, say something like, Maybe we need to wait until you care about me enough towear one.Remember to consult your religious leader if you are in any doubt about condomuse - your sexual activities should fit in with your personal moral code.

Point to ponderWhen I wear a condom it helps me stay erect longer, so I have more time for love making,experimenting and my partner appreciates that. Discuss

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Activity 6.11 Role play: Talking about safer sex with a new partnerIntroduce the role play with the briefground brief. Different people should read thedifferent thoughts and words of the players. Start the role play by using Chisomoand Mphatso’s words, and continue by making up your own.

Background to the role playChisomo, is a first year teacher trainee student. She meets Mphatso at a party given bya mutual friend. They have known each other since secondary school, but they haven’tmet in a long time. Tonight they are really attracted to each other. They have beendancing all night and having a wonderful time talking together.

Mphatso is thinking:• Chisomo is beautiful, elegant and so hot!• She smiles a lot and is still here with me• I think sex with her will be better than with both my

other lady friends• I really want her tonight, but I have never used a

condom and I am not really sure how to!• I want to play safe but how do I bring up the topic?• if i mention condoms she’ll think I believe she’s infected

or even worse, that I sleep with every girl I date!

Chisomo is thinking:• I loved being with him he’s so handsome, strong and intelligent• I don’t have a boyfriend maybe he is the one, let me find out• Men expect you to sleep with them as an appreciation of a good date, but HIV worries

me, is he HIV+?• I wonder what he’d be like in bed - now Chisomo stop those thoughts right now!• Well, in Mzake ndi Mzake we learned how to put on the male condom correctly• But maybe I could convince him to use a condom• But that would make me appear cheap, wouldn’t it?• Maybe I will just abstain until I know him better

The role-play begins:Chisomo: I have really enjoyed myself tonight. Mphasto, I am so glad that I have met

you again after so long.Mphatso: Chisomo, this party’s breaking up. Can I walk you home, or maybe we can

stop somewhere to talk some more?

After the role play• Did each actor/partner communicate clearly?• What style did they use?• Did the partners succeed in developing a plan

that would protect them both from STDs,HIV infection?

• What else could have been said?• How could this role play be adapted?

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Activity 6.12 Alcohol drinking or drug use and sexualityHow can taking alcohol and other drugs put people in danger from HIV infection?

Points for your discussion, debate, drawing, song, story, play, poem, poster etcWhat concerns have peer group members raised about alcohol use and mis-use?

Alcohol and other drugs like chamba, produce feelings of well-being, relaxation,pleasure or excitementProblem drinkers or drug users are people whohave may have other problems in their livesSocial customs tolerate and even encouragesocial use of alcohol, especially for menPoverty, unemployment and jobs away fromhome cause stress that may lead some to drinkAlcohol and home brew are widely availableand affordable for many peopleFew health services are available for people withalcohol problems

How can drink put people at risk of getting HIV?What have peer group members suggested?

Having sexual relations when they planned to abstainHave sexual relations with someonethey don’t really know wellCompromises their judgement aboutsexual partners and protection against HIVArgue and refuse to take No for an answerand use force to have sexual relationsSerious arguments or physical fights mayoccur - some people may hurt their partnersIf a person is high on alcohol they may have troubleusing a condom because they have less control over their movements than usual

Why is it hard to help people who drink alcohol to change their behaviour?What have peer group members suggested?

Some people who drink to excess don’t recognise that they have a big problemPeople who abuse alcohol and substances usually deny that they have a problem.They know that they feel better after a drink and so look forward to itDrinking with friends may be the traditional way that a person relaxes - if hisfriends drink and he stops he may feel like an outsiderIf people depend on alcohol or drugs to feel good, they rarely want to changetheir behaviour - it can be hard to find an enjoyable replacement activityPeople who rarely drink can put themselves in danger as they may refuse toacknowledge that they coul get drunk and then behave out of characterThere is so much advertising related to drinking alcohol that it is hard to avoidMany alcoholics would like to live sober a lifestyle but want to delay acting untilthe next day - reformed or recovering alcoholics may need to advise them

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What discourages excessive drinking of alcohol?What have peer group members suggested?

The first step is for the person to admit thatthey have such a problem - the next step isto want to change the situationUse the behaviour change ideas on page 40to make a plan for giving up alcoholAccept that drinking alcohol is a form ofselfishness where the drinker is the one whoalone enjoys that drinkAccept that drinking alcohol uses money thatcould be better spent on other things - familyfood, school fees, transport, pension, health issues etcLearn more about Alcoholics Anonymous (AA) a worldwide organisation helpingrecovering alcoholics and how you can join - stories and tips at www.aa.orgCouples who are open and honest with each other find it easier to tackle aproblem like alcoholism or drug addictionPeople who have kicked the habit of drinking can act as mentors for othersFaith groups can provide confidential support for members struggling to do soWomen can counsel friends - traditionally women are expected to either not drinkalcohol or drink only a little on special occasions

Men can help each other by spending leisure time inplaces where beer is not soldTaking up sports or other active leisure pursuits canreplace the trip to the bar as the main social activityPeople living with HIV and AIDS are discouraged fromdrinking alcohol as it can weaken the immune systemPray both individually and in groups for the spiritualstrength to beat the addictionFamily and friends who will stick by you and keepencouraging you to give upCounselling the drinker of the consequences of drinkingon individual, family and communityNever ever stop trying to give up your addiction toalcohol - others have succeeded and so will you!Malawi Times

Activity 6.13 Assignment: Talking about safer sex with your partner• Talk with your partner about sex and

what is safe and satisfying for both ofyou - what each partner find particularlyenjoyable?

• If you do not currently have apartner, talk (or role play) witha friend or neighbour

• Make a list of things that you willdo to protect yourself and yourpartner from getting HIV and STIs

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Unit 7 HIV and AIDS testing and ARV treatment

IntroductionA person who is living with HIV (PLWH) may look perfectly normal, before theydevelop AIDS. Only an HIV test can tell whether a person is carrying the virus or not.AIDS is diagnosed using mainly clinical observation or using laboratory tests alongwith observation. If a person knows their sero-status (whether they are HIV+ or not )then they can plan ahead and start anti-retroviral treatment (ART) when it is appropriate.ART is proving very successful in Malawi. You may wish to look back at the diagramon page 19 before starting this unit.

Learning outcomesBy the end of this unit you will be able to:• describe what happens when you go for VCT• state some of the reasons why people do not go for VCT• list some of the advantages of going through VCT• explain why counselling is an important part of VCT• describe the clinical approach to diagnosing AIDS• describe the laboratory test approach• list the advantages of finding out if you are

HIV negative• describe where you can go for free VCT• explain what ARVs are• list the groups of ARV drugs• describe what we must know about ARVs

if we want to use them• describe what happens before someone starts taking ARVs• list places where people can get ARVs• list some of the challenges faced by people taking ARVs

Activity 7.1 Assignment reviewReview the assignment and select ideas that may be useful when studying this unit.

IMPORTANT: Since this manual was published new drugs and new methods oftesting and treatment may have been introduced. So you should always listen tothe most current medical advice from your health professional.

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Activity 7.2 What happens when you go for VCT?VCT stands for Voluntary Counselling and Testing. Ask the group about their experiencesof same-day VCT is. What does VCT involve?

Points for your discussion, debate, drawing, song, story, play, poem, poster etcA counsellor explains the whole procedure and helps you think about what it willmean if you test positive or test negative.During a test, a finger prick blood sample is takenWhile you are waiting, the counsellor will talk toyou about HIV and AIDS preventionIn about an hour you will get your results - thecounsellor tells you your results and talks with youabout what these results mean for you.Everything is done in privacyYou can go alone or you can go with your partner

Activity 7.3 What are some reasons for not going through VCT?Discuss and list all the disadvantages there could be to being tested for HIV.


Not wanting to know that you have a serious diseaseNot wanting others to react negatively if they learn you are HIV positiveFear that if people see you going to be tested they will assume you are positiveFear of losing your partner or not having a future partner if you are HIV positive

Activity 7.4 What are the advantages of going through VCT?What some of the advantages of being tested, whether you learn that you are HIVinfected or free of infection?


Counselling is done before and after the testHIV test is quick, not painful and privateIt is your right to know your HIV statusYou can start making informed decisions and planfor the futureYou no longer have doubts or anxiety about yourHIV statusYou can take responsibility for yourself and yourpartnerIt’s like a new start for your lifeGoing for an HIV test protect community and countryThere’s no real stigma in our community around going for a VCTs

Point to ponderI am so afraid of going for VCT. What if I am found to be HIV positive? I think that it isbetter not to know. Discuss

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Activity 7.5 Why is counselling an important part of VCT?Counselling before and after VCT is very important. Many people go through a mourningprocess when they hear they have HIV or AIDS, it is as if they are mourning forthemselves. They may feel as if they had lost their beloved wife, mother, father, childor dearest friend all rolled into one. In order to reach a position of living positively withHIV a person will probably have to go through the stages of mourning shown below.

The 8 stages of the mourning process are:1 Shock .............When first hearing the news that they are HIV+, people can go into

shock. Shock is an intense emotional and physical reaction to devastingnews. This is similar to shock after a physical accident; feelings ofhysteria, numbness, an ability to think and act clearly. They may beunable to take in any more information or to respond to counselling.

2 Denial ............ Denial is linked to shock, it is a deep seated inability or refusal to takein the information. This might continue after the initial shock hasworn off. Continued denial becomes problematic as it blocksappropriate behaviour change towards coping and living positively

3 Anger ............ Feeling as if you have been singled out for this terrible situation.Wanting to blame someone else. This anger may be directed at aspouse, the opposite sex, children, God or members of the community.

4 Bargaining .. The person prays or begs supernatural powers or medical staff tochange the diagnosis. This often includes pledges to change behaviour.

5 Guilt ...............The person starts to blame themself for the situation. This often greatlyreduces self-esteem and concern for all those who are directly orindirectly affected. The amount of guilt the person feels may be fargreater than expected.

6 Depression.. Deep sadness, helplessness, which stops many ordinary activities, withlow self esteem and loss of hope. This may be linked to loss and fear:eg loss of job, loss of loving relationships, loss of having children, lossof control. Fear of stigma, rejection, loneliness and death, or leavingdependents without support. At this stage PLWHA may give up andcontemplate suicide or believe they have nothing to lose if they goback to dangerous sexual behaviour.

7 Acceptance.. No longer feeling overwhelmed; recognising that the situation cannotbe changed and beginning to come to terms with living with HIV.

8 Coping ......... Adjusting to the new life situation and getting back to normal as faras possible. This means rebuilding self esteem, coping with life, andplanning effectively for the future by adopting appropriate behaviourchange. The best form of coping is living positively with HIV, wherehope for the future is continually reinforced through positive actions.

If a family member or friend was in an early stage of mourning for themself what couldyou do? Is giving information enough?

Point to ponderThe families and friends of PLWHA, play a very important role in helping them through themourning process to the coping stage. Discuss

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Activity 7.6 What is the clinical approach to diagnosing AIDS?How do medical staff decide if a person has AIDS? Discuss experiences of the processused to diagnose AIDs in a friend, family member or anyone else.

Points for discussion - bring up if not mentioned - add new ideas you discover• It is carried out by qualified staff in medical centres• Using the clinical approach a person is diagnosed with AIDS when they have a

pattern of infections that come back again and again - these infections (such asmalaria, rashes, spots and TB) can be common even in people without HIV

• Some opportunistic infections, like oral thrush, are unusual and rarely occur inpeople who are not living with HIV

• A person has repeated infections only in late stages of HIV infection• Clinical observation does not help identify when infections may start, and it

doesn’t allow careful monitoring of a person’s condition - however, clinicaldiagnosis is important because it is relatively low cost and readily available

Activity 7.7 What is the laboratory test approach?Using the laboratory approach, a person’s blood is tested.

Points for discussion - bring up if not mentioned - add new ideas you discover• The immune cell count gives a more precise indication of how well the immune

system is functioning and can guide drug treatment• If the immune cell count is 200 or less, the person is considered to have AIDS• There are generally two tests which search for antibodies to HIV• The ELISA test uses colour changes to detect presence of antibodies• Elisa tests may produce false results - this occurs when newly infected person is

tested for HIV• The body of a newly infected person will not have produced antibodies to HIV

and they are said to be in the window period. People who are newly infected byother diseases that suppress the immune system such as malaria, TB, diabetes andother parasitic infections may test positive

• Some people may be HIV positive but too ill to have enough antibodies that canbe detected by a laboratory test

• The Western blot and other tests is used to confirm the ELISA test• The Western blot test reacts to specific proteins of HIV antibodies• The PCR tests detect the presence of HIV in the blood

Points to ponderHIV tests cannot dispel fears or myths aboutHIV transmission, nor do they tell where andhow the person was infected. Discuss

The window period can lull some people whogo for VCT into a false sense of security. Discuss

Why is important for every pregnant woman toknow if she is HIV positive or not? Discuss

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Activity 7.8 What are the advantages of finding out you are HIV negative?Ask any group members who have been tested, to describe their feeling before, duringand after the test. Then discuss the advantages of a couple discovering that they areboth HIV free.


Means past partners may be safe tooFeel relieved you don’t have to inform your partner if you have been unfaithfulIf I am HIV free this will encourage me to do careful planning for the futureHelps decide to practice abstinence or safer sex in thefutureYou can make informed decisions about marriage,pregnancy, and sexual relationshipsIf you are both completely faithful, you can have sexwithout using a condomYou can plan to have a baby knowing that the baby will not be infected with HIV

Activity 7.9 What are the advantages of going for VCT with your partner ifyou learn that both of you are HIV positive?What are the advantages of going for VCT with your partner, especialy if you learn thatboth of you are HIV positive?


You can take good care of each other and stay healthy as long as possibleLearn more about ARVs and the ART available in the communityYou can become a role model to other couples, showing them how to livepositively with HIV and AIDSPlan to have regular tests speedy treatment for other illnessesPractice safer sex or abstinence so you will not re-infect each otherPlan for the future for both of yourselves and your family eg pregnancy andsuccession planning which helps protect the family if you die (see page 140-1 )Join or set up a self-help group for PLWHA

Point to ponderKnowing whether you are HIV positive or negative means that you can get on with therest of your life and live it positively! Discuss

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Activity 7.10 What are the advantages of testing with your partner if youlearn that one of you is HIV positive and the other one is not?If partners go for VCT together and one is positive and the other is negative, what doyou think could happen? What would be the disadvantages?


It may cause an argument over the assumedunfaithfulness of the HIV+ partnerPartners can be careful to protect the negativepartner from infectionCouples decide to abstain or practice onlynon-penetrative sex(kissing, hugging, etc) toavoid the risk of infecting the other partnerSome couples continue to have sexual relationswith each other using condoms - many coupleshave done this, and when they ALWAYS usecondom, the person who is HIV negativeremains negativeYou can be behave carefully to protect thenegative partner from infectionreYou can be role model and show other coupleshow to live positively with HIV and AIDS

Activity 7.11 Where can I go for a free VCT?Where can people go to get free VCT or HIV counselling and testing? Ask the group tomention the different options available locally and throughout the country.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcWhat have peer group members suggested?• The government, NGOs and private clinics are

now active in providing VCT - MACRO offersfree voluntary HIV counselling and testing

• Invite a health professional to speak aboutVCT to reassure members that - testing iscompletely confidential but testing alone isnot as helpful as testing and counselling

• HIV counselling and testing is now available at district hospitals - however, thecounselling in these settings may emphasize medical management and may nothave a great deal of time to focus on all methods of prevention

• List the local places where VCT is available and publicise its contents by postingon notice boards in schools, colleges, meeting places and shops

Point to ponderI don’t want to go for VCT at the local health centre, because people will see me goinginside and then the gossip will begin. Discuss

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Activity 7.12 What are ARVs ?ARVs or antiretroviral drugs work to decrease the HIV viral load (the amount of HIV inthe body) and improve the immune system in this process. Why do we need ARVs?Why haven’t scientists discovered a cure for HIV/AIDS? Some of the reasons given byscientists are that medicines that can cure HIV/AIDS may penetrate the brain andcause more harm. ARVs protect T cells by stopping HIV from attaching its self to,entering, reproducing inside or leaving the T cells.

Activity 7.13 What are the four groups of ARV drugs and why do we need touse four of them?There are four groups of anti-retroviral drugs and each attacks HIV in a different way.Each of the four groups acts during a different time in the life cycle of the virus.

These are the four most popular ARV drugs used at present:1 Entry InhibitorsIn order for HIV to enter the human cell, it has to attach itself the surface of the cellfirst and then move into the cell. This group of drugs interfere with process andprevent HIV from entering the human cell.2 ‘Nukes’ or Nucleoside Analogue Reverse Transcriptase Inhibitors or NukesThese slow down the reproduction of the virus by blocking the action of the enzyme(reverse transcriptase) which is essential to the virus being absorbed into the host cell,where it can reproduce itself using the cell’s own genetic material - they ensure that theHIV copies are poor or faulty.3 ‘Non-nukes’ or Non–Nucleoside Reverse Transcriptase InhibitorsInactivates the transcription of the RNA (of the HIV) into the human cell DNA.4 Protease InhibitorsThese interfere with the enzyme (protease) needed in the final stage HIV copying bycausing the production of immature viruses.

These drugs are used in a combination so they:reduce HIV mutationboost the immune system by decreasingthe resistance to a particular drugstop or delay the conditions favourable for the opportunistic infections

The HAART combination uses the last three groups of drugs. Any one or two ofthem can also be used alone. If you take HAART, you need to regularly check on theeffect of the treatment on your CD4 cell count and your viral load - the CD4 cellcount measures how strong your immune system is

IMPORTANT: Since this manual was published new drugs and new methods oftesting and treatment may have been introduced. So you should always listen tothe most current medical advice from your health professional.

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Activity 7.14 What must we know about ARVs if we want to use them?


Find out if a member of the group who is on ARVs, will lead the discussion ordescribe their personal experiencesThe activity works well by using a real case studyMedication should be taken exactly as prescribedYou must be able to adhere to treatment regime.Change your lifestyle so you can more easilystick to the routineMissed doses should be taken as close as possibleto the scheduled time, if it is not possible then theregular amount at the next scheduled timeBottles, glasses, medicine spoons should be keptseparate from other medication equipment tokeep uniformity of doses and avoiding accidentaluse by family membersDrugs should be stored as prescribed - yourmust work out how to store and carry your drugs duringthe work routine or travelsFind or ask for support from people who know about your HIV status or ARVsUnderstand the possible side effects of proposed treatment and let your friends orpartners know about these

Point to ponderYour lifestyle changes when you start taking ARVs regularly. It’s as if I am in training,like an athlete, making sure my life is disciplined and focused. Discuss

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Activity 7.15 When should a person start taking ARVs?Try to use a real case study from the group or their family or community. What do youknow about starting ART?

Points for your discussion, debate, drawing, song, story, play, poem, poster etcThe decision to begin ART (taking ARVs) is one that will be taken after discussionbetween the client and the doctor. The decision to begin taking ARVs will, amongother things, depend on the following:• Your viral load• Your CD4 count (T cell count)• Your symptoms• Your willingness to adhere to drugs

instructions provided by the doctor

Consider the following factors when undertaking antiretroviral drug treatment:You should to start treatment before the immune system is severely damagedYou should delay treatment to delay the development of resistanceIt is dangerous to begin HIV drug treatment without testing and continuousmedical follow-up

Activity 7.16 What happens before someone starts taking ARVs?The National AIDS Commission recommends that, after it has been agreed that a personwill start taking ARVs, a clinician counsels the person and provides the followinginformation about:• How many tablets to take• How often to take the tablets• How long to take the tablets• The need to follow instructions when taking ARVs

as advised by a professional• Any signs and symptoms of side effects as a result

of taking ARV• The importance of keeping fit• The importance of eating nutritious food• The importance of practising safe sex• Not to share the drugs with anyone• Visting the health centre as advised or when the need arises

Activity 7.17 Where can people get ARVs?Do you know where ARVs can be found? ARVs are available at central hospitals, somedistrict hospitals and private hospitals. There are now over 100 hospitals and healthfacilities (including all Central, District and major CHAM hospitals, Malawi DefenceForce and Police hospitals) providing free ARVs while over 20 private sector healthfacilities are providing ARVs at asubsidised rate of K500 per patient per month.

It is important that everyone realises that ARV drugs can only be safely obtained fromauthorised health service providers. Black-market ARVs may be very dangerous!

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Activity 7.18 What is HIV resistance to ARVs?Like other viruses, HIV is constantly changing. Each copy HIV makes of itself may bea little different. There are more than 8 subtypes of HIV. When two different subtypesmeet they can produce a new hybrid and this may be a virus that is resistant to allknown ARVs.

Here are some of the ways in which the rate of HIV resistance to ARVs increases:If HIV is allowed to manufacture too many copies, eventually some mutate intodifferent forms - the present HIV medicine (ARVs) then cannot recognise themanymore and the medicine stops working effectivelyMost people who are HIV positive eventually develop resistance to one set ofdrugs and need to have medications adapted - some people become resistant to allthe available drugsWhen a person develops resistance, they can pass on this resistant type of HIV tosomeone else - the newly infected person then cannot be treated with the sameARVsAs more people take anti-retroviral drugs, more viruseswill mutate or develop resistance - as a result, a higherproportion of the HIV that are being transmitted fromperson to person will be drug-resistantResistance is a problem for both the individual and society

Activity 7.19 How can we reduce the rate of resistance to ARVs?What do health professionals suggest?

Medicines must be taken everyday exactly as directed.Don’t miss doses. When doses are missed or medicines are taken incorrectly, HIVgets a chance to make different copies of itself.When medicines are taken correctly, most of the HIV factories stay closed, sothere is less chance for HIV to make lots of different copies and for resistance tothe medicine to occur.Once a person has developed resistance to a medicine, the person needs to stoptaking that drug. If possible, the person can take a different drug to fight the HIV.A person may also need to stop taking the medicine if they develop severe sideeffects from the drug.People must have regular viral load testsOne important element of treatment is regularly checking of the patient for drugresistance

Review the diagrams onpage 19 and 90

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Activity 7.20 What challenges are faced by people taking ARVs?Ex-president of the USA, Bill Clinton has said, AIDS is no longer a death sentence forthose who can get the medicines. Now it’s up to the politicians to create the comprehensivestrategies to better treat the disease.

• Discuss the quotation from Bill Clinton• Identify problems faced by people taking ARVs in the community.• What problems could be encountered at work, school and other places?

Points for your discussion, debate, drawing, song, story, play, poem, poster etcWhat have health professionals have suggested?

Problems associated with treatment include:- Difficulty monitoring treatment effectively- Difficulty in distribution of drugs- Difficulty in sticking to treatment regiment- Development of resistanceSome people come late to treatment because of denial- they have problems accepting they could be HIV+Some people develop strong side effects so a drugcombination is not workableSome people fail to respond to drugs due to drugresistant strains of HIVSome people cannot access regular drug treatmentfor HIV infectionBlack market drugs cannot be trusted - you cannot be sure what they areSome religious leaders try to persuade people taking ARVs to stop and look to becured through prayerOthers may feel traditional medicines are better than ARVs - if this was true themakes of these medicines would be millionairesPeople may hide their ARVs and take them in secret and not disclose their statusDiscuss other difficulties with drug treatment.

Activity 7.21 Assignment: Using and managing ARVs• Talk to your family members or friends about what you have learnt today• Find out how much they know about anti-retroviral drugs• Make sure you tell them that since the introduction of ART, figures are changing.

People still die, especially during the first few months of treatment, but when wecompare the figures with those that are surviving, there are many more survivors.

• Find out where people are getting ARV drugs and what challenges they are facingin using and managing the treatments

• Prepare for the next session by looking at what your community is doing to fightthe spread of HIV

EvaluationEvaluate the activities in this unit by going through the questions on page 166 andrecord the results in your learning log.

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Unit 8 Things we can do to fight the spread of HIV

IntroductionThere is an traditional African saying, When spider webs unite, they can tie up a lion. Thisillustrates the special power in community action that can mobilise people and resources,which is unique. Nearly all national social initiatives rely upon some form of communityaction. In this unit we will look at the many different ways communities can worktogether to fight the spread of HIV.

Learning outcomesBy the end of this unit you should be able to:• describe how all adults have the right to protect their health either by

abstaining or by having safer sex• describe ways to protect groups who are at risk of HIV infection• list the factors in our society which encourage the spread of HIV• describe cultural practices that increase the risk of HIV infection• explain why Malawian laws do not allow nkhanza• describe Malawi’s National HIV/AIDS policy• describe ways to protect widows from HIV infection• describe ways to protect young girls from HIV infection• describe ways to protect women and men from HIV infection• explain the work of teacher networks fighting HIV : T’LIPO• identify other networks fighting HIV• describe how Malawi’s sex industry can spread HIV/AIDS• explain why education is called a vaccine against HIV• explain why staying silent on homosexuality may help

spread HIV/AIDS• describe one global approach to HIV prevention• explain why people who spend time in prison are at risk• explain how trafficking for sexploitation spread HIV and AIDS

Activity 8.1 Assignment reviewReview the assignment.

Activity 8.2 Standing in someone else’s shoesLook back at activity 2.25 on page 42 and spend a few minutes talking about whatyou learned from that activity. This should prepare you for the next block of activitieswhich look in greater detail at how we can assist all members in our communities.

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Activity 8.2 How to assess the risk of HIV infectionA risk assessment is a strategy used as part of the behaviour change process, but itcan also be used for other purposes. Look back at Unit 4, especially from page 60onwards, and think about the story of Cecilia and the number of people she sharedbody fluids with.

If you feel that you have assessed your ownpersonal risk of HIV infection then go on theactivity 8.3. If you’d like to learn more orreview some key points then read on.

During a risk assessment, health care workers use aperson’s responses to questions about their behavioursand the behaviour of their partners, in order to gauge the riskof HIV infection.

Risk assessment questions focus on:• Age - Are you in an age group at greater risk of HIV infection?• Partnership status - Are you single and abstaining or married and faithful?• New sexual partners - Do you have a new sexual partner?• Multiple partners - Do you have more than one sexual partner?• Partners with multiple partners - Does your partner/s have more than one

partner?• Partner who often travels - Do you or your partner travel for work or business?• History of an STI, pelvic inflammatory disease (PID), reproductive tract infection

(RTI) - Do you or your partner have a medical history that increases risk of HIV?• Partner with symptoms of an STI - Have you or your partner ever had an STI?• Current symptoms or signs - Do you or your partner currently have an STI?

Using a information handouts. By providing information about risks in general,and asking the participants to self-assess whether or not they are at risk. Thishappens without people revealing specific information. This approach is often usedwhere it is considered culturally inappropriate to disclose more specific informationabout sexual practices and partnerships.

Using a peer pair or peer group. This approach is likely to be more effective inassisting a peer to recognise his or her risk of HIV infection. Many people havedifficulty perceiving their own risk of infection, even if they know, in general, whatplaces a person at risk. Find a person who you trust. In private, discuss the factorswhich may be putting you at risk of infection. Your peer may understand yourindividual risks and may be able to help you apply information to yourcircumstances if necessary. You can arrange to meet privately on many occasions todiscuss matters arising from Mzake ndi mzake.

Point to ponderYou are free to put your life at risk, but you don’t have the right to put other people’s livesat risk. Discuss

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Activity 8.3 Ways to protect groups who are at risk of HIV infectionIdentify the people in your community are at risk. Look at all the different members ofa community and how they could be put at risk of HIV. You may want to refer to page49, where over thirty reasons for having a sexual relationship are listed.

Points for your discussion, debate, drawing, poem, poster, story, song etcDo you think the following are at higher risk? If so how would you work to protecteach group from abuse and risk of HIV?• Boarding secondary school pupils and boarder at college or university• Unborn baby of an HIV+ mother• Professional at a workshop away from home• Long distance lorry driver• Sugar-daddy and sugar mummy• Cross-border trader• Health worker• Child labourers or seasonal worker• Orphan with no means of support• Orphan living with relatives• Refugee or displaced person• School child• House servant• Sex worker• Street child or youth • Police officer • Prisoner• Adolescent • Widow • Tourist

Activity 8.4 Which factors in our society encourage the spread of HIV?The points listed below may overlap, so you can combine some of them if you wish.

Which factors encourage the spread of HIV?Rank the following in order of 1st place, 2nd, 3rd, 4th, 5th to 10th:• Condoms• Prostitution• Unemployment and poverty• Homosexuality• Lack of a full primary education• Gender inequalities• Pornography• Power relationships within the family, school,

workplace and community life in general• Traditional cultural practices• Witchcraft, sorcery or evil supernatural forces• Lack of information about HIV and AIDS• Westernisation and consumerism culture• Lack of effective moral education• Injectable drug and alcohol abuse• Lack of communication about sexual matters,

between partners and between adults and childrenCompare your list with the lists made by other members of the group.

Sunday Times, Mar 2, 2008 by Agnes Mizere

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Activity 8.5 Cultural practices that increase the risk of HIV infectionYou may wish to combine this activity with the next one. Review some of the culturalpractices in our society which increase the risk of married couples contracting HIV.Decisions to change any of these practices may involve the whole community or themost important leaders in the community to meet and act.

Points for your discussion, debate, song, poem etcWhat have peer group members suggested?

Wife replacement (kusunga mwamuna)Temporary husband replacement (mbulo)Husband and wife exchange (chimwanamwayi)Widow inheritance (chokolo)Sex with the girl-child coming of age (kusasa fumbi)Sex with the boy-child coming of ageEarly marriageDeath cleansing (kulowa/kupita kufa)Menstruation cleansing (kuthintsa mchele)Polygamy - since there is contact with a number of sexual partners within eachmarriage, the risk of infection if one partner becomes infectedExtra-marital affairs Forced marital sex Seasonal ‘marriages’Lack of communication on issues related to sex and HIV/AIDSMyth that sex with a virgin is safe or can cure a person from HIV and AIDSDominant position of men in society and within all types of marriage, leavesmany women powerless to negotiate safe sex even if they suspect their husbandmay be infected. Because men usually have control over when, where and howsex takes place, women don’t have much decision making power concerning sex

This cartoon appeared on the front page of The Sunday Times, in March 2008. TheMalawi Traditional Healers Association threatened to march to parliament. The Hon.Secretary for Nutrition and HIV/AIDS had said, I have not said it’s a witchdoctor’s law.We want to protect people from healers who use albinos, people with disabilities and virginsas zizimba to treat AIDS. Read the policy on page 106.

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Activity 8.6 Do Malawian laws allow nkhanza?Cultural practices which go against the laws of Malawi are not allowed. Marriage is alegal relationship between people, no matter how they are married. In this activitywe will look at how the legal consequences of marriage are very different from whatmany people believe. The laws of marriage usually outlaw nkhanza.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcJust because certain things happen in many marriagesdoes not make them legalAllowing nkhanza, can increase the risks of spreadingHIV both within a marriage and societyEven if people are married it does not mean thatthey can commit illegal acts against their spouseIf the law does not allow a certain practice, then it isnot a lawful within a marriage and no-one can beforced to submit to it

Spousal beating (including educational beatings) are a criminal offence if physicalassault takes placeNkhanza can take place if a partner refuses to take care of the family (eg notbuying food or clothes and a home maker not looking after the house or notcooking properly). Depending on how badly people have behaved, these could beoffences under sections 164 and 165 of the penal code, which makes it an offencefor any parent or guardian to desert a child under the age of 14Marital rape, although not yet recognised as rape in Malawi, a number of crimesmay be committed during this act, including assault, sexual attack or assault withintent to do grievous bodily harmForcing a wife to have sex with another person in the customary practice of wifeand husband exchange. A criminal offence (rape) if the wife does not consentAlthough Malawian law does not recognise witchcraft, some actions associatedwith the idea of witchcraft can be considered crimes - fssor example if a personconfesses to using witchcraft and the potions are poisonous, they could becharged with the criminal offence of poisoning or administering dangeroussubstances, murder, attempted murder or manslaughterDefilement is a criminal offence

Point to ponderIt will take at least a generation to get rid ofnkhanza from the villages. Discuss

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Activity 8.7 Malawi’s National HIV/AIDS policy (2004)What is the difference between a policy and a law? A policy lays down general rules,goals and procedures on how government decisions are to be made or taken. Forexample, if the National Gender Policy says that girls’ attendance should be increasedat university level, then government must ensure that during university selection, aset number of girls must be selected. Although not legally binding, government musttry to stick to its own policies. After a policy has been made, government often drafts alaw, once passed by parliament it makes the policy legally binding.

Points for discussion from the national HIV/AIDS policy 2004Discourage customary practices in marriage which may lead to HIV infectionAims to sensitise traditional leaders and their subjects on the dangers of certaincustomary practices such as consensual adultery for childless couples (fisi), wife-exchange and husband-exchange (chimwanamayi) and temporary husbandreplacement (mbulo) all of which may lead to HIV infectionCalls on traditional and religious leaders to sensitise their communities to thedangers of, and discourage, customary widow- and widower-inheritance practicesAims to ensure that men and women are empowered to make independent andinformed decisions and choices regarding widow- and widower-inheritance toreduce the risk of HIV transmissionEncourage women and men to use condoms if they engage in customary practicesthat increase the risk of HIV transmission within a marriageEncourage the promotion of monogamous marriages and fidelity within marriage- monogamous marriage means being married to only one person and fidelity inmarriage is when a husband and wife are both faithful to each other and do nothave any other sexual partnersMalawi’s national policy recommends that: All customary laws that help spreadHIV or that discriminate against women in marriage relationships shall bemodified or banned after consultation with traditional leaders and the people.A law should be passed to provide for the rights and obligations of men andwomen in any type of marriage to ensure their protection from abuse andexploitation (which can lead to HIV/AIDS)

The Government of Malawi is also considering the following changes to the law thatwill impact on marriage and hopefully reduce the rate of infection:

Make the minimum age for marriage 16 years old, by amending section 22 of theconstitution - this will prevent children from marrying early and getting exposedto the HIV virus at a young ageChange the law, so that having sex with a child below 16 years of age is an offence(defilement), whether the child consents or not - at the moment this is only anoffence if the child is below the age of 13. Such a change will make marriage togirls younger than 16, a criminal offence as well as protect them from sexualabuse and HIV transmissionThere is also a proposal from civil society that marital rape should be a crime in itsown right. This will help women refuse sex from a husband who they believe orknow to be infected with HIV. This is being proposed in a new law which is still indraft form - the Domestic Violence Bill. A Bill is a law, that is still in draft form and,that has not been passed by Parliament

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Activity 8.8 What are stigma and discrimination?Look back at activities on page 41-42 which look at prejudice, stigma anddiscrimination. You may wish to combine this activity with 8.9.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcWhat have peer group members suggested?• Stigma is associated with the words like shame, disgrace and dishonour.• We negatively discriminate (stigmatize) when our words and actions make

people feel ashamed, disgraced or dishonourable• Say things like, She behaves like a prostitute or

He got what he deserved.• Say that HIV+ people have been cursed by God• Εxclude people with HIV or AIDS and AIDS orphans from

being part of our group or community discussions ordecision-making

Activity 8.9 What are some of the causes of stigma and discrimination?Why are certain people in our communities stigmatised? What causes stigmatising?

Points for your discussion, debate, drawing, song, story, play, poem, poster etcWhat have peer group members suggested as causes of stigma?

Lack of recognition that stigma actually existsIgnorance, lack of information on causes and modes oftransmission, that leads to irrational risky behaviourMyths and fears about HIV transmissionWhen HIV infection is viewed as punishment for immoralbehaviour then nobody wishes to be associated with PLWASelf-interested people trying to create a divide betweenthe healthy and those who are not so healthyMass media images portraying PLWA as defenceless,weak and dying - images of thin diseased AIDS babiesin adverts for charitiesPeople who are infected with HIV remind us that we are all at risk unless wepractice prevention - this may scare us

Point to ponderWhen there is an unwanted pregnancy in yourcommunity, who usually carries most of the blame? Discuss

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Activity 8.10 Stigma and discrimination in college and community

What forms of stigma have people experienced in colleges and communities. If youhave time, group the examples to show any patterns of behaviour.


Stigma attached to occupation, family, tribe, race, religion, appearance or looksTreating people from different region or tribal groups badlyPhysical and social isolation from peers, family or community membersBeing left out of decision making that concerns family or even yourselfGetting to hear gossip, condemnations and name calling by fellow students,family members and community membersSelf blaming and self isolationRefused employment, membership of benefits schemesSome insurance companies refuse to offer life insurancesIn the past, many people are refused proper health care,especially bed space in hospitalsA whole family being isolated by communityPLWA and their families suffer when people react negativelyto themBeing tested without consentBreaking of confidentiality (privacy) of medical recordsNegative reactions of others make some people afraid to gettested or to tell others if they are infected - testing helps people plan their futuresand protect their loved ones from also getting HIV and AIDSHiding HIV and AIDS from neighbours makes people less aware of the need fortaking action against the HIV and AIDS epidemic in Malawi.Cause someone to feel unwanted and depressed, and contemplate commit suicide

Point to ponderIf stigmatizing - of any type - is allowed to continue openly in any place, it will eventuallycreate an angry, unhappy, and unjust community. Discuss

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Activity 8.11 How can we stop negative discrimination in colleges?Reducing the stigma of HIV is the first step in combating HIV infection. We know thatnegative discrimination exists at times in our communities, but it may not be easy toidentify. Make a list of what you would do or ask others to do, to stop discrimination.


Help educate communities about the true facts of HIV and AIDSThe best defence against HIV/AIDS is tolerance and talk - partners, families,communities and nations which maintain silence on the issue hinder the fightOrganise campaigns against stigmatizing and discriminationEducate parents, community and neighbours to understandconditions of people living with HIV and AIDS in order toreduce stigmaOpenly admit if a family member dies of AIDSOpenly encourage people PLWHA to live positive livesIntroduce or assist care and support groupsEncourage the development of counselling servicesEducate PLWH and PLWA on legal rightsIt takes courage to stand up and speak out against somethingthat is wrong - but take courage and assistIf we want to break down prejudice and discrimination, youmay have to make the same points over and over againBe a role model by making show the best side of your character - do not usenegative or blaming language when discussing HIV and AIDSPolitely challenging people who make negative comments, makes them awarethat others do not share their negative attitudesEducating family members about HIV and AIDS prevention helps reduce the fearthat leads to denialExtended family members need to create and maintain a supportive environmentCare and support family and community members living with HIV and AIDSChristians should ask, What would Jesus do in this situation? Refer to The Gospelaccording to Luke, especially Jesus’ reaction to the outsiders of society like lepers,adulterers and prostitutes

Points to ponderNew government HIV legislation is waiting to be discussed in parliament and thenpassed into law. Among other things it legally protects PLWHA from different forms ofabuse. It will also make some traditional customs which spread HIV or predisposepeople to HIV infection illegal. The regulations will also be used in the fight to eliminateall forms of discrimination against PLWHA and other members of vulnerable groups.A MANET+ statement declared that when this bill is passed into law it would save livesand help people crying out because of the pangs of stigma and discrimination.

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Activity 8.12 Role-play: Helping to reduce stigma about HIV and AIDSHow do you think it feels to suffer stigma and discrimination because you are HIV+?This role play asks you to look at how we might react in a situation where someone isbeing stigmatized and discriminated against.

BackgroundAbigail is a student teacher from the village of Kapesi. William, is her uncle. He is avery important man in a nearby community. And a successful businessman who enjoysspeaking his mind. During a visit to her village, William makes a negative remarkabout a family whose son died from AIDS. Abigail wants to reduce negative attitudeswithout quarrelling with her uncle.

William Let all these promiscuous people die from AIDS. It is theirpunishment for breaking our traditional codes of behaviour

Abigail What do you mean uncle?William After they die out, the good people will be left and we

can create a new better future for this communityAbigail (What could she say?)

After the role play• What did Abigail says next?• How did you feel about what was said?• What was it like to role play being the uncle?• Did Abigail manage to successfully challenge her uncle’s views in a way that will

not create family quarrels?

Activity 8.13 Do humorous cartoon help in the fight against HIV?The late Vic Kasinja’s Taxina cartoon character is an empowered woman using herbeauty to help her through life, but has she helped the fight against HIV and AIDS?

Point to ponderCartoons depicting the disappointing activities of an unfaithful husband reveal theaddictive nature of extra-marital sex, but may not promote behaviour change. Discuss

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Activity 8.14 Ways to protect widows from HIV infection?Review the reasons why you think widows are vulnerable to HIV infection, then identifyactions which would protect them from HIV.


Introduce alternative widow cleansing rituals which don’t involve unprotected sexInheriting a widow is an act of enslavement - take her into your home andcare for her as a loving relativeSpeak out against accusations of witch craft being made against widows - all overthe world societies have used this as a reason to get rid of poor and vulnerablecommunity members, but it is an abuse of fundamental human rightsActively encourage income generating activities for unemployed and widowedHusbands and wives should make wills in order to protect their spouse fromabuse after a death - stopping both property grabbing and widow inheriting

Activity 8.15 Ways to protect young girls from HIV infection?Review the reasons why young girls are particularly vulnerable to infection, then identifyactions which could protect them from HIV.


Educate boys and men in life skills education so they see sex as being part of aloving relationshipEducate and build self-esteem andassertiveness in both boys and girls, sothey can just say, No to sexual advancesReport all rapes to the policeEncourage girls to complete a full educationEducate the community about HIV to dispellocal myths or urban legends about HIVEducate the community about the health risksof a grown man having sex with a childbrideDiscourage inappropriate relationships betweenvery young girls and older menRun an awareness campaign againstchild-brides and report offenders to peoplewho can help (eg TA, police, NGOs)Educate elders involved in the initiation of girls in human rights and HIV/AIDSCommunities should modify dangerous initiation practices that can spread HIVMake sure local orphans or street children are educated and supported - girls andboys are particularly vulnerable to HIV infection through selling-sex to surviveDesign and implement orphan care programmes (eg care and literacy etc)

Point to ponderMy friend likes to go with the youngest girls working around the bar. He feels that bygiving his money to them, he is probably helping to pay their school fees. Discuss

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Activity 8.16 What can we do to reduce early sexual activity in children?What can we do to help reduce the risk of early sexual activity and HIV infection ofchildren? If you wish, you can link this activity with the next one and with the activitieson page 126-8.


Adults should make sure that children are well informed about their sexualdevelopment, sexuality as well as HIV and AIDSGive children clear and truthful information they can make better decisions ifthey are well informed with the factsEducate elders in your community sothey know what we know and educatetraditional initiators of both boys and girlsKeep updating your information onHIV/AIDS from newspapers and radioby writing extra notes in your copy ofMzake ndi mzakeAdults should make sure they are out--standing role models displaying goodsexual behaviour - they should not becomeinvolved with school-age girls and boysReport teachers who have sex with underage girls and boysTeachers should be made aware that if they drink or take drugs their pupils willeventually learn about this and try to copy - drinking excessive amounts ofalcohol has been shown as one of the causes of sexual misbehaviour in adultsExpress disapproval of people who encourage risky behaviours, including earlysex; sex with older persons; sex for money or favours and boasting about sexHelp children feel good about themselves - high self-esteem helps children resistpeer pressure and achieve their goalsHelp children stay in school, so they have a future worth waiting for - they mayneed encouragement and sometimes financial helpProvide opportunities for youth to have success and approval to build self-esteemEncourage extra-curricular activities in school - hobbies, clubs are alternativeactivities which children enjoy and help them resist less desirable activitiesWatch for warning signs of possible trouble - being secretive, suddenly havingmoney or new things, hanging around with questionable friends or losinginterest in schoolProtect young people from being home alone or going to dangerous places duringthe hours of darkness

Points to ponderIf we keep children ignorant of sexual matters by treating sex as a mystery or a big secret,is it any wonder that children find it fascinating and want to experiment? Discuss

Every friday, my father meets his friends in the bar of the local hotel. They chat and buyeach other drinks. My mother says that it’s his way of relaxing after a hard week’s work. Ireally like and respect my father, and want to be just like him when I grow up. Discuss

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Activity 8.17 Ways to protect young people from HIV infectionReview the reasons why children and youths, are vulnerable to infection then identifyactions which could be used to sprotect them from HIV.


Give children sexual and reproductive health information before the age ofinitiation - talk to primary school teachers who havelife skills books which include HIV education topicsHelp children stay in school and learn to stay safeDefend childrens’ rights and speak out againstchild-brides, child labourers and traffickingLife skills and health education which includesreproductive health educationParents could provide literature on sexual andreproductive health in the homeIdentify or create youth drop-in centres whereliterature and peer education is availableWork to abolish sexual rituals such as thetraditional behaviour of Fisi during certain ceremoniesHIV is transmitted through unsafe use of cutting tools or sharing needles andpiercing objects - new or boiled blades should be used for each person to preventHIV cross-infectionMany parents today have decided that HIV issues are so important that they want totalk to their children themselves - they must know where to get informationParents can ask another adult to talk with their child about sex and HIV - thisadult must be someone both parents and child trust who is also well informedWhat is important is that children and youths can go to an adult to learn aboutsexuality and other issues - otherwise, they will learn from peers, books or videosPlan and provide alternative entertainment for youths and school children - suchas after-school sports activities, science clubs, community action groups etcIdentify or establish places in the community to be used as drop-in centres forout-of-school youth where they can also learn about HIV and AIDSEncourage faith-based groups to start youth clubs and provide HIV and AIDSeducation within their faith communitiesParents can modify the way they speak to youths so that it is more adult-to-adultYouths-to-youth and child-to-child peer group methods can be used to pass oncorrect and clear information about HIV - without the need for adults to believethey should (or have to) lead all meetingsEncourage bar owners to ban young children and youths from their premisesAll mothers in developing countries, whether HIV positive or negative, shouldbreastfeed exclusively for the first six months - exclusively means only to give breastmilk, the baby should be given no other liquids or foods for the first six months of life

Point to ponderThe youth can reverse the effects of HIV and AIDS by being foot soldiers and carrying themessage of the disease to all parts of the country. Discuss

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Activity 8.18 Ways to protect women and men from HIV infectionReview the reasons why women are vulnerable to infection and identify actions whichcould protect them from HIV. We have listed the positive steps that can be taken toprotect both women and men together because they often overlap. Sometimes there isa way a man can protect himself and his partner, another time there is a way a womancan protect herself and her partner.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcWhat positive actions have peer group members suggested?

Encourage girls and women to accept their equal status under the constitution -this also means that boys and men should not necessarily bear the whole burdenof funding and decision making in relationshipsPromote assertiveness rather than aggression orpassivity among boys and girlsEncourage community members to join or establishpositive-action groups for community developmentPartners should be role models - observers learnmore from what they see others doing, than fromwhat they hear others tell them to doTalk to your partner about how HIV and AIDS isspread and is not spreadTalk with relatives, friends and neighbours about HIV and AIDSEmpower girls and women through education and counsellingSpeak out against spousal abuse, male-on-female and female-on-male - abusedmales often fail to speak out because of shame, but are at riskReport men who hit their partners to the police - it is often hard to communicatewith someone who physically or sexually abuses a partnerReport incidents of gender-based violence to the police or tradtional authorityCampaign for or establish victim support groups in your communityEliminate gender-based violence from your community by voting in politicianswho make it part of their election manifestoThings are changing fast and we have more women in positions of power, aspoliticians, principals, police officers and defence forceEducate both men and woman on human rights and discuss how these may beinfluenced by religious beliefsKeep girls in school as long as possible - this has many positive effects on society.When educated girls grow up to be women they will know the facts about HIVand are empowered to live a healthier more prosperous lifestyleEncourage succession planning and will-making to stop property grabbingCounsel family, friends and collegues who have an addiction to alcohol or violenceAssist abusive alcoholics to get help through counselling and other supportSpeak out or campaign against spousal abuse, child abuse and child labourEducate unemployed women on condom use and identify sources of condomsEducate the elderly about HIV and AIDS - they are often care givers of PLWHAForm peer groups for unemployed women for HIV education for sprevention

Point to ponderThe elderly must be included and educated about the risks of HIV. Discuss

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Activity 8.19 More ways a community can protect itself from HIV infectionIdentify community actions which would protect members from HIV. Many of thesuggestions mentioned overlap with the actions you may have brought up in earleractivities. Check off the ideas against what you already know.


A community full of positive role models is the best action to takeTalk openly about HIV and AIDS and the need to support PLWADiplomatically challenge and correct people who make incorrect comments aboutHIV/AIDS issues or discriminate against PLWHAChristian and Muslim beliefs strongly condemn stigmatising the sick or weak.Religious leaders, like Jesus and Muhammed showed that the marginalised ofsociety were one of their main concerns. We should emulate themDiscuss the fact that thousands of people living with HIV are not promiscuousEnsure the community can provide or support voluntary counselling and testing(VCT) programmes and ART educationTreat the girl child with respect and work againststereotypingHelp persons living with HIV and AIDS andtheir families or carersForm peer groups for youth-to-youth,elder-to-elder, widow-to-widow educatorsProvide information about HIV and STIsprevention to community the peer groupsSupport the different peer HIV educationgroups and use them to train futuretraditional marriage counsellors on HIVCampaign for reform of any pre-marriagecounselling techniques which involve unsafesexual activitiesPut up HIV awareness posters around the communityTell everyone in the community that HIV+ mothers can have HIV negative babiesif the proper procedures are followedEncourage income generating activities for unemployed, unmarried or widowedSpeak out against community practices that encourage the spread of HIV andSTIs such as sugar daddies or sugar mommies or traditional practices like childlabour, circumcision, initiation and under-age marriagesIdentify places where risky situations are common, eg beer halls and discosTalk to local bar owners about banning the young, sex-workers, drug dealers fromtheir establishmentsOrganise support for sex-workers in your community, encouraging those whocannot give up to use condom

Point to ponderThe spread of HIV and AIDS has given women a reason to speak out, and this has hadunexpected benefits such as greater equality within sexual relationships. Discuss

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Activity 8.20 Teacher networks to fight HIV: T’LIPOT’LIPO is the Association Of Teachers Living Positively with HIV. In Chichewa it maybe taken to mean we are alive. It has over 2,500 members nationwide. Read theinformation below and discuss what T’LIPO is proposing and how far they mightassist in HIV prevention, treatment, care and support.

IntroductionTeachers interact with many people as they perform their many roles as counsellors,parents and role models both in the classrooms, and at home. In the communityteachers are often held in high esteem and this enables themto effectively advocate for behaviour change.

Why was T’LIPO formed?It was formed when it was noted that many HIV+teachers were suffering from self-stigma, denialand shame about their sero-status.

The Vision of T’LIPOT’LIPO envisages a nation with healthy teachers in which the rights of HIV+ teachers areprotected, and in which teachers live positively in order to reduce the transmission andenhance positive living.

The Mission of T’LIPOT’LIPO exists to provide adequate services and support to teachers infected and affected byHIV and AIDS in order to reduce HIV transmission and enhance positive living while atthe same time upholding the dignity and professionalism of teachers.

The Objectives of T’LIPOT’LIPO works to:

Create an opportunity for sharing experiences among teachers in relation to theirHIV status and enable them to demand for services on prevention, treatment,care and support from service providersReduce stigma and discrimination against teachers living with HIV and AIDS andorphans in and out of schoolPromote access to high quality HIV/AIDS treatment, care and support servicesTarget teachers who are not infected with behaviour change out reach initiatives

Some recommendations of T’LIPOMore dialogue should be encouraged between education managers and teachersand also among the teachers themselves on HIV and AIDS issuesThere is a need to disseminate the Ministry of Education HIV and AIDS strategyand plan of action and advocate for its implementationThe work place measure policy should state clearly punitive measures for anyteacher found stigmatizing another and action taken immediatelyThe views of HIV+ teachers should be sought for any further amesndment to theeducation sub sector work place policyBecome a member by going for VCT and registering

Source: T’LIPO Blantyre Urban, c/o Balntyre DEM. E-mail: [email protected]

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Activity 8.21 Networks to fight HIV: MANETPeople living with HIV (PLHIV or PLWH) founded the Malawi Network of PeopleLiving with HIV/AIDS (MANET+) in 1997. People living with HIV/AIDS identifiedthe serious need to harmonise the efforts of NGOs working with PLHIV. MANET+ isa web of solidarity of associations or support groups of HIV+ persons and thoseaffected. The image of the spider’s web is found in our traditional proverbs like,When spider webs unite, they can tie up a lion.

The Mandates of MANET+MANET+ has the mandate to:

Facilitate free flow of information betweenPLHIV support groups and all collaboratorsInitiate and promote harmonious andeffective networking amongst differentgroups and all other playersEnsure representation and participation ofPLHIV in all national policy-making bodies regarding HIV and AIDSHelp solicit support for support groups and associations from various sources,locally and internationally with the view of strengthening the capacity of peopleliving with HIV and AIDSAdvocate for greater respect and protection of the rights and freedoms of peopleliving with HIV and AIDS in all spheres of human treatment, be it social,religious, ethical, political, legal etc

The Vision of MANET+MANET+ envisages an enabling environment for people living with or affected by HIVand AIDS in Malawi - one that is free of stigma and discrimination. This vision statementis a long-term commitment.

The Mission of MANET+MANET+ exists to improve the quality of life of people living with or affected by HIVand AIDS in Malawi through the promotion and protection of their rights and freedoms,empowerment and meaningful involvement in issues that affect their lives at individual,family, community, workplace and national levels.

The Core Values of MANET+Together with the vision, MANET+ has core values that provide the fundamentalbuilding blocks for the Network as outlined below:

Peaceful co-existence with all people whether living with/affected by HIV andAIDS or notOpenness about HIV and AIDSFreedom of expression and association for PLWHIVRespect of human dignity regardless of HIV status by volunteering for an HIV testNon-discriminationMoral behaviour Postive living Being an exemplary role model

Source: MANET+, Kang’ombe House, City Centre, Private bag B377, Lilongwe 3Tel: 01-772-727, E-mail: [email protected] website: www.manetplus.com

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Activity 8.22 Malawi’s sex industry and the spread of HIV/AIDS

Patricia is a sex worker in Blantyre. Here is part of her storyas told by Wonderful Hunga in the Daily Times in Oct.08

Points for your discussion, debate, drawing, song, story, play, poem, poster etc• I can’t go back home. Nobody can help me. My grandparents are too poor.• Patricia is wiggling her waist as she strolls... the tavern is the busiest place... music

is blaring... people are dancing... sipping their beers...• I got myself here some months ago... my mum passed away... things became difficult at

home... I packed up and left... I wanted to do my own thing• Welcome to Malawi’s sex industry. Patricia is not alone. Sex work is a trend in

Malawi, and it is especially affecting young women... forced to engage in sex workor transactional sex in exchange for survival items such as food, protection andmoney... Although illegal... women congregate at nightclubs and bars and selltheir bodies in order to survive. Some begin work at 14 or 15. It is survival sex.

• Women like Patricia earn anywhere from K1,000 to K140 per day depending onthe type of customer and place. So, everyday they are risking their lives, healthand dignity for these incomes... Some male customers refuse to put on acondom... the majority of those infected with HIV in Malawi are women...

• Gender equalities, which stem from cultural beliefs... put woman at greater risk...It continues despite Malawi is bound by the principles of the UN Charter, theUniversal Declaration of Human Rights, the Convention on the Elimination of AllForms of Discrimination Against Women and the Convention on the Rights of theChild. All these treaties discourage discrimination on the basis of gender.

• Patricia always uses a condom. She says it is to guard against pregancy not HIV/AIDS... young girls have proven to be especially vulnerable to sexual violence, or tobeing trafficked or coerced into sex work... Patricia recalls such violence...

• I was ambushed... he wanted to kill me... he grabbed me by the neck... I screamed and ranaway. It was just around 11pm... Since then I refuse to be taken to anybody’s place... Wetell each other... this guy did this and that and don’t ever accept him.

• Like many sex workers in Malawi, Patricia admits to a history of violence in previousrelationships.

• No, I reject love relationships. No, I don’t want to get married. Somebody once abused meand that was enough... He was jealous. He beat me up when I was late from the marketfor no reason... He called me a whore... But, eh, he was abusive. If I came late fromdrawing water, he would beat me up. That was slavery, so I kicked him out of my house...life is better as a bar girl or sex worker than at the hands of an abusive boyfriend orhusband... I will marry but not now. I’m enjoying my life. That lover really abused me.

Point to ponderPoverty turned Patricia into a prostitute. What else could she have done? Discuss

It has a nickname‘survival sex’

Welcome toMalawi’s

sex industry

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Grace’s story• They said I was the most beautiful young woman in

the village. They told my mother I would get a good job inSouthAfrica. I’d have a good life and be able to sendmoney home. My mum agreed as they were such a nicelydressed man and woman... and the money was needed.

• We travelled a long way, but when we got to the citythere was no housemaid’s job... then the man came shoutingthat he needed me to pay back the money owed to him fortransport, clothes, accommodation and food... He said Iowed him hundreds of dollars! I told him I had nothing.

• He said if I had no money he would make me work ata nearby hotel until I had paid off all that I owed him.

• At the hotel he made me wear a very short shirt and lowcut top and high heeled shoes. I now knew how I was to gethis money back. I was so embarrassed and refused.

• I never expected what happened next. He took me into a room, beat me all over mybody and violently raped me... I was bleeding... I was a virgin and had never known aman... It hurt so much... I cried and cried... two more men came in and raped me... Istill refused to sell myself... so they took all my clothes and locked me in the room.

• Over the next week I was beaten and raped so many times I could never count. Iworried about HIV as none of the men used a condom... They said I would starve anddie in the room if I didn’t agree. No one would ever know what happened to me. If Iagreed I could send money home to my mother and relatives and help them as planned.

• So, I agreed to become a sex worker. Me! A regular church-goer and choir member.• The man is now my pimp. He takes me to places where men want company, finds me

clients (Johns) and protects me. The clients pay well but my pimp takes most and hisrepayments. Hotels know us and my pimp arranges my rooms... he gets a cheap rate.

• In primary school I had dreamed of being a teacher, doctor even our MP... How didthis happen? Will I ever pay off my debt? Am I HIV+? Will ever see Malawi again?

Points for discussionIn your opinion, which of these people has committed the most serious offence?1 Grace (prostitute)2 The John (client) who pays and uses the prostitute3 The pimp (or madam) who controls and makes money from the prostitute4 The person who rents the client and prostitute a bedroom

In some countries prostitution is legal for those over the age of consent (eg Holland).In other countries a third time offender may be sentenced to death for prostitution(eg Sudan). In other countries prostitution is not illegal, but living off the earnings ofa prostitute is a crime. While in Germany prostitution is a legal business and sexworkers have their own unions and pay tax to the government on what they earn.

Point to ponderThe issue of prostitution and HIV in Malawi will not be resolved by silence. Unless westart to discuss more openly the part played by all those in the sex industry: prostitute;client; pimp/madam and traffickers, we are in serious danger as a society. Discuss

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Activity 8.23 The education-vaccine against HIV?Read the following extract from a UNESCO report. It was written by Father MichaelKelly from Zambia, one of our regions experts on both education and HIV.

• Select four positive statements from the passage thatyou would like to share with others

• Select four negative statements thatidentify issues that need addressed

• Malawi is addressing some of the issuesthrough the Safe Schools initiative, howfar are you aware of its achievements?

• If you were the President or the Ministerof Education, what would you do inorder to make the best use of educationas a vaccine against HIV?

Point to ponderWe must encourage behaviour change in the home, in the work place and at school.Discuss.

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Activity 8.24 Does staying silent on homosexuality help spread HIV?Recently, stories have appeared in our newspapers which seem to conflict with whatcommunities say are traditions or culture. Read the newspaper article below and discussthe implications in the fight against HIV.

Points to ponder fromMalawian newspapers

Policeman rapes a maleprisoner held in police cellMan raped by fellowinmates while in prisonUncle sodomises nephewSchool boy caughtsodomising a friend atboarding schoolTourists pay for homo--sexual sex with locals

Points to ponderTalking about homosexualityis a taboo that needs to beaddressed now! Discuss.

Homosexuality is illegal in Malawi, but in August 2008, the Malawi Gay Rights Body wasformed to protect the rights of gay citizens. Is this right? Will it help fight HIV? Discuss.

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Activity 8.25 Looking closely at the global approach to HIV preventionIn activity 2.13 (page 34) we looked at the values that the United Nationsrecognises as key parts of the Millenium Development Goals.

Point to ponderI am just a poorly paid Malawian living in a rural village,so what has the UN action plan got to do with me?

The following passage comes from the UN documentCommitting to action: Achieving the Millenium Development Goals.It lists the specific actions to be taken by countries who want to meet the goals.

Read through the passage and discuss how far you think community, national andinternational efforts are moving towards the goals.

The UN believes the following things should happen?Implement a long-term multi-stakeholder, multi-sectoral and gender-sensitiveapproach, based on national AIDS plans.Create closer linkages between HIV/AIDS interventions and sexual andreproductive health care to reduce unsafe sexual risk-taking behaviours, andreduce sexually transmitted infections, including HIV.Increase access to both male and female condoms, which are the onlycurrently available and effective ways to prevent HIV and other sexuallytransmitted infections among sexually active people.Make sure all young people, who are at the centre of the epidemic, have theknowledge and means to prevent infection.Ensure predictable and sustained funding to address the HIV/AIDS pandemic.Scale up programmes for HIV prevention and ensure universal access totreatment for HIV/AIDS for women and men.Develop sustainable national health systems, delivering quality services andretaining professional staff.Develop primary healthcare systems to ensure universal coverage for essentialhealth services, including for poor and underserved populations in rural areasand urban slums.Promote mechanisms to substantially increase funding for research anddevelopment of essential drugs to treat tuberculosis, malaria, HIV/AIDS andother infectious diseases.Fill critical funding gaps for the World Health Organisation (WHO) strategy tocombat tuberculosis (DOTS) programmes, and new research and developmentactivities, including work on a vaccine.Ensure adequate financing for key interventions under the Roll Back MalariaPartnership to end malaria deaths in Africa by 2010.Take decisive action to control and treat neglected tropical diseases.Commit additional funding for the global partnership for affordable essentialdrugs.

Point to ponderIf people in over 200 member states of the United Nations, are working to slow downand halt the spread of HIV, that is such a combined force, it cannot fail. Can it?Discuss

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Activity 8.26 How are people who spend time in prison put at risk?

The Malawi Human Rights Commission and other international human rightsgroups, have produced reports showing that many prisoners’ rights to health and lifeare being abused. Many of the problems and solutions are outlined below.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcMany prisoners have little knowledge about HIV transmission and AIDS care.Prisoners share razors or razor blades can cause HIV cross-infection.Rape of both female and male prisoners by other inmates - especially the youngand new prisoners - in some cases gang rape. Rape is about power not just sex.Rape by police officers while in holding cells at police stations - police officersraping both females and males in detentionPrisoners exchanging sexual favours for food,freedom or protection from violenceOvercrowded and unhealthy living conditionsspread diseases like STIs, scabies, TB andprevent prisoners living positivelyPoor nutrition leaves prsoners’vbodies unable to fight opportunistic infectionsShortage of medicines, medical facilities and proper nutritionShortage of transport for hospital referralsLack of access to education on HIV and ART or a regular supply of ARV drugsPoor medical care for patients suffering from STIs and other infectionsGreater protection of inmates from intimidation and violence especially rapeMore funding for prisons and free distribution of condoms to inmatesHIV/AIDS education for prisoners and officers, possibly through peer groupsReduce number of prisoners per cellCampaign for a new prison building programme and expansionEducation on ARVs and regular distribution of ARVs to prisoners LWHAMore funding for medicines, medical facilities and nutritionMore funding for transport for emergency referrals to hospitalEstablish more prison farms with a wider variety of animals and plant breedsComplementary basic education programmes to improve education levelsEducation programmes on income generation and rehabilitationBanja La Mtsogolo ran The Health For Prisons Initiative from 2005-8, whichfocused on sexual and reproductive health programmes for prisoners

Point to ponderOnce a prisoner is released he has completed his sentence, his debt to society is paid off, butif he became HIV positive in prison doesn’t society now owe him compensation? Discuss.

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Activity 8.27 How does trafficking for sexploitation spreads HIV and AIDS?A report for the United States government stated:As unimaginable as it seems, slavery and bondage still persist in the early 21st century.Millions of people around the world still suffer in silence in slave-like situations of forcedlabor and commercial sexual exploitation from which they cannot free themselves.Trafficking in persons is one of the greatest human rights challenges of our time.

Read the following article and carry out the activities that follow.

Points for your discussion, debate, drawing, song, story, play, poem, poster etc• Pick out five or six sentences from the passage that you think carry the most

important points• Who should stop people trafficking?• What can you and your peer group

do to help stop trafficking?• What can communities do to support victims of people trafficking?• What do you think are the best ways in which to eradicate people trafficking?

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Activity 8.28 How does HIV /AIDS affect the elderly?A report by the Population Reference Bureau in 2007 said: As the HIV epidemicprogresses, the elderly must be counted and educated about the risks of HIV.

Here are some more extracts from the report:Of the estimated 40 million people living with HIV, thevast majority are adults in their prime working years,but as this middle generation dies of AIDS, a generationof young children and a generation of elderly ages 50and older are left behind. Despite extensive amounts ofresearch on the AIDS epidemic, little attention has beengiven to the impact of HIV/AIDS on the elderly indeveloping countries.

It highlights the following areas of concern• Caring for families and ARVs. Some elderly take on the care of their adult

children or relatives who are sick. More elderly are also assuming the role ofcaretaker for their grandchildren and other orphaned children. Expanding accessto antiretroviral therapy will likely decrease deaths of adult children and delayserious illness. As a result, parents may change how they help - instead ofproviding terminal stage care, they may help ensure adherence to demandingregimes of medications.

• Economic impact. Old age, declining health status, and caretaking responsibilitiesat home compromise older people’s ability to earn an income.

• Health consequences. In developing countries where family support systemsexist, elderly people who care for their adult children or relatives often receivematerial support from other relatives. In Malawi, for example, intergenerationalsupport networks exist between adult children and their parents and also withmaternal and paternal aunts and uncles.

• Attitudes. Community reactions toward those living with HIV as well as towardtheir caregivers have generally been positive or neutral, despite widely heldassumptions to the contrary. Educational campaigns and knowledge about HIVhave likely alleviated fears about casual transmission, thus contributing to lowerlevels of stigma

Despite their considerable caretaking role, the elderly still remain largely hiddenfrom the international HIV/AIDS agenda. Because it is assumed that they are not atrisk of contracting HIV, the elderly have received minimal program and policyattention. Older people are not only at risk of infection, but their income and health mayalso be adversely affected when they take on the role of caregiver.

Particularly important in the context of increasing access to antiretroviral therapy isdetermining the potential of older parents in encouraging treatment and monitoringadherence and how increased access to these drug regimes alters the consequencesof having an HIV-infected son or daughter.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcThe Mzake ndi mzake peer education programme covers prevention, treatment, careand support. How far do you think that the elderly are involved in all of the fouraspects of HIV/AIDS programmes in your community?

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Activity 8.29 Talking to children about sexual and reproductive healthYoung children are interested in almost everything they see and hear. A child’s world isfull of suprises and they love asking questions. One of the most popular children’squestion is, Where do babies come from? Have you ever been asked this question by achild? What did you say in reply to the question?

Here are a some answers children have received from adults:• The stork (bird) brought him• God put baby into mummy’s tummy

What do you think is the best explanation to give a child?Depending upon the age of the young person, these talkscan take various forms. They could be part of talks whichcan be classified as man-to-boy, woman-to-girl, child-to-child, sister-to-brother for example.

Point to ponderThe most important thing to tell children about sex is the truth,but the truth phrased in such a way that it neither over-excitesnor seriously frightens them. Discuss.

If an adult does not give answers to a child’s questions, then the child will go and asktheir peers. Adults must be prepared for comments or questions about breasts, genitalia,sex and relationships. How should they prepare properly for this responsibility?

Points for your discussion or role playRead through the following examples of conversations betweenadults and children. Discuss whether they contain ideas that areacceptable in your community or if they need to be adapted.

What would you say in this conversation?Child What are those two dogs doing?Adult Making a baby dogChild Mummy, can those two goats make a baby goat?

Mummy, does it take two people to make a baby?Adult Yes, a mummy and a daddyChild Do all animals have mummies and daddies?Adult Most animals and many plants have mummies

and daddiesChild Has everything in the whole world got a mummy

and a daddy?Can children be mummies and daddies?

What would you say in this conversation?Girl child Can I make a baby with my brother when we grow upMother No, mummies and daddies have to be grown up

People are not allowed to marry their sisters and brothers. They will findother really special friends to marry

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Activity 8.30 Role play: Discussing sex education for young childrenIntroduce the role play with the brief overview found below.

Background to the role playTwo mothers, Christine and Ada, are concerned about their children because they aregrowing up rapidly. They have just finished listening to a radio programmme thattalked about the importance of preventing child sexual abuse, early sexual activitiesand HIV infection. They both want their children learn how to lead healthy lives.

The role play beginsChristine How am I going to tell my son the facts of life?Ada And how am I going to tell my daughter the important things she needs to

know, to keep her safe from HIV/AIDS and pregnancy?Christine Should we leave it until the initiation, that is the traditional way isn’t it?Ada Children can be sexually active in primary school, I am not so sure we

should leave it until initiation, that is too late!Christine What would you say to your daughter if she asked about sex and babies?Ada What would you say to your son if he asked you why he has a penis*?

(* substitute a traditional term if appropriate)Christine Who should we ask? The elders, religious leader, teacher or nurse?

After the role play• How old should children be when they start learning about sex?• Who should teach the children about sex?• Does life skills education at school provide enough information and skills?• Where could parents and community elders get information about reproductive

health and child sexual abuse to share with their children?

Girl child Is daddy your special friendMother Yes, because he helped to make you!Girl child Will I find a special friend to be

happy with and make babies?Mother Yes, I hope you will find a good

man to marry. But you have togrow up into a woman first

Girl child Why can’t little girls have babies too?Mother Babies grow inside the mummy and

a little girl’s baby hole is not bigenough to let the baby out

Girl child Does every girl and woman havea baby hole?

Mother Yes, that’s one of the things thatmakes us special. There a lots ofthings about us that make us special

Girl child Are boys special too?Mother They are special too, for lots of reasonsGirl child What makes boys special?Use role play to continue this conversation

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Activity 8.32 Keeping children safe from sexual abuse and HIVYou may combine this activity with earlier role plays if you wish. Look back at pages65-67, 104 and 111 for source material.

Background to the role playEdina should be baby sitting, but she runs out of the house.Her uncle looks out of the window as she races past herolder brother George.

The role play begins:George What’s wrong with you?Edina Nothing. It’s just uncle wanting to tickle me againGeorge You shouldn’t let him touch you that way

After the role play• What did George say to Edina and what did he do?• Describe or act out, four different endings to this play• Which ending seemed to bring the most satisfying conclusion to the situation?

Activity 6.20 AssignmentSelect one of the socialissues raised in thisunit and carry outresearch within yourlocal community, todiscover how far itmay be linked to thespread of HIV and AIDS.

EvaluationEvaluate the peer group activities in this unit by using the questions on page 166.

Activity 8.31 Role play: Talking to a child about sex and HIV/AIDSContinue the previous role-play• Choose whether your role play will involve a young boy or a young girl• Try to use the exact words that could be used when talking to the young person

The role play beginsAdult You may have heard some boys talking about sexChild Some boys say that everyone who has sex will die of AIDS

After the role play• In what other ways could you have started this conversation?• Were the explanations clear and simple?• Did the conversation mention sexual feelings and values?• Will the child feel that they can come to the adult for more advice at a later date?

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Unit 9 Living positively with HIV and AIDSIntroductionIn the past, if a person was tested and foundthat they were HIV+, they felt as if a deathsentence had been passed upon them. Somepeople living with HIV+, gave up on life andprepared to die. But, experience has shownthat there are many things an HIV + personcan do to both prolong and enrich their life.

Learning outcomesBy the end of the unit you should be able to:• describe how different people may react

when learning that they are HIV+• explain how reducing stress can help a

person live postively with HIV• describe ways of living positively with HIV

and AIDS• explain the importance of eating positively• identify foods which should be used by

PLWHA• identify medicinal plants that can be used

by PLWHA• describe how some foods can relieve the

common symptoms of HIV/AIDS• describe natural remedies that can be used

to alleviate diarrhoea• explain the importance of hygiene for a

PLWHA• explain how spirituality may strengthen the

immune system• carry out succession planning• explain why home-based care is important• identify the time when a family may begin

home-based care for PLWA

Activity 9.1 Assignment reviewShare your research with the group.

Activity 9.2 How do people react when learning they are living with HIV?By the time you reach this unit you will have a lot of ideas on how to answer thisquestion. The focus of the activity in this unit move away from the negative responsesand looking at the the vaiety of positive responses.• Why is it important for a PLWHA to share feelings and concerns with others?• Who would you confide in if you were HIV+? Why did you select that person?

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Living a positive lifestyle can greatly reduce the stress experienced by PLWHAYou may wish to go through activity 9.11 and 9.12 next - they are concerned withmethods of stress relief.

Point to ponderThe greatest amount of stress for a PLWHA is caused by having a pessimistic outlook on life.Discuss

Activity 9.3 What causes stress for people living postively with HIV?What sort of things could cause stress to people with HIV infection?

What have peer group members suggested?Receiving an HIV positive resultOthers being told of someone’s HIV statuswithout their consentThinking how community members will react tothe news that you are HIV+Having inadequate finances to support familyBeing unable to afford medical treatment anddrugsBeing unable to afford school fees for childrenFewer relatives to look after children if you dieFear for children’s futureLoss of employment and opportunitiesLoss of friends and isolationRejection by some community membersFear of dyingDeath of loves ones, a spouse or a child

What problems does stress cause for PLWHA?What have peer group members suggested?

Stress often blocks our minds with negative thoughts and this can stop us doingother important or essential tasksIt makes us feel that we have had enough - we want to escape from the problem,to get away so we can be stress free again - sometimes suicide is contemplated

Stress can blind us to the manyalternative choices and sap us of theenergy to do any thing at allPeople may look only at a problemand not the opportunities orcircumstances around the problemPeople focus on their condition andforget that there is lot they can do toimprove their livesPeople living with HIV/AIDS candevelop stress related illnesseswhich weaken the immune system,which is then more vulnerable toopportunistic infectionss

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Activity 9.4 Living positively with HIV and AIDSMost of us have heard the phrase, Living positively with HIV and AIDS. But, what doesit actually mean? There are many ways in which a person with HIV can protect theirimmune system and prolong a healthy life. The first and major positive move a personcan make is to accept their sero-status.

What can a person do in order to live a positive life, while living with HIV/AIDS?What have peer group members suggested?

Accept your status, denial can hinder living positivelySeek medical advice and decide, where and when to start ARV treatmentDevelop a positive attitude with a determination to liveLearn all they can about HIV, how thebody is affected by HIV and what canbe done to strengthen the immune systemEat a good balanced diet and check onany drop in body weightKeep your digestive system clean, thishelps the body to fight HIV - diarrhoeashould be dealt with immediatelyDrink plenty of clean water -it is essentialLearn how to make and use ORS (oral rehydration solution) - see page 163Use some simple natural remedies to help the immune system stay strong andhelp with common health problems (see pages 134-6)Some people use natural remedies, not to cure HIV and AIDS, but to fightopportunistic infections and their symptoms - it is always wise to get professionaladvice from your health worker or doctor on this matterBeware of some local herbs as they may be toxic and may not be recommendedto be taken together with some drugs like ARVsExercise gently to keep the body as fit as possibleDevelop a healthy mind that can deal with stresses (worry)Live in a more organised way by tidying and keeping a clean environment, be it aroom, house or gardenFind out if there are any HIV/AIDS support groups in your community learnfrom others who have successfully resolved the many issues facing PLWHAHave medical check ups and treat problems like TB promptlyReduce your workload and consider possible retirement issuesEnjoy a full sexual relationships but always practice safe sex to avoid re-infectionor cross-infectionMake a will or a living will - with ART it may not be needed for a long time, andHIV negative people should also make wills to protect their loved onesWrite a memory book for those you may leave behind if you die of AIDS - whatyou write can be kept a secret until after your death

Points to ponderI exercise every day. I walk around the village, usually wearing a smile on my face. If I dothis people always smile back and their smiles really help me to stay positive. Discuss

After I started exercising I noticed that mentally I felt sharper. Exercise does work! Discuss

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Activity 9.5 HIV and nutrition: Eating positivelyWhen your body gets enough of the right foods, you feel better and more positiveabout yourself and the future. Eating the right foods can help your immune systemfight infection and stay stronger during treatment. Following a nutritious diet is key topositive living.

The way foods are classified in Malawi has changed. The diagram above, shows thenew food groupings. Can you identify the 6 food groups shown in the drawing?

Recommended eating habits for people living with HIV and AIDSEat a variety of foods from all of the food groupsChoose small, frequent meals of foods that are easily toleratedby the body - so eat small meals (4-5) instead of 3 big mealsSnacks are foods eaten between meals and help fill theenergy gap and are a way of giving children or people livingwith HIV extra foodTry to eat less meat and fatIncrease amount of fruit and vegetables in the dietAvoid skipping meals or eating only when you are hungryTry to keep your weight constantListen to your body, because some foods make symptoms worseInform health care workers if some foods make you illUse fresh food and try eating raw fruit and vegetables or cook them on low heat,steam or bake them - remember that boiling destroys many vitaminsConsult your health care worker or doctor before taking vitamin tabletsAvoid coffee and don’t eat too many processed foods

by Carmen Aspinell

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Activity 9.6 Which FOOD GROUPSs can be used by PLWHA?Which local plants can be used medicinally by people living with HIV and AIDS?

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Activity 9.7 Which medicinal plants can be used by PLWHA?

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Point to ponderBy relieving many of the uncomfortable symptoms of AIDS, natural remedies play asignificant part in helping people to live more positively. Discuss

Activity 9.8 How can foods relieve common symptoms of HIV/AIDS?

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Activity 9.9 Which recipes can be used to alleviate diarrhoea?

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Activity 9.10 HIV and hygiene: Positively cleanGood hygiene is essential, especially when preparing and storing foodstuffs. Many ofthe hygienic routines for living positively with HIV, are exactly the same as for peoplewho are HIV free.

What do you think are some of the things that need to be done to ensure food andenvironmental safety ?


Always wash hands with soap and water beforehandling foodPounded, clean pawpaw leaves can be used as soapCooking utensils should be dried carefully witha clean cloth or air driedIf you are ill be careful when you prepare foodparticularly if you are vomiting or have diarrhoeaLeft over food should not be left at roomtemperature for longer than two hoursKeep uncooked meat and fish away from othercooked foodsDon’t overcook or over boil foodServe food fresh - as milk, fish, cooked meat andcooked rice can spoil quickly

Other important health and safety tipsWhat have peer group members suggested?

Avoid spreading infections by washing hands frequently with soap and waterCover cuts and sores on hands and always wear clean clothingGo to the clinic immediately at the first sign of infection such as fever, chills,sores in the mouth, diarrhoea, or a rash over their body.Early treatment can catch infections when they are easiest to treatKeep your body warm as a cold body can’t fight infection as well as a warm oneExercise to keep the body warm and workingGentle exercises help you feel good without overstressing the bodyDon’t overstress the body if you have symptoms like diarrhoea, cough or feverAvoid smoking as this can affect the body’s ability to take in vitamin CAvoid alcohol which may affect liver function - some ARVs also affect the liverOnly take medicines advised by professional and qualified peopleAvoid self-medicaton, don’t take unprescribed drugs as they can be harmful andcause serious side effectsProtect food and kitchen surfaces from flies and cockroaches which spreaddiseases which can weaken the body of a PLWHA - cover food and make sureutensils and toothbrushes are not exposed to insects

Point to ponderDon’t let a small insect spoil all of your greatefforts to live positively and happily. Discuss

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Activity 9.11 How can spirituality strengthen the immune system?

Points for your discussion, debate, drawing, song, story, play, poem, poster etcPeer group members with religious faith and others with no faith, have suggestedthese ways of strengthening the immune system:

It is important to use your faith to help you live positively, by asking for advicefrom your religious leader or advisorPeople of faith, believe that humans have a mind, body and a spiritA religious person believes that as well as working to strengthen the mind andthe body, they can strengthen the spirit and this improves personal well-beingAttending regular services or holding a house meeting at home, where fellowshipand worship take place and spiritual matters are discussedFaith is not just about thoughts and words, but more about feelings - so, shareyour feelings with your family, friends and fellow believersFind ways to show your love for God, your family and your fellow human beingand develop a love for all creationGiving and receiving love makes your immune system strongerBe thankful for the beautiful things in the world around you and this will makeyou feel betterIdentify passages from your holy book that lift the spirit and then write somedown on pieces of paper, so that you can carry them with you, to read or shareDevelop respect for people you meet and accept them as fellow travellersthrough life who are born, are living and will one day dieSmile and share smiles with others, because smiling lifts both the spirits of thesmiler and the people who are smiled atThink about your life from childhood to present day - make a list of yourfavourite experiences, share them with friends and relatives and then thank Godfor those special times

Point to ponderIf I exercise my mind and body for health reasons, shouldn’t I exercise my spirit too? Discuss

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Activity 9.12 Reducing stress by deep breathing and quiet timeIn this activity we will look at two things that many people say can reduce stress. Selectone person to quietly read the instructions while others do the practical.

Deep breathingDeep breathing is something you can easily teach peers. Try this exercise to see howrelaxing deep breathing can be:• Close your eyes• Now count 1, 2, 3 as you breathe in through your nose• Hold your breath and count 1, 2, 3• Breathe out counting 1, 2, 3• You need to do this activity at least three times - get to the point where you can

feel yourself relax as you do it• It may not happen the first time you try it - it’s a skill you develop

Quiet timeYou can also encourage peers to set aside a quiet time each day for meditation andprayer. Try this exercise for meditation:• Choose one simple word to focus on - this will help to block-out other stressful

thoughts from your mind• The shorter the word the better - eg. peace, joy, calm, cool, love, happiness• By choosing a peaceful and calming word, the mind will become more peaceful• A religious person may mediate on the 99 names for God or the life of Jesus• It is your individual meditation word - so, experiment with different words• In a quiet place, think of your word over and over again - it should be a word that

makes you feel good, relaxed and comfortable

Activity 9.13 Role play: Talking about living positively with HIV and AIDSJohn and his wife, Rebecca, have loved each other since they married ten years ago.Rebecca has been reading about people living positively with HIV and knows a greatdeal about the topic, but she has never mentioned this to John.

Background to the role playJohn is thinking• How can a person like me, go for VCT and be HIV positive, maybe the test is wrong!• I am a dead man and have probably sentenced my wife to die too!• What will they say at church and work when they find out?• This diarrhoea is going on too long, is it full blown AIDS already?• I think I’ll find a quiet place well away from here, commit suicide and save my family

the embarrassment

The play begins:Rebecca comes in and sees that her husband, John, is almost in tearsRebecca Is something wrong husband? A problem shared is a problem halved.John Just one problem my dear, but I think I can handle the issue by myself

Continue the role play and afterwards, discuss any interesting points raised.

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Activity 9.14 Succession planning Succession planning is planning for what will happen to children and young peopleafter their parents have died. Many children and young people in developing countriesface problems inheriting their parents’ property when they die. This may be partiallydue to cultural traditions concerning property inheritance at death. These may preventwomen and young children inheriting property. Instead, property may be inherited bya male relative of the father. It is expected that he would then take on responsibility forcare of his brother’s family. However, sometimes relatives may take the property withouttaking on responsibility of care.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcThere are many problems when a parent dies. These are worse if there has beenno planning.There are many reasons why succession planning does not happen in developingcountries.Responses which focus on encouraging succession planning use a variety ofmethods, including the use of memory books and boxes.Benefits of succession planning projects include increased appointment ofguardians, improved disclosure of positive HIV test results to children andincreased use of wills.

What are the problems with poor succession planning?There are many problems when a parent dies and these are made worse if there hasbeen no succession planning.

These problems include:children and young people not understanding what hashappened or what will happen to themadults being unclear as to who will care for the childrenand act as their guardianproperty being taken by relatives and others.

What are the barriers to succession planning?There are many reasons why succession planning does not happen in developingcountries. For example, wills can be a key tool in this planning. However, peoplerarely write wills in some developing countries. Reasons for this include:

belief that writing wills and preparing for death can cause death.the tradition that property is onlydistributed after death by seniorpeople within the extended familythe tradition that women and youngchildren can not inherit propertythe tradition that wills are verbal not writtenlimited knowledge and enforcement of lawslimited literacylimited experience with legal issues among NGOs inrural areas

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What would encourage succession planning?Encourage succession planning in a number of different ways, including:

counselling HIV positive parents or guardians, regarding telling their childrenabout their test results.creating memory books or boxes. These consist of a book or box which describesand remembers a person’s life. They may focus on specific events or periodswithin a person’s life. Memory boxes may be used to hold important documents,such as birth certificates and wills. What would you put in a memory box?support to appoint a standby guardian. This person will take on theresponsibilities of a parent for a child ifthe parent is no longer able to do this.training of guardians.education legal matters including practicalsupport to write wills.assistance with school fees and supplies.training in ways of generating income andfunds to get activities started.community sensitization on needs ofAIDS-affected children.

Why is succession planning important?Benefits of encouraging succession planning include an increase in the number of:

guardians appointed before a parent diesparents who tell their children the results of their HIV test - this is particularly truewhere those children are over the age of 12 yearswills written, which protect loved ones

Experience has shown that a project has benefits beyond the area in which itoperates. This is because people within the project area share the benefits withthose outside the area.

Activity 9.15 What things should you put in your will?Choose who you would like to leave your possessions to after your deathMake a list of who you would leave your possessions to - writing down yourwishes and having 2 responsible witnesses sign and date your will.

Activity 9.16 What things would you write in your memory book?Who will read your memory book after your death?What special memories would you write in the book?What special messages would you include?You could include a list of your favourite music, foods,places, books, prayers, books etc

Activity 9.17 What things would you put in yourmemory box?

Put in some of your favourite photographs and lettersSpecial souvenirs, diaries or journals, books, jewelry etcWhat other special things would you leave for others?s

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Activity 9.18 Why is home-based care so important?Point to ponder. Home can offer a far higher standard of patient care than some hospitalsand clinics. What do you think?

Further points for your discussion, debate, song, story, play, poem, poster etcPeer group members have suggested that home-based care can help in various ways.

It provides the personal touch to caringIt is less expensive than a hospital stay andthis is very important for poor familiesCan provide a larger number of carersThe patient is in familiar surroundingsThere is more time for succession planningThe touch of family carers reinforces bondsof love and encourages positive livingImproves the quality of life for a PLWHAHelps to prevent the spread of opportunisticinfections such as TBWhen a person is referred for home-based care,the health care worker needs to find out if the family has been informed of thefull details of a person’s illnessIf the family has not been told, the health care worker has to inform the futurehome care giver to help family members learn moreSometimes it is necessary for the home care giver and family members to beinformed by a qualified counsellor, if health workers feel unable to handle thesituation

Activity 9.19 When should a family start home based care of PLWA?When a family knows that a relative is living with HIV, they must be made aware thata time may come when they will no longer be able to look after themselves. If peergroup members have personal experiences of caring for a PLWA, give them anopportunity to tell their stories.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcPeer group members have suggested• As HIV weakens the immune system the patient starts to get opportunistic, but

treatable illnesses requiring frequent visits to the clinic or hospital• Later on the person then becomes chronically ill, and is no longer able to work

and do daily life activities• At the advanced stage of AIDS, hospitalisation may no longer be effective and

useful or desired by the person who is ill• The person now requires support services through home-based care and the

family now has to take over

Activity 9.20 AssignmentInterview people who have personal experiences of caring for a PLWA. Make a list ofthe issues raised by the interview in preparation for the unit on Educating caregivers.

Evaluation. Evaluate the unit by using the questions on page 166.

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Unit 10 Educating caregivers“

IntroductionThis short unit, aims to bring together what you have already learned about HIV andAIDS, and focus it upon the important role of the care giver. It is essential to educatethe people looking after those members of our communities living with HIV or AIDS.In Malawi carers are found in hospitals, clinics and in our homes. They are often therelatives of PLWHA - the spouses, grandparents, children or neighbours of the patient.By educating first line caregivers it is hoped that their health will be protected and theirwork will be made more effective.

Learning outcomesBy the end of the unit you will be able to:• describe some of the concerns of the caregivers of people

living with HIV/AIDS• describe how healthworkers can help families with PLWHA• practice ways of helping care givers prevent HIV infection• explain the role of counselling in home-based care• describe the different forms of counselling available in Malawi• practice ways of reducing opportunistic infections affecting PLWHA

Activity 10.1 Assignment reviewReview the assignment. When caregivers share their concerns and demonstrate howthey look after a PLWHA, both the care and support systems improve. Carers oftenfear not knowing what course of action to take, worrying about the effects of treatment,concern about the amount of time available and the deterioration in the patient’s health.


By showing new carers what to do, they pass on first-hand experience and skillsHolding a group session with a PLWA in their home or bedroom, brings issuesto life - the PLWA is considered and treated as a resource person during this activityUsing the actual resources of a caregiver, would make the topic real - by repeatingan activity or adapting it can also improves learningCarers need information and skills because, a personliving with AIDS requires:- palliative care to relieve symptoms associated with AIDS- help in preventing opportunistic infections- a support system which includes many

different forms of help- ongoing counselling- safe and supportive environment- spiritual and moral support- a healthy diet and exercise

Point to ponder. Everything I do as a caregiver, is done in order to boost my patient’simmune system and therefore strengthen resistance to infection. Discuss

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Activity 10.2 Practical ways of preventing HIV cross-infectionWhat can be done to prevent HIV cross-infection? Personal experiences will add weightto this discussion.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcYou only need to practice these precautions when you are in direct contact withbody secretions which may carry HIV. Remember, if the caregiver’s hands havewounds, cuts or cracks extra special care must be taken.What have peer group members suggested?

Always wash hands with soap and water if you touch infected body fluids - usepounded pawpaw leaves if soap is unavailableWear gloves or small plastic bags over the hands if possibleMake a plastic apron out of large plastic bag - use this when handling bodysecretions on linen, bed clothes, towels, dressings or cleaning up spills of bloodand other body fluidsNever leave blood spills or other body fluids lying on floors, furniture or incontainers - clean them up or dispose of them safelyCover body fluid spills with bleech or hypochlorine (Jik) solution if possibleFor everyday cleaning of surfaces you can use mix 1 cup of Jik with 2 cups ofwater - pour onto the spill and mop up carefullyBoil soiled laundry for at least 20 minutes or use bleach (Jik).If laundry is not boiled use water and household bleach - 1 part bleach to 9 or 10parts water - to kill the HIV on any household items.If this is not possible to boil or treat items with bleech, let items dry thoroughlybefore using againDiscuss how to dispose of possibly contaminated wasteKeep other family members and friends who may have infectious illnesses - flu,TB - away so that they do not spread their infections to the PLWHABe very careful with sharp instruments and avoid punctures with objects that maycontain bloodPlace used needles and all other sharp instruments in a separate sturdy box orcontainer with a cover and label it SharpsUse caution when administering first aid as blood can pass on HIV infectionCover any sores and cuts with bandages or waterproof plasterPut on gloves when changing wound dressings, giving an injection or cleaning aperson - take them off as soon as you finish

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Activity 10.3 What is the role of counselling in home based care?Counselling is part of home-based care, it is a process of helping another person tobetter understand their own and other’s problem or situation and then constructivelymanage the problem or situation. It aims to prevent further spread of HIV and supportpeople living with HIV or AIDS and the affected. Ask the group to discuss what thingshome-based counselling should include. Then to list them.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcPeer group members have suggested• Educate people living with HIV so that they understand

the nature of the disease• Help people understand the treatment options

and make informed decisions• Explore safer sex option and other preventive

measures• Communicate test results• Deal with issues surrounding grief, loss,

and bereavement etc• Clarify questions the person may have, such as the

development and effects of opportunistic infections andthe need to treat them when they first appear

• Counselling individuals and their families so they understand and can deal withthe implications of HIV and the possible impact of AIDS

• Understand the risks associated with caring for someone with an HIV infection

Activity 10.4 What forms of counselling can a person access in Malawi?In rural areas the counselling role is often assumed by traditional elders. In urban areas,many people may be unaware of the different types of counselling that are available.The provision of counsellors in Malawi is improving. Ask the group to look at thepoints below and discuss which issues would fit under the different types of counselling.

Points for your discussion, debate, drawing, song, story, play, poem, poster etc• Preventive counselling - to stop something before it develops.• Problem solving counselling - help individuals understand, analyze and find

solutions to problems they may be experiencing• Decision making counselling - to help on e to make difficult decisions such as

getting pregnant when one is HIV positive• Bereavement counselling - offered in response to loss, especially by death,

whether real, imagined or anticipated - it offers support to individuals and theirfamilies and friends throughout the grieving process

• Spiritual counselling - often offered by religious groups to cater for spiritualneeds of those with whom they come in contact

Points to ponderI didn’t know there were so many different types of counselling available, but what are thedifferences between them? Discuss

Some of our traditional activities, give more ‘guidance’s than ‘counselling.’ Discuss

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Activity 10.5 How can we reduce opportunistic infections?How can families and care providers reduce opportunistic infections in PLWA? Usingpersonal experiences where appropriate, ask the group to list examples of best practice.


People with HIV get infections easily and have a hard time getting rid of themA person with an infection may have a fever, chills, sores in the mouth,diarrhoea,or a rash over their bodyGo to the clinic immediately on noticing any of these signs of infection, as this cancatch the problem when it is easiest to treatHealth care providers may give medicine to take regularly to stop an infectionfrom coming back and these should always be taken as prescribedWhen a person has a cough that won’t go away, they should go to the clinic to betested for TBPrior to starting ART (antiretroviral treatment), the patient must be checked andtreated for TB, malaria, and parasites, as these conditions weaken immunityBecome familiar with traditional herbal treatments which relieve symptoms, butremember no traditional medicine can cure HIV infection or AIDS

Activity 10.6 How can health professionals help families with PLWA?What sort of help should people expect from a health professional? In an ideal worldevery PLWA in Malawi could expect the very best treatment. Unfortunately, our healthprofessionals are under a lot of pressure, with time and medicines often in short supply.But, we must always remember that health workers are the experts in the HIV AIDSfield and they must always be consulted before traditional healers or self-medication.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcWhat have peer group members suggested?• Hospitals need to provide family members with sanitary

facilities for toileting, bathing, cooking, doing laundry andwaste disposal so that guardians do not spread infection

• Health workers need to teach families how to use universalprecautions so they can care for their relatives withoutspreading infections

• Family members and caregivers also need some basicsupplies to provide safe care, including hand washingfacilities and gloves

• When health workers use gloves, it helps family membersunderstand that using gloves (or plastic bags) and takingother precautions does not mean a lack of love and respect

• When health workers have a positive, non-blaming attitude, it helps reduce thefeelings of shame or stigma associated with HIV and AIDS

• The National Council of Nurses and Midwives of Malawi (NMCM) is mandated todevelop, maintain, monitor, evaluate and control the profession of nursing andmidwifery and encourages the public to report any form of malpractice andnegligence - everyone should help NMCM achieve this goal

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Activity 10.7 What can care-givers do in the fight against HIV and AIDS?Health professionals and other caregivers are intimately involved in the fight againstHIV/AIDS, and their personal experiences are an invaluable resource for communityaction. This activity can be combined with 10.5 and 10.6.


Provide counselling or opportunities to chat informallyShare basic information about HIV and AIDSJoin or create support groups and networks of PLWHATake part in home-based care education activitiesCommunity mobilisation for better health servicesProvide guidelines for individual patient managementHelp people get access to essential drugsProvide specialist bed services for AIDS managementArrange support for children orphaned or children living with HIV and AIDSEncourage people to behave responsibly even when living with HIV and AIDS

Activity 10.8 Living positively: ideas for role playsThese role plays will assess how much you have learned about care giving, bybringing up many of the ideas from previous units. During the role pays make sureyou both act (use the appropriate actions) and talk about:• ways to live a positive lifestyle with HIV/AIDS• the safety precautions to protect people from infection or re-infection

Choose from the following role plays:Cooking healthy meals togetherEating a meal togetherKeeping the house tidy and healthyBathing a PLWHAWashing clothes and bed linenListening to hopes and fearsDiscussing keeping children safeDiscussing succession planningDiscussing and writing a willDiscuss what to put in your memorybox or memory bookGiving spiritual supportTalking to a child about the death of a relativeAdministering first aid on a fresh cutDiscussing ART and checking whether the patient is keeping to instructionsReturning to work and planning for the future, because the ART has beensuccessful and the patient is healthier and ready to do more!

Activity 10.9 AssignmentFind out about the prevention of mother-to-child-transmission of HIV (MTCT).

Evaluation. Evaluate the unit by using the questions on page 166.

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Unit 11 Preventing Mother-To-Child-TransmissionIntroduction and learning outcomesFor you assignment you were asked to find out about preventing mother-to-child-transmission of HIV (MTCT). We will review your findings and by the end of the unitparticipants will be able to:• define mother to child transmission (MTCT)• identify why mothers are at risk of HIV infection• identify when HIV can be transmitted through MTCT• describe how HIV can be transmitted through MTCT• identify cultural practices which can put a child at risk

of becoming infected with HIV through MTCT• describe methods of preventing MTCT of HIV• describe the importance of exclusive breastfeeding of

babies for the first six months of their lives

Activity 11.1 What is mother-to-child-transmission?Mother-to-child transmission is when an HIV positive woman passes the HIV virus toher child. This can happen before, during or after birth, and as the child grows up.• Mother-to-child transmission (MTCT) is the second most common mode of HIV

transmission in Malawi• In recent years, 90% of child infections are from their mothers, with 10% of

infections coming from exposure to infected body fluids and child sexual abuse• In the past most people believed that if a woman was HIV+ she would always give

birth to an HIV+ child - but, that is not the case today, because drugs which willreduce the risk of a mother passing on HIV to her baby

Activity 11.2 Preventing mother-to-child-transmission during pregnancyHow can we prevent HIV being transmitted from a woman to her unborn child?

These factors increase the chances of a baby being born HIV positive:Mother having a high viral load or in an advanced stage of AIDSSpousal abuse when expressed physically, mentallyor through neglectRough sexual intercourse during pregnancyRe-infection from an HIV+ sexual partner

These factors increase the chances of a baby beingborn HIV negative:

Pregnant women need to be cared for and lovedeven more than usual, because pregnancy cancause mood changesHelp to reduce pregnant mothers stress levelTreat any STIs especially open sores before giving birthPregnant women need more food than normal to stay healthy - the healthier theexpectant mother the healthier the babyInvolving men in PMTCT helps to involve men in feeding programmes as well

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Activity 11.3 Preventing mother-to-child-transmission during childbirthDuring labour and delivery, membranes may rapture early, exposing the child to the mother’sbody fluids.

These factors increase the chances of a baby being born HIV positive:Mother is very young and her birth passage is too small,it can tear badlyMother has a high viral load or in an advanced stage ofAIDSMother has an STI and open sores in and around genitalsMother’s amnion is infected by HIVMother has a severe lack of vitamin AUnclean surrounding during birthBirth attendent is HIV positive and does not wear glovesBirth attendants not washing hands properly before a birthBirth attendent uses old, unsterilised blade to cut the umbilical cord

These factors increase the chances of a baby being born HIV negative:Deliver at health care centre or with qualifiedmedical staff presentAvoid trauma to the unborn baby (foetus) throughinstrument deliveriesCaesarean section is the best mode of deliveryTake anti-retroviral medicines at the beginning oflabour pains. The drug passes through the placentato the babyDon’t put unclean traditional medicines on theumbilical cordUse a new or boiled blade to cut the umbilical cordCampaign against the child abuse of child brides andunder-age marriageDo not let local midwives put any herbal medicineinto the new mother’s vaginaEducate traditional birth attendents on the newmedicines available and why they are importantEducate school girls and boys, in appropriate sexual and reproductive healthissues related to healthy childbirth - then allow them fully mature before theybecome well-educated parents

Points to ponderIf a woman is cared for during herpregnancy then her baby has a farbetter chance of being born healthy.Discuss

The education of parents begins athome and in our primary schools.Discuss

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Activity 11.4 Preventing HIV transmission during breastfeeding?In Malawi all mothers , whether they are HIV positive or negative, should breastfeedexclusively for the first six months of their babies’ lives! Exclusively means only breastmilk, the baby is given no other liquids, no foods nor local medicines for six months.

These factors increase the chances of a baby being born HIV positive:One baby in every five, born in Malawi, dies before it is one month oldOne child in eight dies before its fifth birthdayIn Malawi, 27% of children are underweightAlmost 50 % of our children are stuntedMalnutrition is associated with 54% of child deathsDwale, can kill a baby - drinking dirty water can’t straightenthe baby’s intestines or stop abdominal pain - it can make ababy seriously ill and irritates the babies digestive systemand makes it even smore vulnerable to HIV infectionIt is not true that the first breastmilk a mother produces aftergiving birth contains bad elements - first breast milk is goodHundreds of Malawian babies die, because their mothers thinkthat bottle feeding is the best way, even if the milk mixture ismade with unsafe, germ-filled water - this can kill baby!Bottle feeding lacks many health benefits of breast milk for babies, includingprotection from many infectious diseases, much less diarrhoea and better growthUnclean bottles, water and rubber nipples are often used and these can kill babies- bottles and rubber nipples must be boiled in order to kill germsBreast milk does contain HIV and their is a risk of it passing to the baby

These factors increase the chances of a baby being born HIV negative:Research shows that babies in Malawi will be healthier with exclusive breastfeeding for six months, even if the mothers are HIV positiveBreastmilk is easily digested and the child gets the nutrients it needs - the bodycan easily absorb these nutrients and it does not cause constipationBreastmilk protects the child from allergies and promotes emotional bondingbetween child and motherThe chance of getting HIV infection from breast feeding is not as great as thechance of dying due to lack of breast feeding or poor quality bottle milkCultural gender imbalances, which leave women with lots of domestic work, alsoprevent women from suckling their babies properlyFight strongly and vocally in your community, to stop practices like dwale, wherea new born is given dirty water to drink instead of breastmilk!Encourage mothers to let the baby drink the first breast milk, because it is theperfect food for the new born baby - speak out when local beliefs are wrongThrough frequent skin-to-skin contact the baby learns to trust its mother

Point to ponderApart from being the best food for the health of the child, breast milk is also the cheapestand most convenient food for the baby. Breastfeeding for six months is the equivalent ofbuying 400 tins of milk, each costing K1,000 and that amounts to spending overK400,000. (2008) Discuss

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Activity 11.5 Why is it dangerous for a mother to mix feed a baby?These words were spoken in 2008 and reported in the Nation newspaper, I raised myfirst two children in a traditional way, breastfeeding them and other foods. I havebreastfed my third child for six months; he is healthier than the other two.

Points for your discussion, debate, drawing, song, story, play, poem, poster etcNever use mixed feeding in the first six months, as it damages the baby’s gutmaking it easier for HIV to enter the baby’s body.Ban these things from a new born baby’s diet:water, formula milk, gripe water, herbalmedicines or cooking oilBabies who are on supplementary feeding schemescan be at risk and can develop sores, thrush andinflammation in the mouth and gut - this exposessuch babies to HIV that may be in breast milkConditions like STIs, cracked nipples and soresor thrush in the baby’s mouth need immediatemedical treatmentAsk for medical advice before using replacementfeeding includes commercial full infant formula from cow - cow milk or soyaprotein

Ban foods like skimmed milk and yoghurt, eggs, meat, fish,fruit and vegetables from a baby’s diet for the first six monthsif it is being breastfeedIf there is an irregular supply of formula milk or lack of cleanwater then don’t use formula feedIf sanitation services are poor, the water supply may becontaminated - boil water before using it in a feed bottleSome nursing mother does not fully understand how to mixthe formula milk - educate themIf a mother develops a cracked nipple she should feed the babywith the other breast as the crack could expose the child to risk ofcontracting HIV - then seek medical attention

Don’t allow another mother to breastfeed your baby, even if she is HIV negative, this canupset baby’s digestive system and leave it open to HIV infectionPractising safer sex during the breastfeeding period, by usingcondoms correctly, and consistently or abstaining, to preventacquiring more virus or re-infection with different HIV strainsRicher nations advise mothers with HIV not to breastfeedwhenever the use of replacements is acceptable, feasible,affordable, sustainable and safe. If you are HIV positivemother living a very good lifestyle where you have anadequate supply of clean and safe formula, you maywant to discuss bottle feeding with a health professional

Point to ponderEveryone in every community should know that an HIV positive mother can have an HIVnegative baby, provided the proper procedures are followed. Discuss

Why do you think thatpowdered milk is shown

as a monster?

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Activity 11.6 Role play: Partners talking about having an HIV free babyIn the role play a couple are discussing the best way to have a baby that is HIV free.

BackgroundMwayi and Taylor are planning to get married and start a family. When they first startedgoing together they used condoms, but they stopped using condoms because theytrusted each other. Through peer group meetings they have learned about thePrevention of Mother-to-Child Transmission of HIV (PMTCT).

• Mwayi really wants to be a mother• She is worried about having unprotected sex• She does not want to take a chance on having a baby

that is infected with HIV• She worries that if Taylor finds out that she is infected

with HIV then he will leave her• Taylor is worried, because he had several partners

before Mwayi - but he really wants to be a father• He feels that there is no point in getting tested now

because they already had unprotected sex

The play begins:Mwayi and Taylor are sitting together listening to musicTaylor How many children do you want? Mwayi, one day I’d like to be a grandfather.Mwayi Two children, a boy and a girl. I’d like two healthy children, that’s why we

should plan carefully for the future.

After the role playWhat have peer group members suggested?

Preventing babies being infected through MTCT, means that couples and theirfamilies could produce HIV free children - this gives fresh hope to familes hit byHIV who feel that their name or history will be lostBoth parents should take joint responsibility in order to prevent MTCTInvolving men in PMTCT helps to involve men in feeding programmes as wellPartners should both go for VCT - the only way people can be sureAfter VCT it is easier to make decisions about sex, marriage and childrenUse condoms for three months and then have a blood test for HIV and AIDSIf the blood test confirms that both you and your partner do not have HIV andAIDS, you can have unprotected sex with each other until pregnancy occursYou and your partner must not have sex with other partners, or always usecondoms with other partners, to avoid the possibility of becoming infected

Point to ponderIf a man and a woman are both HIV positive, and wish to have an HIV free child, then theymust both closely follow medical advice. Discuss

Conclusion. The last learning activity of the Mzake ndi mzake course involves usingour A to Z of HIV as a quick revision tool. Go through the A to Z and use song, danceand poetry to celebrate successfully completing the course.

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The A to Z against HIV: it’s much more than just ABCWe created these simple messages based upon all of the letters of the alphabet. Youmay wish to use or adapt some of them for your activities. Remember, that some ofthese messages may not be appropriate for some audiences. Be careful when, whereand how you use them.

AUseful starter words: ask; always; assert; avoid;all; abstain; attitudes; adultery; ARVs; alcohol

1 Abject poverty leaves millions of peoplemore vulnerable to HIV infection and otherhealth problems... help relieve poverty

2 Abstain3 Adultery can kill4 Aged grandparents caring for orphans may

need your help and education about HIV5 Agree-to-differ if an HIV prevention

strategy is being hotly debated.6 Alcohol can alter your feelings and

thoughts, and they influence your actions7 Anal sex is a very high risk and illegal8 Aroused sexual passions can be

dangerous... keep control of them9 ART works for most people but not for all10 Assert yourself and help other to do so

BUseful starter words: boys; babies; become; bad;behave; beliefs; birth; babies; blood; body fluids

1 Be faithful2 Break the silence over HIV and AIDS3 Be careful with Body fluids4 Boys and girls both need to know the true

facts of life about love and sex5 Bed nets to combat malaria6 Bars can be dangerous places7 Behaviour change may be hard8 Bar owners have a part to play9 Birth certificates protect children10 Babies should be born in a clinic/hospital

CUseful starter words: choose; caregivers; child;clubs; classroom; courage; circumcision; change

1 Caesarian births save many new babies2 Chaste - do not have sex except with

the person to whom you are married3 Correct and consistent use of condoms4 Child protection officers are now at work in

Malawi5 Clinics are special places6 Colleges and schools should be safe

places free from abuse7 Counselling plays an important part8 Condoms should be used by every

prostitute and every one of the clients9 Condoms should only be used once10 CHBC - Community Home-Based Care

DUseful starter words: do; don’t; delay; daughters;discrimination;

1 Delay your first sexual activity2 Don’t do dry sex - where medicines are

put in the vagina can kill both partners3 Don’t let anyone touch your private

parts - except a nurse or doctor4 Don’t self-medicate when on ARVs

5 Development is good change - what areyou going to change for the better today?

6 Don’t let Development be slowed by HIV7 Diplomatically challenge and correct

people who make incorrect or negativecomments about PLWHA or HIV

8 Don’t give up if your discipline weakens,resolve to stay strong

9 Deal with STIs immediately!10 Deal with Depression by talking to a

trusted person

Always abstain!

Beware of body fluids!

Don’t self-medicate ifyou are on ARVs!

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GUseful starter words: girls; get; government;good

G1 Get tested for HIVG2 Generosity can fight poverty and HIVG3 Girls need encouragement to be assertiveG4 Girls should delay first sexual encounterG5 Grooming small children for sex is wrongG6 Grow vegetables and fruits to eatG7 Greater involvement of PLWHAG8 Genital sores should be treated now!G9 Genital parts are special and privateG10 Grow in confidence and self-discipline

HUseful starter words: help; halt; hope; home;happiness

H1 Homeless people are vulnerable to HIVH2 Halt Human traffickingH3 Handle and dispose of condoms carefullyH4 Help Homeless girls from becoming

Hookers (sex workers)H5 Help PLWHA and their families and carersH6 Humans spread HIV not by witchcraftH7 Hold the hand of your HIV+ friend and let

the fingers speak of your friendshipH8 Home-based care is very importantH9 Homosexuality can spread HIVH10 Hope Is Vital when PLWHA

IUseful starter words: if; improve; information;imagine; infant; identify; inmates; infections

I1 Imagine an HIV and AIDS free MalawiI2 Information on HIV is essential for allI3 Identify human traffickers of children and

adults for sexI4 Income generating activities helpI5 Improve the well-being of the poor and give

them more life choicesI6 Innocent people may be blamed for bringing

HIV into the relationshipI7 Impoverished communities are at great riskI8 Ignorance spreads HIV and AIDSI9 Imagine the best things you could do to

fight HIV in Malawi... then talk them overwith others... and act

I10 Injecting drugs can spread HIV

JUseful starter words: join; joke; justice for;

J1 Join together to spread the informationJ2 Joke about your HIV, talk to it. Positive

living and these ARVs will keep you (HIV)locked up in my body. You will neverescape from me HIV!’

J3 Just say NO to unprotected sexJ4 Join together to fight HIV and AIDSJ5 Join local networks to national networks,J6 Join house visits and house religious

services for PLWAJ7 Joke about things in life - humour and

smiling makes life feel betterJ8 Jesus would not leave PLWA to suffer and

die alone - will you?

KUseful starter words: kill; keep; know;

K1 Know your sero status - go for VCTK2 Know how to stay safe from HIVK3 Keep VCT test results confidentialK4 Keep good company in safe surrounding if

you are at risk of being temptedK5 Keep faithfulK6 Keep hoping for new medicines to make

life easierK7 Keep taking your ARVs as prescribedK8 Keep HIV from reproducing - take ARVsK9 Keep your trousers zipped (men)K10 Keep your legs crossed (women)

LUseful starter words:leaders; let; listen; life; live;love; look; liberate; laws

L1 Let all discussions on HIV be peacefulL2 Learn all you can about HIVL3 Liberate child labourersL4 Love without prejudiceL5 Life is precious, protect it!L6 Literacy helps defeat HIVL7 Live positively with HIV+L8 Loose morals can make you lose your lifeL9 Listen to the bereaved... encourage them

to celebrate the life of the deceased.L10 Let only your marriage partner be your

only sexual partner

Literacy against HIV!

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MUseful starter words: mothers; men; man; make;Malawi; Muhammed would; myths

M1 Malawians have a duty to fight povertywhich encourages the spread of HIV

M2 Malawi is star in the fight against AIDS(headline in Daily Times 18 Aug 2008)

M3 Man-to-man talks between boys and theirfathers about sex and HIV, can really helpin the fight

M4 Most people living with HIV were notpromiscuous

M5 Memory boxes or books bring greathappiness to those left behind after abereavement

M6 Mother-To-Child-Transmission of HIV canbe prevented by following the correctprocedures

M7 Malnurished people cannot fight offinfections and are more vulnerable to HIV

M8 Malnurishment contributes to the spreadof HIV we must address it - if we fightmalnutrition of the poor, we fight HIV

M9 Most cases of child sexual abuse and rapeare carried out by people the victim knows

M10 Mother’s breast Milk exclusively for sixmonths for new born HIV free babies

NUseful starter words: no!; never; new mothers;

N1 No condom no sex!N2 No traditional Malawian medicines can

cure AIDS - but there are local medicineswhich ease the symptoms of HIV

N3 No sex until marriage or VCT!N4 Never put local medicines in the vagina to

make it dryN5 Non-penetrative sex is safe sexN6 No sex is safer sexN7 Nations budgets should have the needs of

the poor at its heart - Need can spread HIVN8 Never put your penis into the vagina of

someone who is not your wifeN9 Nevariprim during childbirth (check for any

new drugs being used locally)N10 Nobody has ever died from abstinence.

Try it!

OUseful starter words: only; orphans; open; over;oppose; organise; orgasms

O1 Open and frank talk about HIV and AIDSO2 Openly say if a relative died of AIDSO3 Organise to fight any discrimination

against PLWHAO4 Over seventy percent of human traffickers

in Malawi are no prosecutedO5 Oppose child bridesO6 Only drink in bars where there are no sex

workersO7 Orgasms are important for both partnersO8 Orphans are vulnerableO9 Oral Rehydration Solution (ORS) saves

lives (see page )O10 Opportunistic Infections must be treated

promptlyO11 Only One faithful partner for life

PUseful starter words: put; prevent; proper;parents; partners; poverty; poor; powerless;power: play; prosecute;

P1 Poverty Prevention is an important factorin Preventing the spread of HIV

P2 Peer education on HIV and AIDS doesmake a difference

P3 People living with HIV and AIDS have thesame rights as everyone else

P4 Prevent mother-to-child transmission ofHIV learn the facts and tell others

P5 Prisons can spread HIV, Protect inmatesand officers through peer education

P6 Partners should learn how to open up andtalk about sex and HIV

P7 Property grabbing is a crime - stamp it outin your community by making wills

P8 Power relationship need to changeespecially those connected with gender

P9 Professional medical advice is importantP10 Pray with or for all those infected or

affected

Poverty is a factor inthe spread of HIV!If we fight poverty

we fight HIV!

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QUseful starter words: question; quote; quiz;

1 Question traditional practices that putpeople at risk

2 Quiz - create a quiz from these messages3 Quote from the holy books - the messages

that bring courage, love, compassion andresponse to the fight against HIV

4 Question the community that allows fullsexual intercourse to be part of girls’initiation

5 Quit those bad habits!6 Question if he really does love you, if he’s

pressuring you for sex before marriage7 Qualify as a HIV/AIDS peer educator8 Quietly and forcefully say, “No!”9 Question your own beliefs and behaviour10 eQuality of opportunity for all citizens

RUseful starter words: remember; refuse; report;role model;

1 Religious groups of all faiths should worktogether in the fight against HIV and AIDS

2 Role model by living positively andhelping others to do so

3 Refugees are very vulnerable4 Religious leaders must know accurate facts

- and share them with their community5 Remember to carry a condom if you cannot

abstain or be faithful6 Rural communities need the information

about HIV just as urban areas do7 Refuse sex before marriage or before VCT8 Review your behaviour regularly9 Read for pleasure and for learning about

HIV/AIDS issues and development10 Report teachers sexually abusing their

students

SUseful starter words:sons; stop; speak out;share; stigma; safe; sex; schools; street-children

1 Stop early marriages and child-brides2 Stop Stigmatizing PLWHA3 Sex is beautiful, with the right person, at

the right time, and in the right place4 Sex Should be Safe and pleasurable for

men and women5 Street children need our protection6 Schools must treat boys and girls equally7 Stigma feeds the Spread of HIV8 Succession planning is vital9 Spread Safe Sex10 STIs (STDs) must be treated Swiftly

TUseful starter words: think; thoughts; talk; tell;teach; train; truth; translate;

1 Train Traditional birth attendents2 Talk openly about about irradicating

stigma from society3 Traditional customs may put people at risk4 Translate these messages into local

languages when speaking in a local setting5 Temptations can be overcome6 Temperance helps us behave well7 Think Twice before you act, especially if

you have been drinking8 Teacher support groups are important9 TB is the most opportunistic infection10 Tatooing and body marking can be very

dangerous

Carefully choose the rightwords for your audience

Stop early marriages!

Quietly say, “No!”

Report sexuallyabusive teachers!

Uneducated,unemployedand unloved

take more risks!

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UStarter words: umunthu would; unprotected

1 Unprotected sex with an HIV+ person isresponsible for 90% of all HIV infections

2 Umunthu - the role model to aspire to3 U should try to be Umunthu4 Unmarried people should wait before sex5 Unemployment can breed desperation and

encourage risky behaviour6 Uneducated, Unemployed, Unskilled,

and the Unloved, take more risks7 UDHR: Universal Declaration of Human

Rights (1948)8 UNAIDS: United Nations Joint programme

on HIV/AIDS9 UNICEF: United Nations Childrens’

Fund10 Unitedand Unable to stop fighting HIV

VUseful starter words: voices; volunteer; VCT;value; virtue; vice; virgin; vagina

1 Voluntary Counselling and Testing beforeand during marriage

2 Vote for candidates who are part of thefight against HIV

3 Virgins are Vulnerable4 Values are the key to behaviour change5 Vices can make you Vulnerable6 Volunteer to help the Vulnerable7 Voices of the poor, Voices of women and

Voices of PLWA should be listened to more8 Violent partners put people at risk9 Vulnerable children are at risk of HIV10 Voice your fears and hopes

WUseful starter words: women; widows; wash

1 Want to make that important behaviourchange so much that you change

2 We cannot ban Workshops because of therisk of HIV infection - Want to abstain

3 Women Will be empowered4 What do you think Jesus would do to

fight HIV/AIDS?5 When people are really in love they can

and Will Wait until after marriage or VCT6 Wills protect the Widowed and the childen7 Witchcraft cannot cure AIDS8 Wives club meetings can assist9 Work place HIV education is needed10 Welcome positive behaviour changes

XUseful starter words: seX;

1 seX workers need educated2 seXploitation of human being infringes

their human rights3 seX is to be enjoyed within a lifelong

relationship with one faithful partner4 seX that is safe and within marriage5 eXplore the many different ways you and

your partner can stay safe from HIV6 eXpose aduts who have seX with children7 eXchange marriage vows before you

eXchange body fluids8 eXamine your values and behaviour

YUseful starter words: you; your; youths; young;

1 You can stop any risky behaviour if youreally want to!

2 You may have a vice that puts you at risk.So, you are the one who must make thechange!

3 Your partner and children may be at risk ifyou have casual sex partners

4 Your marriage is worth more than a onenight stand

5 You can get pregnant when you have sexfor the first time

6 You can’t be cured by having sex with avirgin

7 Behaviour change begins with You!8 Youths need education for protection9 Young children should not marry10 Your Young ones need information

ZUseful starter words: zero

1 Zero tolerance for sexual abuse anywhere!2 Zero tolerance for initiation practices that

put children at risk of HIV infection... adaptor stop it

3 Zero tolerance for body cutting andtatooing using an unsafe blade

4 Zero tolerance for spousal abuse5 Zero tolerance in my marriage if my partner

has sex with some who is not me!

Zero tolerance ofspousal abuse!

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Facilitation techniquesThe aim of this programme is to help group members to learn , share what theyknow and apply what they have learnt.

A peer leader or the group as a whole, can choosethe best teaching and learning techniques to beused during a session. It should be rememberedthat when working with adults it may be necessaryto use a variety of different techniques. Adultsoften resent being told what to do, they may learnmore from discussions with their peers. They areoften highly motivated if they can see the trainingas relevant and composed of a variety of differentactivites. They often learn more by developing their

own ideas, than from just listening to theideas of others. So, interactive methods are suitablefor teaching and training adults.

Before each session, ask the following questions:• Who are you working with?• Which activities are you going to go through?• Where will the group work?• When will the group meet?• How will you teach/facilitate the selected activities?

Peers can decide how each activity will be completed and when people will work as:• individuals• pairs• small groups• whole group

Mzake ndi mzake peer group members have suggestedthe following techniques:

1 Discussion - This is the consideration of a question in an open and often informaldebate. Group discussions can be used to generate a lot of ideas and opinions, shareinformation and facts under the guidance of a facilitator.2 Lecturette - Lecturettes are short lectures. A lecture is an oral presentationintended to transmit knowledge and procedure that often have to be memorized.3 Presentation is the practice of showing and explaining the content of a topic to anaudience or learner. It can be illustrated with models, posters, slide shows etc.4 Question and answer - Group work or as a checklist for individual work5 Demonstration is used to reinforce theory, by showing exactly what should orcould happen in a situation. It helps to pass on both skills and knowledge, and showprocedures that may be difficult to describe in words alone. It can help both thedemonstrator and the audience to recognise future problems that may arise andwhere opportunities for improvement exist.6 Research is a systematic inquiry or investigation into a subject in order todiscover or revise facts, ideas or procedures. Research results can then be presented

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in a detailed and accurate manner to the group.7 Diary or journal writing - Members may wish to keep a diaryor help a PLWHA to do so. This diary may be a very useful sourceof ideas for the group sessions.8 Story telling and story writing - The story can be true orficticious, in prose or verse. It is designed to interest, amuseand instruct the audience. Case studies and extracts form lifestories are particularly useful in open peer group work.9 Proverb - A short memorable saying that expresses simplyand effectively some commoplace truth or useful thought.Often of unknown or ancient origin, traditional proverbs focuson a ‘teaching point’ or moral.10 Poetry reading and writing - Poetry is a way in which we canget in touch with our inner feelings and then share those feelings with others. Poetrycan also be found in drama, hymns, song lyrics, rap and chants as well as in prose.Look at the A-Z of HIV on page 157 for ideas. You can also use ideas as slogans onposters and charts.11 Singing and song writing - Traditional songs can be adapted as icebreakers topass on simple messages. Songs can also be used to open and close a session. Look atpages 157 to 161 to find new words to fit with well known tunes.12 Music - Adapt well known tunes from traditional and religious sources for use inHIV education. Find out who can play a musical instrument. Drumming is asignificant part of using and developing music for dance.13 Dancing and dance developing - Traditional dances can be adapted to carryimportant messages. New dances can be developed by group members. Dancing canbe integrated into dramas and story-telling.14 Drama and drama development - Drama allows participants to use words andactions to tell serious stories to an audience. Peer groups can focus on issues theymay face in everyday life and gives the opportunity to generate possible solutions.Unlike our role-plays, drama is rehearsed.15 Roleplay - In a role play, members are given a situation and a little background.the chose actors continue the play. Actors can develop their own ending and remainin their roles for the first part of discussions that follow. This can help people to gainan insight into behaviour and feelings and look at, and practice life skills necessary toprevent HIV infection. The actors often answer questions in their roles before theyde-role. A general discussion follows after they de-role.16 Writing replies to imaginary ‘Problem page’ letters about HIV and AIDS -Most magazines have a problem page, where readers letters are printed and anexpert writes a reply giving advice. Group members can both write and reply to realor specially created problems.17 Drawing or cartooning - Make use of the groups drawing skills by workingtogether to design posters and cartoons on HIV education.18 Educational visits - Some people caring for someone living with HIV and AIDSmay have created a successful caring environment in their home. With the patientspermission the group may find an on-site visit both interesting and enlightening.19 and 20 Writing speeches and newspaper briefings - Members can assistreligious, traditional and civic leaders when they are asked to speak about HIV andAIDS. Short statements, like or A-Z on page 157 may be useful for ‘sound bites’.

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The TALULAR ChallengeTeachers and trainers, often say that theydo not have enough teaching and learningmaterials. But, we often ignore the richvariety of resources that are all aroundus in our communities.

Talular stands for Teaching And LearningUsing Locally Available Resources. Thisdouble page contains drawings ofhundreds of objects and ideas. All of themcan be used as resources.

Take a few minutes to look over thesepages and then complete the activities.

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HIV prevention activities1. What does the word TALULAR mean?2. Why is TALULAR important for Mzake ndi

mazke peer group training?3. Make a list of 30 objects found in your

community that could be used duringpeer group training activities. Brieflydescribe how you would use each one.

5. Which people in your community couldbe the most useful to a peer group?

6. What important resources (materials,skills, attitudes etc) do you think we’ve leftoff these pages?

7. What do you think are our most valuableresources in the fight against the spreadof HIV?

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One participant should represent the human body while others represent white bloodcells (WBC), which protect the body from infection by germs, represented by a thirdgroup of participants. Choose one participant to represent HIV.• Ask participants to act out the spread of HIV• HIV knocks out the white blood cells so they can no longer protect the body• The body is now open to attack by germs of all kinds (eg. TB, diarrhoea)• Eventually the body is overcome by diseases which are normally not fatal• Adapt the drama to suit participants of different ages and educational background

Model: How amniotic sac and fluid protect an unborn baby• Place a plastic doll inside an empty, clear plastic bag• Pass the doll around the peer group• Fill the bag with water, place the doll inside and

know the opening soit is sealed• Pass the water-filled bag around the group and

discuss how a baby is protected while insideits mother

• Amniotic sac and fluid can also play arole in protecting an unborn babyfrom HIV - see pages 148-149 toconsider the risks of HIV infection before and during childbirth

Model: Coughs and sneezes spread diseasesConstruct the model as shown in the diagram. Ignite one of the matches at the edgeof the model. Use the resulting effect to illustrate how coughs and sneezes canspread diseases. Catching coughs and sneezes in a handkerchief reduces the rate oftransmission.

Drama: The spread of HIV

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Model: The dangers of dehydration• Make a model baby from a bottle, can

or gourd• The main opening of the container

represents the mouth of the baby• Put two holes in the bottom of the

container - a large hole to representthe anus and a small hole to representwhere urine leaves the body

• Put two stoppers in the lower holes• Fill the baby with water to represent a

healthy hydrated body• Remove the smaller stopper (cork)

and water will be lost slowly• Remove the large stopper to illustrate how diarrhoea can cause severe loss of water• Water lost through the holes can only be replaced through the mouth• If more water is lost than is taken in dehydration occurs and this can be fatal,

especially in small babies

Practical: The ORS miracle• Dehydration caused by diarrhoea is probably the

biggest killer of children in today• Our bodies need water to function normally, but we

also need essential electrolytes like sodium andpotassium - these are lost in diarrhoea and must bereplaced

• The ORS drink (oral rehydration solution) is used tosave lives by replacing some of the lost electrolytes

• For smaller amounts of the drink put a pinch of saltinto a cup of clean water and add 8-10 pinches ofsugar

• Consult a health professional if diarrhoea persists

Game: What is AIDS?Games are a good way to interest and motivate participants. The game illustratedbelow is based upon four cards. The cards can be used individually at first tointroduce each word in isolation. Then the four can be put in the correct order andused to define the term AIDS.

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ChalkboardThe chalkboard will the most readily available teaching and learning resource for manypeer groups. Here are a few tips that may improve the effectiveness of boardwork.

• Untidy presentation encourages untidy work from learners• Divide a large chalkboard into smaller sections• Write clearly - do not add too many flourishes to writing style• Underline headings and key statements• Do not write toomany words in upper case• When dusting a board pull the dust to the side• If you wash a board, let it dry and then pat the surface with a

duster - chalk can react with water making it hard to rub off• Boards are useful for presenting group feedback and lists• Floors and table surfaces can be used as writing surfaces

Different types of linesThere are many different ways of creating lines on a chalkboard.

• Chalk can be sharpened with a knife like a pencil• Experiment using other surfaces like tables and floors (both inside and outside)

String display linesStrings can be used in many ways to display items. Here are a few ideas.

Experiment with different types of string and thread,length of string and ways of attaching the ends ofstrings to supports.

Stick a flap or tail onthe back of picturesand this will help tohold them in place.

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Display: Zigzags and multi-boardsZigzag multi-boards are made from pieces of board joined together in such a waythat they can be folded easily and carried. A zigzag multi-board can be built up fromone portable board. The faces of each board can be prepared to suit a teacher ortrainers personal requirements. Eight different types of board are shown below.

The board can be displayed in a variety of different ways. It can be free-standing orhung on a wall or support. Experiment with different angles and techniques.

Carrying handles can be made from rope or cloth strips. Protect the outer surfacesby paint or bycovering themwith plastic.

Design a zigzagboard to fit yourown particularneeds.

Mother tongue songs, music and dance• Translate the A to Z of HIV messages into your mother

tongue - spread them among different groups withinyour community

• Adapt traditional dances for use in spreading importantmessages about sexual and reproductive health

• Create new costumes and steps by using the role playsand other ideas found in our activities

• Use the A to Z of HIV as a source ideas for song lyricsThey can be very useful as chorus lines between verses

• Songs that are developed in your mother tongueand then translated often work better than songsfirst written in your second language. Discuss

Experiment with other TALULAR ideas that could be adapted for Mzake ndi mzake.

We have marked the peer group members suggestions with the symbol b

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Evaluation questionsThe aim of this programme is to help group members to learn, share what theyknow and apply what they have learnt.

After each sesion go through the questions suggested by peer group members:

1 Did you start the session on time?2 Which unit or activities did you cover in this session?

Have you put a mark next to them in the contentssection of this manual?

3 Was the introduction clear?4 Was the content clear? If your answer was ‘No’,

give reasons for your answer so that it help futureplanning.

5 Did the group use a variety of teaching and learningtechniques, such as question and answer, pair andgroup work, lecture, song, poetry, role play, visits etc?

6 Did you feel comfortable or uncomfortable during the session? If so, talk aboutthese feelings and the need to talk about sexual activity within the peer group.

7 Have you made a note of interesting or useful ideas that could be added oradapted to the units or activities in this manual.

8 Have the group or individuals chosen activities or topics as assignments?9 Have members set an agreed date and time for the next meeting?10 Do group members know the activities that will form the core of the work for

the next meeting? Remind members that activities can be added to the core if thegroup thinks that they are important.

Peer groups are free to add other questions to this list.

There may be some people in your group whofind it difficult to discuss the sensitive issues inthis programme. They may decide not to continuethe training. If so thank them for attending and tellthem they would be welcome to return or joinanother group later.

Did the group manage the do if people find thediscussion of HIV and AIDS or partner sexual relationship issues upsetting? Be sureto emphasize the positive messages about protection from HIV and AIDS.

However, for those who continue the training, you probably should not change thelater units. Always remember to be sensitive to people’s discomfort in discussingthese important issues.

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Planning future Mzake ndi Mzake peer groupsNow that you have finished the units about HIV and AIDS prevention, some of youmay wish to start a new group to teach others. You might want to have a partner, asthe two of you could help each other. You could start by inviting your friends,neighbours or the people you work with to join your group.

Now we need to develop simple action plans, to outline the different ways in which wecan continue to work for HIV and AIDS prevention.Peer group members have suggested that you can do the following:• What is one way each of you can help stop the spread of HIV and AIDS?• What specifically are you going to do in the next four weeks?• Would you like to continue meeting as a group? If we meet, what will we do and

how often should we get together?• Do you know where to get good information about testing and other services and

about new developments in the fight against HIV and AIDS? Here is a list ofservices available to you that you may find helpful.

• Thank you all for being a part of the group. We’ve really enjoyed getting to knowyou and talking about these important issues with you.

• Ask each member of the group the following questions to help them plan theirfuture HIV and AIDS prevention activities. Encourage several people to worktogether.

• Discuss whether the group wants to continue meeting and if so, how you willorganise this.

• Thank the group for participating.

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Glossary of termsAIDS: Acquired Immune Deficiency Syndrome; this is the stage where a person wholives with HIV becomes very weak and his or her immune system cannot fight illnessesvery well anymore. This happens when a person’s T-cell count decreases to about 200.Usually this happens about 6 to 8 years after getting HIV. When HIV and other illnessessuch as tuberculosis, cancer or pneumonia enter ther body when it is weak from HIV,we call it AIDS.AIDS related illness: an illness that a person living with AIDS gets because HIV hasseriously weakened their immune system. TB can be an AIDS related illnessantibody: a chemical made by your body. It is one of the main ways in which yourbody fights HIV and other illnesses...substance produced by the human immune systemthat reacts to antigensantigen: that identifying feature on organisms and foreign tissues that triggers theimmune system to produce antibodiesART: anti-retroviral treatmentARVs: anti-retrovirals; medicines used to fight HIV. ARVs are used at the AIDS stage ofinfection. There are different types of ARVs. each type fights HIV differently. Usually, aperson takes two or three types of ARVs to fight HIV. This is called combination-therapy or HAART.asymptomatic stage: the period between becoming infected with HIV and becomingill that ranges from a few week to as many as 8 to 10 yearsincubation period: period between the time of infection and becoming ill due to HIVCD4 cell count: a count of the number of T-cells in a small amount of you blood,which shows the measure of how strong your immune system is.chronic: a situation or an illness which goes on for a long time without being curable,eg HIV is a chronic condition as there is no cure; one has to live with it for a long time.combination-therapy: a combination of two or more drugs taken by a person to fightHIV infection. See ARVs and HAARTcoping: a process of adjusting to new life situation and getting back to near normal aspossible. That means regaining hope, self esteem, self confidence, planning and goingon with life, making appropriate behaviour changes and regaining hope.depression: deep sadness, helplessness, coupled with low self esteem and loss of hopethat is linked with fear of rejection, loneliness, loss of control fear of stigma, blamesuffering and death and leaving dependents without support.epidemic: Large outbreak of a disease, AIDS is an epidemicfundamental rights: your basic human rights under the Bill of Rights in theConstitution.generic drugs: drugs that replace well-known drugsHAART: stops HIV from multiplying and reduces viral load in the blood.helper T-cell: cells that are a very important part of the immune system, they fightgerms that invade the body. Helper T-cells are the main kind of cells that HIV attacks.HIV test: a test to see if there are antibodies in a persons blood. HIV anitibodies willonly be in your blood if you have HIV. It can take up to six months for the body tomake antibodies so it is important for some one who tests HIV-negative, to be testedagain after six months.HIV status: whether a person is HIV- positive or HIV-negative. You can only know thisif you take an HIV/AIDS test.

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Names used to for human sexual organs and sex acts1 Malawian names and slang for female genitaliaVagina: nanyoni; nyo; njira ya abambo; puna, kumaso; cunt**; fanny*; twat**; pussy*.Clitoris: phiri, joy-pea, passion-pea, kongo, clit, mnakanaka.2 Malawian names and slang for male genitaliaPenis: willy*, prick, cock*, dick*, boner*, mbolo, chida, abambo, nododo, Mangochi.Testicles: nuts*, balls*, bollocks*, machende, mapwala, mabativi, ingiri.3 Slang for sexual intercourse and non-penetrative sexMake love: have sex; sleep with; make babies; fuck***; screw**; shag*; bonk*.bone**.4 The sexual climax: ejaculation (male); orgasm; come, cum.5 Oral sex on male genitalia (tehnical name is falatio): blow-job; head; giving head.6 Oral sex on female genitalia (cunnilingus): going down on; tonguing.7 Anal sex most often refers to the act involving insertion of a penis into a rectumMasturbation: jerk off; pull off; wank off**; touch yourself.

The English slang names with * next to them indicate how unacceptable they are atpresent in the mainstream media. Be very careful when and where you use some ofthese words.• Write the names on the board or flip chart.• Ask the group to decide what names they want to use in the group for each organ

or sexual activity. Scientifc names or slang or a mixture.• This activity usually produces a lot of laughter and that can relieve tension!• Which of these names are you all comfortable using? Scientifc names or slang or

a mixture? These are the names we will use during the group units.

PLWHA, People living with HIV and AIDS: when you have tested positive or havedeveloped AIDS then you are said to be living with HIV and AIDSimmune system: the system in your body which uses all knids of different cells tofight infection by germs.opportunistic infections: an infection that attacks people with weaker immune systems,TB, herpes are opportunistic infectionspandemic: large outbreak that is at local level. AIDS is a pandemic in Malawiseroconvertion: occurs when there are enough HIV antibodies in your blood that canbe detected by an HIV test which imply that you are changing from being HIV negativeto HIV positive in that teststress: competing issues with limited ability to accomplish them which leads to mental,spiritual tiredness, frustration and a threatening feeling and eventual depressionT-cell count: same as the CD4 or helper T-cell count. A test to see how many T-cells arein a small amount of blood. To see how strong the immune system is. A healthy personmay have 800 to 1000 cell count.window period: the time it takes for a body to make HIV-antibodies; usually this isonly a week or so, but can be up to six months from the time of infection.the timebetween infection and the possible detection of antibodies to HIVvaccine: a medication that is normally taken as an injection to prepare your body’simmune system to recognize and protect itself against a virus or diseaseviral load: the amount of HIV in your body. The number of HIV viruses present inyour blood; a test is done to find out what your viral load is. A count higher than100,000 is considered a high viral load.

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References and further readingAmerican Dietetic Association (2004), Appetite for Life: an easy eating guide for people with HIV/AIDS,New York, UNIMEDANAMED (2006), Healing plants in the tropics (poster), Winnenden, ANAMEDBraslavsky, Cecilia et al (2002), Prospects vol XXXII: Scaling up the response to HIV/AIDS withineducation systems, Paris IBEByers, Andy et al (1994), The science teacher’s handbook, Oxford, HeinemannByers, Lillian Muyunda et al (2002), Stress: its origins and management, Lusaka, GOZCargnel, Antonietta (2006), Assistance and care for the terminally ill, Nairobi, PaulinesCCAP (2006), HIV/AIDS policy: love, care and compassion, Lilongwe, CCAPCoombe, Carol (2003), HIV and teacher education in east and Southern Africa, Bonn, INWENTDepartment of Nutrition, HIV and AIDS (2005), Malawi HIV and AIDS: Monitoring and evaluationreport 2005, Lilongwe.Domasi College of Education (2003), HIV/AIDS awareness (version 1.1), Domasi, DCEEuropean Union (2004), Living positively with HIV and AIDS, Blantyre, PakachereGoergen, Regina (2001), Healthy relationships: The questions adolescents ask most frequently, Dar esSalaam, GTZGordon, P and Crehan (1999), Gender, sexual violence and the HIV epidemic, London, Macmillan.Granich, R (2001), HIV Health and your community: A guide for action, New York.GTZ (2001), German workplace initiative: Reference manual for HIV/AIDS focal persons, Kampala.Hirt, Hans-Martin et al (2004), AIDS and natural medicine: a resource book for carers of AIDS patients,Winnenden, ANAMED.Hirt, Hans-Martin et al (2001), Natural medicine in the tropics, Winnenden, ANAMED.International HIV/AIDS Alliance (2005), Getting started in HIV prevention: a toolkit on participatorycommunity assessment and project design, Lusaka,International Organisation of Employees (2002), Employers’ handbook on HIV/AIDS: A guide for action,Geneva, IOE.Kabwila, Venencia et al (2005), Lekani Nkhanza: HIV/AIDS and Nkhanza, Trainer’s notes, GTZ-Combatinggender-based violence, Zomba, KachereKabwila, Venencia et al (2005), Employees’ handbook on HIV/AIDS, Lilongwe, GTZKurian, Manoj(2002), Religion and education for HIV/AIDS prevention: a Christian view, Paris,UNESCO/IBEKelly, Bob (2003), HIV/AIDS: A response of love, Nairobi, PaulinesMalawi Council of Churches (2004), HIV/AIDS Learner’s manual for the clergy, Lilongwe. MCC.Malawi Institute of Education (1998), A student’s handbook for population education in Malawi, Domasi,MIE Malawi Institute of Education (2004), Life skills for HIV and AIDS education for teacher training inMalawi: a training manual, Domasi, MIEMalawi Institute of Education (2006), IPTE Life skills: tutor units, Domasi, MIEMoloney, Michael (2005), Counselling for HIV/AIDS: the use of counselling skills for HIV/AIDS, Nairobi,PaulinesMuchiri, John (2002), HIV/AIDS: Breaking the silence: a guide book for pastoral caregivers, Nairobi,PaulinesMusso, Sandrine et al (2002), Religion and education for HIV/AIDS prevention: an Arab-Islamic view,Paris, UNESCO/IBENational AIDS Commission (2007), Voluntary counselling and testing of HIV, Lilongwe, NACNational AIDS Commission (2004), Malawi National HIV/AIDS strategic framework 2000-04, LilongweNational AIDS Commission (2005), Malawi HIV/AIDS National action framework (NAF), LilongweNational AIDS Commission (2004), National HIV and AIDS Policy: A call for renewed action, LilongweNational AIDS Commission (2003), Peer education at the workplace: Training manual, LilongweNGO/HIV/AIDS Code of practice project (2007), Renewing our voice: Code of good practice for NGOsresponding to HIV/AIDS, Oxford, OXFAM

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Office of the President and Cabinet (2005), HIV/AIDS Research strategy for Malawi 2005-07, LilongweOpen Society Initiative for Southern Africa (2007), Amplifying Voices: a series of digital stories (CD),Johannesberg, OSISAOrr, Neil M (2005), Positive health: Living positively with HIV, Cape town, Double Storey.Pridmore, Pat et al (2006), The role of open, distance and flexible learning in HIV/AIDS prevention..,London, DFIDSlattery, Hugh (2004), HIV/AIDS A call for action: responding as Christians, Nairobi, PaulinesSteinberg, Abraham et al (2002), Religion and education for HIV/AIDS prevention: an Jewish view, Paris,UNESCO/IBEUNAIDS (1999) AIDS and HIV infection: Information for United Nations employees and their families,Geneva.UNAIDS (2006) Global facts and figures, Geneva.UNAIDS (2006) Fact sheet on sub-Saharan Africa, Geneva.UNAIDS (2006) Report on the global AIDS epidemic, Geneva.UNDP (2002) Impact of HIV/AIDS on human resources in Malawi public sector: UNDPUNESCO (2002) Education for HIV/AIDS prevention, Paris, IBEVack, Dale le (2005), God’s golden acre: a biography of Heather Reynolds, Oxford, MonarchWorld Health Organisation (2001), Prevention of Mother to child transmission of HIV: Selection and useof Nevirapine, Technical notes, Geneva.

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Certificate

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The Mzake ndi Mzake peer educators’ manual has been developed specifically forthose people who wish to enhance their life skills by participating in AIDS preventionprogrammes as peer educators. This manual is not intended as a substitutefor medical advice. Peer group members and the communities members theyreach should regularly consult their doctors or qualified medical health practitionersin matters relating to their health, particularly in respect to symptoms and treatmentwhich require diagnosis or medical attention. It is essential that people who havebeen exposed to the risk of HIV, and their sexual partners seek proper medicaldiagnosis and treatment.

The aims of the manualThe manual was developed to equip peer educators with knowledge and lifeskills to enable them to disseminate information on STIs, HIV and AIDS anddevelop skills and attitudes in their peers that will consequently influence positivebehavioural change.

After going through the manual it is hoped that you will be able to:• explain basic facts about human sexuality, STIs and HIV and AIDS• protect yourself and others from HIV and AIDS by changing any

behaviours that put people at risk• help yourself and others in your community avoid getting infected by

STIs, HIV and developing AIDS• encourage yourself and others in your community to live positively with

HIV and AIDS.

Mzake ndi mzakeTraining manual for peer educators for HIV prevention

Documents

Mzake Ndi Mzake - HIV and AIDS Manual