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__________________________________________________________________________________ HOW TO INTEGRATE WATER, SANITATION AND HYGIENE INTO HIV PROGRAMS USAID/HIP – WHO JOINT DOCUMENT - JULY 23, 2009

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Front Cover


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WHO Library Cataloguing-in-Publication Data:

How to Integrate Water, Sanitation, and Hygiene into HIV Programs to Improve Lives / by Renuka

Bery, Julia Rosenbaum

1. HIV/AIDS. 2.Water quality. 3.Sanitation. 4.Hygiene.

ISBN 978 92 4 159841 5 (NLM classification: WA 675)

© World Health Organization 2010

All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: [email protected]).

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication.

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This document was jointly funded and produced by the United States Agency for International Development and the World Health Organization. The document was written by Renuka Bery and Julia Rosenbaum, from the USAID/Hygiene Improvement Project (HIP), funded from 2004-2010, by the USAID Bureau for Global Health, Office of Health, Infectious Diseases and Nutrition and led by the Academy for Educational Development partnering with ARD, Inc., the Manoff Group, and the IRC International Water and Sanitation Centre. HIP aims to reduce diarrheal disease prevalence in children under five through the promotion of key hygiene practices: hand washing, safe disposal of feces, and safe storage and treatment of drinking water. This document supports a key HIP task, which is to promote the integration of hygiene considerations into health and non-health programs, such as HIV/AIDS, education, and nutrition. The views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

Comment [K1]: To be

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How to Integrate Water, Sanitation, and Hygiene into HIV Programs to Improve Lives We shall not finally defeat AIDS, tuberculosis, malaria, or any other infectious diseases that plague the developing world until we have won the battle for safe drinking water, sanitation and basic health care.

Kofi Annan, former UN Secretary General

Authors

Renuka BERY and Julia ROSENBAUM

January 2010


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FOREWORD Water, Sanitation, and Hygiene (WASH) practices are essential to maintaining healthy lives, yet most countries and donors have not included WASH when developing national HIV policies and programs. The World Health Organization and the United States Agency for International Development began to explore how to integrate WASH into HIV programming and the U.S. Centers for Disease Control and Prevention, in particular, developed and studied approaches to providing safe drinking water for people living with HIV. Since 2006, WHO and USAID have supported three pioneering country applications that integrated WASH into HIV programs: in Ethiopia, Malawi and Uganda. In addition, USAID has promoted WASH-HIV integration within different US Government programs through various working groups of the President’s Emergency Plan for AIDS Response. Many different donors, organizations and programs are now considering WASH when developing HIV programs and are seeking more guidance for how to do it. This practical document is a response to requests from countries and programs for concrete guidance on how to integrate water, sanitation, and hygiene practices into HIV policies and programs. Our colleagues around the world who have reviewed this document think this is a valuable publication and we hope that you will find it useful in your work to improve the health and lives of people living with HIV. Merri Weinger Yves Chartier United States Agency for International Development World Health Organization [email protected] [email protected] www.usaid.gov www.who.int


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Acknowledgements

This new publication was conceived to integrate WASH considerations into existing national HIV policies, guidelines and handbooks and HIV programming.

This publication is derived from many different sources developed by the USAID/Hygiene Improvement Project (HIP) and others over the past three years. Kate Tulenko of the World Bank wrote the initial WASH and HIV literature review that was then adapted by Renuka Bery and Julia Rosenbaum of USAID/HIP and appears as an annex. Julie Chitty wrote several documents specifically for a USAID government audience that were adapted and included in this publication. Other efforts contributing to this publication include: Eleonore Seumo, Academy for Educational Development (AED), and Elizabeth Younger, Manoff Group, Marie Coughlan, Save the Children/US, and Julie Chitty, USAID/HIP consultant, developed WASH-HIV Integration Training Workshops from which material has been adapted and job aids included as an annex. Lonna Shafritz, AED, provided valuable research efforts and a welcome critical input in structuring the document. Orlando Hernandez, AED, developed the monitoring indicators in collaboration with the authors.

Merri Weinger, USAID and Yves Chartier, WHO have championed and supported pioneering WASH-HIV integration activities in three countries without which we could not have written this document. The communities of practice in Ethiopia and Uganda and the three country teams that have pioneered WASH-HIV integration include: Antonia Powell, CRS, and her team in Malawi; Mesfin Tesfay, AED, and the Water and Sanitation Program in Ethiopia; and Lucy Korukiiku, AED, and the Plan International team in Uganda.

Careful review and informed comments were provided from the following people: Sandra Callier, AED; Julie Chitty, USAID/HIP consultant; Libertad Gonzalez, International Red Cross and Red Crescent Society; Ben Harvey, International Rescue Committee; Orlando Hernandez, AED; Patricia Mantey, AED; Alana Potter, International Water and Sanitation Centre, Netherlands; Antonia Powell, Catholic Relief Services; Robert Quick, Centers for Disease Control and Prevention; Shannon Senefeld, Catholic Relief Services; Foyeke Tolani, Oxfam UK; Dennis Warner, Catholic Relief Services, Elizabeth Younger, Manoff Group.

The development of this document was coordinated and edited by Merri Weinger, USAID; Anne Kerisel, WHO consultant; and Yves Chartier, WHO.


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List of Acronyms AFASS Acceptable, feasible, affordable, sustainable and safe

ART Antiretroviral therapy

ARV Antiretroviral

BCP Basic Preventive Care Package

CBO Community-based organization

CDC Centers for Disease Control and Prevention

COP Community of Practice

CT Counseling and testing

DALY Disability-adjusted Life Years

EPI Expanded program on immunization

HBC Home-based care

HIP Hygiene Improvement Project

HIV/AIDS Human Immunodeficiency Virus/Acquired ImmunoDeficiency Syndrome

NaDCC Sodium dichloroisocyanurate

NGO Non-governmental organization

OI Opportunistic infections

OSSA Organization for Social Services for AIDS

OVC Orphans and vulnerable children

PEPFAR President’s Emergency Plan for AIDS Relief

PLWHA Persons living with HIV

PMTCT Prevention of mother to child transmission of HIV

PSI Population Services International

SODIS Solar disinfection

SWS Safe water system

UN United Nations

UNICEF United Nations Children’s Fund

US United States

USAID United States Agency for International Development

UV Ultraviolet

WASH Water, sanitation, and Hygiene

WHO World Health Organization

WSP Water and Sanitation Program, World Bank


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Table of Contents

I. INTRODUCTION

II. REVIEW of CURRENT EVIDENCE ON WHY WASH MATTERS

III. EFFECTIVE INTEGRATION APPROACHES

IV. PRIORITY WASH PRACTICES to INTEGRATE into NATIONAL PROGRAMS

V. A RECOMMENDED APPROACH to IMPROVE WASH PRACTICES

VI. NATIONAL HIV/AIDS POLICY and GUIDELINES

1. HOW to INTEGRATE WASH into GLOBAL HIV/AIDS POLICY and GUIDANCE

2. HOW to INTEGRATE WASH into COUNTRY HIV/AIDS POLICY and GUIDANCE

3. ASSURING HIV/AIDS POLICY/GUIDELINES SUPPORT WASH

VII. PROGRAM APPROACHES for WASH-HIV INTEGRATION

VIII. COORDINATION with WATER and SANITATION SECTORS

IX. MONITORING and EVALUATION

X. CASE STUDIES

XI. CONCLUSION

ANNEXES 1. WASH Competencies for home-based care workers 2. Small doable actions chart 3. Job aids 4. Things to Get the Community Talking about and Acting against Stigma 5. Full literature review

BIBLIOGRAPHY

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I. INTRODUCTION A small but growing body of literature has identified linkages between water, sanitation, and hygiene (WASH) and HIV/AIDS. Opportunistic infections, including diarrhea and skin diseases, negatively impact the quality of life of people living with HIV and can speed the progression to AIDS. A correlation exists between opportunistic infection frequency and water and sanitation services available to households and the hygiene practices of household members (Hillbrunner 2007). Further evidence suggests that diarrheal disease reduces the absorption of antiretroviral medicines and essential nutrients further exacerbating HIV and AIDS consequences (Bushen 2004). Hand washing, sanitation, and water treatment and safe storage have each been proven to reduce diarrhea rates by 30 to 40 percent (Fewtrell 2005; Curtis 2003, Clasen 2007). Ensuring proper WASH practices benefits the entire HIV-affected household by keeping all family members stronger, better nourished, and able to contribute to the household. In addition, such good practices also prevent the caregivers and other household members from contracting water-borne diarrheal diseases, which, in turn, helps to keep households economically viable and generally resilient for longer periods of time. WASH practices benefit all people. The main reason for emphasizing WASH in the HIV context is because these practices can have a multiplier effect on the health status of their beneficiaries. Further, integrating WASH into HIV programs provides additional opportunity and resources to improve overall public health outcomes. The objective of this document is to facilitate the integration of water (access and quality), sanitation (safe feces handling and disposal), and hygiene practices into official HIV guidelines and standards and HIV programming. The programming component of the document provides specific guidance on what, where, and how to integrate these WASH practices into national and country HIV programs. Organized as follows, the document—

• outlines why WASH should be included in HIV programs

• details which WASH practices to include in HIV programs

• identifies how to include WASH in HIV programs supported by case examples from various countries

• provides concrete recommendations for country programs and implementers on what and how they can begin to integrate WASH into HIV policies and programs

The annexes provide practical tools that can be adapted and more detailed descriptions of the available evidence. The prime target audiences for this document are program managers and implementers in national governments, specifically directors of HIV care and support programs, under the Ministry of Health and National AIDS Commissions. This document also targets program managers and implementers within NGOs who manage HIV and AIDS programs in various areas including prevention of mother-to-child transmission of HIV (PMTCT), care and treatment, nutrition, pediatrics, and orphans and vulnerable children (OVC). The secondary audience is water and sanitation sector program planners who can use this document to begin the process of integrating HIV considerations into water and sanitation programming.

II. SUMMARY of CURRENT EVIDENCE on WHY WASH MATTERS


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Diarrhea rates are 2-6 times higher in HIV-infected people and acute and persistent diarrhea rates are double in HIV-infected populations (Lule 2005). The immuno-compromised status of PLWHAs makes them more susceptible to opportunistic infections including those related to water, sanitation, and hygiene—diarrhea and skin diseases. A full literature review on WASH and HIV is available in Annex 5. Water Access Access to safe water is considered a basic human need and in most countries a basic human right (Kamminga 2005) for all people. Yet this basic right remains unrealized for a large majority of people in developing countries, especially in rural communities. The negative impact of low access to necessary quantities of water, to water of reasonable quality, to basic sanitation and hygiene are magnified for HIV-infected, immuno-compromised individuals. Further, HIV-infected individuals require more water for bathing, laundry, and hand washing (Ngwengya 2006). The added burden affects not only the PLWHA, but the entire affected family, increasing risk of diarrheal disease and lost productivity. Labor saving technologies such as longer pump handles or higher platforms should be adopted to make gathering water easier especially for weaker individuals and children. Water Quantity

Meeting the water and sanitation needs of PLWHA underscores some of the biggest challenges in basic access. The people with the greatest needs often are the most disenfranchised and vulnerable and have the fewest resources available to solve problems in sustainable ways. Issues of water supply and sanitation must be addressed to meet the increasingly complex needs of PLWHA households. The World Health Organization recommends a minimum of 20 liters of water per person per day to cover consumption, food preparation, cleaning, laundering, and personal hygiene. For a person living with HIV, the needs can increase significantly to over 100 liters per day. Table 1 below illustrates the potential water needs of a person living with HIV (Ngwenya 2006, Molose 2007, Water and Sanitation Program 2007).

Table 1. Basic Water Needs of Person Living with HIV and AIDS

Basic water for drinking, food preparation, laundry, and personal hygiene

20 liters per day (recommended minimum)

Water intake for taking anti-retroviral medications Additional 1.5 liters per day

Water for replacement feeding of infants less than 6 months

Minimum 1 liter per day (without water needed for cleaning)

Water for replacement feeding of infants greater than 6 months

2 liters per day (without water needed for cleaning)

Cleaning PLWHA and laundering clothes and bedding (daily during bouts of diarrhea)

20-80 liters per day

Total Approximately 100 liters per day

Water Quality While piped water is available in some areas, in many settings it is untreated or often contaminated between the source and the home. Treatment and safe storage of drinking water at the point of use


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(POU) has been shown to reduce the risk of diarrheal disease by between 30 to 40 percent (USAID 2004). The Lule study in Uganda showed that the use of a simple, home-based Safe Water System (Lantana 2003) consisting of a chlorine solution (e.g. WaterGuard) to disinfect water and storage in a container with a narrow mouth, lid, and a spigot reduced the frequency (by over 30 percent) and severity of diarrhea in PLWHA (Lule 2005). Safe water (treated water that is safely stored) in combination with a locally available antibiotic prophylaxis (Cotrimoxazole) reduced diarrhea episodes by 67 percent in PLWHA. Evidence is now conclusive that simple, low-cost strategies for treating and safely storing water at the household level can greatly improve the microbial quality of water and reduce diarrheal disease comparable to outcomes achieved by hand washing and safe feces handling and disposal (Sobsey 2002). Several technologies are viable for treating water in the home, including chlorination, storage in an appropriate vessel, various types of filters, proper boiling, solar disinfection (SODIS) using heat and UV radiation, and combined chemical coagulation, flocculation, and disinfection. Safe Feces Handling and Disposal Safe feces handling and disposal has been shown to reduce the risk of diarrheal disease by 30 percent or more (Fewtrell 2005). Moreover, PLWHA are more susceptible to contracting diarrhea when any fecal matter is present in the environment. Over half of PLWHA suffer from chronic diseases (Curtis 2003) so having a clean, safe and easily accessible latrine is an essential WASH service for PLWHA and all household members should handle and dispose of feces safely. This means encouraging all family members over the age of five to defecate in a hygienic latrine, supporting young children (three to five years) to defecate in a hygienic latrine, potty, or fixed place, and training caregivers to dispose of very young children’s feces hygienically in a latrine. PLWHA who do not have indoor plumbing and are too sick or too weak to use a latrine may need special equipment or supports. For example, appropriate bedside commodes or bedpans may help those who are too sick to go to a latrine, and squatting poles or stools may support a weak person using a conventional latrine. These technologies and approaches are being tested with weak and bedbound PLWHA by HIP in project sites in Ethiopia and Uganda and by various NGOs in Malawi. In a recent field trial in Uganda, presence of a latrine in a compound was associated with fewer episodes and fewer days of diarrhea in PLWHA (Lule 2005). Additionally, as diarrhea becomes progressively worse, keeping a home clean of feces can be difficult. This may require new approaches and renewed vigilance in cleaning the home. For example, promoting commodes, bedpans, developing washable mats, or placing cloth that can be easily washed over straw beds will help reduce exposure to pathogens from diarrhea. Though feces itself presents little risk of HIV infection (CDC 2007a), the feces of end-stage AIDS is likely to have increased amounts of blood and white blood cells carrying the HIV virus and other infections that could affect household members. To the extent possible, caregivers should use gloves or plastic bags to protect their hands when handling feces to prevent the spread of diarrhea causing pathogens. Optimal Hand Washing Washing hands with soap or an abrasive substance such as ash prevents diarrhea effectively when done properly and at critical times. A recent meta-analysis of hand washing studies conducted in developing countries concluded that hand washing can reduce the risk of diarrhea in the general population by 42 to 44 percent (Curtis 2003). Hands should be washed before preparing food,


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before feeding a child or eating, after defecating, after cleaning a baby or changing a diaper, and before and after cleaning a person who is chronically ill. Proper technique includes using soap, or an effective substitute such as ash, rubbing hands together at least three times, rinsing under running water, and then drying them with a clean cloth or by shaking them in the air. A study in Uganda demonstrated that the presence of soap in the house was associated with fewer days with diarrhea (Lule 2005), inferring that washing hands reduces diarrhea. Proper hand washing at critical times will help prolong and improve the quality of life of PLWHA and will help ensure the health and safety of family members and caregivers. Menstruation Management Menstrual blood is not discussed in the literature and only the grey (unpublished) literature and anecdotal conversations between scientists and program managers have linked hygiene, disease, and menstrual blood in HIV positive women. Before anti-retroviral therapy became prevalent, women often stopped menstruating once the HIV virus had advanced. However, now that ART is more widely used even in resource poor countries, women continue menstruation, which poses a hygiene challenge and possible risk of HIV transmission to caregivers. Menstrual blood of HIV positive women contains the HIV virus, sometimes at a higher viral load than regular blood (Reichelderfer 2000). Thus, HIV-positive women and their caregivers must prevent HIV virus transmission from menstrual blood by practicing universal precautions. No link between menstrual blood and diarrhea-causing pathogens exists. While no evidence describes increased water needs for menstruating women, it is reasonable to conclude that increased quantities of water are needed to care for the woman’s personal hygiene and to clean blood-soiled rags and bed sheets of bedbound women. Food Hygiene Global estimations show that each year 1.8 million people die as a result of diarrheal diseases and most of these cases can be attributed to contaminated food or water. Raw fruits and vegetables and undercooked or spoiled meat, poultry, fish or eggs are often contaminated with microorganisms that cause diarrhea (WHO 2006a). Proper food handling and storage, combined with food and water management, is vital for maintaining a hygienic atmosphere and preventing illness. A breastfeeding study in Kisumu, Kenya illustrated that diarrhea is not always caused by poor quality water, but could also be caused by unhygienic food and greater exposure to feces in the environment (Harris 2009). Studies show that whether weaning foods are contaminated depends largely on the food type, storage time, ambient storage temperature, the storage method, and the temperature reached on re-warming before feeding (Lantana 2003). Personal and Environmental Cleanliness Ample evidence exists that improved body hygiene (daily bathing) and regular laundering of clothing and bed linen decrease skin infections and skin parasites in the general population, and are even more important for people with compromised immune systems. Ensuring a hygienic environment (in the facility, school, and home) is also essential to infection control and can lead to reduced diarrhea in HIV-affected households. The chart below describes how specific WASH activities will reduce diarrhea, respiratory illnesses and skin and eye diseases to support outcomes in different care and treatment programs.


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Table 2: WASH Actions that Support Different HIV Programs

Prevention of Mother-to-Child-Transmission of HIV (PMTCT)

• Use safe water, sanitation and hygiene practices during delivery.

• Ensure safe infant feeding: use treated water for replacement feeding and complementary feeding; wash hands with soap before preparing food or feeding.

Adult Care and Treatment

• Treat and safely store water for drinking.

• Wash hands with soap.

• Promote hygienic latrines and labor saving water and sanitation technologies or modifications for the mobility impaired.

Pediatric Care and Treatment

• Use treated water for drinking, feeding, and safe reconstitution of medicines.


• Safely handle and dispose of children’s nappies/feces; promote a hygienic potty or latrine, etc.).

Nutritional Care and Support

• Use treated water for drinking, food preparation, and taking medicines.


• Prepare food safely.

Orphans and Vulnerable Children (OVC)

• Treat and safely store drinking water for children in household.


• Promote hygienic latrine use.

• Prepare food safely.

Counseling and Testing

Counsel clients to—


• Treat and safely store drinking water.

• Use a latrine and safely dispose of feces.

• Wash surfaces used to prepare and eat foods.

Special Concerns around Water and Sanitation

Water and sanitation issues are important to all people in all contexts to keep the whole family safe from diarrheal diseases. Water and sanitation issues affect infant and young child health and place a particular burden on women and girls, especially in an HIV context. The key issues are described below and though may not be specifically related to HIV, are even more important in the HIV context where preventing diarrhea in the whole family reduces burdens on care givers and keeps HIV-positive individuals healthier. Many common infections that cause diarrhea can spread from one person to another when people defecate in the open air. Intestinal worms, which are transmitted when people ingest fecal matter in unclean water or step in it barefooted, divert around one-third of the food a child consumes and impair a child’s health, nutrition and cognitive development. Malnutrition is a contributing factor to over 50 percent of childhood illness (United Nations Water 2008). Burden on Women and Girls. Water issues impact on women and girls differently than men and boys. Across many countries, girls reportedly spend up to three hours each day fetching water and cleaning latrines. Women and girls are the primary caregivers for the chronically ill, and women now compose the majority of PLWHA in many countries. Infants and Young Children. Diarrhea accounts for nearly 20 percent of child deaths worldwide, largely resulting from unsafe drinking water, inadequate sanitation, and poor hygiene (Morris 2003). Although some cultures do not consider infant feces infectious, when contaminated with pathogens


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it is as infectious as adult feces and must be disposed of safely. The youngest children are much more likely than adults to become ill from eating contaminated food or drinking contaminated water. Therefore, breast milk is the best and safest source of nutrition for infants; however, infants are at risk for mother-to-child transmission of HIV through breast milk when the mother is infected. And yet at 7 months, the risk of death due to not breastfeeding is equal or greater than the risk of HIV transmission from breastfeeding (Thior 2006). In many resource poor settings, evidence indicates and UN agencies recommend exclusive breastfeeding for six months because it is more realistic than meeting the international criteria for acceptable, feasible, affordable, sustainable, and safe replacement feeding (e.g. breast milk substitutes). However, circumstances that may prevent an infant from being breastfed include death of the mother, severe illness in the mother, or the inability or lack of desire by the mother to breastfeed. See section 6.7 on preparing replacement feeding. School Children. African countries typically recommend 1 toilet per 30 students; however, some schools have a ratio of 200 students to 1 toilet or no toilets at all (Rockefeller Foundation). In Nigeria, the national toilet-to-pupil ratio is as low as one latrine to 292 students while the national target ratio of one latrine to 40 pupils has been set and is being pursued (UNICEF/IRC 2005). Despite the challenges, simple, high-impact interventions exist to prevent diarrhea and worm infestation in children. For example, a Kenyan school reduced diarrheal episodes in school children by promoting hand washing and treating and safely storing drinking water at the point of use, despite the fact that the water source was an unprotected shallow well (O’Reilly 2007). Access to hygienic toilets can reduce child diarrheal deaths by more than 30 percent and prevent some worm infestations in children. Though poverty is still a leading factor in determining school attendance, young women attending school have special needs that are now becoming better understood. UNICEF estimates that about 1 in 10 African school-age girls do not attend school during menstruation, or drop out when puberty starts because schools lack clean and private sanitation facilities. Regular absence from school for several days each month can, even in the short term, have a negative impact on a girl’s learning and therefore on her academic performance. For girls who cannot afford to buy washing soap, cleaning uniforms or school clothes regularly may not be easy and may prevent many girls from attending school. However, simple approaches such as adequate gender-specific latrines can ensure that children, especially girls, are not excluded from fully participating in the educational system because of their maturing bodies (Rockefeller Foundation). Orphans and Vulnerable Children. In the HIV context, many children are affected by HIV—either when their parents die or because they are living in households with HIV-positive individuals—and have greater responsibilities and/or less access to basic needs. Targeting programs that provide services to orphans and vulnerable children with WASH messages and practices helps prevent the spread of pathogens that cause diarrhea and skin and eye diseases. Stigma against HIV and AIDS is a hidden epidemic as large or larger than the HIV epidemic itself. PLWHA face different types of discrimination that affects housing, employment, social interactions, childcare, access to medical services and water and sanitation (Magrath 2006). The WASH needs of PLWHA are greater than those without HIV, yet PLWHA often have less access to water and sanitation facilities than their neighbors because of sickness or discrimination (Magrath 2006). PLWHA and their families have been subjected to discrimination if a person’s positive status is known; sometimes PLWHA are unable to use communal latrines (Magrath 2006).


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In some communities, a person with diarrhea is considered to be HIV positive whether that person’s status is known or not. Sometimes PLWHA are forbidden to use communal latrines because users fear HIV can be transmitted through latrines. Indeed, many clients go to distant cities to get their medicines to avoid being recognized at a local health clinic (OSSA/Bahir Dar; personal communication 2009). Special equipment or new technologies that target HIV programs specifically while addressing real PLWHA needs can inadvertently contribute to stigma and discrimination. In Ethiopia, some PLWHA learned about using a water-saving hand washing device called a tippy tap from home-based care workers working for an HIV support organization. While many clients adopted the tippy tap, other clients said making a tippy tap would identify them to their neighbors as HIV positive (Tesfagoh/Bahir Dar, personal communication 2009). In Uganda, one program gave a water container with a spigot along with a hypochlorite solution for clients to treat their water. Anecdotal evidence indicates that because the water container was not local, everyone in the community knew that people with those water containers were HIV positive.

III. EFFECTIVE INTEGRATION APPROACHES Safe water, sanitation, and hygiene improvements clearly have the potential to improve the lives of people living with HIV/AIDS and their affected families, based on solid efficacy studies. But because this area of integration is just emerging as a programming option, very little data from rigorous program evaluations exist to guide which programming approaches are most effective. Over the next few years, relevant and vital field data will emerge on programming techniques as integration efforts are more systematically evaluated. As mentioned earlier, very little evidence exists supporting the integration of WASH into HIV programming. The box below outlines the available evidence from program evaluations of what is effective and cost effective. Current evidence indicates that— Using a Safe Water System reduces diarrhea and death in high HIV incidence areas. A study in western Kenya (in a general population with high HIV rates) noted that 43 percent fewer deaths occurred using the Safe Water System or PuR (Crump 2005). The study found that the presence of residual chlorine correlated more closely with risk reduction than did a good container. In large, uncovered clay pots, where drinking water is kept for up to 3 days, chlorine disappears in one day. Drinking safe water, presence of soap, and presence of a latrine mean fewer and shorter bouts of diarrhea in people living with HIV and their affected families and fewer missed days of work and school. People who drank water outside the home saw fewer benefits than those consistently drinking treated water. An evaluation of a basic care package in Uganda demonstrated that Safe Water System use must be consistent. In general, clinic-based distribution of SWS commodities has high uptake while community-based promotion shows mixed results (Lule 2005). Softening food for PLWHA with clean water helps PLWHA ingest food. In advanced


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stages of AIDS, PLWHA often have mouth sores that make eating difficult. Documented evidence has shown that softening food with water helps PLWHA ingest the food, which is important for maintaining good nutrition (Kamminga 2005, WELL Briefing Note 5 2004). Focusing on water and sanitation matters, but is not enough. A breastfeeding study conducted by the Centers for Disease Control in Kenya illustrated that diarrhea is not always caused by poor water, but perhaps also by contaminated food and greater exposure to fecal pathogens in the environment (Harris 2009). Addressing WASH needs of PLWHA households can create stigma/ discrimination. WASH inputs that target PLWHA households directly can create stigma. Organizations are now designing special WASH considerations to benefit the entire community. Consider alternative latrine designs to accommodate weaker individuals who may need assistance: the less mobile, the disabled, the elderly, children, and PLWHA. WaterAid now discusses water and sanitation needs in terms of inclusiveness since often people with lower social status— whether disabled, PLWHA, elderly, or women—often have decreased access yet increased needs (Magrath 2006). Inclusive design means offering a range of options, exploring cost implications, and not targeting a specific audience but considering everyone’s needs. Focusing on WASH as part of HIV programs is cost effective. A reanalysis of the much quoted safe water study in Uganda (Lule 2005, cost data reanalyzed by Mermin 2005) estimated that WASH interventions would cost approximately the same as the widely accepted and cost effective expanded program on immunization (tuberculosis, diphtheria, pertussis, tetanus, polio, measles). By comparison, the cost for ART therapy in Africa is calculated to be almost 400 times this amount. (See cost effectiveness section in Annex 4.) Much more will soon be known that will include emerging programmatic evaluations that explore the most effect approaches for integrating WASH into HIV programs to change key practices and improve health outcomes. The guidance that follows draws both on available evidence and what is reasonable to infer as effective based on available data for making decisions.

IV. PRIORITY WASH PRACTICES to INTEGRATE into NATIONAL HIV/AIDS PROGRAMS

1. Treat Drinking Water Water programs should provide potable water (chlorinated piped water, covered well) and help ensure that transport and storage practices are safe. However, even where a reliable source of safe water is available, it is often difficult to assure safe transport and storage practices. Thus, HIV programs should support treating drinking water at the point of use for HIV-infected persons and promote safe storage practices listed in the next section. While use of household bleach can be effective in treating drinking water, it is very difficult to recommend effective dosage because the bleach concentration varies both within and across brands. Adding to this difficulty is lack of a commonly available standard measure to use as the dosage


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measurement. Instead, one of the following four strategies could be considered for treating water. The ideal treatment is the first below because the chlorine residual lasts for several days. 1.1. Use a chlorine product to treat water and an appropriate vessel for storing treated water safely. Chlorination is the most widely-practiced means of water treatment at community level, apart from boiling. Chlorine treats water for up to one week (7 days) if stored in a tightly closed container; if drinking water is not in an enclosed storage container, it should be retreated after 24 hours. The chlorine source can be sodium hypochlorite, chlorinated lime, or chlorine tablets that are usually available and affordable. Three options with a proven health impact:

1.1.1 Safe Water System (SWS): The Safe Water System has three steps: chlorine treatment, a safe storage container with a spigot, and behavior change techniques. Available in 30 countries, this sodium hypochlorite disinfectant is easy to use and disseminate. It may have residual taste/smell. Turbid water can be treated with a double dose of chlorine solution. To increase user acceptability, turbid water can be filtered through a cloth first. This approach includes an improved storage vessel/container with a narrow mouth, lid, and a tap to prevent recontamination. If improved storage vessels are not available locally, two alternatives are jerry cans with a lid or tightly covered buckets. The most important barrier to infection is the chlorine residual. 1.1.2 Flocculant/disinfectant powder (PuR): This powder is especially effective in removing the vast majority of bacteria, viruses and protozoa in turbid waters, e.g., water drawn from a muddy stream. Using PuR involves a multi-step process in which the powder is added to an open bucket containing10 liters of water. After stirring for 5 minutes, the solid particles settle to the bottom of the bucket. The water is then strained through a cotton cloth into a second container and after 20 minutes is safe for drinking. Available in 10 countries, this product is more expensive and requires more steps (and training and supervision) to treat water but also effectively clarifies murky water and removes heavy contaminants. The Red Cross recommends using this product only when water is muddy and other methods are not available. Treated water should be properly stored as described below.

1.1.3 NaDCC tablets (Aquatabs). NaDCC (sodium dichloroisocyanurate) is an alternate chlorine source that is used in the Safe Water System and has benefits such as a longer shelf life, resistance to degradation from sunlight, single use packaging, and low weight in distribution although it is higher than in chlorine solution. Initially used primarily in emergencies, NaDCC is increasingly being used for routine drinking water treatment in urban areas, although it may be more expensive than some chlorine solutions. Treated water should be properly stored as described below.

1.2. Use the sun to treat water (SODIS) and store in an appropriate vessel. SODIS is practiced in 20 countries and uses UV-A radiation from the sun to treat water. This method does not affect color, taste or odor of the water. Water must be clear to use this method. SODIS requires transparent, one-to-two-liter plastic bottles, and a longer period of time for effective treatment (6 hours bright sun or 2 cloudy days). Treated water should be properly stored as described below. Treating large quantities of water is difficult, acquiring a sufficient number of plastic bottles is challenging in some locations, treatment is not effective in turbid water, and the warm temperature of the water can be a deterrent to consumers.


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1.3. Boil water and store in an appropriate vessel. The World Health Organization and the Centers for Disease Control recommend bringing water to a rolling boil (the point where large bubbles begin to come to the top) to kill pathogens. Boiling is costly; typically requires biomass fuels that can contribute to climate change and deforestation; can put small children at risk of burns; and boiled water is subject to recontamination. Boiled water should be properly stored as described below.

1.4. Filter water and store in an appropriate vessel. Several different filtration methods exist to treat water for drinking. The ceramic filter is a proven method that improves microbiological content and decreases diarrhea. Most ceramic filter household water treatment and storage systems are based on a filter/receptacle model. To use the ceramic filters, families fill the top receptacle or the ceramic filter itself with water, which flows through the ceramic filter or filters into a storage receptacle. The BioSand Filter is widely used and has been shown to reduce the risk of diarrhea even though it does not disinfect water as thoroughly as some other technologies. The BioSand filter is a slow-sand filter adapted for use in the home. Treated water should be properly stored as described below. 2. Safely Store Treated Drinking Water

Storing water is critical and requires a vessel/container with a narrow mouth and lid to prevent re-contaminating treated water. A tap is ideal, but often not feasible. If such a vessel is not available, alternatives such as dippers can be substituted for the tap. Ideal Option: Store treated water in a closed container with a tap or spigot. Acceptable options: 2.1. Store water in a narrow neck container or jerry can with a lid

2.2. Store water in a bucket with tightly fitting lid and either pour water from container or

use a clean ladle to serve water Whatever type of container is used, it is important to keep hands away from the mouth of the container and to store the container on a shelf away from babies and animals. Programs should encourage proper water treatment and storage practices by considering affordability and ease of use, and ensure timely replenishment of water treatment products to avoid stock-outs and opportunities for contamination. HIV programs should consider linking with the water sector to improve the number of safe water supply points that are accessible and in close proximity to where they are needed.

Reducing stigma must always be a consideration when promoting new WASH actions. Lessons learned indicate that locally available materials and products should be used wherever possible so PLWHA are not immediately recognized because they are using a particular technology or apparatus that is not common in the area. 3. Promote Hand Washing


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Given the overwhelming evidence in support of hand washing behaviors, HIV programs should promote hand washing with soap at critical times and with proper technique. If soap is not available, ash is an acceptable substitute. Program strategies can include: 3.1. Provide guidance and training on washing hands at critical times and with proper technique across all HIV programs (e.g. home, community, school and facility-based programs). 3.1.1 Programs should prioritize washing hands with soap (or ash) at five critical times: (1) after

defecation, (2) before preparing food, (3) before eating food, breastfeeding or feeding children or PLWHA, (4) after cleaning a child’s or PLWHA feces and (5) before and after caring for clients.

3.1.2 Programs should encourage proper hand washing technique, using the following steps: (1) wet

hands, under running water, (2) rub hands together for at least 20 seconds with soap (or soap-substitute, such as ash), (3) rinse hands under running (poured) water, (4) dry hands thoroughly by shaking them in the air. Towels are not recommended because they are too often contaminated, but under certain conditions programs could add an alternative suggestion to dry “with a clean, dry towel, preferably a paper towel.”

3.2. Place hand washing stations with needed supplies (soap or ash and water) in program sites in facilities, community care points, schools, and in the household to improve hand washing practice. When possible, place hand washing station in convenient proximity to where the washing needs to take place, by the bedside, at the cooking site, near latrines. These facilitate hand washing and serve as a reminder to wash hands. Programs in water scarce situations or without running water should consider using a “tippy-tap”, a simple plastic jug, gourd or local receptacle with a tap or opening that provides a slow, steady stream of water for washing hands with very little water. (See Appendix 3: Making a Tippy-tap.) A bucket with a tap or a bucket and pitcher can also be used to wash hands when no running water is available.

4. Safely Handle and Dispose of Feces

Typically HIV/AIDS programs have not included constructing simple, on-site waste disposal systems like latrines, nor supported simple methods to safely handle and dispose of feces in clinical settings and in households that will benefit PLWHA and their families. Programs can introduce the following important interventions to keep clients clean and to reduce feces in the environment. Studies show that HIV is not transmitted through blood in feces, however, many other pathogens are present and it is a good precaution to use gloves or plastic bags to avoid direct contact with feces and to prevent spreading illnesses. While this might be an ideal precaution, it is very rarely feasible in a resource-poor setting. The guidance below mentions using gloves or plastic bags recognizing that this may not be possible.

4.1 For the client who has control of bowel function and is mobile: 4.1.1 Upgrade existing pit latrines to meet minimum standards, including a washable sanitation platform and a cover to

the pit. (See Annex 3: Minimum Standards Ladder Diagram)

4.1.2 Clear the path to the latrine; remove obstacles like stones and branches and fill holes in path.

4.1.3 Sensitize and train on how to maintain existing latrines hygienically. Priority strategies include promoting latrine cleanliness, use, maintenance, and deodorization. A latrine must always be kept free of


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feces on the platform, seat, or other surfaces; however, no special cleaning is needed after PLWHA use the latrine. A scoop of ash or lime after defecation helps with odor and to deter flies.

4.1.4 If a latrine is not available, consider options for sharing a latrine or toilet with others in the community.

Leverage support from donors, NGOs, and local government to build a latrine or ensure adequate access to latrines. In the interim, collect and bury or dispose of feces away from the facility, clinic or home and away from where animals can dig it up.

4.2 For the client who has control of bowel function with mobility problems 4.2.1 If a client is too weak to walk unassisted to an existing latrine, install assistive devices (poles, ropes

or stools) inside and/or outside the latrine to support a person to get to and use the latrine. (See Annex 3: Latrine Designs)

4.2.2 Ensure access to locally available, simple bedside commodes and/or bedpans that PLWHA can use to

defecate in the bed or house and that caregivers can empty. Where supplies are not accessible, programs can use locally available materials to create commodes and bedpans that include buckets, plastic bowls or jerry cans cut-in-half, gourds, ceramic pots, modified chairs and stools, or other secure collection materials.

4.2.3 Encourage proper cleaning of bedside commodes/bedpans as follows. 1. Put a handful of ash in

the commode/bedpan before use to prevent solids from sticking and a handful of ash on top of the solids to prevent odors. 2. Dispose of feces in a latrine or toilet or bury it. 3. Wipe away any feces from the client’s bottom with a disposable cloth or paper wiping front to back. 4. Pour water and bleach solution (9 parts water to 1 part bleach) into the bedpan and let sit for about 20 minutes. 5. Dump bleach solution into a hole (not the latrine) and let bedpan air dry. Wash hands with soap and water. (See Annex 3: Bedpan/Commode Designs.)

4.2.4 Protect the skin, clothing, sheets, and mattress of PLWHA and children from becoming soiled with feces

to reduce the risk of spreading diarrhea causing pathogens to other household members and to prevent skin rashes, bed sores and infection. Strategies such as placing a plastic sheet covered by paper or a cloth under the client’s buttocks are very simple and cost-effective measures that can ease the care giving burden. (See Annex 3: Turning Bedbound Client in Bed.)

4.2.5 Wash soiled clothes and bed linens. First soak the soiled clothes and bed linens for 20 minutes

in soapy water. Then wash them with soap and water. Dry in the sun. (See Annex 3: Washing Clothes and Bed Linens)

4.2.6 If PLWHA are treated differently from other community or household members and are

barred from using a latrine or flush toilet, conduct anti-stigma and educational opportunities for people to understand that feces itself does not spread HIV. (See Annex 4 for anti-stigma activities and references.)

4.2.7 Wash hands after defecation, as specified in the hand washing section above. (See Annex 3:

Hand Washing Instructions.)


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4.3 For clients who are bedbound

4.3.1 Place a bedpan under the client’s buttocks. If a bedpan is unavailable, create a bedpan by

cutting a smooth opening in the side of a plastic 20-liter container or find local clay or

plastic bowls to use instead. 1. Put a handful of ash in the bedpan before use to prevent

solids from sticking and to prevent odors. 2. Immediately dispose of feces in a latrine or

toilet or bury it. 3. Wipe away any solids with a disposable cloth or paper. 4. Pour water

and dilute bleach solution (9 parts water to 1 part bleach) into potty and let sit for about

20 minutes. 5. Dump bleach solution into a hole (not the latrine) and let bedpan air dry.

6. Wash hands with soap and water. (See Annex 3: Feces Disposal Diagram; Using a

Bedpan.)

4.3.2 Use available materials (linen, nappies, leaves) to assist in hygienic handling of feces or items

soiled with feces. This may include gloves or using polythene (plastic) bags to hold

soiled linen and feces if gloves are not available.

4.3.3 Safely dispose of non-reusable materials used for cleansing feces (burn, bury or discard into a

pit latrine).

4.3.4 Wash hands after handling feces or soiled linen, as specified in section 3.1.2 and 4.2.5.

4.4 For clients and children who cannot control bowel function:

4.4.1 Use and safely dispose of diapers (nappies) or properly clean rags used to contain feces of those

who have no bowel control function. Follow steps in 4.3.1 for safely disposing feces and

steps in 4.2.5 to safely wash soiled clothes/linens.

4.4.2 Provide small children with potties or partially cover the latrine hole with a small board so children

will not fall in.

5. Menstrual Management Sanitary pads, towels, rags, banana fibers or cloth soaked with menstrual blood cannot be thrown or discarded just anywhere. Soiled materials that will be reused must be cleaned using a specific process. Blood-soaked materials that cannot be reused must be completely burned or discarded in a pit latrine. Necessary steps for menstrual management include: 5.1 Soak up blood with sanitary pads, rags, or other local materials used.

5.2 Do not store soiled rags for more than a couple of hours. Bloody rags will start to

smell and will attract insects and flies.

5.3 Keep clean rags, washing water, and a container for soiled rags near the woman if she is bed bound.


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5.4 Caregivers should always protect the hands with gloves or plastic bags when touching someone else’s blood and always wash hands with soap or ash after handling or disposing of materials with menstrual blood to prevent virus transmission. This is critical even after gloves or bags are used.

5.5 Throw away blood-soaked materials that cannot be reused (sanitary pads, banana fibers, etc) in a pit latrine or in an urban setting with shared latrines, burn these materials completely.

5.6 Wash soiled rags using the following process— 5.6.1 Make a dilute bleach solution (9 parts cold water (to prevent stains), 1 part bleach). Leave

blood-soaked rags in this solution for 20 minutes. 5.6.2 If no bleach solution is available, soak the rags in soapy water for 20 minutes. 5.6.3 Rinse with soap and water and again with water only. 5.6.4 Hang rags in the sun to dry. 5.6.5 Keep in a dry place for future use.

6. Safely Prepare, Handle, and Store Food Preventing diarrhea requires sanitary food preparation, handling and storage. Below are listed ideal recommendations adapted from World Health Organization and Centers for Disease Control guidance (WHO 2006a). While these recommendations describe optimal practices, they may not be feasible in resource poor contexts. Local adaptations that consider local context and feasibility should be developed and incorporated into national guidance. 6.1 Keep Food Areas and Utensils Clean: Clean all surfaces and equipment used for food

preparation. If possible wash surfaces with a dilute bleach solution (9 parts water,1 part bleach) to eliminate germs. Wash utensils with soap (or ash) and water. Protect kitchen areas and food from insects, pests, and other animals. Use closed containers to keep food protected.

6.2 Wash Hands: Wash hands with soap or ash before preparing or handling food. 6.3 Separate Raw and Cooked Food (to avoid cross-contamination): Separate equipment

and utensils used for handling raw foods from those used for cooked foods; store foods in proper containers to prevent contact with raw foods; and use separate plates for raw and for cooked foods.

6.4 Cook Food Thoroughly: Bring foods like soups and stews to a boil to prevent worm infestation.

6.5 Keep Food at Safe Temperatures: Do not eat food that has been sitting for more than 2 hours. Thaw food in the refrigerator. Do not thaw food at room temperature. Keep food “piping” hot (with visible steam rising from it) until served.

6.6 Use Safe Water: Use treated, safe water to wash raw food, to mix with food, and to make drinks, and prepare ice.

Formatted: Bullets and

Numbering


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6.7 Practice Special Food Hygiene Behaviors for Infants and Young Children: If a mother or caregiver is unable to practice exclusive breastfeeding for infants under 6 months, she must follow WHO’s safe infant feeding criteria:1 use a reliable supply of treated water that is stored properly to prepare replacement foods, wash hands and utensils thoroughly with soap, boil water to prepare foods, store unprepared foods in clean, covered containers, and treat or boil utensils regularly to sterilize them, or if boiling is not feasible, use detergent with water treated with chlorine, which has been shown to safely disinfect containers and utensils (Ma 2009). This includes feeding bottles, teats, cups, spoons, etc. Keeping bottles and teats clean may be especially difficult in developing country settings and their use is discouraged. Using a cup and spoon for feeding infants is recommended. Discard prepared feeds, including infant formula, within one hour if the child does not finish the entire portion. Following these precautions is very difficult for most families but critical in preventing diarrhea in young children.

At six months of age, mothers should combine breastfeeding or safe replacement feeding with additional complementary foods requiring the same critical hygiene strategies as stated above (safe water, safe food preparation, and safe storage), while the mother and baby continue to be regularly monitored for adequate nutrition. HIV-infected mothers should receive specific counseling and support for at least the first year of the child’s life to ensure adequate infant feeding.

For resource poor households, adaptations of the recommendations may include:

• Dedicate a small, cleanable surface to food preparation. This area should be out of reach of small children.

• Create another place to store cleaned dishware. Basic dish racks or tables off the ground will help keep utensils from contact with soil or animals. If possible, cover this place with a washable surface like plastic, if possible, or a sheet of paper that is changed regularly.

• Clean food preparation surfaces before use with soap and water or dilute bleach solution (9 parts water, 1 part bleach).

• Cover all raw and cooked foods with clean cover (bowl, plate, plastic, newspaper) to keep flies off.

• Heat all food until steam is seen rising from food.

• Serve food hot.

• Do not eat food that has been sitting more than 2 hours.

• Treat or boil water to wash food, to mix with food that will not be boiled, to make drinks, etc.

7. Ensure Personal Cleanliness of PLWHA and the Surrounding Environment The cleanliness of PLWHA, health care workers, and their families and the environment is an important component in preventing the spread of infection, boosting client morale, and achieving a positive health impact for HIV-affected communities. Priority recommendations include:

7.1 Bathe daily with soap: Pay special attention to cleaning client’s hands, face, genital area, and anus. Females should always cleanse their genital and anal region from “front-to-back” to avoid contamination. Uncircumcised males should gently pull back the foreskin and clean from the tip of the penis to the shaft. If clients are immobile, they

1 AFASS is the WHO guideline that means acceptable, feasible, affordable, sustainable and safe.


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may have a bath in the bed or chair. Note that some skin conditions may worsen with daily baths and adjust accordingly.

7.2 Clean equipment and dressings used to provide care and safely dispose of other bodily fluids and secretions while giving care such as the client’s urine, vomit or sputum. Caregivers should wear gloves if possible or use plastic bags to cover their hands. Use a dilute bleach solution (9 parts water, 1 part bleach) to decontaminate spills of blood. A significantly stronger solution is needed when large quantities of blood are present such as in childbirth. Use gloves to protect from blood-borne pathogens.

7.3 Wash clothing and bed linens regularly. See section on safe feces handling.

7.4 Remove dirt by sweeping and dusting and reduce pathogens by washing with hot soapy

water, rinsing, air drying (preferably in the sun), or cleaning with household bleach or other household disinfectant products.

7.5 Safely dispose of garbage and non-reusable materials into a waste receptacle, protected pit, or

latrine.

7.6 Disinfect key surfaces: Clean latrines, toilets, baths, basins, and kitchen/site of food preparation using a dilute bleach solution (9 parts water, 1 part bleach) if available or with soap and water.

7.7 Keep animals away from the household, clinic, and food or water sources as they may

expose household members to diarrheal disease and worm infestation. Control vectors such as flies, mosquitoes, cockroaches and rats by reducing the presence of uncovered food, improperly disposed feces, standing water, garbage, etc. by plugging holes in walls, and trap and bait if necessary.

V. A RECOMMENDED APPROACH TO IMPROVE WASH PRACTICES

Reducing diarrhea and improving the quality of life for people living with HIV/AIDS and their

families implies changing hygiene and sanitation behaviors—of PLWHA themselves, or their families, home based caretakers, clinicians, and others. Specific WASH behaviors, or practices, are elaborated for incorporation into guides and programs because families, outreach workers and clinicians aren’t currently practicing all the recommended WASH behaviors consistently or correctly.

Many factors affect people’s WASH behaviors, not just knowledge or even attitudes and beliefs. Too often, health promotion efforts focus on educating target audiences, assuming that increased knowledge is the factor most critical to the performance or non-performance of a particular behavior. Smoking behavior—the classic example—illustrates that things other than knowledge influence behavior. For WASH practices, knowledge is essential, but not sufficient to improve behavior. Also important are knowledge of key WASH skills, availability of key supplies and services, perceptions of community norms (what you think people important to you believe you should do), and anticipated and actual consequences for doing or not doing the behavior. So promoting hand washing, for instance, often requires a combination of specific knowledge (knowing when to wash, and that people carry ‘invisible’ feces on our hands); skills (how to wash hands


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properly); social norms (what your family would think if you came to the table with unwashed hands); and access to the needed water and soap or ash for washing. Because it is not always easy to get people to change their WASH practices, this guides suggests two fundamental ways to approach behavior change that encourage small improvements that can significantly improve the life and livelihoods of PLWHA and their families.

1. Make it Possible People rarely go directly from their current practice to the ideal practice, such as washing hands with soap at the 5 critical times, or drinking water from a protected source and storing it in a jerry can with a spigot. So instead of encouraging a householder with limited resources to adopt the ideal practice immediately—a recipe for failure—programs can identify a few feasible and effective

actions that move closer to the ideal, but will still have a household and public health impact. These are referred to as SMALL DOABLE ACTIONS that can be promoted by programs.

Definition A small doable action is a behavior that, when practiced consistently and correctly, will lead to household and public health improvement. It is considered feasible by the householder, from HIS/HER point of view, considering the current practice, the available resources, and the particular social context. Although the behavior may not be an “ideal practice”, a broader number of households will likely adopt it because it is considered ‘feasible’ within the local context.

To identify feasible practices, imagine a continuum (a spectrum) from the worst, to the current, to

the ideal practice. The ‘minimum standard’ practice is where consistent and correct practice will have a positive public health outcome (reducing diarrhea, in the case of WASH behaviors). The practices above a minimum standard are small doable actions that move people towards the ideal practice.

Illustrative Small Doable Actions for Safe Water Treatment and Storage

�� Use a 20-liter jerry can with a cover to store drinking water. �� Attach the cover to the jerry can using a string to keep it off the floor. Wash can

and its cover with soap and water every day. �� Treat drinking water in the 20-liter jerry can with Water Guard/chlorine

treatment. �� Pour water from jerry can into a clean cup or glass OR pour into a clean jug

with cover and then pour into a clean glass. Do NOT touch jerry can on the inside or on the rim with hands.

2. Negotiate… Problem Solve…Listen… Do not Insist, “Educate” or Proscribe. More than knowledge or awareness of a particular behavior influences what people do or do not do—many factors influence the performance or non-performance of a behavior. Change agents must work with household members to solve problems and get them to try to improve their WASH practices. This is called NEGOTIATING IMPROVED PRACTICE. Key information is needed, but is often not enough. Householders need skills, access to required supplies, social acceptance, and confidence that they can succeed in practicing the new behaviors. The home visitor, counselor, family member, or clinician must assess the


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barriers and facilitators to each WASH practice, and negotiate a commitment to try a few practices that seem feasible and worth changing, from the point of view of the householder, not someone else’s assessment of what is important.

Elicitation techniques can help the change agent to negotiate improved practice. Some questions to ask are:

? What makes it hard to… [wash your hands with running water and soap after defecation, before preparing food, and before eating or feeding others]?? ? What would make it easier to … [wash your hands with running water and soap after defecation, before preparing food, and before eating or feeding others]?? ? Who approves of you spending time and resources to … [wash your hands with running water and soap after defecation, before preparing food, and before eating or feeding others]??

These questions help to identify problems, fears, barriers, and facilitators to the practice. Different tools are available to support the behavior change dialogue process. Some tools are practical, simple and can be used by community workers with good facilitation skills. Participatory Hygiene and Sanitation Transformation (PHAST) is a participatory approach for promoting improved sanitation. The WHO web site has a number of useful tools for engaging communities in dialogue about WASH: http://www.who.int/water_sanitation_health/hygiene/envsan/phastep/en/. The International Red Cross has also adapted some participatory tools for hygiene promotion programming. A few places to find behavior change tools include the following web sites: www.coregroup.org, www.hip.watsan.net, www.manoffgroup.com. Answers to the questions highlighted above will provide input for program design, e.g., current knowledge and skills, relevant social factors, cultural practices, and access to products and services. Everything cannot change at once. Identify two or three improved practices, and negotiate with the householder to try these practices until the next visit.

VI. NATIONAL HIV/AIDS POLICIES, GUIDELINES, STANDARDS, OTHER MATERIALS

Many countries have written various documents to assist health professionals develop HIV programs including strategies, guidelines, standards, action plans, handbooks, and training manuals. Further, some countries have specific guidance for different aspects of HIV prevention, care, and support: that include guidelines for home-based care, orphans and vulnerable children, counseling and testing, food and nutrition, prevention of mother-to-child transmission of HIV, etc. The USAID/HIP team conducted a systematic review of HIV and AIDS policies and guidelines from 14 countries—eliciting the documents directly from country programs or from national AIDS program web sites. Special attention was given to obtaining available materials from several countries with high HIV/AIDS prevalence. Every country had very different types of materials. Thirty HIV policy-related documents from 14 countries (Cambodia, Ethiopia, Guyana, Haiti, India, Kenya, Malawi, Namibia, Rwanda, South Africa, Tanzania, Vietnam, Zambia, and Zimbabwe) were reviewed. The WASH areas addressed most often were safe drinking water and safe food consumption. A few documents mentioned hand washing, feces disposal, and personal hygiene, and this was frequently located in the background information. No document mentioned anything about


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water quantity, water storage, menstrual blood management or adapting sanitation and water supply systems for people with mobility restrictions. And these documents provided almost no information on how to practice WASH actions. Countries often have very comprehensive WASH action information in more general health or environmental health documents. If so, special efforts should be made to link these health documents more comprehensively with HIV policy documents. The two standards reviewed (Zimbabwe 2004 and Namibia 2008) were the most explicit in listing specific WASH behaviors and Zambia’s nutrition guidelines covered many WASH behaviors in some detail. A review of home-based care guidelines for a 2007 WASH-HIV integration meeting in Malawi found that Zimbabwe’s policy most comprehensively integrated WASH and HIV and Zimbabwe’s guidelines have some good material and graphics that can be adapted for use in other countries. Malawi’s home-based care guidelines provided greater detail than most on using safe water and keeping the environment clean. Malawi’s sanitation policy suggested that programs be HIV and AIDS aware. Kenya has several levels of HIV policy and guidance. The HIV Care and Support Handbook for home-based care workers provides useful and specific information, actions and standards for WASH. In documents from other countries, language was very general for example, suggesting providers and HIV affected families maintain personal hygiene and perhaps drink boiled or “clean” water, but most documents did not give any specifics. Clearly, enhanced guidance and recommendations are needed regarding water, sanitation and hygiene in national HIV guidelines from home-based care, OVC, food and nutrition, PMTCT, etc. In fact, as observed, most documents provide very general guidelines that need to be made more specific and actionable. The sections below highlight where to include greater WASH emphasis and suggest specific language to include, especially for country policies and guidance.

1. HOW to INTEGRATE WASH into GLOBAL HIV/AIDS POLICY and GUIDANCE

Key agencies such as UNAIDS, USAID, WHO have developed key reference documents that are used by national AIDS programs and NGOs to set local policy and guidance. To assist countries in integrating WASH into HIV policies, these agencies also need to integrate WASH into these reference documents. The following list identifies the types of actions that should be taken at this global level. � Modify reference documents used to develop country policies and guidelines.

•••• Include necessary WASH behaviors in the minimum package and counseling sheet and supplies in the kits. Be specific, e.g. list key WASH practices, any equipment, supplies needed and how to do each practice.

•••• Include WASH in monitoring and recording forms

� Revise “Minimum Packages”, “Home-based Care Kits”, school-based HIV education kits, indicator lists, and monitoring forms to include WASH.

•••• For policies, provide a general description of any WASH package contents •••• For guidelines, provide more specific descriptions of WASH topics •••• For standards, explain each WASH practice in detail so providers know what to do and how to instruct householders in WASH practices.


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�� Ensure policies and guidelines suggest environmental health collaboration at all levels, as part of the multisectoral focus. This could include water, sanitation, education program managers and others as appropriate.

�� Learn from other multisectoral interventions. For example, food/nutrition security guidelines may already have highlighted important WASH behaviors.

•••• Ensure WASH elements, indicators, etc. are integrated into food/nutritional security activities

•••• Promote a WASH minimum package for home-based care and support services that emphasizes key hygiene behaviors and related enabling products and infrastructure such as latrines, hand washing stations, soap, chlorine solution.

�� Develop list of key WASH behaviors for PLWHA

•••• Develop generic assessment and counseling tools on the WASH behaviors.

2. HOW to INTEGRATE WASH into COUNTRY HIV/AIDS POLICY and GUIDANCE

This section aims to help countries identify where and how to include specific language on water, sanitation and hygiene in guidance documents to minimize the spread of diarrhea throughout HIV affected communities and beyond. It is not necessary to develop a free-standing WASH and HIV Policy, but preferable to integrate WASH policies and guidance into overall HIV policies, whether general HIV or area specific (such as OVC, HBC, PMTCT, etc.). Provide a framework for integrating evidence-based WASH approaches into HIV/AIDS policies and guidelines. To support PLWHA, OVC, and their families further, foster linkages with other health and non-health programs that address water and sanitation insecurity and needs in targeted populations, etc. The table below provides criteria to assess the extent of WASH considerations in current country policy documents.

HOW to ASSESS COUNTRY POLICIES, GUIDELINES & HANDBOOKS for SAFE WATER, SANITATION and HYGIENE CONSIDERATIONS

Your overall objective is to assess the current level of WASH considerations in existing national policies, guidelines, and handbooks, and add or improve key sections as appropriate. The following definitions are provided to clarify the general content of policies and guidelines, to guide the evaluation and/or modification of documents. Policy: As a general rule, national or regional HIV/AIDS policies state a set of basic principles and associated guidelines, formulated and enforced by the governing body, intended to influence and determine decisions, actions, and other matters. Guidelines aim to streamline particular processes according to a set routine. By definition, following a guideline is not always mandatory (protocol would be a better term for a mandatory


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procedure). Guidelines are issued or adopted by an organization (governmental or private) to make the actions of its employees more predictable, and presumably of higher quality. Standards are technical specifications or procedures that lay out characteristics of a product or procedure such as levels of quality, performance, safety, or dimensions. Handbooks further elaborate guidelines to specify processes further, and often include job aids and/or counseling tools to support the quality implementation of processes. Steps for Assessing and Strengthening Country Policies, Guidelines and Handbooks: 1. If possible, obtain both printed AND electronic versions of any documents. If not available, it is possible to work with just print documents.

2. Start with the table of contents and chapter headings.

• If the electronic version is available, literally do a word search (the “find” function under edit). Otherwise, visually scan the table of contents (TOC) and headings for the following key words:

Water, drinking, sanitation, toilet, latrine, hand washing, hygiene, feces (faeces for British English) and diarrhea (diarrhoea for British English).

3. Highlight these words in the TOC and headings. 4. Refer to the sections corresponding to the sections containing the key words. 5. Evaluate existing descriptions/statements associated with the key words.

• Assess if the description or entry is adequate to precisely describe policy or guide a practitioner to implement the policy or practice.

o Is it specific enough to serve as a recipe or formula? o Will it guide choices, when decisions are required or several options available?

6. Scan the document again, and note where entries should be added.

• Appropriate places include any mentions of nutrition, feeding, supplementary feeding, home hygiene, personal hygiene and sections pertaining to care and support, home-based care, prevention of mother-to-child-transmission of HIV, counseling and testing, etc.

Text from this document, particularly from the PRIORITY WASH PRACTICES for NATIONAL PROGRAMS can be added in appropriate sections. The following sections provide suggestions for how countries can improve WASH guidance when they write or revise their HIV-related policies, guidelines and handbooks. Water Access

�� Care and support guidelines should identify technologies to gather water more easily such as lengthening pump handles or installing cement platforms for children to stand on to pump water. Further, guidelines should identify water-saving techniques and describe how to install them. For example, instructions on rain water catchment systems and how to construct a



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“tippy-tap” should be included in all care and support guidelines in resource-poor areas. Often made from a plastic jug, gourd, or other local material, a tippy-tap regulates water flow to allow for hand washing with a very small quantity of water. See Annex 3 for possible material to include in handbooks.

Water Quantity

�� National HIV/AIDS guidelines should include estimates of water needed by HIV-affected households, which are greater than the “basic access” estimate of 20 liters per person per day for the general population. Evidence suggests that an additional 20 to 80 liters of water per day is required to support bedridden PLWHA (Ngwenya 2006). Home-based care guidelines should include a section on the amount of water needed to keep PLWHA and their environment clean. This should include an estimate of water quantity needed specific to the area as well as information on what to clean and how to clean. Care and support guidelines should provide specifications for water collection technologies such as water conservation and rain water catchment. See chart on page11 that specifies quantities of water by activity.

Water Quality �� Guidelines and training of care providers should include detailed instructions on water treatment techniques such as disinfection with sodium hypochlorite solution (chlorine), boiling, SODIS, and filtration, as well as information on proper storage and handling to reduce the potential for recontamination. See Annex 3 for possible material to include.

�� Include sodium hypochlorite solution and information on other water treatment options as part of all ARV distribution to ensure medicines are taken with clean water.

�� Include covered water vessel with taps (if commonly available) in a preventive care package distributed to PLWHA along with oral rehydration salts, soap, or other evidence-based interventions; use the most typical locally manufactured vessels available to avoid stigmatization. For the community at large, promote the same container and water treatment product that is included in ARV distribution or broader social marketing of water disinfection products.

Sanitation Access

�� Identify and promote sanitary options for defecation. �� Promote construction of improved pit-latrines at the household level where space exists. In urban areas where space is limited, promote a feasible option such as "condominial" latrines/toilets connected to shared septic tank/system, privately managed pay-for-use public toilets, above ground latrines, based on contextual and environmental factors.

�� Promote client-friendly latrines in household that incorporate the following suggestions: • Ensure that the toilets or latrines and the entrance are wide enough to accommodate more than one person to assist unstable users.

• Recommend/provide alternative technologies such as installing poles or strengthening venting poles to serve as support; installing ropes, bars, or handrails; providing seats/stools and other devices; constructing a ramp for easy access.

• Design latrines that use natural light and have adequate ventilation.

• Identify and promote appropriate options for sanitation when mobility is limited, such as bedside commodes or bedpans (made of plastic or locally available materials) and squat pots.

• Provide a hand washing facility with soap or soap substitute (ash) near the latrine.


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• Provide detailed instructions on keeping the person, house, and surrounding environment clean.

Sanitation, Hygiene and Hand Washing Knowledge and Practice

�� Develop a comprehensive water, sanitation, and hygiene component to include in all care and support guidelines and training, including:

o guidance and technologies on hand washing in water-scarce settings; o critical times for hand washing and proper technique; o soap substitutes; o proper disposal of waste water; proper use and maintenance of water and sanitation facilities;

o household water treatment and safe storage; and o clear communication of risks associated with and protective measures required for feces handling (e.g., when bathing clients and laundering soiled bedding/clothing).

�� Develop hygiene promotion materials for care and support programs that use visuals and are suitable for low-literacy audiences; distribute them to caregivers and others who interact with HIV-affected households.

�� Include water, sanitation, and hygiene in all nutrition guidelines for care and support programs as diarrhea prevents PLWHA from absorbing ARV medicines and essential nutrients.

3. ASSURING HIV/AIDS POLICIES and GUIDELINES SUPPORT WASH

Review current policies and guidelines and modify texts appropriately. The section above provided suggestions for topic areas to include when revising HIV policies, guidelines and handbooks. This section provides examples of specific language that can be used to do this using safe drinking water as an example. In a national policy, existing text might read:

All HIV-infected persons should drink safe water or all households without safe water should boil water for PLWHA to consume.

An improvement to this text would be to add:

All HIV-affected households should treat all drinking water and store in a narrow mouthed, covered container.

The text in national guidelines would include the text above from the policy, but include more details about safe hygiene practices.

Any containers provided at no cost should only be those that are commonly used and readily available in the marketplace. A container with a spigot is ideal but not always feasible for households. Items only available to PLWHA should be avoided because they identify recipients as HIV-positive and may be stigmatizing. Sodium hypochlorite solution or tablets are the ideal methods of water treatment because the residual chlorine will protect the water from recontamination for 24 hours, but any of the four effective methods (hypochlorite solution/chlorination, solar, filtration, and boiling) are acceptable.


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Develop and implement national Standards of Practice (SOPs) that delineate the essentials of delivering WASH in HIV/AIDS settings at various practice levels and settings. This may include performance expectations for individuals responsible for WASH or HIV programming (e.g. nurses, volunteers, teachers), professional standards, etc. National standards should repeat the guidelines but also include language on ‘how-to’ treat water, using each method. This language can be adapted from the WASH priority actions section at the beginning of this document. Handbooks that are developed would repeat the language from the standards, but also include counseling tools and job aids for treating and safely storing drinking water. National program managers are encouraged to understand the essential WASH actions for diarrheal disease prevention; to use this information to determine what types of water, sanitation and hygiene approaches already exist in country programs (HIV or otherwise); to examine the types of potential WASH approaches, the cost of these approaches, and which programs might fit best into HIV/AIDS programming in your country; and to prioritize these activities for integration into country plans. The following language could be included in its entirety or adapted and inserted into different documents such as guidelines, standards, handbooks, etc.

SAMPLE TEXT

Integrating WASH into HIV Care and Support Settings Many life-threatening opportunistic infections are caused by exposure to unsafe water, inadequate sanitation and poor hygiene. Diarrhea, a very common symptom which can occur throughout the course of HIV/AIDS, affects 90 percent of PLWHA and results in significant morbidity and mortality, especially in HIV-positive children. At least 30 percent of diarrheal diseases could be prevented through integrated programs involving the provision of water treatment and safe storage, safe feces disposal, and promotion of key hygiene practices. HIV and AIDS programs should consider building linkages among the health, water and sanitation sectors to improve the number of safe water supply points and latrines that are accessible and close to where they are needed. Hand Washing: Washing hands at critical times, with soap and with proper technique is the most important hygiene measure to be integrated across all HIV and AIDS programs. Although hand washing studies are limited in HIV-positive clients, data support the benefits of hand washing in the general population, sometimes showing a reduction in diarrhea in Bangladeshi adults by 62 percent (Shahid 1996) and by 53 percent in a randomized controlled trial of children in Pakistan (Luby 2004). Programs can provide guidance and training on washing hands and proper technique, at a minimum. Programs should place hand washing stations with soap (or soap-substitute, such as ash) in facilities, community care points, and in the household. Some programs in water scarce situations should consider using a “tippy-tap,” a simple plastic jug, gourd, or local material that regulates the flow of water to allow for hand washing with a very small quantity of water. Safe Drinking Water: HIV/AIDS programs are encouraged to ensure PLWHA have access to safe drinking water in facility-based care settings and to support PLWHA with household water treatment and safe storage methods in communities where there is not a reliable source of safe water. Several technologies are viable for treating water in the home, including chlorination and storage in an appropriate vessel, various types of filters, proper boiling, solar disinfection (SODIS) using heat, and UV radiation and combined chemical coagulation, flocculation, and disinfection.


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Sanitation generally includes the collection and disposal of human excreta (feces, urine, sputum, and sweat) and management of trash, wastewater, storm water, sewage, and hazardous wastes. Most countries have poor access to a range of basic sanitation systems; therefore it is important to focus on simple efforts, like feces handling and disposal, which have the biggest health implications. Disposing of feces safely, isolating feces from flies and other insects, and preventing fecal contamination of water supplies would greatly reduce the spread of diseases. Studies have shown that those without easy access to latrines will often resort to open defecation methods. Although HIV programs have not traditionally funded the construction of simple, on-site waste disposal systems like latrines, many sanitation interventions that will benefit PLWHA and their families can be supported. For example, health workers, caregivers, family members and PLWHA need to learn how to build a latrine and be trained on how to use existing latrines safely. Further, installing poles or stools in a latrine will assist weak PLWHA to use the latrine. If a latrine is not available, feces must be collected in a bedpan and buried away from the facility, clinic, and home, and away from where animals can dig it up. If a client is weak, less mobile, or bedbound and cannot use a latrine, programs can ensure access to simple commodes or bedpans that can be used by PLWHA to defecate in the bed or house and that can be emptied by caregivers. Adult treatment care programs can ensure that PLWHA with diarrhea are supported to protect their skin, sheets, clothing and mattress from becoming soiled with feces. Strategies such as placing a plastic sheet covered by paper or a cloth under the client’s buttocks are very simple and cost-effective measures that can ease the care giving burden. Ensuring personal, nutritional, and environmental hygiene is essential to reducing the infectious disease burden experienced by PLWHA. The combination of improved water treatment and handling, feces removal, personal hygiene (PLWHA & health worker hygiene and cleanliness), food hygiene (safe cooking, mixing, storing and disposing of food), and ensuring a hygienic environment in clinics and in homes will effectively reduce water and sanitation related diseases. Hygiene education must particularly be targeted at caregivers and volunteers involved in home-based care and must be one element in home-based care training.

VII. PROGRAM APPROACHES for WASH-HIV INTEGRATION

Comprehensive water, sanitation, and hygiene strategies include a wide range of interventions to improve the quality of life for the individual and family. These interventions are not specific to any one setting or location and are generally delivered through the home, community, school and/or facility. Recognizing that water, sanitation and hygiene interventions cannot be standardized for all situations and countries, specific methods of implementing WASH are likely to vary within regions, and even within countries, depending on the setting and the capacity of the partners who are implementing such programs. Thus, a “menu” of interventions that could be considered is presented here. Prioritizing and selecting WASH components must be performed locally, and should be consistent with national guidelines.

Illustrative Program Approaches

Program Approaches

Examples/Links


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Integrate/ mainstream WASH as an issue spanning across all intervention areas (OVC, PMTCT, CT, etc.)

Integrate WASH into existing community-based approaches (e.g., home-based care, post test clubs, PMTCT/HBC support groups, behavior change communication strategies and campaigns-drama, etc). Mainstreaming can be facilitated into home-based and community care through distributing a WASH household assessment tool for all who do home visits to quickly identify existing WASH conditions and recommendations for practical "small doable actions" based on assessment and resources/support in the community; integrate WASH into all HIV/AIDS service delivery training for providers, caregivers, community health workers, etc.); make available appropriate curriculum for adaptation/integration and job aids.

• Training of Trainers Guide and Participant Manual for Integrating WASH into Home-based Care. http://www.hip.watsan.net/page/2708

• Pictorial tool/counseling cards for HBC givers in Ethiopia to counsel community and family members on WASH actions. http://www.hip.watsan.net/page/2708

Build NGO and government capacity

Build the capacity of water, sanitation, health, and HIV/AIDS programs to deliver in-country technical assistance, supervision, planning, and training. USAID is currently implementing this approach in Ethiopia and Uganda across sectors to facilitate improved WASH and HIV/AIDS programming. See annex for program resources.

Integrate WASH training into all HIV/AIDS service delivery trainings

CDC has developed training resources that can be easily adapted locally.

• Safe Water Treatment and Storage (at least 4 hours of training)

• Hand washing at critical times and with proper technique and other personal hygiene measures (at least 4 hours of training)

http://www.cdc.gov/safewater/publications_pages/fact_sheets/SWSTrainingGuidNurses.pdf

http://www.cdc.gov/safewater/publications_pages/fact_sheets/SWSCurriculumNurses.pdf

http://www.shea-online.org/Assets/files/IHI_Hand_Hygiene.pdf

Training is also essential in these other aspects of WASH:

• Promoting improved sanitation (at least 4 hours of training)

• Food hygiene (at least 2 hours of training)

• Personal and environmental cleanliness (at least 2 hours of training) Develop & use curricula, behavior change and counseling tools/materials

Develop supplements or integrate WASH themes into: • Participant manuals • trainer manuals • flipcharts • IEC materials, especially reminder materials for PLWHA homes • Pocket cards for health workers to remember key points

Examples of available professional training and school-based curricula are found under separated headings in Annex 1.

Implement a basic care package through the clinic system

Include a hypochlorite product, container (available from local market) and soap, with accompanying hygiene education, reinforcement, and follow up as part of a package of commodities given to HIV+ and PMTCT clients. The package represents evidence-based practices that can help to maintain PLWHA health. Other commodities may include condoms, ORT, multivitamins, and cotrimoxazole. Health care providers are trained in how to educate and counsel clients on the kit.

Include a comprehensive WASH package for adult PLWHA and families in the home setting

Include a hypochlorite product, container (available from local market) and soap, with accompanying hygiene education, instructions on making home-made devices for hand washing with limited water; homemade bedpans for facilitating safe feces disposal; tips for making latrine use easier for PLWHA and limited mobility; gloves; plastic sheeting.

Ensure adequate supply of

Safe Water Treatment and Storage Commodities

• Treatment products (hypochlorite solution or tablets, filters, etc. for water purification)


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essential hygiene commodities

With appropriate behavior change communication and counseling

• 1- to 2-liter transparent plastic bottles appropriate for solar treatment of water (SODIS)

• Safe water storage containers (clay pot, jerry can or container with a spigot), lids and dippers

• Spigot/tap available in local market http://www.cdc.gov/safewater/publications_pages/proven.pdf http://www.cdc.gov/safewater/publications_pages/options-sodis.pdf http://www.cdc.gov/safewater/publications_pages/fact_sheets/SWSCurriculumNurses.pdf

Hand Washing Commodities

• Soap and other local products such as ash

• Tippy tap materials – plastic jug, gourd or local material with spigot or opening to provide slow stream of water and rope

http://www.cdc.gov/safewater/publications_pages/tippy-tap.pdf

• Hand washing stations in health facilities or schools (Parker, O’Reilly) Safe Feces Handling and Disposal Commodities

• Rubber, Mackintosh or plastic sheets to protect linen, mattresses and skin

• Bedpan and/or commode (bedside structure) to assist clients who are unable to get to a latrine or toilet (created with local materials – for both infants and adults)

• Clean cloth, nappies/diapers, plastic pants for incontinent clients (infants and adults)

• Gloves for safely handling feces and body fluids

• Hygiene stations (for hand washing with soap or ash) – can create a tippy tap

• Sanitation platforms (SanPlats) for latrines Food Hygiene Commodities

• Use treated water to prepare nutrition products (complementary foods, formula), sanitize food or formula preparation vessels, and treat raw fruits and vegetables

• Hygiene stations (for hand washing with soap) – can create a tippy tap Personal Cleanliness and Environmental Hygiene Commodities

• Clean cloth for daily bathing, hygiene, etc.

• Bags for collecting and disposing of waste

• Hygiene stations (for hand washing with soap) – can create a tippy tap Behavior Change Communication and Counseling Ensure that adequate education, follow-up, reinforcement, and monitoring accompanies all commodity distribution. This may include clinic-based education, home visits, peer support groups, etc. Commodities are only effective if they are used correctly and consistently.

Support

supervision

Follow-up with providers or teachers, staff, etc. to reinforce improved WASH behaviors. Add to or develop and use supervision checklists and tools to enhance the performance monitoring of providers, teachers, etc. Include job aids and supervision checklists: presence of hand washing station with signs of use, latrine with signs of use, presence of soap. Distribute “how to” sheets (e.g. on making a tippy tap—water saving hand washing device) as part of monitoring.

Recruit and fund coordinator

Support a local WASH integration coordinator who is dedicated to working with partners to integrate hygiene into the HIV/AIDS program.


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Explore options for increasing access to water and sanitation infrastructure

Within the local country context, identify existing partners already working in water and sanitation and explore possibilities for leveraging water and sanitation infrastructure. Start by examining UNICEF and World Bank operations. Some programs will support water and sanitation infrastructure.

Support national committees on WASH and HIV/AIDS

Form National Steering Committees to improve programming and leadership on WASH and HIV/AIDS. The Government of Uganda has formed a National Working Group on Hygiene Improvement and HIV/AIDS to guide the technical mainstreaming of WASH and HIV with donor support.

VIII. COORDINATION with WATER and SANITATION SECTORS HIV and AIDS are often characterized as health issues and therefore, not integrated into plans and activities of other sectors. In particular, ministries of health and ministries of water and or sanitation rarely coordinate or develop joint plans. Even within NGOs, water, sanitation, and health program managers are often unaware of each other’s strategic planning—even health and HIV program managers are often strangers to one another. Yet, to remain healthy, everyone needs water and sanitation services and to practice good hygiene—especially those who are infected with HIV. Further, these services must be accessible, affordable, and reliable. Households that have lost their primary income generators are less able to pay water or latrine fees and fewer able-bodied householders mean fewer people available to manage water and sanitation activities in the community (Franks). Integrating HIV considerations into water supply and sanitation activities As noted throughout this document, people affected by HIV and AIDS have increased needs for water and sanitation services. The burden of HIV care and support falls largely on the most vulnerable: sick people, female care givers who are often elderly, and children who are often most affected by insufficient water supply and sanitation. Further, as documented by a case study in Tanzania, labor-poor households, youth-headed households, and elderly women are all under-represented on water and sanitation committees where decisions are made (Kamminga 2005) Research indicates that most WASH-related programs do not address HIV/AIDS (Kamminga 2005) either from the human resource perspective (i.e., high HIV prevalence can decimate staffing within the water and sanitation sectors) or from the hardware standpoint, by applying technological innovations to improve access to services. Thus, integrating HIV into the water and sanitation sectors must deal with two parallel spheres simultaneously: 1. Protecting sectoral human resources through HIV prevention and mitigation programs (not addressed by this document); and 2. Considering the special hardware needs of those affected by HIV in WASH programs and activities. Examples of the latter might include lengthening pump handles to make it easier to pump water, building wells or latrines closer to HIV-affected households, or building ramps or platforms for easier access. Water and sanitation technologies were designed for able-bodied people who could operate, maintain, and walk to the facilities. (UN Habitat 2007) The HIV/AIDS context demands new


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paradigms such as placing facilities near people too weak to walk long distances and designing water points and latrines in ways that consider the special needs of PLWHA and their families. Finally, being unable to participate in planning, decision-making and implementation will limit the consideration of PLWHA specific water and sanitation needs. The communities must have the ability to finance and manage water supply and sanitation changes in the HIV context and water and sanitation sectors must strive to ensure that installations are robust, affordable, and can be sustained without reliance on a declining pool of skilled outsiders (Kamminga 2005). The chart below describes some activities the Water and Sanitation sectors can include when planning infrastructure and education programs with communities. Integrate HIV Considerations into Water and Sanitation Sector Plans and Programs

Planning 1. Consider HIV needs when developing water and sanitation policies, planning, regulation,

service delivery, and provision. 2. Develop strategic partnerships with other sectors/stakeholders (e.g., HIV/AIDS, home-

based care providers) to address the most vulnerable: women and children 3. Develop guidelines/strategies to integrate HIV/AIDS awareness into all water and

sanitation sectoral projects. Create an institutional framework that is HIV-sensitive to ensure that poorer communities that experience difficulty in paying for services have access to improved water sources.

4. Identify and address issues specific to HIV-infected and affected families, such as needs for additional quantity of water, latrine access, etc.

5. Map access to water and sanitation points and target areas of HIV prevalence and/or vulnerability when constructing new water and sanitation points.

6. Integrate PLWHA and affected family perspectives into community water management and planning schemes by including PLWHA and community care organization representatives in decision-making.

Technology 7. Develop and promote new water collection technologies and strategies to bring water closer

to the home (rainwater catchment systems, ergonomic pump designs using local materials, etc.).

8. Recommend hand washing stations as part of a twin design for all latrine construction. 9. Promote water-saving technologies such as “tippy taps” for washing hands and clothing/

linens. 10. Include minimum standards for latrines that allow for an assistant to accompany the

PLWHA to the latrine and options for outfitting latrines with support poles, squatting stools, or seats for greater comfort.

Community Access 11. Assess effects of inability to pay on water and sanitation systems; develop alternative

structures, such as focused subsidies, to ensure that vulnerable households have access to water and toilets/latrines.

12. Promote community participation to provide support to vulnerable groups digging the pit, constructing the super-structure.

Education 13. Incorporate information on the special needs of PLWHA and other vulnerable populations

into education and training for water and sanitation sectors.





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14. Assess how to support communities to access safe water supply sanitation and hygiene education to mitigate the impact of HIV/AIDS and to support community care to those infected and affected.

IX. MONITORING and EVALUATION To achieve the desired impact on diarrheal disease reduction and other improvements for families affected by HIV, program objectives and relevant ways of measuring those objectives must be clearly articulated by donors and program managers.

Below are a set of illustrative objectives and indicators that can be used to measure integration activities:

Illustrative Indicators Programs can select or adapt the illustrative indicators listed below depending on the scope of integration activities and the extent to which the program can monitor them. Organized by objectives Objective #1 Increased policy support for integrating WASH into HIV programs

Objective #2 Increased institutional capacity to plan, implement, and evaluate the integration

of WASH into HIV programs in communities and households Objective #3 Increased adoption of WASH practices in households of PLWHA and

households affected by HIV

Objective #1: Increased policy support for integrating WASH into HIV Programs 1. Appropriate specifications of WASH elements included in HIV guidance and policy – hand washing, food safety, safe water handling and treatment, and sanitation/feces management in OVC, PMTCT, Nutrition/Food Security, general HIV related documents: a. Policy b. Standards c. Guidelines d. Handbooks

2. % of HIV budget dedicated to WASH-related activities or commodities (may or may not be chosen for inclusion)

Objective #2: Increased institutional capacity to plan, implement, and evaluate the integration of WASH into HIV Programs in communities and households 3. % of targeted organizations/ministries/bureaus reporting modifications that include WASH in their current HIV programming

4. Number of HIV providers by cadre (HBC workers, PMTCT counselors, OVC providers, nutrition counselors, VCT counselors, etc.) trained in: a. WASH essentials




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b. Negotiating behavior change

5. % of trained HIV providers who have mastered WASH knowledge and skills 6. % of trained HIV providers who perform competencies according to established standards 7. % of targeted organizations who have modified follow-up supervision and monitoring to include WASH elements

8. % of targeted organizations/ministries/bureaux reporting collaboration of HIV programs with WASH programs

9. % of targeted organizations/ministries/bureaux with joint documents, joint decisions/policies, work plans, etc.

10. % of targeted organizations mapping / assessing communities to determine all organizations providing water, sanitation, and hygiene improvement as part of their planning assessments

11. % of anti-stigma sessions that address some element of water and sanitation stigma (HIV+ using common water sources or shared latrines)

12. % of households enrolled in HBC receiving minimum package of services that include key WASH elements of care and counseling (reported by HH/reported by provider (forms)

13. % of households enrolled in HBC receiving HBC kit that includes WASH-related supplies (reported by HH/reported by provider (forms)

Objective #3: Increased adoption of WASH practices in households of PLWHA and households affected by HIV (OVC) Household indicators Hand Washing First collected at household level, then calculated as % of households 14. % of targeted households with a designated place for hand washing (hand washing station) commonly used by caretaker and client equipped with hand washing supplies (water AND local cleansing agent (e.g. soap or ash))

15. Is the hand washing device fixed in one location or movable?

16. Can name at least 2 of 4 critical times to wash hands to prevent diseases

Safe Handling and Disposal of Feces First collected at household level, then calculated as % of households


Numbering


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17. Presence of latrine in compound or shared between two compounds (none, unimproved (no slab, no pit, bucket), improved (washable platform, superstructure, cover over pit, 5 meters away from house)

18. % of latrines in targeted households that are modified to address HIV/mobility issues (stools, grip pole/rope, double chamber for larger latrine, etc.)

19. % of households that put children’s feces into a latrine 20. % of targeted households with presence of commode or bedpan 21. % of targeted households with gloves or bags used for gloves to protect caretakers from HIV exposure

Menstrual Management 22. % of female clients reporting hygienic disposal of soiled feminine hygiene products 23. % of caregivers reporting appropriate washing of soiled rags used for client menstrual hygiene

Treatment and Safe Storage of Drinking Water at Home First collected at household level, then calculated as % of households 24. With a safe water storage container (narrow neck vessel with tightly fitting cover; spigot ideal)

25. Reporting sufficient quantity of water available for a. …. the PLWHA (and household) to drink b. … the PLWHA to take meds c. … for bathing PLWHA d. … for cleaning clothing/bedsheets

Personal Hygiene and Household Cleanliness 26. % of clients that bathed the day prior to the survey 27. % of targeted households that washed bed linen in the 7 days prior to survey

28. % of targeted households that disposed of solid household waste in protected pit

29. % of targeted households that kept domestic animals outside home the of day of survey

Food Hygiene 30. % of PLWHA households where available raw meat, poultry or seafood on day of visit is kept separate from raw foods

31. % of PLWHA households where no cooked food is left standing more than 2 hours after being cooked

32. % of PLWHA households where fruits and vegetables eaten raw on the day of the interview were washed (with safe water) or fully peeled prior to consumption


Numbering


Numbering


Numbering


Numbering


Numbering



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X. CASE STUDIES

The case studies below give a snapshot about types of intervention activities that different programs are trying around the world to integrate WASH and HIV. USAID/HIP tried to identify a more geographically representative sample of case studies, but most of the examples were located in Africa where HIV/AIDS is most prevalent and where programs are more advanced.

ETHIOPIA: Integrating WASH into HIV Programs The USAID/Hygiene Improvement Project (HIP) created a community of practice (COP) in 2007 comprised of six organizations based in Addis Ababa, Ethiopia interested in integrating WASH and HIV. The COP is designed to share experiences and to develop together programming guidance and tools that can be used to integrate WASH and HIV. In 2008, the COP compiled a set of small doable actions for key WASH practices and identified areas in which further research in the HIV context was needed. USAID/HIP then conducted a Trials of Improved Practices research with two COP partners: Catholic Relief Services and Save the Children in Addis and Oromiya. The results helped to define the gaps – in sanitation practices, treatment and safe storage of drinking water practices and a new area, menstrual management practices – and complete the set of small doable actions for the HIV program context. In 2009, HIP held a WASH-HIV integration workshop for COP members and other organizations interested in joining the COP. Members from seven organizations attended to identify ways to integrate WASH into their HIV programs or HIV considerations into their water, sanitation and hygiene programs using existing assets to integrate activities. Facilitators and participants discussed tools that have been developed such as job aids, materials, etc that are useful and relevant. HIP will train trainers to cascade WASH activities into these organizations and their programs, provide job aids for all COP outreach workers, and help develop indicators to include in monitoring and assessment tools. In Bahir Dar, USAID/HIP trained a cadre of trainers and then approximately 350 home based care workers from three organizations who have begun integrate WASH into their home-based care programs. The home-based care providers said that prior to the USAID/HIP training they would talk generally about personal hygiene, but did not focus on specific hygiene practices. They appreciated the practical training and now understand how important WASH is for PLWHA and OVC. Since the training, many people have constructed a tippy tap, a water-saving hand washing device made from an empty plastic bottle or calabash. In addition, the home-based care workers are giving practical instructions on how to wash hands, when to wash hands and the importance of using a latrine. For more information, contact Julia Rosenbaum, [email protected].

KENYA: Household Water Treatment for Home-based Care Workers The Kenya Red Cross Society is implementing family health home-based care projects targeting PLWHA and other chronically ill persons in 7 branches countrywide. Key components include training communities and community health volunteers in nursing care, psychosocial, nutritional and


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other social support. Through partnerships with various institutions the program has enhanced access to VCT and ART, and opportunistic infection treatment services and supported OVC. A pilot program targeted safe household water interventions to 1500 households in Siaya and Kisumu. Households were introduced to water treatment methods and products (filters, PuR, Aquatabs and WatermakerTM) and trained on the safe water chain including proper transportation, handling, storage, use and re-use. IEC materials were used for hygiene promotion and education and the program regularly followed up and monitored the practices. The community widely accepted the safe water activities since all community members in the project target group were included. This considered everyone’s needs and avoided targeting PLWHA households directly. Most clients were exposed to different treatment methods; the majority preferred using chemicals, followed by filtration, and boiling. The target group reported proper practices around safe water storage; most clients treated drinking water the day prior to the interview and used appropriate water containers—ordinary clay pots, plastic jerry can, and a modern clay pot. Clients reported adhering to hygiene practices such as hand washing using correct technique and correctly identifying critical times to wash hands. For more information, contact Libertad Gonzalez: [email protected] or Robert Fraser: [email protected]

KENYA: Safe Water Systems and Hand Washing Stations in Schools

Program experiences in Kenya demonstrate that unsafe water, sanitation and hygiene conditions not only have a detrimental effect on the health of children under age five, but also have an impact on the health, attendance and learning capacities of school-age children, including OVCs. A U.S. government-supported program in western Kenya placed Safe Water Systems and hand washing stations by primary school kitchens and latrines. Primary school teachers and students were taught correct hand washing and water treatment and storage and students were encouraged to teach their parents improved WASH behaviors. CARE/Kenya, PSI/Kenya and CDC facilitated technical assistance, training and commodity distribution (water treatment with bleach, safe storage and behavior change communication). An evaluation of this program documented a 35 percent decrease in student absentee rates (O’Reilly 2007). Other examples of school programs include developing WASH friendly school guidelines, teacher and student trainings, integrating WASH into youth clubs, etc., and other strategies available on www.PEPFAR.net that can be used in schools and with OVC groups. UNICEF guidelines promote that all schools have child friendly water and sanitation facilities for all schools, along with hygiene education programs. For more information, see http://www.cdc.gov/safewater/publications_pages/fact_sheets/Kenya.pdf MALAWI: Paving the Road to Health with Small Doable Actions: Improving WASH knowledge and behaviors among home-based care households In 2006, Catholic Relief Services (CRS) assessed the WASH component of home-based care in both Zambia and Malawi supported by WHO. The Malawi assessment (Lockwood et. al) found—


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1. A high prevalence of diarrhea among HBC household members; 2. A lack of close, available water supply sources; 3. Low access to hand washing facilities and unclean sanitation facilities; 4. Low treated drinking water levels arising from a false belief that water from the source was safe; 5. Low levels of WASH education and a discrepancy between knowledge and behavior 6. HBC volunteers not trained or equipped to provide water and sanitation education. CRS Malawi worked with WHO and USAID in 2007 to organize a national conference on integrating water, sanitation, and hygiene into HBC strategies and to mobilize other agencies to think about integration. The conference occurred in October 2007, with more than 50 participants. The conference developed recommendations for integrating WASH activities into HBC programming and for integrating HIV considerations into WASH programming. Malawi partners developed action plans for integrating WASH and HIV. CRS and Dedza Catholic Health Commission developed a pilot project to improve the WASH conditions of HBC households and community-based childcare centers (CBCCs)—focusing on hand washing, treatment and safe storage of drinking water and safe disposal of feces especially through consistent latrine use. Pilot project activities included training HBC volunteers and CBCC caregivers in small, doable WASH actions and Participatory Hygiene and Sanitation Training (PHAST), distributing water treatment products, constructing sanplat demonstration slabs and tippy taps using locally available materials, and conducting community education through drama, music and meetings. Significant changes in knowledge, attitudes, and behaviors among targeted HBC households were recorded one year after the pilot project started. Some results include the following:

• Significantly fewer respondents reported that someone in their household had suffered from diarrhea in the two weeks prior to the survey (15%) compared to baseline (26%).

• Household members who had experienced bloody diarrhea, decreased (from 6% to 1 case). • HBC household knowledge about washing hands before eating increased (81% to 93%) as did washing hands after defecating (68% to 87%). Respondents reporting hand washing facilities almost tripled (21% to 60%).

• HBC households with treated drinking water almost doubled (43% to 84%) and households using a two-cup system to get drinking water increased (23% to 56%).

• Half the respondents reported latrines with slabs and the remaining reported an open pit latrine. The number of clean latrine slabs (no visible fecal matter) increased by 14 percent.

• A significant increase in health-seeking behavior, with 43 percent of those with diarrhea reporting having visited a health center in response to the diarrhea (from 20%).

Performance on almost all project indicators improved during the one year pilot project. Outcome indicators demonstrated an increase in WASH knowledge, attitudes and practices. These increases contributed to improved health among HBC household members. This project found that small doable actions for HBC households are an effective method to improve WASH practices. For more information, contact: Antonia Powell, [email protected]


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MALAWI: AIDS Drinking Water Project

In Malawi, 12 percent of the adult population is infected with HIV, more than half (59%) of whom are women. Safe Water International is currently implementing a project in central Malawi that makes drinking water more accessible to HIV-positive people and their families. The project has built rainwater collection tanks (7000 gallon capacity) at three HIV/AIDS treatment centers and is beginning to distribute locally-produced sand filters to HIV affected households. The project found that these rainwater tanks had a dual purpose: first they provided non-contaminated water to clinic clients and second they motivated clients to come to the clinic. Weekly and bi-weekly session attendance at the health centers increased after the tanks were constructed. In addition, Peace Corps volunteers are developing materials to train villagers to use the sand filter and to teach information about basic WASH practices such as hand washing with soap, safe water storage and latrine construction and use. In June 2009, Safe Water International and home-based care volunteers established some village health centers and work to create a model for a village health care and education program that incorporates WASH practices and touches all in the village. For more information, contact: Larry Siegel, [email protected]. SOUTH AFRICA: Leveraging External Resources for Water and Sanitation Infrastructure The USAID/South Africa and the Coca-Cola Company have created a unique Global Development Alliance to address community water needs in Africa. With support from the Global Environment and Technology Foundation, the “Water and Development Alliance” contributes to improving water use efficiency through targeted interventions, increasing access to water supply and sanitation services, and enhancing productive uses of water. In South Africa, implementing agents, are targeting youth and HIV-infected and affected using an approach involving expanded water reticulation (piped water) in especially deep rural areas jointly with hygiene and sanitation behavior change programming and training. PEPFAR funding is being leveraged to reach up to 25,000 residents in 10 rural villages in Amathole District of the Eastern Cape where HIV antenatal prevalence is 21 percent and where 30 percent of the province has no access to piped water. For more information, contact Malik Jaffer: [email protected] . UGANDA: WASH Commodities, Training and Technical Assistance PSI/Uganda is improving water treatment and safe storage and promoting hand washing with soap by delivering the Basic Preventive Care Package (BCP) for PLWHA and their families. This package of commodities is given through health facilities in coordination with the ministry of health to HIV+, ART and PMTCT participants; education on the behaviors and follow up is included. The program helps to reduce morbidity and mortality caused by opportunistic infections (OIs) in PLWHA and to reduce HIV transmission to unborn children and sexual partners. Currently, the


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BCP components include identifying PLWHA through family based counseling and testing, prolonging and improving the quality of their lives by preventing OIs, and prevention with positives interventions. The basic preventive care package combines key informational messages, training, and provision of affordable health commodities. The health commodities include free distribution of a starter kit with:

• two long lasting insecticide treated bednets;

• household water treatment chlorine solution, a filter cloth, and water vessel;

• condoms; and

• health information on how to prevent HIV transmission. A multi-channel communication campaign supports program implementation by educating PLWHA on how to prevent OIs, live longer and healthier lives through cotrimoxazole prophylaxis, prevent diarrheal diseases using household water treatment and safe storage, prevent malaria by using insecticide treated nets, and prevention with positives interventions. The expanded campaign will include palliative care, TB/HIV and nutrition communication and will produce education materials (posters, brochures, positive living client guides and stickers) for PLWHA, health care providers, and counselors in eight local languages. In partnership with Uganda’s Ministry of Health and the Straight Talk Foundation, PSI is producing radio spots and ‘parent talk’ programs. PSI has trained service providers, and peer educators who are now implementing community activities that reinforce these messages. PSI now works with 30 HIV care and support organizational partners who have a total of 102 BCP implementing sites across Uganda reaching 250,000 people. Of these, 45 sites have adult clients and distribute condoms, while 8 faith-based organizations work with young infected children. Of the 163,735 kits that have been distributed, nearly 11,000 have been given to children. For more information, Cecilia Kwak, [email protected] UGANDA: Integrating WASH into HIV/AIDS Home-based Care Programming Poor water, sanitation, and hygiene practices exert a heavy toll on people living with HIV/AIDS, especially in terms of vulnerability to opportunistic infections and loss of dignity. The additional bouts of diarrhea and opportunistic infections experienced by HIV positive individuals also increase the work load for their caregivers. USAID/Hygiene Improvement Project (HIP) is implementing activities to address poor WASH practices in homes of HIV positive individuals. HIP first conducted focus group discussions and in-depth interviews in Kampala [urban] and Kamuli [rural] districts to assess hygiene conditions, practices, and related behavioral factors in four key WASH areas of hand washing, feces handling and disposal, water treatment and storage, and menstrual blood management. The program then developed and tested improved practices in the households in Kampala and Kamuli districts from which the program developed tools and manuals for home based care workers. In May 2009, HIP and Plan/Ugandaconducted a pilot trainingof home-based care providers from organizations that provide home-based care services. A training of master trainers was later conducted in Fall 2009, with the intention to replicate trainings in each of the participating organizations. Organizations will also receive technical assistance in planning and implementing integration activities. Training materials and guides are on the USAID/HIP web site (www.hip.watsan.net).


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To enrich these measures and to ensure their sustainability and uptake in the sector, HIP initiated a sub-group on Sanitation & Hygiene Integration in HIV/AIDS, in partnership with Uganda Water and Sanitation Network, under the National Sanitation Working Group. For more information, contact Elizabeth Younger, ([email protected]).

VIETNAM: Integration of Safe Water Systems and Health Communications in Care and Support Services

PSI is working closely with CARE and community based organization (CBO) partners to improve and increase access among OVC and PLWHA to the SafeWat safe water system and behavior change communications to promote correct and consistent household water treatment and good hygiene practices among PLWHA, OVCs, and their affected households. Safe water and hygiene promotion activities are integrated into existing care and support services in provinces particularly affected by cholera to reduce the incidence of diarrheal diseases among immuno-compromised and otherwise vulnerable populations in Hanoi, HCMC, Quang Ninh, Can Tho, and An Giang. Specific activities: The project integrates SafeWat promotion and hygiene awareness into existing community outreach events with PLWHA/OVCs and their families. This has increased the acceptability of targeted communications messages. The project has trained local CBO partners on the link between unsafe drinking water, health and recommended good hygiene practices. Nutrition training in the South and North provinces also included this WASH component. On-going interpersonal communication sessions and product demonstrations have built self-efficacy among potential users, demonstrated effectiveness of SafeWat and encouraged initial trial of SafeWat. Findings from program implementation monitoring and research into current safe water practices, user experiences and reasons some users lapsed will inform the 2009 phase 2 design of the SafeWat project. Results: • Since the project launched in August 2008, over 20,000 SafeWat bottles were distributed to HIV affected households. Over 18,000 leaflets, posters and flipcharts were distributed through 23 local partner organizations.

• Program activities reached over 18,000 people: PLWHA (4,875), OVC (4,025), and family members/caretakers (9,315).

For more information, contact Cecilia Kwak, [email protected]

XI. CONCLUSION

This is the first time that information on integrating WASH and HIV has been systematically brought together to assist country-level programming. In the three years since the USAID/Hygiene Improvement Project began exploring this topic, many new activities that integrate WASH and HIV have evolved and are being documented and shared. This publication was developed to accelerate


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the process so that WASH becomes a routine part of HIV prevention and care and so that HIV considerations are automatically included in water and sanitation programs around the world. Water, sanitation, and hygiene are essential to living a dignified life. Yet the know-how and tools that make improved WASH practices possible are beyond the means of many people, especially those affected by HIV. In response to this reality, this resource represents a call to action for all WASH and HIV practitioners to work diligently to integrate these important health considerations and to document, share, and promote the experiences widely to enhance people’s lives. Annexes 1. Small Doable Actions chart 2. WASH Competencies for HBC workers 3. Job Aids

a. How to make a tippy tap b. How to use a bedpan c. Sanitation d. Menstrual period management e. Making a commode f. How to make a tippy tap g. Turning client h. How to wash hands i. WHO food safety flier

4. Full Literature Review 5. Resources


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Watsan into HIV programs draft document€¦ · diarrhea rates by 30 to 40 percent (Fewtrell 2005; Curtis 2003, Clasen 2007). Ensuring proper WASH practices benefits the entire HIV-affected