Prevention of\
Mother-to-Child\
Transmission of HIV

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Generic Training Package

# Trainer Manual {#trainer-manual .Cover-Name}

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WHO Library Cataloguing-in-Publication Data

World Health Organization.

> Prevention of mother-to-child transmission of HIV generic training
> package: trainer manual.
>
> 1.Acquired immunodeficiency syndrome - therapy 2.HIV infections -
> therapy 3.Disease transmission, Vertical - prevention and control
> 4.Teaching materials 5.Manuals I.Title.

ISBN 92 4 159204 4 (NLM classification: WC 503.2)

**© World Health Organization 2004**

All rights reserved. Publications of the World Health Organization can
be obtained from Marketing and Dissemination, World Health Organization,
20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax:
+41 22 791 4857; email: <bookorders@who.int>). Requests for permission
to reproduce or translate WHO publications--- whether for sale or for
noncommercial distribution--- should be addressed to Publications, at
the above address (fax: +41 22 791 4806; email: permissions@who.int).

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.**

The World Health Organization does not warrant that the information
contained in this publication is complete and correct and shall not be
liable for any damages incurred as a result of its use.

**Acknowledgment**

This package was prepared by the Department of HIV/AIDS, World Health
Organization (WHO) in collaboration with the United States Department of
Health and Human Services, Centers for Disease Control and Prevention
(HHS-CDC), Global AIDS Program (GAP), and is jointly published by WHO
and HHS-CDC. Tin Tin Sint (WHO) and Omotayo Bolu, Cristiane Costa,
Cheryl Mayo, and Andrea Swartzendruber (CDC) were the primary team
responsible for supervising the development and field testing of the
curriculum. René Ekpini and Isabelle de Zoysa (WHO) and Nathan Shaffer
(CDC) provided overall guidance and support for this project.

WHO and CDC would like to thank Matthew Chersich, Inam Chitsike, Halima
Dao, Ian Grubb, Peggy Henderson, Yvan Hutin, Rafael Lopezolarte, David
Miller, Nozighu Tatiana Ndondo, Kevin O\'Reilly, Constanza Vallenas and
Mayada Youssef Fox (WHO); George Bicego, Tracy Creek, Beth Dillon, Chris
Galavotti, Joan Kraft, Joel Kuritsky, Michelle McConnell, Dorothy
Mbori-Ngacha, Jan Moore, Serigne Ndiaye, Monica Nolan, Joseph Petraglia,
Rose Pray, RJ Simonds, Monica Smith (CDC); and Ellen Piwoz (AED) for
their review of draft materials. Acknowledgments are also due to Thurma
Goldman, from HHS-HRSA, and Estelle Quain (USAID) for their support and
to UNICEF and UNFPA for their technical contributions.

WHO and CDC would like to thank the Ministries of Health and the CDC/GAP
offices in Guyana, Ethiopia, Mozambique, and Cambodia for hosting the
field tests.

WHO and CDC would also like to acknowledge the significant contribution
of the François-Xavier Bagnoud (FXB) Center at the University of
Medicine and Dentistry of New Jersey, who led this project from initial
development through field tests and revisions along with JHPIEGO, an
affiliate of Johns Hopkins University, through the University Technical
Assistance Program (UTAP) with CDC. In addition to the curriculum
development role, the FXB Center provided essential support for overall
project coordination and final production of the training package. The
FXB Center group include Mary Boland, Virginia Allread, Karen Forgash,
Magaly Garcia, Nancy Lerner-Weiss, Nancy Paradis, Linda Podhurst, Anne
Reilly, Monica Reiss, Natalia Rivera, and Deborah Storm. JHPIEGO staff
who contributed to this project includes Jean Anderson, Linda Fogarty,
Emmanuel Otolorin, and Kai Spratt.

Table of Contents

**ABBREVIATIONS AND ACRONYMS** iii

**INTRODUCTION TO THE TRAINER MANUAL** v

**COURSE OVERVIEW AND INTRODUCTION** xii

**MODULE 1** **Introduction to HIV/AIDS**

Appendix 1-A WHO staging systems for HIV infection and disease in
adults, adolescents, and children 1-30

Appendix 1-B CDC AIDS surveillance case definitions for adolescents,

adults, and children 132

# MODULE 2 Overview of HIV Prevention in Mothers, Infants and Young Children

Appendix 2-A MTCT services for the woman who is HIV-2-infected 2--23

[]{.mark}

**Module 3** **Specific Interventions to Prevent MTCT**

Appendix 3-A Antiretroviral prophylaxis regimens to prevent MTCT 329

Appendix 3-B Clinical situations and recommendations for the use of
antiretroviral drugs in pregnant women and women of child-bearing
potential in resource-constrained settings 331

[]{.mark}

**MODULE 4** **Infant Feeding in the Context of HIV Infection**

Appendix 4-A UN infant-feeding recommendations for mothers who are

HIV-infected 427

Appendix 4-B Advantages of cup feeding 428

Appendix 4-C Feeding from 6-24 months 429

[]{.mark}

# MODULE 5 Stigma and Discrimination Related to MTCT 

Appendix 5-A Summary of the International Guidelines on HIV/AIDS and

Human Rights as adopted by the Second International

Consultation, July 2002 526

Appendix 5-B Guidelines for PLWHA panels 528

Appendix 5-C Sample question guide to be used with PLWHA panellists 530

Appendix 5-D Alternative exercise 5.3 531

[]{.mark}

**MODULE 6** **HIV Testing and Counselling for PMTCT**

Appendix 6-A Training, roles, and responsibilities of HIV counsellors
631

Appendix 6-B Talking with parents about their child's HIV test results
632

Appendix 6-C Basic counselling skills 634

Appendix 6-D Providing pre-test information, Exercise 6.3 636

Appendix 6-E Post-test counselling checklist, HIV-negative result 641

# Appendix 6-F Post-test counselling checklist, HIV-positive result 642

Appendix 6-G Role play scenarios for post-test counselling, Exercise 6.4
and counselling checklist 643

[\
\
]{.mark}

# MODULE 7 Linkages to Treatment, Care, and Support for Mothers and 

#  Families with HIV Infection

Appendix 7-A Tuberculosis (TB) 7--26

Appendix 7-B Community resource information worksheet 728

Appendix 7-C *Pneumocystis carinii* pneumonia prophylaxis in adults

and infants 729

Appendix 7-D Suggestions to maximise food intake for PLWHA 730

Appendix 7-E WHO immunisation recommendations 7--31

**MODULE 8** **Safety and Supportive Care in the Work Environment**

Appendix 8-A Guidelines for cleaning, sterilisation, and disposal of
infectious

waste materials 827

Appendix 8-B Managing occupational exposure to HIV 830

[]{.mark}

# MODULE 9 PMTCT Programme Monitoring

Appendix 9-A Examples of PMTCT performance indicators 916

Appendix 9-B Sample PMTCT columns to add to standard ANC and maternity

ward registers 917

**FIELD VISIT (OPTIONAL)** Field Visit-1

# GLOSSARY & RESOURCES

Glossary Glossary-1

Resources Resources-1

[]{.mark}

Abbreviations and Acronyms

**AIDS** Acquired immunodeficiency syndrome

**ANC** Antenatal care

**ARV** Antiretroviral

**ART** Antiretroviral therapy

**CDC** United States Centers for Disease Control and Prevention

**CMV** Cytomegalovirus

**ELISA** Enzyme-linked immunosorbent assay

**FAO** United Nations Food and Agricultural Organisation

**HAART** Highly active antiretroviral therapy

**HIV** Human immunodeficiency virus

**IMCI** Integrated management of childhood illness

**MAC** *Mycobacterium avium complex*

**MCH** Maternal and child health

**MTCT** Mother-to-child transmission of HIV

**NGO** Non-governmental organisation

**NVP** Nevirapine

**PCP** *Pneumocystis carinii* pneumonia

**PEP** Post-exposure prophylaxis

**PLWHA** People living with HIV/AIDS

**PMTCT** Prevention of mother-to-child transmission of HIV

**RCHS** Reproductive and child health services

**STD/I** Sexually transmitted disease/infection

**UNAIDS** Joint United Nations Programme on HIV/AIDS

**UNFPA** United Nations Population Fund

**UNGASS** United Nations General Assembly Special Session

**UNICEF** United Nations Children\'s Fund

**USAID** U.S. Agency for International Development

**VCT** Voluntary Counselling and Testing

**WHO** World Health Organization

**ZDV** Zidovudine, the generic name for azidothymidine (AZT)

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**Introduction to the Trainer Manual**

This Trainer Manual is designed to support the implementation of the
Prevention of Mother-to-Child Transmission of HIV (PMTCT) Generic
Training Course. The Trainer Manual contains the same material found in
the Participant Manual, supplemented with specific instructions for the
trainer.

**The Trainer Manual contains the following materials:**

-   Information on how to prepare, plan, and organise each module

-   Guidance about sections that might need to be customised or adapted
    for a specific region or country

-   Training tools and tips on scheduling, training activities, and time
    management

Keep the Trainer Manual with you each day for use as a reference, but
avoid reading directly from it during sessions.

Icon key

The Trainer Manual includes symbols (icons) in each section to direct
you in conducting the sessions.

  ------------------------------------------------------ -------------------------------------------------------------
  ![](media/image8.png){width="0.4395833333333333in"     Trainer Instructions: Notes specific trainer tasks
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  ![](media/image9.png){width="0.5291666666666667in"     Make These Points: Draws attention to key concepts for
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  ![](media/image10.png){width="0.44027777777777777in"   Clock: Sets estimated time needed for session
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  ![](media/image11.png){width="0.3in"                   Advance Preparation: Describes trainer preparation for the
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  ![](media/image12.png){width="0.5291666666666667in"    Pocket Guide: Refers the reader to material in the Pocket
  height="0.43333333333333335in"}                        Guide
  ------------------------------------------------------ -------------------------------------------------------------

Text that appears in the Participant Manual is surrounded with a dashed
border to help the trainer keep track of the materials available to the
learners.

Before you offer this course

Teaching the course

Familiarise yourself with the training package, described later in this
session, and review training guidelines. Ensure that trainers and
participants have clear and accurate expectations about the course.

Trainers play a unique role in helping their audiences confront the
dynamics of the HIV/AIDS epidemic. Although you might be an expert in
technical content and training, your role in this course extends beyond
lecturing or providing information. Trainers need to inform, support and
acknowledge implementation issues within the social and cultural context
of the existing training setting to ensure a successful experience for
all PMTCT training participants.

This section will review the principles of adult learning generally and
within the specific context of training to provide HIV/AIDS care.

Principles of adult learning

Principles to keep in mind when working with adult learners:

-   Create a supportive learning environment and establish safe training
    practices, eg, be sure that learners feel confident their
    contributions will be received respectfully.

-   Build trust with learners by demonstrating that you are equally
    committed to the course and are willing to share your own
    experiences.

-   Provide opportunities for learners to practise what they are
    learning and to address feelings and ideas that arise.

-   Build teamwork and a sense of group belonging by encouraging active
    participation.

-   Be accountable. Explain how you know what you know.

-   Create a culturally sensitive and respectful learning environment by
    becoming familiar with local customs and values.

The role of the trainer in adult learning

The trainer\'s role is to facilitate the learning experience of the
adult learner. To that end, you should create a climate in which
participants can accomplish course outcomes and explore participants\'
life experiences to help them to learn.

Trainer tips

-   Emphasise the immediate usefulness and applicability of material
    presented. Adult learners are particularly receptive to information
    that will make a difference in their daily practice.

-   Elicit personal experiences that are culturally sensitive and
    appropriate. Adult learners can bring a reservoir of experience to
    the course, and their contributions are an important resource for
    training programmes.

-   Encourage group interaction and participation early in each session.
    During the first day or two, interact at least once with each
    participant, and encourage them to interact with you.

-   Make an effort to learn participants\' names early on and to use
    their names whenever possible.

-   Instead of talking with other trainers during breaks, remain in the
    classroom and talk with participants.

-   Be available after each session to answer questions and discuss
    concerns.

-   Consult with participants throughout each presentation to gauge
    their comprehension and attentiveness. Generally, the more
    conversation and noise in a room, the less the participants are
    focused on the material. Pay attention to nonverbal cues to gauge
    learners\' attentiveness.

-   Praise or thank participants when they perform an exercise well,
    participate in a group discussion, ask a question or help other
    participants.

Strategies for educating adults

*Presentations and discussions*

Use didactic training methods (as directed on the following page) to
present scientific and technical content. Avoid reading directly from
the overheads or slides. Instead, supplement them with examples,
practical problems, and discussion questions. Elicit feedback from the
audience at critical junctures; encourage discussion.

*Role-plays*

Engage trainees in problem solving by having them act out situations
they are likely to encounter in real life. Role-playing can be scripted
or improvised.

*Small group discussions*

Facilitate small group discussions to foster team coherence. Those
discussions provide trainers with an opportunity to validate or modify
learners\' perceptions and knowledge.

-   Assign a topic, issue, or question that participants can address in
    small groups.

-   Designate a leader to facilitate and summarise the group\'s
    findings.

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-   Consider the task objective as you determine how to constitute
    groups. You might divide participants according to discipline
    (nurses or midwives) or by region (clinic X or clinic Y). If you
    want the groups split up randomly you could ask participants to
    count off by threes (or any small number); the first person is in
    group 1, the second is in group 2, the third is in group 3, the
    fourth is group 1 and so on.

*Storytelling*

Use culturally appropriate stories from learners to illustrate critical
points. Weave cultural beliefs and personal experiences into stories to
convey information vividly.

*Case studies*

Present culturally relevant, hypothetical clinical situations. Ask
learners to propose solutions.

*Interactive exercises and games*

Use interactive exercises to facilitate teambuilding and reinforce
learning.

-   Invite learners to consider a specific topic.

-   Pose questions, allowing time for learners to record their answers.

-   Encourage participants to discuss their answers and exchange ideas.

-   Record responses on the flipchart and encourage learners to respond
    to the group\'s feedback.

*Panel discussions*

Use panel discussions to help participants gain insight into the
physical, emotional, and financial impact of HIV/AIDS. Panels with
persons infected or affected by HIV can be a powerful tool for
influencing the attitudes and behaviours of healthcare workers. *Module
5: Stigma and Discrimination Related to MTCT* of the Generic Training
Package recommends utilising a panel of people living with HIV/AIDS as
one of the teaching methods. Other panels that may be considered for a
national curriculum include:

-   Healthcare workers panel: to share ideas for handling the emotional
    challenges of caring for patients with HIV infection.

-   Ministry of Health leaders and staff member panel: to provide
    information about national policies and strategies for fighting
    HIV/AIDS.

-   Nongovernmental organisation (NGO) employees panel: to share
    information about the important role of NGOs in providing PMTCT
    services and support for people living with HIV/AIDS (PLWHA).

The flow of training

*Flow and pacing*

Pay attention to the order and flow of activities to ensure that new
information is assimilated at an appropriate pace. Make sure that
learners complete the course with a clear action plan for applying their
knowledge.

*Didactic training*

Didactic training progresses from the simple to the complex. The trainer
first reviews and outlines fundamental concepts to establish a shared
understanding of the basics. New material is integrated gradually and
illustrated with practical examples when possible. Remember that
learners can absorb and integrate only five or six new pieces of
information at a time.

*Interactive/experiential learning*

In interactive or experiential learning, the trainer might start with a
group activity. The learners then use this new, shared experience as a
starting point for discussion.

Begin with a group activity or interaction. When the activity is over,
the group should share observations about the experience and examine
themes or patterns that have emerged. Focus on generalising, drawing
inferences from the shared experiences and linking to practice (the
"why" of learning). Training should focus on the practical application
of new insights, information, and skills.

\`

Trainer skills

Facilitating the group

A facilitator helps participants learn through individual and group
discussions. As a trainer, you are the facilitator.

You should be thoroughly familiar with module content. Preparation is
the key to conducting a successful training course. Complete the
following before starting each module:

-   Read module objectives and teaching exercises.

-   Prepare for each of the exercises.

-   Obtain and organise the materials needed.

-   Read the text and overhead materials.

-   Ensure that you understand all national/local policies; if the
    policies are not in the Participant Manual, have copies made for the
    participants.

-   Read and understand key points at the end of each module.

Responsibilities of facilitator include the following:

-   Introduce each module and key concept

-   Lead group discussions and training exercises

-   Answer questions

-   Explain ideas and clarify issues

-   Discuss how learners can apply the information to their own work

-   Give constructive feedback

You are encouraged to go beyond formal lecturing. It is your job to
answer questions, talk with participants about exercises, lead group
discussions and give participants any help they need.

Familiarity with the local cultural environment is essential to
effective group facilitation. Training strategies could require
modification to respect various cultural standards. For example, in some
countries, cultural norms dictate acceptable eye contact or physical
proximity of the trainer and learners.

Managing difficult participants

Throughout training, continually assess the interpersonal dynamics of
the group. Occasionally, the learning environment might be disrupted by
individual participants. A difficult participant might be overly
talkative or dominating in discussions. He or she could be determined to
play "devil\'s advocate" in every discussion or be disrespectful of
other participants and, as a result, other participants may be hesitant
to express themselves. Depending on the situation, the trainer should
address such behaviours either in public or privately. It can be helpful
to remind participants of the norms established at the beginning of the
programme and to reinforce the ground rules throughout the course.

Eliciting participation from all participants

HIV/AIDS is a controversial subject in many communities that is likely
to prompt fervent debate. To tackle key underlying issues and foster
discussion, the trainer should actively engage participants who express
disparate viewpoints. In some settings, the group might accept the
position or approach presented in the curriculum. In others, the group
could need additional time to reach consensus on complex issues.

Managing time

Times allocated for each session in the curriculum are guidelines only.
All of the curriculum content is important; however, the trainer should
acknowledge the particular needs, knowledge and experience level of the
group and make adjustments accordingly.

For example, in countries where infection control is taught and
principles applied routinely in clinical settings, there may be less
time required on specific sessions. Where information and assistance is
needed in application of infant-feeding recommendations, more time may
be necessary.

Each trainer may re-allocate time provided that the key concepts of each
module are addressed and the programme presented as a comprehensive
PMTCT package.

**Trainer preparation checklist**

**Daily preparation**

Each day arrive with enough time to set up the materials and equipment
and arrange the furniture and audiovisual equipment in a way that
fosters learning and teamwork. An informal arrangement is more
comfortable than an auditorium style, which creates a formal "lecture"
atmosphere.

Climate setting

Ensure that the physical environment is comfortable, well lit, and
adequately equipped. Create a psychological environment where learners
feel accepted, respected, and supported.

Room setup

Because this course uses a combination of didactic, interactive, and
experiential techniques, the classroom should have tables and chairs
that can be rearranged easily. For didactic presentations, the room
should be set up so that all participants can see the slides or overhead
projections. For interactive activities, more informal arrangements work
best. In either case, you might need to arrive early to organise the
room.

Goals and objectives

Review the course goals and objectives.

Course content

Review existing resources to ensure you have all background materials
related to the course content. Although you will not be able to answer
every question, try to master the curriculum content and related support
materials.

Course materials and teaching aids

Be sure that all educational materials (overheads, flipcharts, markers)
are available and that equipment is in good working order.

Course schedule

The course schedule is outlined in the Participant Manual and re-printed
below. It is recommended that each training day begin with a recap of
key points covered the previous day. This can be done in approximately
15 minutes. Strategies to review the previous day's learning points
might include:

-   The trainer presents yesterday's key points using a lecture and
    question/answer format. If possible write the key points on the
    board or flipchart paper in the morning before participants arrive.

-   Large group discussion---which the trainer may start by asking the
    group, "What were the most important points from yesterday's
    presentation?" The trainer should then add any additional key points
    that the group may have missed.

-   Small group discussion---trainees break into four small groups (or
    even pairs) and take five minutes to come up with the three most
    important points from yesterday's presentations.

    Once the key points have been summarised, ask trainees what
    questions they have from the material covered yesterday.

Course schedule

Although this PMTCT generic training programme was developed to be 6
days long including the optional field visit, it may be expanded or
shortened, depending on the target population's learning needs,
priorities, and resources. The syllabus for the generic course is
presented below.

**Course syllabus for PMTCT Generic Training Package**

+-----------------------+---+----------+----------------------------------+
| **Day**               | * |          |                                  |
|                       | * |          |                                  |
|                       | C |          |                                  |
|                       | o |          |                                  |
|                       | n |          |                                  |
|                       | t |          |                                  |
|                       | e |          |                                  |
|                       | n |          |                                  |
|                       | t |          |                                  |
|                       | * |          |                                  |
|                       | * |          |                                  |
+-----------------------+---+----------+----------------------------------+
| **Pre-course          |   | *        |                                  |
| session**             |   | *Opening |                                  |
|                       |   | Ceremony |                                  |
| (2 hours)             |   | and      |                                  |
|                       |   | Introdu  |                                  |
|                       |   | ctions** |                                  |
+-----------------------+---+----------+----------------------------------+
| **Day 1**             |   | #        | Introduction to HIV/AIDS         |
|                       |   | Module 1 |                                  |
|                       |   |          | Overview of HIV Prevention in    |
|                       |   | #        | Mothers, Infants, and Young      |
|                       |   | Module 2 | Children                         |
+-----------------------+---+----------+----------------------------------+
| **Day 2**             |   | #        | Specific Interventions to        |
|                       |   | Module 3 | Prevent                          |
|                       |   |          |                                  |
|                       |   | #        | MTCT                             |
|                       |   | Module 4 |                                  |
|                       |   |          | Infant Feeding in the Context of |
|                       |   |          | HIV Infection                    |
+-----------------------+---+----------+----------------------------------+
| **Day 3**             |   | #        | Stigma and Discrimination        |
|                       |   | Module 5 | Related to MTCT                  |
|                       |   |          |                                  |
|                       |   | #        | HIV Testing and Counselling for  |
|                       |   | Module 6 | PMTCT                            |
+-----------------------+---+----------+----------------------------------+
| **Day 4**             |   | #        | Linkages to Treatment, Care, and |
|                       |   | Module 7 | Support for Mothers and Families |
|                       |   |          | With HIV Infection               |
|                       |   | #        |                                  |
|                       |   | Module 8 | Safety and Supportive Care in    |
|                       |   |          | the Work Environment             |
+-----------------------+---+----------+----------------------------------+
| **Day 5**             |   | #        | PMTCT Programme Monitoring       |
|                       |   | Module 9 |                                  |
+-----------------------+---+----------+----------------------------------+
|                       |   | *        |                                  |
|                       |   | *Closing |                                  |
|                       |   | the      |                                  |
|                       |   | Course** |                                  |
+-----------------------+---+----------+----------------------------------+
| **Day 6**             |   | **Field  |                                  |
|                       |   | Visit**  |                                  |
| (Optional half-day    |   |          |                                  |
| session)              |   |          |                                  |
+-----------------------+---+----------+----------------------------------+

Endnote to Trainer Manual introduction

As a trainer, you are a facilitator of learning, not merely an
instructor. Encourage participants to identify their aims and objectives
for the course. As a trainer, you will help them accomplish those aims
and objectives. Remember that all members of the group respect and learn
from each other\'s unique skills, perspectives, and life experiences.

![](media/image7.png){width="1.0263888888888888in"
height="1.5798611111111112in"}

Course Overview and Introduction

![](media/image10.png){width="0.5597222222222222in"
height="0.5597222222222222in"} **Total Time:** 100 minutes

SESSION 1 Course Overview and Introduction

+------------------------------+----------------------------+---------+
| **Activity/Method**          | **Resources Needed**       | *       |
|                              |                            | *Time** |
+------------------------------+----------------------------+---------+
| Introduce course structure   | None, other than those     | 20      |
| and organisation             | listed below               | minutes |
|                              |                            |         |
| Review course syllabus and   |                            |         |
| give overview of materials   |                            |         |
+------------------------------+----------------------------+---------+

SESSION 2 Ice Breaker and Ground Rules

+------------------------------+----------------------------+---------+
| **Activity/Method**          | **Resources Needed**       | *       |
|                              |                            | *Time** |
+------------------------------+----------------------------+---------+
| Introduction Exercise 1:     | 12 x 20 cm (approximately) | 30      |
| "Getting to know each other" | cards or plain paper,      | minutes |
| card game                    | divided into three columns |         |
|                              | labelled: "Concerns,"      |         |
|                              | "Objectives," and          |         |
|                              | "Strengths"                |         |
|                              |                            |         |
|                              | Tape                       |         |
+------------------------------+----------------------------+---------+
| Explanation of anonymous     | Bowl or large manila       |         |
| question bowl or envelope    | envelope                   |         |
+------------------------------+----------------------------+---------+
| Introduction Exercise 2:     | Tape                       | 20      |
| Determining the ground rules |                            | minutes |
| for the course               |                            |         |
+------------------------------+----------------------------+---------+

SESSION 3 Pre-test (optional)

  ------------------------------- ----------------------------- ----------
  **Activity/Method**             **Resources Needed**          **Time**

  Explain and distribute course   Copies of the pre-test: one   30 minutes
  pre-test                        per participant               
  ------------------------------- ----------------------------- ----------

**For all sessions, also have available the following:**

-   Flipchart or whiteboard and markers or blackboard and chalk

-   Pencil or pen for each participant

SESSION 1 Course Overview and Introduction

  -------------------------------------- ------------------------------------------------------------
  ![](media/image11.png){width="0.6in"   Advance Preparation
  height="0.9395833333333333in"}         

                                         The trainer should be completely familiar with the course
                                         materials and be prepared to address participants'
                                         questions.
  -------------------------------------- ------------------------------------------------------------

  ----------------------------------------------------- ------------------------------------------------------------
  ![](media/image10.png){width="0.6263888888888889in"   **Total Session Time:** 20 minutes
  height="0.6263888888888889in"}                        

  ----------------------------------------------------- ------------------------------------------------------------

**After completing the overview and introduction, participants will:**

-   Understand the structure and organisation of the course.

-   Be acquainted with other participants in the course.

-   Verbalise concerns about HIV/AIDS in the healthcare setting.

-   Identify the ground rules for the course.

-   Complete the pre-test.

    *Note*: Whenever possible, conduct all of the sessions in the Course
    Overview and Introduction as part of the Opening Ceremony. If there
    is no Opening Ceremony, the Course Overview and Introduction may be
    incorporated into Day 1 of the training.

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image8.png){width="0.6131944444444445in"   Trainer Instructions
  height="0.5930555555555556in"}                       

  ---------------------------------------------------- ------------------------------------------------------------

Provide an overview of MTCT and PMTCT using the information below as a
guide. Discuss the course\'s function in the context of PMTCT (details
are provided below). This information may be presented by the trainer or
a guest speaker during the Opening Ceremony or it may be presented by
the trainer on the first day of training.

Background on mother-to-child transmission (MTCT) of HIV programmes

Of the 40 million people living with HIV/AIDS worldwide at the end of
2003, 2.5 million were children under age 15 years. Last year alone,
700,000 children were newly infected with the AIDS virus, or about 2,000
new infections in children each day. Most of these infections (90%)
occurred in sub-Saharan Africa. The most significant source of HIV
infection in children and infants is transmission of HIV from
mother-to-child during pregnancy, labour and delivery, or breastfeeding.
By integrating comprehensive Prevention of Mother-to-Child Transmission
(PMTCT) of HIV programmes---including prevention and treatment
interventions---as an essential part of maternal-child health (MCH)
programmes, the PMTCT programme may significantly reduce the number of
infants who are HIV-infected and promote better health for their mothers
and families.

Unprecedented commitment by international organisations and national
governments--- and the availability of effective short-course and longer
combination antiretroviral regimens---are now making effective national
PMTCT programmes possible, even in countries most burdened by the HIV
epidemic.

Because PMTCT programmes have broad access to the sexually active adult
population and address key issues of family health, they provide an
important foundation for national HIV prevention and treatment
programmes. Beginning with primary prevention, PMTCT programmes
recognise the importance of knowing one's HIV status and keeping
parents-to-be HIV-negative. Testing and counselling in antenatal clinics
and maternities allows for early identification of HIV infection. These
settings serve as a gateway to comprehensive PMTCT services, including
ARV treatment and prophylaxis, safer delivery practices, and safer
infant-feeding practices for mothers who are HIV-exposed and their
infants who are also HIV-exposed.

National scale-up

Pilot projects in multiple countries have demonstrated the feasibility
of implementing various PMTCT interventions, including ARV prophylaxis,
in resource-constrained settings. Most countries are now shifting from
pilot projects to national programmes and are integrating PMTCT
interventions as a component of standard antenatal care (ANC) and
maternal and child health (MCH) services.

There is an increasing range of PMTCT interventions, based on capacity
and policy at the country level. Policymakers must determine which PMTCT
programme interventions can be supported for national scale-up and
ensure that guidelines are in place to promote the success of
implementing the programme. A coordinated, national plan for building
capacity to train and strengthen maternal and child health services at
the local level will ensure beneficial outcomes for communities and the
people they serve.

International support

PMTCT remains central to global HIV/AIDS initiatives. Currently,
scale-up of PMTCT programmes is recognised as an important gateway for
scale-up of broader HIV prevention and care programmes. With the
commitment of the international community to increasing access to
treatment for persons living with HIV/AIDS, PMTCT programmes are seen as
a central rallying point for enhanced treatment, care, and support
services for women, their children, and families. This has resulted in
growing support for PMTCT and new international initiatives to combat
HIV/AIDS. The Global Fund for AIDS, TB and Malaria (GFATM) is providing
significant international support for HIV/AIDS country programmes. The
"3 by 5" World Health Organization (WHO)-led UNAIDS initiative aims to
treat 3 million people in developing countries by 2005. In addition, the
U.S.

government now offers unprecedented support in the fight against
HIV/AIDS with the President\'s Emergency Plan for AIDS Relief. The
Emergency Plan provides large-scale funding to treat 2 million people,
prevent 7 million infections, and provide care for 10 million people.

Key programme elements for all of these international efforts include
increasing access to HIV testing and counselling, strengthening
prevention interventions linked to treatment services, enhancing access
to PMTCT programmes, and fostering community participation.

Training and capacity development

To achieve their goals, the leaders of initiatives to combat HIV/AIDS
need to address the challenge of human capacity-building at all levels
of the healthcare system. Globally, up to 100,000 people need to be
trained for the \"3 by 5\" initiative to reach the target. Meeting that
training goal will require strong collaboration among communities,
nations, and international organisations.

The rapidly growing HIV/AIDS pandemic requires global and in-country
collaborative efforts to maximise the use of existing human resources
and develop strengthened human capacity. Training is a key part of this
strategy.

*This generic PMTCT training package is designed to provide a template
for the development of a national training plan and an appropriate
national curriculum, based on a rapid adaptation process. For countries
that already have begun PMTCT training and have draft materials, this
generic training package can be used to update and strengthen the
national training plan and curriculum. Providing appropriate information
and training for the cadres of healthcare workers at the provincial,
district, and local level is an important step for scale-up and
sustainability of PMTCT programmes.*

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image8.png){width="0.6131944444444445in"   Trainer Instructions
  height="0.5930555555555556in"}                       

  ---------------------------------------------------- ------------------------------------------------------------

Briefly introduce basic information about the course structure.

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image9.png){width="0.7597222222222222in"   Make These Points
  height="0.48680555555555555in"}                      

  ---------------------------------------------------- ------------------------------------------------------------

-   Ensure all participants are familiar with the syllabus. Note that
    the course is designed to span 6 days including the optional field
    visit. Reiterate key organisational and logistical details,
    including daily start times, end times, and breaks.

-   Stress the importance of group interaction and participation.

-   Ensure that participants understand the structure and purpose of all
    course materials. Point out that the Participant Manual includes an
    instruction sheet for each group activity. Explain that the support
    tools should serve as handy references for use in the healthcare
    setting.

-   Remind participants to bring the Participant Manual with them each
    day and to be prepared to use it throughout the course.

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image8.png){width="0.6131944444444445in"   Trainer Instructions
  height="0.5930555555555556in"}                       

  ---------------------------------------------------- ------------------------------------------------------------

Explain the key features of the course. Feel free to refer participants
to the following paragraphs in the Introduction to the Participant
Manual rather than covering them in detail.

Overview of the PMTCT generic training package

This training package is an evidence-based course on PMTCT and is
targeted to healthcare workers in resource-constrained settings. It is
intended to be one component of a training plan that reflects national
strategies--- including policies and priorities---for combating
HIV/AIDS.

The package content, provided in modular format, presents the basic
components of PMTCT programming. The time frames suggested for each
module are intended to be flexible to meet the requirements of each
country or region.

[]{.mark}

PMTCT refers to a comprehensive, family-centred spectrum of clinical and
supportive services---provided in conjunction with other public health
initiatives---to prevent the transmission of HIV from a woman to her
infant.

Development of the PMTCT generic training package

The development of this package involved several activities:

-   WHO conducted a systematic inventory of MTCT training materials,
    strategies, and plans for scale-up in East, Central, and Southern
    Africa.

-   In 2001, visits were made to review pilot project sites, training
    strategies, and scale-up plans. PMTCT trainers, staff from the
    Ministry of Health, national AIDS programme, local NGOs, and funding
    agencies provided valuable input.

-   In 2002, a WHO interregional workshop brought consultants together
    to arrive at a consensus on package components and implementation of
    training strategies, including in-country roles during the scale-up
    process.

-   In November 2002, WHO invited the U.S. Centers for Disease Control
    and Prevention (CDC) to collaborate on the development of a
    comprehensive training package.[^1] CDC asked two university
    technical assistance partners to help with the development of
    materials and field testing: the François-Xavier Bagnoud Center at
    the University of Medicine and Dentistry of New Jersey and JHPIEGO,
    an affiliate of Johns Hopkins University.

-   Field tests were conducted in Guyana, Ethiopia, Mozambique, and
    Cambodia to evaluate the package and gauge its adaptability for use
    in resource-constrained settings.

-   The package was reviewed by PMTCT and training experts from WHO,
    CDC, and country programmes.

-   The package will be updated on an ongoing basis to reflect the most
    current information from WHO and CDC about PMTCT.

Target audience

This training course is targeted to staff working in (or intending to
work in) PMTCT programmes or healthcare settings that provide PMTCT
services:

-   Doctors

```{=html}
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```
-   Nurses

-   Midwives

-   Social workers

-   Outreach workers

-   Counsellors

-   Programme managers

Every setting that provides PMTCT services can maximise the
effectiveness of their programmes by involving staff in specialised
training and encouraging other healthcare workers to expand their
existing knowledge, defining them as key members of the PMTCT programme
team.

Hands-on clinical training is strongly recommended. Where feasible,
complementary onsite or offsite clinical training---especially in HIV
testing and counselling and infant-feeding counselling---will greatly
improve the capacity of healthcare workers to use their new knowledge.

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image8.png){width="0.6131944444444445in"   Trainer Instructions
  height="0.5930555555555556in"}                       

  ---------------------------------------------------- ------------------------------------------------------------

As necessary, clarify terminology used in the course, as explained
below.

A word on terminology

In these course materials, the term "healthcare worker" is intended to
be synonymous with "healthcare provider." It includes all staff working
in the PMTCT service system (doctors, nurses, midwives, social workers,
outreach workers, counsellors, programme managers). "Maternal and child
health" (MCH) is used to refer to a variety of services, including\
maternal and newborn child health services and reproductive and child
health services (RCHS). MCH encompasses the system of treatment, care,
and support that aims to\
protect and improve the health of women of reproductive age and their
infants, as well as young and adolescent children, and families.

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image8.png){width="0.6131944444444445in"   Trainer Instructions
  height="0.5930555555555556in"}                       

  ---------------------------------------------------- ------------------------------------------------------------

Provide an outline of the course by reviewing the Participant Manual
with the group, pointing out the title of each module, the appendices
associated with each section, the overheads or slides, the Pocket Guide,
and the Wall Charts.

Expectations for the course

This course offers basic information and introductory skills development
in the following areas:

-   Module 1 Introduction to HIV/AIDS

-   Module 2 Overview of HIV Prevention in Mothers, Infants, and Young
    Children

-   Module 3 Specific Interventions to Prevent MTCT

-   Module 4 Infant Feeding in the Context of HIV Infection

-   Module 5 Stigma and Discrimination Related to MTCT

-   Module 6 HIV Testing and Counselling for PMTCT

-   Module 7 Linkages to Treatment, Care, and Support for Mothers and
    Families with

    HIV Infection

-   Module 8 Safety and Supportive Care in the Work Environment

-   Module 9 PMTCT Programme Monitoring

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image9.png){width="0.7597222222222222in"   Make These Points
  height="0.48680555555555555in"}                      

  ---------------------------------------------------- ------------------------------------------------------------

-   Clarify that the course will provide the knowledge and skills
    participants need to implement core PMTCT activities in an
    integrated manner.

-   Encourage participants to pursue further training in specific areas
    of interest.

-   Emphasise the importance of hands-on clinical training, whether
    onsite or offsite.

**This PMTCT training course is designed to provide healthcare workers\
with the information and introductory skills necessary to deliver core
PMTCT services in an integrated manner.**

Healthcare workers are encouraged to pursue additional training to
expand the expertise available in their region or facility.

There is no substitute for hands-on experience when providing both
clinical and social support. All participants are encouraged to view
this curriculum as providing a foundation\
on which to build and develop additional skills.

This can be done through specialised training in areas such as HIV
counselling, infant feeding, or networking within local communities.
Many of these skills require practise to develop proficiency and
participants can benefit by actively seeking opportunities for becoming
comfortable with all aspects of programme implementation.

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image8.png){width="0.6131944444444445in"   Trainer Instructions
  height="0.5930555555555556in"}                       

  ---------------------------------------------------- ------------------------------------------------------------

Provide an overview of the course materials and the use of the
Participant Manual as an ongoing reference throughout the course.

Structure of the training package

The training package, available in printed form and as a CD-ROM,
consists of the following components:

-   The **Training Programme and Course Director Guide** is divided into
    two sections. **Section 1: Training Programme Guide** is targeted to
    those with overall responsibility for developing the PMTCT National
    Training Plan, adapting the generic PMTCT curriculum, and developing
    the plan to evaluate training efforts. **Section 2: Course Director
    Guide** is a resource document targeted to the individual or team
    responsible for organising and conducting the PMTCT training
    courses.

-   The **Trainer Manual** outlines the entire curriculum, describes the
    trainer role in course planning, and offers the trainer directions
    to conduct each session.

-   The **Participant Manual** is the main reference document for course
    participants. It includes an Introduction; nine content modules,
    each with a summary; clearly stated objectives; technical
    information; and exercises. It also contains a **Glossary** and a
    **Resources Guide**.

-   The **Presentation Booklet** includes slides/overheads that
    summarise the main content areas of each module.

-   The **Pocket Guide** provides clear, concise information to support
    the delivery of\
    services and is a handy reference for healthcare workers.

-   The **Wall Charts** can be posted in the health centre or facility
    and are a reference on key PMTCT content areas.

SESSION 2 Ice Breaker and Ground Rules

  -------------------------------------- ------------------------------------------------------------
  ![](media/image11.png){width="0.6in"   Advance Preparation
  height="0.9395833333333333in"}         

                                         For Introduction Exercise 1: "Getting to know each other"
                                         card game, ensure there are enough cards or sheets of plain
                                         paper (approximately 12 x 20 cm) so that each participant
                                         receives one. Each card or sheet of paper should be divided
                                         into 3 columns: the first labelled "Concerns;" the second,
                                         "Objectives;" and the last, "Strengths."
  -------------------------------------- ------------------------------------------------------------

  ----------------------------------------------------- ------------------------------------------------------------
  ![](media/image10.png){width="0.6263888888888889in"   **Total Session Time:** 50 minutes
  height="0.6263888888888889in"}                        

  ----------------------------------------------------- ------------------------------------------------------------

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image8.png){width="0.6131944444444445in"   Trainer Instructions
  height="0.5930555555555556in"}                       

  ---------------------------------------------------- ------------------------------------------------------------

Discussing or teaching about HIV/AIDS can be difficult, and can trigger
feelings about a range of issues, including sexuality, illegal drugs,
stigma, fear, and distrust. Those issues are viewed within the context
of the cultural and religious beliefs of those who are affected and the
communities in which they live. Be aware that addressing HIV/AIDS in the
clinical setting may raise an even higher level of fear in healthcare
workers.

+---------+------------------------------------------------------------+
| !       | Trainer Instructions                                       |
| [](medi |                                                            |
| a/image | #                                                          |
| 8.png){ |                                                            |
| width=" |                                                            |
| 0.61319 |                                                            |
| 4444444 |                                                            |
| 4445in" |                                                            |
| he      |                                                            |
| ight="0 |                                                            |
| .593055 |                                                            |
| 5555555 |                                                            |
| 556in"} |                                                            |
+---------+------------------------------------------------------------+

Once you have completed the overview of the course and materials, it is
important to set the appropriate tone. Create an atmosphere in which
participants feel comfortable expressing fears and concerns.

Use the "Getting to know each other card game" to elicit introductions,
create a comfortable and non-threatening atmosphere, and confront
conflicting or inaccurate opinions.

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image9.png){width="0.7597222222222222in"   Make These Points
  height="0.48680555555555555in"}                      

  ---------------------------------------------------- ------------------------------------------------------------

-   Acknowledge that you realise that HIV/AIDS is a frightening disease
    for which science does not have all the answers. Doing so will give
    participants permission to share their own fears and concerns.

+-----------+----------------------------------------------------------+
| #         |                                                          |
| Introduct |                                                          |
| ion Exerc |                                                          |
| ise 1: "G |                                                          |
| etting to |                                                          |
|  know eac |                                                          |
| h other"  |                                                          |
| card game |                                                          |
+===========+==========================================================+
| **        | Explore participants' concerns about taking care of      |
| Purpose** | women with HIV Introduce objectives for this training.   |
|           |                                                          |
|           | Provide an opportunity to get to know each other.        |
+-----------+----------------------------------------------------------+
| **D       | 30 minutes                                               |
| uration** |                                                          |
+-----------+----------------------------------------------------------+
| **Intro   | Welcome participants to the training course and explain  |
| duction** | that this introductory exercise will help them to:       |
|           |                                                          |
|           | -   Explore their individual concerns as providers of    |
|           |     HIV/AIDS care                                        |
|           |                                                          |
|           | -   Establish their individual goals and objectives for  |
|           |     the course                                           |
|           |                                                          |
|           | -   Realise the value of their professions and           |
|           |     acknowledge the personal strengths they bring to     |
|           |     their work                                           |
+-----------+----------------------------------------------------------+
| **Act     | Distribute one card or sheet of paper to each            |
| ivities** | participant. Explain that they will not be collected.    |
|           |                                                          |
|           | Ask participants to spend 5 minutes thinking about the   |
|           | following questions and then to write their responses on |
|           | their card or paper.                                     |
|           |                                                          |
|           | -   *Concerns:* What concerns you about taking care of   |
|           |     women and children with AIDS?                        |
|           |                                                          |
|           | -   *Objectives:* What do you want to learn or take away |
|           |     with you at the end of the course?                   |
|           |                                                          |
|           | -   *Strengths:* What three strengths do you bring to    |
|           |     your work as a healthcare provider?                  |
|           |                                                          |
|           | While they complete their answers, write each question   |
|           | on a separate piece of flipchart paper and tape it to    |
|           | the wall, or divide the blackboard into sections and     |
|           | write one question at the top of each.                   |
|           |                                                          |
|           | Ask for responses and write each on the flipchart paper  |
|           | or blackboard. Allow for some discussion while           |
|           | documenting the concerns. Limit discussion about         |
|           | objectives; you will be discussing them later in the     |
|           | day.                                                     |
|           |                                                          |
|           | Discuss the participants\' strengths and the role they   |
|           | play in the care of women and children---with and        |
|           | without HIV/AIDS.                                        |
+-----------+----------------------------------------------------------+
| **Deb     | Acknowledge that many healthcare workers must confront   |
| riefing** | HIV/AIDS not only at work, but also at home and in their |
|           | communities. This training aims to support the           |
|           | participants in their efforts to cope with the           |
|           | wide-reaching impact of HIV disease.                     |
|           |                                                          |
|           | Validate the individual concerns they have as healthcare |
|           | workers in HIV/AIDS.                                     |
|           |                                                          |
|           | Acknowledge the importance of professional affirmation.  |
|           |                                                          |
|           | Support the strengths they bring to their work.          |
|           |                                                          |
|           | Close by affirming their experiences and by              |
|           | acknowledging that:                                      |
|           |                                                          |
|           | -   Healthcare workers often are insufficiently          |
|           |     recognised for their efforts and                     |
|           |                                                          |
|           | -   Busy schedules can prevent them from sharing their   |
|           |     time and ideas with colleagues.                      |
+-----------+----------------------------------------------------------+

+---------+------------------------------------------------------------+
| !       | **Trainer Instructions**                                   |
| [](medi |                                                            |
| a/image | Anonymous question bowl or envelope                        |
| 8.png){ |                                                            |
| width=" |                                                            |
| 0.61319 |                                                            |
| 4444444 |                                                            |
| 4445in" |                                                            |
| he      |                                                            |
| ight="0 |                                                            |
| .593055 |                                                            |
| 5555555 |                                                            |
| 556in"} |                                                            |
+---------+------------------------------------------------------------+

Some questions are difficult to ask in a group. Set up a question bowl
or envelope along with paper and a pen or pencil. Place those materials,
if possible, in an inconspicuous but accessible location. When
participants have a question that they do not want to ask in the group
setting, they can write it down and place it in the bowl or envelope.

Tell participants about the bowl, show them where it is, and invite them
to submit questions about HIV/AIDS at any time. Explain that the
questions may include concerns about themselves, their families,
co-workers, or patients.

Check the bowl each day before lunch and read the questions aloud to the
group. Explain that you will give the group time to think about the
questions and that after the afternoon break, you will ask for their
responses so the group can learn together. Set aside a few minutes after
the afternoon break to allow the participants to share their thoughts.

Ensure that participants leave the session knowing the correct answers
to the questions. If an incorrect or misinformed response is offered,
provide the correct answer in a clear but tactful way.

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image9.png){width="0.7597222222222222in"   Make These Points
  height="0.48680555555555555in"}                      

  ---------------------------------------------------- ------------------------------------------------------------

-   Explain that although the course is interactive, it can be difficult
    or uncomfortable to ask questions in the group setting. If a
    question concerns a topic that is to be covered later in the course,
    tell the participants that you will wait to address the question
    until that time.

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image8.png){width="0.6131944444444445in"   Trainer Instructions
  height="0.5930555555555556in"}                       

  ---------------------------------------------------- ------------------------------------------------------------

For participants to meet their expectations and the course objectives,
the group should establish standards for group interaction. Establishing
ground rules provides an opportunity for participants to discuss their
previous training experiences and to share examples of effective
approaches to training.

Facilitate the activity below to help the group establish ground rules
for the course and shared norms for conduct.

+------------+---------------------------------------------------------+
| # Introduc |                                                         |
| tion exerc |                                                         |
| ise 2: Det |                                                         |
| ermining t |                                                         |
| he ground  |                                                         |
| rules for  |                                                         |
| the course |                                                         |
+============+=========================================================+
| *          | Develop and agree on a set of ground rules that will    |
| *Purpose** | guide the development of an environment that            |
|            | facilitates learning.                                   |
+------------+---------------------------------------------------------+
| **         | 20 minutes                                              |
| Duration** |                                                         |
+------------+---------------------------------------------------------+
| **Intr     | We want to learn about national efforts to decrease     |
| oduction** | MTCT, but we also want to create a safe space for       |
|            | sharing what we have already learned: the successes and |
|            | failures, the sorrows and the joys. To do that, we need |
|            | to agree on some ground rules.                          |
|            |                                                         |
|            | Ask the group what ground rules would make them feel    |
|            | more comfortable about contributing to discussions.     |
+------------+---------------------------------------------------------+
| **Ac       | If the group is slow to offer suggestions, consider the |
| tivities** | following examples:                                     |
|            |                                                         |
|            | -   We will respect others, in our language, posture,   |
|            |     and tone of voice.                                  |
|            |                                                         |
|            | -   It is up to the individual whether he or she wants  |
|            |     to contribute during an activity.                   |
|            |                                                         |
|            | -   Participants will raise their hands to ask          |
|            |     questions or make comments.                         |
|            |                                                         |
|            | -   Anyone may contribute ideas, but the trainer may    |
|            |     set limits on speaking time.                        |
|            |                                                         |
|            | -   We will speak one at a time and avoid whispering or |
|            |     side conversations.                                 |
|            |                                                         |
|            | -   We will protect each other\'s confidentiality       |
|            |     ("What's said here, stays here.") and use general   |
|            |     rather than specific examples.                      |
|            |                                                         |
|            | -   Each member of the group will attend to his or her  |
|            |     own comfort needs (refreshment, restroom,           |
|            |     stretching breaks).                                 |
|            |                                                         |
|            | -   We will be on time for each session.                |
+------------+---------------------------------------------------------+
| **De       | Ask what other ground rules participants would like to  |
| briefing** | add to the list.                                        |
|            |                                                         |
|            | -   Make sure everyone agrees on the rules.             |
|            |                                                         |
|            | -   Write the rules and post them on the wall.          |
|            |                                                         |
|            | -   Keep the ground rules visible throughout the entire |
|            |     training course.                                    |
+------------+---------------------------------------------------------+

SESSION 3 Pre-test (optional)

  -------------------------------------- ------------------------------------------------------------
  ![](media/image11.png){width="0.6in"   Advance Preparation
  height="0.9395833333333333in"}         

                                         Review the pre-test to ensure that it is appropriate for the
                                         participants (not too difficult but not too easy). Make
                                         enough copies of the test for each person to have one. Have
                                         extra pens or pencils available.
  -------------------------------------- ------------------------------------------------------------

  ----------------------------------------------------- ------------------------------------------------------------
  ![](media/image10.png){width="0.6263888888888889in"   **Total Session Time:** 30 minutes
  height="0.6263888888888889in"}                        

  ----------------------------------------------------- ------------------------------------------------------------

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image8.png){width="0.6131944444444445in"   Trainer Instructions
  height="0.5930555555555556in"}                       

  ---------------------------------------------------- ------------------------------------------------------------

The overview and introduction will conclude with the pre-test.

Distribute the test to participants. Inform participants that the
post-test will include the same questions as the pre-test. Comparing the
answers to the pre- and post-test questionnaire will measure the changes
that occur in the group's (not an individual's) knowledge between the
beginning and the end of the course. The results will provide some
indication of whether the material and teaching methods have been
successful. This questionnaire will be re-administered just before the
closing session (as the post-test).

Keep track of the time. After 20 minutes, remind participants that you
will be collecting the tests in about 10 more minutes. Assure
participants that if they need more time, you will provide it.

Collect the completed tests (after about 30 minutes).

Thank participants and review the schedule for the following day.

Address questions or concerns about the course.

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image9.png){width="0.7597222222222222in"   Make These Points
  height="0.48680555555555555in"}                      

  ---------------------------------------------------- ------------------------------------------------------------

-   Tests will be anonymous.

-   Participants will be tested again after the course to measure how
    much the group learns. After the post-tests are collected (on the
    last day of training) the test questions will be reviewed.

-   Remind participants of the next session\'s starting time.

-   Remind participants to bring their Participant Manual to every
    session.

[^1]: A training package consists of a range of complementary components
    on a selected topic that serves as a resource for training. The
    components may include, for example, participant materials, slide
    sets, treatment guidelines, clinician support tools (eg pocket
    guide, wall charts), patient information materials, case studies,
    and trainer support materials.