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

![](media/image1.png){width="3.0902777777777777in"
height="4.768055555555556in"}

Generic Training Package

# Participant Manual {#participant-manual .COVER-SH1}

+---------------------+--------------+-----------------+--------------+
| ![](media/ima       | ![]          | ![](med         | ![           |
| ge2.jpeg){width="0. | (media/image | ia/image4.jpeg) | ](media/imag |
| 9701388888888889in" | 3.jpeg){widt | {width="1.05in" | e5.pct){widt |
| height="0.8         | h="0.7611111 | he              | h="0.8270833 |
| 666666666666667in"} | 111111111in" | ight="0.875in"} | 333333333in" |
|                     | height       |                 | height       |
| ## WORLD H          | ="0.89236111 |                 | ="0.84513888 |
| EALTH ORGANIZATION  | 11111112in"} |                 | 88888889in"} |
| {#world-health-orga |              |                 |              |
| nization .WHO-logo} |              |                 |              |
+---------------------+--------------+-----------------+--------------+

WHO Library Cataloguing-in-Publication Data

World Health Organization.

> Prevention of mother-to-child transmission of HIV generic training
> package: participant 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 159205 2 (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** v

MODULE 1 Introduction to HIV/AIDS

Appendix 1-A WHO staging systems for HIV infection and disease in
adults,\
adolescents, and children 114

Appendix 1-B CDC AIDS surveillance case definitions for adolescents,
adults,\
and children 116

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 214

MODULE 3 Specific Interventions to Prevent MTCT

Appendix 3-A Antiretroviral prophylaxis regimens to prevent MTCT 319

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 3-21

#  {#section .TOC-head}

# MODULE 4 Infant Feeding in the Context of HIV Infection {#module-4-infant-feeding-in-the-context-of-hiv-infection .TOC-head}

Appendix 4-A United Nations infant-feeding recommendations for mothers
who\
are HIV-infected 419

Appendix 4-B Advantages of cup feeding 420

Appendix 4-C Feeding from 6-24 months 421

MODULE 5 Stigma and Discrimination Related to MTCT

Appendix 5-A International Guidelines on HIV/AIDS\
and Human Rights 518

MODULE 6 HIV Testing and Counselling for PMTCT

Appendix 6-A Training, roles, and responsibilities of HIV counsellors
620

Appendix 6-B Talking with parents about their child's HIV test results
621

Appendix 6-C Basic counselling skills 623

Appendix 6-D Providing pre-test information, exercise 6.3 625

Appendix 6-E Post-test counselling checklist, HIV-negative result 630

# Appendix 6-F Post-test counselling checklist, HIV-positive result 631

Appendix 6-G Role play scenarios for post-test counselling, exercise 6.4
and

counselling checklist 632

MODULE 7 Linkages to Treatment, Care and Support for\
Mothers and Families with HIV Infection

Appendix 7-A Tuberculosis (TB) 7--14

Appendix 7-B Community resource information worksheet 716

Appendix 7-C *Pneumocystis carinii* pneumonia prophylaxis in adults and\
infants 717

Appendix 7-D Suggestions to maximise food intake for PLWHA 718

Appendix 7-E WHO immunisation recommendations 7--19

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

Appendix 8-A Guidelines for cleaning, sterilisation, and disposal of
infectious\
waste materials 818

# Appendix 8-B Managing occupational exposure to HIV: a sample protocol 821

[]{.mark}

MODULE 9 PMTCT Programme Monitoring

Appendix 9-A Examples of PMTCT performance indicators 911

Appendix 9-B Sample PMTCT columns to add to standard ANC and maternity\
ward registers 9-12

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

**GLOSSARY & RESOURCES**

Glossary Glossary-1

Resources Resources-1

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

**OI** Opportunistic infection

**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)

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

**Introduction:** Prevention of Mother-to-Child Transmission of HIV

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 15 years old. 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
of HIV (PMTCT) 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, initiatives to combat HIV/AIDS need to address
the challenge of human capacity building at all levels of the health
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 curriculum and training plan. Providing appropriate information
and training for the cadres of health workers at provincial, district,
and local level is an important step for scale-up and sustainability of
PMTCT programmes.*

Overview of the PMTCT generic training package

This training package is an evidence-based course on PMTCT and is
targeted to resource-constrained settings. It is intended to be one
component of a training plan that reflects the policies and priorities
of national strategies 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 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 for 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

-   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.

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.

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

**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 practice to develop proficiency and
participants can benefit by actively seeking opportunities for becoming
comfortable with all aspects of programme implementation.

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.

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    |   | and      |                                  |
| session)              |   | de-br    |                                  |
|                       |   | iefing** |                                  |
+-----------------------+---+----------+----------------------------------+

Ice Breaker and Ground Rules

+------------+---------------------------------------------------------+
| # Int      |                                                         |
| roduction  |                                                         |
| Exercise 1 |                                                         |
| : "Getting |                                                         |
|  to know e |                                                         |
| ach other" |                                                         |
|  card game |                                                         |
+------------+---------------------------------------------------------+
| *          | To explore concerns about taking care of women with HIV |
| *Purpose** | and objectives for this training and to provide an      |
|            | opportunity to get to know each other                   |
+------------+---------------------------------------------------------+
| **         | 30 minutes                                              |
| Duration** |                                                         |
+------------+---------------------------------------------------------+
| **Inst     | -   Review the card you have just received; the card    |
| ructions** |     has 3 columns labelled "Concerns," "Objectives,"    |
|            |     and "Strengths."                                    |
|            |                                                         |
|            | -   Think for a few minutes about your responses to     |
|            |     each of the following questions:                    |
|            |                                                         |
|            | > **Concerns**: What concerns you about taking care of  |
|            | > women or children with AIDS?                          |
|            | >                                                       |
|            | > **Objectives:** What do you want to ensure you learn  |
|            | > about PMTCT before the end of this course?            |
|            | >                                                       |
|            | > **Strengths:** What three strengths do you bring to   |
|            | > your work as a healthcare worker?                     |
|            |                                                         |
|            | -   Write your responses in the appropriate columns.    |
|            |                                                         |
|            | -   Share your responses in the large group discussion. |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| # Introduc |                                                         |
| tion Exerc |                                                         |
| ise 2: Det |                                                         |
| ermining t |                                                         |
| he ground  |                                                         |
| rules for  |                                                         |
| the course |                                                         |
+============+=========================================================+
| *          | To develop and agree on a set of ground rules that will |
| *Purpose** | guide the development of an environment that            |
|            | facilitates learning.                                   |
+------------+---------------------------------------------------------+
| **         | 20 minutes                                              |
| Duration** |                                                         |
+------------+---------------------------------------------------------+
| **Ins      | Participate in a discussion on the ground rules         |
| truction** | necessary to ensure a training environment that would   |
|            | make you feel more comfortable talking about the        |
|            | prevention of mother-to-child transmission of HIV.      |
|            | These ground rules will help guide the development of   |
|            | norms within this training.                             |
+------------+---------------------------------------------------------+

[^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.