TRAINING MANUAL ON REPRODUCTIVE HEALTH ...

TRAINING MANUAL ON REPRODUCTIVE HEALTH ADOLESCENCE SEXUALITY AND GENDER EQUALITY TO CAPACITATE Social Work TRAINEES IN INDIA

Editors Dr. Ameer Hamza Dr. R. Parthasarathy Dr. N. Janardhana Dr. Suchismita Mishra Mr. Dharma Reddy. P

TRAININGMANUAL

ISBN NO. NIMHANS Publication No. No of Copies:

1000

Year of Publication: 2014 Number of Pages:

© Indian Council of Medical Research Ansari Nagar, New Delhi. First Edition : 2014

Editor in Chief : Dr. Ameer Hamza Associate Professor Dept. of Psychiatric Social Work NIMHANS, Bangalore – 560029 E.Mail : [email protected] Ph: 080-26995237

Design and Printed by: Akshara Printers 54/4, Police station road Basavanagudi, Bangalore- 560 004 Ph: 080- 26624897

TRAININGMANUAL

ACRONYMS

AIDS

Acquired Immunodeficiency Syndrome

CBO

Community Based Organization

FGD

Focus Group Discussion

HIV

STD STI

RHS IUD

Human Immunodeficiency Virus Sexually Transmitted Disease Sexually Transmitted Infection Reproductive Healthcare Services Intra-uterine Device

PHC

Primary Healthcare Centre

ICRW

International Centre for Research on Women

SHG

Self - Help Group

NFHS

National Family Health Survey

LGBTQ

Lesbian, Gay, Bisexual, Transgender and Question

IEC

Information, Education, Communication

DLHS

District Level Household and Facility Survey

IMR

Infant Mortality Rate

LEB

Life Expectancy at Birth

MDG

Millennium Development Goals

APA

American Psychological Association

CSA

Child Sexual Abuse

NACP

National AIDS Control Programme

NACO

National AIDS Control Organization

UNESCO

United Nations Educational, Scientific and Cultural Organization

POSCO

Protection of Child from Sexual Offences Act

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FOREWORD The meaning of adolescence as a cultural construct has been understood in many ways, however, in general, it is the time of transition from childhood to adulthood. The nature of adolescence varies tremendously by gender, class, region and cultural context. In addition, several socio-economic and political forces rapidly change the way these young people must prepare for adulthood. These changes have enormous implications on their life during and after the adolescence, and neglect of these changes has impact on these people specifically and on the society as a whole. It is to be noted here that most of the problems and health risks faced by adolescents are preventable. Hence, promoting health, preventing health problems and responding to them when they occur are crucial. The professional Social Work practice towards accomplishing these tasks is extremely important and challenging. Social Work practice with adolescents involves dealing not just the adolescents, but also their families, schools/colleges and the society. Helping adolescents to confront adversity and develop mechanism to promote resiliency are critical. Hence, the Social Work professionals are to be empowered through the knowledge on adolescence and the problems of adolescents during their professional training, and hence appropriate culture-sensitive training material for the use by the teachers is the need of the hour. This manual is designed to provide Social Work teachers with guidance on how to train Social Work professionals. This manual is outcome of an ad-hoc project funded by the Indian Council of Medical Research. And it has been developed through a process of workshops and testing, with important inputs from professional Social Workers and Social Work teachers. It is my hope that this manual will gain wide acceptance and application, and that an improved knowledge and awareness of Social Work teachers and professionals on adolescent issues will contribute to the health and wellbeing of the adolescents.

Dr. Bontha V. Babu Scientist-F and Dep. Director General (Sr. Grade) Health Systems Research Division Indian Council of Medical Research New Delhi

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PREFACE Adolescence is a time of dynamic change – new feelings, physical and emotional changes, excitement, ambivalence and difficult decisions. Hence, at this stage of development, adolescents need information about their own sexuality, reproductive health and also look at gender equality so they develop skills to plan for a happy future. During this phase young people begin to have different relationships with family members, peers and opposite sex. Hence, they need to learn to manage their feelings and make responsible decisions about their reproductive health, sexuality and through the lens of gender. This manual titled, “Adolescence Sexuality, Reproductive Health and Gender Equality” helps to facilitate interaction between young people and adults on issues related to sexuality and reproductive health and gender equality. Reproductive health, sexuality and gender equality are interlinked and the practitioners need to understand the broad spectrum of these problems while working with adolescents. This manual is designed for Social Work practitioners, teachers, trainers, counsellors, Social Work students, NGO personnel, medical practitioners working with adolescents to promote reproductive and sexual health by addressing gender discrimination, sexuality, reproductive health, infant mortality, maternal mortality, sexually transmitted diseases, rights, abstinence and preventive behaviours, counselling skills thus facilitating decision making. This manual also empowers the adolescents from rights perspectives. This manual helps facilitators to examine their own values and attitudes towards sexuality, reproductive health and gender. The facilitators need to keep in mind about the culture of the adolescents that they are addressing. The overall design of this manual is to address young people since gender, sexuality and reproductive health is crucial in social and economic development of a country.

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ACKNOWLEDGEMENTS It is our duty to acknowledge all the individuals and the organizations those have contributed directly and indirectly to the development of this manual. It is the result of hard work, dedication and efforts of various people. Our special acknowledgement goes to Dr. Sangeeta Saksena, Founder, Enfold Proactive Health Trust, Bangalore who has given her valuable time to contribute to the entire manual. We express our deep sense of gratitude to Department of Health System Research, Indian Council of Medical Research (ICMR) for funding this project. We are greatly indebted to Dr. B.V. Babu, Scientist F, Department of Health System Research, ICMR for his continuous support thought out the project period. We would like to thank Prof. Satish P Chandra, Director, NIMHANS for his guidance and encouragement on all the aspects of this project. We also thank Dr. Sekar K, Professor and Head of the Department of Psychiatric Social Work, NIMHANS for his unconditional support towards the workshop and encouragement in preparing this manual. We thank Prof Jayashree Ramakrishna,Dept. of Mental Health Education : Prof Shobha Srinath, Dept. of Child and Adolescent Psychiatry : Prof. Prabha S Chandra , Dept. of Psychiatry NIMHANS, Bangalore for their valuable inputs. We express our sincere thanks to Ms. Sangamitra Iyengar, Director, Samraksha Dr. Sudeshna Mukherjee, Asst Prof, Centre for Women's Studies, Bangalore University for being resource persons in our workshops. We specially thank Prof.D.Muralidhar, Dept. of Psychiatry Social Work NIMHANS for his co-operation and contribution during the workshops. We greatly acknowledge Dr. A. Thirumoorthy, Dr. MN Vranda, Dr. Preethi, Dr. Gayathri, Dr. Priya Thomas Ms. Majula, Ms. Jasmine May John, Mr. Ragesh for their contribution as resource persons. We are grateful

to Prof. Parthasarathy , Prof. Muralidhar, Prof. Jayashree

Ramakrishna, Dr. A. Thirumoorthy, Dr. Ramachandra for the Content Analysis of the Manual We express our sincere gratitude to the practitioners, teachers and several others listed below for their inputs: TRAININGMANUAL

Dr. Maya Mascarenhas , Program Officer, MYRADA; Dr. Kavita Jangam Assistant Professor, Department of Social Work, NIMHANS, Bangalore; Dr. Diana Ross, Lecturer, Richmond Fellowship P G college for Psychosocial Rehabilitation; Dr. S. Ubahara Sahayaraj, Cohort Manager, Centre for Addiction Medicine, NIMHANS, Bangalore, Dr. Shreedevi, Assistant Professor, Richmond Fellowship P G college for Psychosocial Rehabilitation, Mr. Ragesh, Psychiatric Social Worker, Department of Social Work, NIMHANS, Bangalore, Ms. Tania Roy, Ph. D Scholar, Department of Psychiatric Social Work NIMHANS, Bangalore, Ms. Edwina Pereira Program Director (Training), INSA India; Ms. Sulekha, Director (continuum of care), Samraksha; Mr. Sudeep Joseph, Ph. D Scholar, Department of Psychiatric Social Work, NIMHANS, Bangalore, Mr. Suresha C

Jagruti, Bangalore ; Nanjundaswamy L. G.

Jagruti, Bangalore. We would like to thank Ms. Shilpa, Ms.Baseema, Ms.Reshma, Ms.Shari, Mr. Srinivas, Mr.Virupaksha, Mr. Manjunath, Ms. Gayathri, Ms. Tansa and Ms. Manju Prabhakaran, Ms. Lekshmi S. Menon from St. Joseph's College, Irinjalakuda, Kerala for their contribution in organising workshops. We thank all the Departments, NIMHANS for their support whenever it was required. We thank all the staff in Project section, NIMHANS for their invaluable support. We immensely thank artists Mr. Rajeev, Mr. Sripathi Achar and Photographers Ms. Lakshmi, Mr. Manja, Mr. Ravi from Department of Mental Health Education, NIMHANS, Bangalore for their significant contribution in bringing out pictures and photographs for the manual and workshops. We are also grateful to the students and authorities of

Dept. of Social Work, Lorven

College, Dept. of Social Work, CMR College, Dept. of Social Work, Kristu Jayanti College, Dept. of Social Work, Bangalore City College, Dept. of Psychiatric Social Work, LGB Regional Institute of Mental Health and Dept. of Social Work, Christ University for participation in the workshops. We are indebted to all the staff of Akshara Printers, Basavanagudi, Bangalore for their help in bringing out the manual beautifully.

EDITORS

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TABLE OF CONTENTS

INTRODUCTION

PAGE NO

1

a. Why this manual is developed b. Why this manual needs cultural sensitivity c. Who is the target group for this manual d. Aim of the manual e. Objectives of the manual

OVERVIEW OF THE MANUAL

2

METHODOLOGIES ADOPTED

3

HOW TO USE THIS MANUAL

3

WHO SHOULD USE THIS MANUAL

3

TRAINING MATERIAL

4

SELECTION CRITERIA FOR A FACILITATOR

4

MANUAL AT A GLANCE

5

SUGGESTED SCHEDULE

5

SESSION BRIEFS MODULE-1 REPRODUCTIVE HEALTH

5

Session 1: Conceptual Framework about Reproductive Health

6 8

Session 2: Realizing Reproductive and Sexual Rights Session 3: Getting Acquainted with the Policies , Programmes and Services

17

Related to Reproductive Health Session 4: Reproductive Health: Issues and Concerns

22

MODULE-2 ADOLESCENT SEXUALITY

28

Session 1: Understanding Adolescence Sexuality

42

Session 2: Adolescence In Transition

44

Session 3: Understanding Sexuality Session 4: Context of Expression of Sexuality

49 55

Session 5: Principles of Working with Adolescents

61

Counselling Skills with Respect to Mental Health Aspects TRAININGMANUAL

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MODULE - 3 GENDER EQUALITY

74

Session 1: Him and Her

77

Session 2: Women's Status

81

Session 3: The LGBTQ Community

87

Session 4: Institutional Mechanisms

92 100

Session 5: Engendering Development APPENDICIES APPENDIX - I

05

Pre and Post Questionnaire on Adolescence Sexuality, Reproductive Health and Gender Equality APPENDIX - II Multiple Intelligences

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INTRODUCTION WHY THIS MANUAL IS DEVELOPED Adolescents (10-19 years) constitute about one fourth of India's population (Ministry of Health and family welfare, 2009) and it is expected that this age group will continue to grow reaching over 214 million by 2020 (Karen Hardee, Pamela Pine and Lauren Taggart Wasson 2003). Within this paradigm of population and development related issues, the role of adolescents cannot be overlooked. The adolescence stage is believed as the formative years which offer an ideal window of opportunity for building the foundations of sexual and reproductive health. They have the right to become safe, informed and voluntary sexual and reproductive life where they can take their decisions in their lives. Gender discrimination is deeply rooted in our society and its effect on the sexual and reproductive health of adolescents. Hence, gender equality cannot be excluded while taking about sexual and reproductive health of adolescents. Adolescent's access to and use of existing health services is observed to be limited due to various reasons where cultural issues remains a major drawback. Health sector's response to address the health need of adolescents has been inadequate even though they require information and skills, health services and counseling as well as a safe and supportive environment for development. Hence, programmes and services must recognize their needs by considering their existing health status within their prevailing socio-cultural settings and vulnerabilities. WHY THIS MANUAL NEEDS CULTURAL SENSITIVITY In the Indian society, due to westernization, there is a growing concern about sexual promiscuity and changing attitudes toward sexuality. Most girls perceive menstruation as disgusting and as a curse (Gupta, 1998). He also emphasized that in most cases, their mothers are the only source of providing information related to menstruation. A study conducted by the State Education Resource Centre (SERC) in Uttar Pradesh established that gender equity was unknown and adolescent girls felt that they were a burden to their families and had poorer self-image while their counterparts felt superior (SERC, 1998). Adolescent girls are also at higher risk of psychosocial stress because of gender discrimination (Government of Rajasthan, 1995). In India, where talking about sexuality is considered as a taboo, it's difficult for adolescents in India to get the accurate information on sexuality and health care of any kind is hard to come as the adolescents are seen as essentially healthy and not in need of service. Those who seek sexual and reproductive health services often get judgemental health providers with little or no privacy. To make the adolescents aware about the sexual and reproductive health related information the culture and gender component should be added. Hence, we have developed a culture sensitive training manual on Reproductive Health, Adolescence Sexuality and Gender Equality.

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WHO IS THE TARGET GROUP FOR THIS MANUAL Every year nearly 16, 000 students complete their post graduation in Social Work and join the work force to meet the psychosocial needs of people in difficult situation. Some of these Social Workers would work with the children and the adolescents in helping them to deal with the difficulties and their health hazards but in the curriculum of master of Social Work course many aspects of adolescence sexuality, reproductive health and gender equality are not adequately covered. With their insufficient knowledge they may not be able to do justice for the professional activities after they complete their post graduation course where they are expected to cover the assignments on health, welfare, industry and allied fields where in these issues play a vital role. Keeping in view about the lacuna of the post graduate Social Work curriculum, this manual is developed for the faculty members, so that they can train their students. AIM To develop and test the training manual on Adolescent Sexuality, Reproductive Health and Gender Equality to capacitate the Social Work Trainees in India BROAD OBJECTIVES 1) To develop a culture sensitive training material to educate on reproductive health, adolescence sexuality and gender equality 2) To develop participatory training methodologies in areas related to reproductive health, sexuality and and gender equality 3) To test the manual by training 90 Social Work trainees on reproductive health, adolescence sexuality and gender equality 4) To develop a training manual on adolescence reproductive health, sexuality and gender equality and distribute manual copies to 400 schools of Social Work in India

OVERVIEW OF THE MANUAL The manual is prepared for the benefit of the Social Work students in India to impart the knowledge on reproductive health, adolescence sexuality and gender equality. It aims to develop culture sensitive training materials to educate adolescents about sexuality, reproductive health and gender equality. This manual has been prepared with the help of Social Work professionals from all over India. The Social Work professionals joined in a focus group discussion organized at NIMHANS, Bangalore and prepared the draft manual. The draft manual was again revised wherever it was required. This manual is designed and tested on Social Work students of Bangalore University. There are around 15 Social Work post graduate colleges in the Bangalore city. There are nearly 900 post graduate Social Work TRAININGMANUAL

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students studying in Bangalore. Six students from each college and total of 90 students were recruited for the training after obtaining the permission from 15 colleges. The training programme was planned for three days to test on 30 participants in each training programme. The first day training included module one i.e. Reproductive health, the second day module two i.e. adolescent's sexuality, third day module three i.e. Gender equity. The modules are modified according to the post graduate Social Work students’ comfort level, their understanding and requirements. The draft manual was again reviewed by a group of Social Work professionals from both governmental and non governmental organizations of Bangalore city in a two day programme. After their suggestions each module was modified according to the need.

METHODOLOGY ADOPTED The manual uses a mix method approach of participatory methodologies. The participatory training methodology is adopted to make the students aware about these three areas by involving them in the activities proposed by the faculties of Social Work from all over India. So that the students can get better knowledge and understand the manual properly. It will also help them to implement practically in their future studies. The manual employs small group discussions to encourage sharing and exchange of ideas between the participants, brainstorming to enhance understanding of related issues and facilitate opportunities for practical application of knowledge gained through small group discussions and case studies as per the demand of specific topics. The manual also has few audio visual presentations which helps the participants to understand different issues. The manual provides space for discussions and clarification of doubts.

HOW TO USE THIS MANUAL This manual is developed and designed as a training guide to help Social Work trainees in India on reproductive health, adolescence sexuality and gender equality. It builds information and skills related to adolescence's sexual and reproductive health where gender term cannot be excluded. This manual uses a gender sensitive and rights-based approach by keeping the cultural sensitivity term combinedly throughout the manual. The manual includes session-wise objective, methodology, duration of time, process (activities), materials to be used, facilitator's discussion, and expected outcome and fact sheet. The videos are enclosed in the form of CD. The videos are downloaded from You Tube Website. WHO SHOULD USE THIS MANUAL? This manual is to be used by the faculty members of Social Work post graduate college/institution. So that, while developing the curriculum for post graduate Social Work students the faculties can incorporate things from this manual. Hence, the direct beneficiaries of this manual are the faculties and indirectly the TRAININGMANUAL

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students of post graduate school of Social Work. The other people who can use this manual are medical practitioners/counsellors/trainers working on adolescence sexuality, reproductive health and gender equality. This manual can also help the NGO personnel working in these three areas to understand and apply the concepts related to adolescent population. HOW MANY DAYS SHOULD THE TRAINING BE ORGANIZED The manual is tested within three days (one day for each module approximately). TRAINING MATERIALS Try to use many different training materials when presenting the topic. Examples include: · Black/ white board

· Chalk pieces/markers · Flip chart papers/KG card sheets · Photographs or pictures

· Background materials · Audio Visuals

SELECTION CRITERIA FOR A FACILITATOR Facilitators are backbones of any training program. It is the responsibility of a facilitator to help a group of participants, understand their common objectives and achieve them during the given time frame. The trainer should have both subject knowledge and experience of training and teaching. He/she must have the experience of working with adolescents. The facilitator should have right skills and qualities which is one of the most critical factors in delivering the module successfully. The facilitator should have: · Good communication skills · Facilitation skills · Ability to manage conflict constructively · Ability to ask exploratory open-ended questions · Ability to encourage all participants to participate actively · Familiarity with experiential and participatory forms of learning · Basic knowledge of subject matter and competence to answer all questions related to the subject

matter · Gender sensitivity, commitment to gender equality and willingness to challenge one's own sexist TRAININGMANUAL

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attitudes and values · Sensitivity and openness to discuss topics such as sex and sexuality · Non-judgemental attitude towards adolescents and their issues

MANUAL AT A GLANCE Setting the context 1.1

Welcome and self-introduction

1.2

Expectations from the training and objectives

1.3

Ground rules

SESSION BRIEFS PRE-SESSION PROCESSES Preparation • Ensure that all arrangements are made and all the training material/equipments are ready for use. For example; check if adequate number of copies of the pre-test formats and flip charts are available • Check seating arrangements to ensure there is enough space for games and activities • Ensure logistics for drinking water, tea, snacks and lunch, etc and other arrangements • Select an appropriate icebreaker game and prepare material as required • Start the training programme at the stipulated time • Before the training, request all participants to fill the registration forms with all the required details • Distribute kits to all participants Pre/ Post-test Suggested time frame - 30 minutes Training material - Pre-test formats Pre-test format is a questionnaire given to participants at the beginning of the training. It contains objective type multiple choice questions related to the manual . The same sets of questions are also given at the end of the training programme as post-test. The difference in the scores that participants get in pre and post-test will indicate the effectiveness of the training and the level of knowledge that is transferred through the training (See the Appendix for Questions).

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Reproductive Health Module 1

2

3

4

Sangeeta Saksena , Jyothsna K.A. , Nisha Wagmare , Sreenivasa Reddy , 5

6

Sulekha , Ramakant Dubey , Nagaveni7

1. Founder, ENFOLD Proactive Trust, Bangalore 2. Visiting Faculty, Padmashree School of Public Health, Bangalore 3. Assistant professor, Walchand College of arts, Solapur, Maharastara 4. Associate Professor, S.K. University, Anantapur 5. Director, Continuum of Care, Samraksha NGO, Bangalore 6. Counsellor, SMC air force station Jalahalli, Bangalore 7. Psychiatric Social Worker, District Hospital, Bangalore

ReproductiveHealthModule

INTRODUCTION What is Reproductive Health? Reproductive Health is defined as “A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to reproductive systems and to its functions and processes”. This definition is taken and modified from the WHO definition of health. Reproductive health addresses the human sexuality and reproductive processes, functions and system at all stages of life and implies that people are able to have a “responsible, satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so”. Implicitly in this last condition, are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health care services that will enable women to go through pregnancy and child birth safely and provide couples the best chance of having a healthy infant”. Men and women have the right to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice that are not against the law. Furthermore, men and women should have access to appropriate health care services that will enable women to go safely through pregnancy and childbirth, as well as to provide couples with the best chance of having a healthy infant. Reproductive health is a universal concern, but is of special importance for women particularly during the reproductive years. However, men also demand specific reproductive health needs and have particular responsibilities in terms of women's reproductive health because of their decision-making powers in some reproductive health matters. Reproductive health is a fundamental component of an individual's overall health status and a central determinant of quality of life. Why is Reproductive Health important? Reproductive health is important for healthy social, economic, and human development. Individual reproductive health needs differ at each stage of life. Reproductive health is a crucial feature of healthy human development and of general health. It may be a reflection of a healthy childhood, is crucial during adolescence, and sets the stage for health in adulthood and beyond the reproductive years for both men and women. Reproductive life span does not begin with sexual development at puberty and end at menopause for a woman or when a man is no longer likely to have children. Rather, it follows throughout an individual's life cycle and remains important in many different phases of development and maturation. Reproductive health status may reflect cumulative effects and experiences that occurred in earlier life phases. What participants should get from this module? Participants will · Be familiar with concepts related to male and female reproductive anatomy · Learn functions of reproductive health/organs. · Create awareness about issues and concerns related to reproductive health TRAININGMANUAL

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· Develop understanding towards reproductive and sexual rights · Get acquainted with the policies, programmes and services

Topic

Objectives

Process

Structure and function of the reproductive system

· To generate awareness about reproductive anatomy and function

• • •

Realizing reproductive health: issues and concerns

· To enhance knowledge · Discussion and skill of the trainees in dealing Demonstration with reproductive health issues and concerns.

Rights and Challenges

· To sensitize the trainees to reproductive rights andexual s rights

Getting acquainted with policies, programmes and services related to reproductive healthcare

· To acquaint the trainees with the · Discussion availability and accessibility of existing re productive health care services, and policies and programmes related to reproductive health. · To enable trainees to explore youth friendly health care services

Brainstorming Film clips Discussion

· Lecture and discussion. · Case studies

SESSION-1 : REPRODUCTIVE HEALTH Learning objectives : To generate awareness about the structure and function of the reproductive system Duration: 2 hrs Materials to be used : Index Cards, Statement Sheet, Papers. Index cards with these words: Urethra, vagina, labia minora, labia majora, cervix, uterus, fallopian tube, ovary, clitoris, penis, scrotum, testis, vas deferens, seminal vesicle, prostate,Video clippings on female and male reproductive system Methodology : Ice Breaker Activity, Brain Storming, Discussion. Activity 1: (30 min) Ice breaker : • The facilitator provides all participants with an A4 sheet of paper and a pencil. Participants are TRAININGMANUAL

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asked to close their eyes and draw their body in as much detail as they can, filling in external and internal parts and organs. When the participants finish drawing, they can open their eyes. · The facilitator discusses what has been drawn and asks if any particular system or parts of the body were left

out. · Facilitator then uses the index cards and asks the participants to draw the organs named in the index card on

the back of the A4 sheet. · Participants are then asked to match their drawings with the male and female anatomy in the fact

sheet on reproductive health. Activity 2: Discussion on female and male reproductive functions using statements. (60 min) · The facilitator provides statement sheet on male and female reproductive system to all the participants. · The participants indicate whether they agree, disagree or are not sure about the statements by marking the

appropriate column. The time provided to them is 10 minutes. · Subsequently the facilitator discusses all the statements with the help of fact sheets provide to the

participants, addressing their attitudes and beliefs. After this all the worksheets have to be returned to the facilitator. STATEMENT SHEET

Statement 1

The menstrual cycle can be affected by stress and illness.

2

A girl should have menstruation every month otherwise ‘bad blood’ will collect inside and make her ill.

3

White discharge fro m the vagina makes a girl weak.

4

Size of the breast determines how much milk will be produced. Small breasts cannot produce enough milk for a baby.

5

A man may be producing semen but may be infertile.

6

Length of penis is important to ‘satisfy’ the sexual partner

7

One drop of semen is equal to 40 drops of blood TRAININGMANUAL

Agree

Disagree Not sure

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8

Scrotal temperature should be a little lower than the rest of the body for proper sperm production

9

Sex of the baby is determined by the chromosome carried by the sperm.

10

Pubic and maxillary hair must be removed to maintain hygiene

11

The egg cell dies if it is not fertilised within 12-24 hours after ovulation

Activity 3:Video clippings on female and male reproduction (15 min) · Video clips on the anatomy and functioning of the male and female reproductive system are shown to all the

participants. · The facilitator clarifies any queries related to this session.

Facilitator's Discussion: a. How do you feel about this session? Do you feel uncomfortable discussing reproductive function with

others? b. At what age should we discuss human reproduction with children? c. Do you think both male and female systems need to be understood by an adolescent? d. Do you think that some aspects were not addressed? If yes, kindly mention them.

Expected outcome: Trainees would be able to identify various parts of the male and female reproductive anatomies. The participants would gain scientific knowledge about reproductive health. Participants should be familiarized with the physical development that takes place during adolescence with emphasis on the reproductive anatomy. Fact Sheet Reproductive system Puberty Pubertal changes that result in a child becoming an adolescent and finally an adult begin around 8-10 years of age. Maturity of brain structures is reached by 22 years of age, though biological reproductive capacity is reached much earlier, with onset of menstruation in girls and production of semen in boys. In girls pubertal changes are heralded by breast growth which generally begins first anywhere between 8-13 years, followed by growth of maxillary and pubic hair (8.5 – 13.5 years of age). This is followed by the beginning of the growth spurt (10-12.5 years) Average age for onset of first menstruation is around 12.5 years. The normal range for onset of menstruation is 9-16 years . Adult height is generally reached by 15.5 years of age in girls. TRAININGMANUAL

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In boys, pubertal changes begin with increase in size of the testis between 9.5–13.5 years of age, followed by growth of pubic hair between 10–14 years age. Growth spurt begins by 14 years and is usually completed by 17 years of age. Female reproductive anatomy and function Following are the structural make up of the external genitalia: Clitoris : A pea sized structure, located in the soft folds of skin in front of a woman's vagina. It is richly supplied by nerves and blood vessels and it provides sexual pleasure. Urethra : Below the clitoris is the opening of the urethra, which is the passageway for urine from the bladder to the outside of the woman's body. The opening is a few millimetres wide. Vagina : Located behind the urethra, the vagina is a hollow organ with elastic walls that leads up to the womb. Its walls are collapsed normally, but can stretch to accommodate a tampon, a penis or a full-term baby. It receives a man's penis during sexual intercourse. It is also where tampons are inserted to absorb menstrual discharge. In normal delivery the baby passes from the womb to the outside through the vagina. Hymen: A thin membrane that stretches across the entrance of vagina. It has a perforation to allow menstrual flow out of the vagina. The elasticity and blood supply to the hymen varies. The shape and size of the opening in the membrane also varies from person to person. Actually, the hymen hardly exists in some women. In others it is very easily stretched. For some women in whom the hymen is still intact, first sexual intercourse may be uncomfortable. Labia : The clitoris, the urethral opening, and the vagina are surrounded by folds of soft skin - the labia minora (inner lips) and the labia majora (outer lips). Following are the structural make up of the female internal reproductive organs: · Cervix : The neck of the uterus, which is called the cervix, protrudes down into the upper end of the vagina.

It feels like the end of a nose with a dimple in it. The cervix is the entrance to the uterus and contains mucus producing glands. At the time of ovulation (release of ovum from the ovary) it produces fertile mucus which helps sperms travel easily through the cervical opening and into the uterus. At other times the cervix produces thick mesh like mucus which makes it hard for the sperms to travel into the womb. · Uterus : The uterus, also known as the womb, is a pear-shaped muscular organ in which the fertilised egg

grows and develops into a foetus. Normally, the uterus is about three inches long and two inches wide. During pregnancy, it stretches and grows with the foetus. In a pregnant woman, the lining of the uterus, called the endometrium, nourishes the foetus. · Fallopian tubes: It is about 10 cm long narrow soft tubes which stretch from the sides of the uterus to the

ovary on either side. These tubes help pick up the ovum after ovulation and propel it towards the uterus. Sperms travel up from the vagina, through the cervix and uterus to the tubes where fertilization occurs. The fertilized egg is propelled towards the uterus by the movements of muscles and cilia (fine hair like structures) in the wall of the tube. TRAININGMANUAL

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· Ovaries : One almond shaped ovary measuring 1 cm /2 cm/3 cm is present on either side of the womb.

Each ovary contains lakhs of immature ova at the time of birth of the female child. With onset of puberty the ovaries begin to develop the immature ova and make estrogen and progesterone hormones under the influence of the master gland – the pituitary and hypothalamus in the brain. Menstruation In women who are not pregnant, the lining of the uterus is shed about once a month. This shedding is called menstruation. Menstruation, often referred to as a 'period', comes about once a month for most women. Normal range is 21-35 days. In the beginning, periods may be irregular – once every three, four, five or six months. Gradually the body develops its own pattern of regularity. Menstrual flow lasts for two to seven days in most women. Menstrual cycle is calculated from the first day of bleeding to the first day of the next cycle. Regularity of the cycle can be affected by emotional stress or changes in diet or illness since any of these can affect the various hormones that control the cycle. Some women feel uncomfortable the first or second day of their periods, experiencing abdominal pain, bloating, constipation or breast heaviness and pain. For most women menstruation does not interfere with normal activity. The individual girl preparation for and attitude toward menstruation may be a factor in the amount of discomfort she feels. Premenstrual tension can also be produced by monthly changes in hormone levels. There may also be nutritional causes. Premenstrual tension can occur during the ten days before menstruation. Some women experience tension with symptoms such as fatigue, anxiety, irritability, headache, a feeling of puffiness in the pelvic region, craving for sweets, breast tenderness and depression. Exercise and a balanced diet are thought to help alleviate this syndrome. Menstrual hygiene: a) The pads or cloths or tampons used during menstruation should be changed at least every 6-8 hrs b) While bathing or after passing urine or stools, genitals should be cleaned from the front to the back. This direction of cleaning avoids contamination of urethra and vagina by stools. c) There is no medical or health reason to remove pubic or maxillary hair. Ovulation Connected by ligaments to the uterus are two ovaries, one on each side of the uterus. These are the organs that store egg cells. They also produce hormones that regulate the menstrual cycle and are responsible for the development of female secondary sexual characteristics like breast and wide pelvis. At birth, a girl's ovaries contain all the eggs shell ever have – about 400,000. However, shell probably use only about 400 of the eggs in her lifetime. The eggs or ova (which are about the size of a dot made by a sharp pencil) are among the largest cells in the human body During the first part of the menstrual cycle the pituitary gland in the brain secretes a hormone called Follicle Stimulating Hormone (FSH). This stimulates an ovary to develop a number of follicles. As the follicles are TRAININGMANUAL

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developing, they secrete an increasing amount of estrogen into the bloodstream. The estrogen then signals certain changes to occur. The uterine lining (endometrium) begins to build and the mucus producing glands in the cervix begin to secrete mucus. As oestrogen increases, the mucus becomes fertile, facilitating sperm travel through the cervical opening into the uterus and fallopian tubes. When estrogen reaches its peak level, the pituitary gland responds by sending out another hormone i.e. Luteinising Hormone (LH). LH causes one follicle (rarely, two) to develop fully and burst releasing the ovum from the ovary, a process called ovulation. Ovulation marks the beginning of the second phase of the menstrual cycle. It occurs 12 to 16 days before the next menstrual bleeding. The ovum dies if it is not fertilised within 12-24 hours after ovulation. Fertilisation occurs in the outer third of the Fallopian tube. If fertilisation does not occur, the ovum will dissolve and be absorbed by the body. The ovum carries 23 i.e. half the chromosomes of the woman. The ovum always carries an X chromosome. After ovulation, the ovary secretes progesterone along with more estrogen. The progesterone maintains the uterine lining. If fertilisation does not occur, the ovary stops producing oestrogen and progesterone after about two weeks. This decline in hormone levels signals the uterus to shed its lining. This is called menstruation. If fertilisation does occur, oestrogen and progesterone continue to be produced and the uterine lining is not shed. This lack of a menstrual period is usually the first signs that pregnancy has occurred. Menstrual flow consists of blood, mucus and fragments of lining tissue. This flow gradually comes out of the uterus through the vagina. Shortly afterwards, more egg follicles begin to develop under the influence of the pituitary gland and a new lining begins to build up in the uterus and the cycle starts all over again. The blood in the uterine lining nourishes the baby during pregnancy. In the absence of menstruation, the blood is shed along with the lining. It is not 'bad' 'dirty' 'unclean' or 'sinful' in any way. White discharge: Secretions from the reproductive tract come out as white discharge. It is not foul smelling and not irritating. It is normal and natural and does not cause weakness. This discharge is acidic in nature and tends to leave a stain on the undergarment. Infection is denoted by foul smell, change in colour of the discharge from whitish or greyish to yellow or green or red, itching and burning sensation around the vagina. Male reproductive anatomy Penis: The testicles and the penis are the external male sex organs. The penis is made up of spongy erectile tissue. Most of the time it is soft and limp but when a man becomes sexually excited, the penis stiffens and grows larger in width and length. An erect penis is about five to seven inches long and an inch to an inch-and-ahalf in diameter, regardless of its size in a normal (flaccid) state. The entire penis is highly sensitive, particularly the glans or head of the penis. The loose fold of skin around the glans is called foreskin. For hygienic reasons the foreskin should be pulled back a little and glans cleaned well while taking bath. Testicles: The testicles, which produce sperms and the hormone testosterone, are located in a wrinkled-looking pouch called the scrotum, which hangs behind the penis. Men have two testicles. The testicles contain hundreds of thousands of chambers where sperms are produced from puberty onwards. Pubertal changes in boys begin TRAININGMANUAL

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about 2 years later than in girls. Scrotum: The scrotum controls the temperature of the testicles. Scrotal temperature is about 1-2 degrees centigrade below body temperature. This is ideal for producing sperm. In warm weather, the scrotum becomes somewhat larger and limp to expose and cool a larger skin area. In cold weather, the scrotum contracts to conserve heat. Use of laptop computers, working for long periods in very hot conditions can raise scrotal temperatures. Men should use lose cotton undergarments. Vas Deferens: As sperms are produced, they pass through two fine tubes, each called a vas deferens. They carry the sperms to the urethra. The vas deferens is cut during vasectomy operation. Seminal vesicles: These are located behind the urinary bladder and produce seminal fluid. Their ducts open into the vas deferens. It is possible that a man may not be producing any sperms but would continue to make semen as well as the hormone testosterone. He would look and function like a normal male but would not be able to father children. Semen is the whitish fluid that carries the sperm and is ejaculated during intercourse. Each ejaculation contains from 100 million to 600 million sperm in about a teaspoon of fluid. Prostate Gland: This gland is present below the urinary bladder. After passing through the seminal vesicles, the vas deferens goes through the prostate gland where additional fluid is added to nourish the sperm. Then the vas deferens joins with the urethra. Urethra: It extends from the urinary bladder to the tip of the penis. Besides being the passage for urine, it allows passage of sperms through the penis to the outside of the body. Sperms are the microscopic male reproductive cells. They make up less than two percent of the total ejaculated semen. They are much smaller than the egg. Each has a head and tail, like a tadpole and carries half of a man's chromosomes. Half the sperms carry the X chromosome and half carry the Y chromosome. If a sperm carrying X chromosome fertilizes the ovum (which always has an X chromosome) a girl baby develops. If a Y chromosome fertilizes the ovum, a boy baby develops. When ejaculated during sexual intercourse, the sperms swim through the vagina, through the cervical opening into the uterus and on up into the Fallopian tubes. Sperms can live for six to eight hours in the vagina. Once they get up into the cervix, uterus or tubes they can live for three to five days. Of several hundred million sperm ejaculated, only about 2,000 reach the tubes. Even though the egg must be totally surrounded by sperm in order to be fertilised, only one sperm is actually able to penetrate it. The rest disintegrate. Male Circumcision is the removal of the hood of skin called the foreskin, which covers the end of the penis. Some religions prescribe circumcision, though it is not necessary for medical or health reasons. It does not interfere with the act of sex or pleasure derived from it. Female circumcision - removal of the clitoris – is practiced in some societies. This causes much scarring and disfiguration, making the sexual act painful and prevents the woman from experiencing sexual pleasure. Wet dreams, also known as seminal or nocturnal emissions in males, are erotic dreams that cause sexual TRAININGMANUAL

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excitement during sleep and lead to orgasm (climax). Because males ejaculate fluid during orgasm such dreams have come to be known as “wet dreams.” Females also have erotic dreams that can lead to orgasm. Wet or erotic dreams are common for both sexes at all ages and are normal and natural part of our body's sexual expressions. It is also common not to have wet or erotic dreams.

Male Reproductive Organs

Female Reproductive Organs

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Male sexual response Erection, Ejaculation and Orgasm When a male experiences sexual arousal, the brain secretes certain chemicals that cause dilation of blood vessels in the penis. As more blood flows into the penis, it becomes wider, longer and stiff and begins to point upwards. This is called erection. In this state the penis can penetrate inside the vagina. This is called penovaginal sex. With further stimulation, the muscles in the pelvic area and other parts of the body contract rapidly and rhythmically, resulting in ejaculation of semen from the penis. This is called orgasm. After ejaculation the release of chemicals from the brain stops and blood flow to the penis reduces. Slowly the penis returns to its normal flaccid state. For a variable time after ejaculation the male cannot experience another erection. Female Sexual Response During sexual arousal the brain releases chemicals which cause more blood to flow into clitoris and external genitalia. The clitoris becomes more prominent and sensitive. The glands present in the vulva (that is the external genitalia) secrete fluids that help in lubrication. In peno-vaginal sex, the penis penetrates through the hymen into the vagina. During male orgasm, ejaculation of sperms occurs in the upper part of the vagina. Female orgasm may or may not occur during peno-vaginal sex. Stimulation of clitoris or vagina or cervix can lead to orgasm during which muscles of the pelvic area contract rapidly and rhythmically. This also helps in drawing up sperms into the uterus. The orgasm is associated with an intense feeling of pleasure and satisfaction. Orgasm in women is slower to achieve and lasts longer as compared to male orgasm. Women can experience multiple orgasms. Contrary to common belief, female sexual pleasure does not depend on the length of the penis. Masturbation This is the process by which a person stimulates himself/ herself by touching the genitals to derive sexual pleasure and reach orgasm. It is a common, normal and natural practice and has been observed in many animals as well. Since no other person is involved there is no risk of HIV/STI or pregnancy. It does not result in weakness / infertility/ pimples etc. Semen is a natural body fluid like saliva or tears. It is not equal to any amount of blood. Sexual Acts Peno-vaginal sex is most commonly practised by heterosexual couples. While Peno-anal sex is mostly practised by male homosexual couples. It is associated with greater risk of bleeding and damage to anus, HIV transmissions and infections. Oral genital sex, often practised by couples, does not carry the risk of pregnancy. However, here, HIV and STI transmission can occur. Fertilization and pregnancy Fertilization is the union of a human egg and sperm, usually occurring in the outer third of the Fallopian tube. The result of this union is the production of zygote, or fertilized egg, initiating development of the baby. During a normal 28-day reproductive cycle, a woman's body releases a single egg from one of her ovaries. The TRAININGMANUAL

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egg travels down one of two fallopian tubes, where it can be fertilized by sperm – which can survive for 48 to 72 hours within the female body. If the sperm reaches and penetrates the egg, the couple's genes combine to create an embryo, and a new life begins. As the first few cells divide, the embryo travels to the uterus where it implants in the lining or endometrium, and begins to develop into an embryo. If fertilization doesn't take place, or if for some reason the embryo is unable to implant, the uterus lining is expelled from the body, leading to menstrual bleeding (the period). However, in case of fertilization the lining of the uterus gets thicker and the cervix is sealed by a plug of mucus. It will stay in place until the baby is ready to be born. Placenta is formed by the embryo to nourish the baby. It may normally take 2-3 weeks to detect pregnancy through clinical urine test. Pregnancy normally lasts for 40 weeks (counting from the first day of the last menstrual period) after which labour begins. The uterine muscle contracts rhythmically and intermittently, the cervix opens out and the baby slowly descends down the vagina to be born. The placenta is expelled within the next 15 minutes. Labour process normally takes around 16 -20 hours. Breast feeding should begin immediately after birth of the baby. Putting the baby to the breast in the first 30 minutes after birth helps milk production and ensures maximum benefit to the baby. Breast feeding should continue at regular intervals thereafter. The yellow colostrum produced in the first 3 days after delivery is essential for baby's health. Nothing else, not even water is required for the next 6 months. Amount of milk produced does not depend on the size of the breast. SESSION - 2: REALIZING REPRODUCTIVE RIGHTS Learning objective: To sensitize the trainees about the reproductive and sexual rights of an adolescent Duration: 80 Mins Materials to be used: White Board/ BlackBoard; Marker Pen /Chalk and Duster, Case Studies, Chart Paper Methodology : Brain Storming, Case Study and Discussion Process: Activity -1: · The participants are divided into two groups. One group is asked to brainstorm and come up with what they

think should be the reproductive rights of adolescents. The other group lists the sexual rights. Groups are given 15 minutes to do this. · The representative from each group presents their list. · The facilitator asks the participants to refer to the fact sheet on reproductive and sexual rights and then

discusses the same with the whole group. Facilitator explains the difference between reproductive and sexual rights. TRAININGMANUAL

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Activity -2: · The participants are divided into four groups. Each group is given one case study. · Each group lists the violations of the reproductive rights of the case given. They brainstorm about the

systems and services which would help adolescents achieve and protect their reproductive and sexual rights. · Presentations of all groups are followed by the comments and feedback from the facilitator

Case Study 1: Sanjeeta is a 16 years old girl living in a rural village. She is studying in class 9 and wants to continue her studies. A good marriage proposal comes and her parents are interested in arranging this marriage. She does not want to marry at this young age. But she is forced to get married. After her marriage she comes to know that her husband is addicted to alcohol. Even if she does not have any interest in sexual activities she cannot express her feelings to her husband. Two months after marriage she comes to know that she is pregnant. As she knows the hazards of early pregnancy she comes to a health worker to get her suggestions. Case study 2: Ramesh is a young boy aged 16 years. He is enticed by a 25 years old man in his neighbourhood and tricked into watching a pornographic film. Ramesh feels uneasy but can't get away. He tells the man but the man threatens him of dire consequences if he reveals this to anybody. The man continues to manipulate and blackmail Ramesh. Over a period of time Ramesh is forced to engage in sexual activities with the man. Ramesh is scared and begins to feel unwell – has fever, scary dreams and hardly goes out of the house. He has difficulty telling his family about these incidents. Case study 3: Radha is a housewife and lives in a joint family. Her husband is the only son of his parents. When she comes to know that she is pregnant she feels very happy. Their family members are also happy. But they want a boy child. They ask her to go to a private clinic and do a sex determination test. Although she is not in favour of this test she undergoes the test under pressure from her in-laws. She comes to know that it is a girl child. Her husband and inlaws start forcing her to undergo an abortion. Radha cannot imagine losing her child and wants to continue her pregnancy. She does not want to undergo an abortion. Case study 4 Joe is 15 years old. He is studying in 10th standard. Of late he is feeling nervous and anxious. His board examinations are approaching. Though good at studies he is scared he is going to fail. He masturbates on and off and starts thinking an elderly person say that God punishes those who masturbate. Joe is sure that God will punish him for this sin by causing him to fail in the board examinations. Facilitator's Discussion: 1. Have you experienced a violation of your rights? Would anyone like to share? 2. Do you know of any friend or family member whose rights were violated and she/he took steps to redress the same? Would anyone like to share? TRAININGMANUAL

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Expected outcome: Trainees should be aware of the reproductive rights and sexual rights. Trainees should be able to advocate and apply the reproductive rights and sexual rights in their personal as well as professional life. Trainees should be able to disseminate the information related to reproductive and sexual rights to the community. Fact Sheet Introduction: About 315 million people in India—nearly one-third of the country's population—are young people aged 10–24 (RGI 2001). REPRODUCTIVE RIGHTS AND SEXUAL RIGHTS OF ADOLESCENTS A right is something that an individual or a population can legally and justly claim. For instance, individuals can claim equality within a population or such civil liberties as the right to vote. Reproductive rights include rights specific to personal decision-making and behaviour in the reproductive sphere, including access to reproductive health information, guidance from a trained professional and reproductive health service. In addition to rights established within individual countries, major international conventions have articulated reproductive rights, including those that are specific to adolescents. These policies provide the basis for the following rights:

Sexual Rights

Reproductive Rights

The right to sexual pleasure without fear of infection, disease, unwanted pregnancy or harm

The right to the highest attainable standard of health The right to life and survival

The right to sexual expression and to make sexual decisions that are consistent with one’s personal, ethical, and social values The right to sexual and reproductive health care, information, education, and services The right to bodily integrity and the right to choose if, when, how and with whom to be sexually active and engage in sexual relations with full consent

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The right to liberty and security of the person The right to health, reproductive health and family planning The right to decide the number and spacing of children and to have the information and means to do so The right of women to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free from coercion, discrimination, and violence 1 19


The right to enter relationships, including marriage, with full and free consent and without coercion

The same right of men and women to marry only with their free and full consent

The right to privacy and confidentiality in seeking sexual and reproductive health care services

The right to privacy The right to education ,participation, access to information

The right to express one’s sexuality without discrimination and independent of reproduction

The right to be free from discrimination on specified grounds

Source: Health, Empowerment, Rights and Accountability (HERA) International Women’s Health Coalition

The right to be free from practices that harm women and girls and not be subjected to torture or other cruel, inhuman, or degr ading treatment or punishment The right to be free from sexual violence

The Medical Termination of Pregnancy Act (MTP) 1971: An estimated three million girls aged 15-19 undergo unsafe abortions every year (WHO, 2013). This Act provides for termination of certain pregnancies (abortion) by registered medical practitioners and for matters connected therewith or incidental thereto. MTP Act provides the right to safe abortion to women under certain situations. PNDT Act: Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act, 1994 was enacted by the Parliament of India to stop female foeticides and arrest the declining sex ratio in India. The act banned prenatal sex determination. Types of Birth Control Methods The various contraceptive methods listed below are to be adopted by a person or couple after discussion of the advantages and disadvantages, indications and contraindications of each method with a health care provider. Continuous abstinence: This means not having sex at any time. It is the only sure way to prevent pregnancy and protect against sexually transmitted infections (STIs), including HIV. Natural family planning/rhythm method: This method is when a woman does not have sex on the days she is most fertile (most likely to become pregnant). A woman who has regular menstrual cycles have about 9 -14 days each month when she is fertile. These fertile days are about 5 days before and 3 days after ovulation, and the day of ovulation. Normally ovulation occurs 14 days before the next menstrual period. Cervical mucus test and body temperature can also be used as guides to fertile days. This method has a high failure rate of 24 pregnancies per 100 women in a year. In a 28 day cycle, the fertile period lasts from day 8 to almost day 21 – almost two weeks. She is unlikely to conceive for the first Seven days of the cycle (these Seven days include the TRAININGMANUAL

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days that she is menstruating) and the last Seven days before menstruation begins. Contraceptive sponge: This barrier method is a soft, disk-shaped device with a loop for taking it out. It is made out of polyurethane foam and contains a spermicide nonoxynol-9. Spermicide kills sperm. Before having sex, the wet sponge is placed, loop side down, deep inside the vagina to cover the cervix. The sponge is effective for more than one act of intercourse for up to 24 hours. It needs to be left in for at least Six hours after having sex to prevent pregnancy. It must be taken out within 30 hours after it was inserted. It has a failure rate of 12-24 pregnancies per 100 women in a year. Barrier methods : Diaphragm, cervical cap, and cervical shield: These barrier methods block the sperm from entering the cervix and reaching the egg. The diaphragm is a shallow latex cup. The cervical cap is a thimble-shaped latex cup. The cervical shield is a silicone cup that has a one-way valve that creates suction and helps it fit against the cervix. All three barrier methods must be left in place for 6 to 8 hours after having sex to prevent pregnancy. The diaphragm should be taken out within 24 hours. The cap and shield should be taken out within 48 hours. They have a failure rate of 9-10 pregnancies per 100 women in a year. Female condom: This condom is worn by the woman inside the vagina. It prevents the semen from falling in the vagina. It is made of thin, flexible, manmade rubber and is packaged with a lubricant. It can be inserted up to 8 hours before having sex. Use a new condom for each intercourse. Do not use it along with male condom at the same time. Failure rate is about 20 pregnancies per 100 women in a year. Male condom: Male condom is a thin sheath placed over an erect penis to prevent sperms from entering a woman's body. Condoms can be made of latex or polyurethane. Condoms work best when used with a vaginal spermicide, which kills the sperm. A new condom should be used for each sexual act. Failure rate is about 18% per 100 women in one year. Hormonal methods : Oral contraceptives — combined pill ("The pill"): The pill contains the hormones estrogen and progestin. It is taken daily to keep the ovaries from releasing an egg. The pill also causes changes in the lining of the uterus and the cervical mucus to keep the sperm from joining the egg. Some women prefer the "extended cycle" pills. These have 12 weeks of pills that contain hormones (active) and 1 week of pills that don't contain hormones (inactive). While taking extended cycle pills, women only have their period three to four times a year. Failure rate in typical use is 2-8% per 100 women in a year. Women should wait three weeks after giving birth to begin using birth control pills that contains both estrogen and progestin. These methods increase the risk of dangerous blood clots that could form after giving birth. The failure rate is 0.3% as commonly used and only 0.1% on correct and consistent use. Shot/injection: A high dose of the hormone progestin is injected in the buttocks or arm every 3 months. A new type is injected under the skin. The birth control shot stops the ovaries from releasing an egg in most women. It also causes changes in the cervix that keep the sperm from joining with the egg. The shot should not be used more than 2 years in a row because it can cause a temporary loss of bone density. The loss increases the longer this method is used. The bone does start to grow after this method is stopped. But it may increase the risk of fracture and osteoporosis if used for a long time. Failure rate is six pregnancies per 100 women in a year. Vaginal ring: This is a thin, flexible ring that releases the hormones progestin and estrogen. It works by stopping the ovaries from releasing eggs. It also thickens the cervical mucus, which keeps the sperm from joining the egg. The ring is pressed between the thumb and index finger and inserted into the vagina. It is worn TRAININGMANUAL

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for three weeks and taken out for one week to allow menstruation. After the fourth week a new ring is worn. Failure rate is 9%. Implantable devices: This is a matchstick-size, flexible rod that is put under the skin of the upper arm. The rod releases a progestin, which causes changes in the lining of the uterus and the cervical mucus to keep the sperm from joining an egg. Less often, it stops the ovaries from releasing eggs. It is effective for up to three years. Failure rate is 0.05% Intrauterine devices: Copper IUD —This T shaped device is inserted into the uterus. It releases a small amount of copper continuously, which prevents the sperm from reaching and fertilizing the egg. If fertilization does occur, the IUD keeps the fertilized egg from implanting in the lining of the uterus. A doctor needs to put in the copper IUD. It can stay in the uterus for 5 to 10 years. Failure rate is 0.8% per year. Hormonal IUD —This intrauterine device releases progestin into the uterus, which keeps the ovaries from releasing an egg and causes the cervical mucus to thicken so that sperms can't reach the egg. It also affects the ability of a fertilized egg to successfully implant in the uterus. A doctor needs to put in a hormonal IUD. It can stay in the uterus for up to 5 years. Failure rate is 0.2% per year. Permanent birth control methods : Sterilization implant: Essure is a non-surgical method of sterilizing women. A thin tube is used to thread a tiny spring-like device through the vagina and uterus into each fallopian tube. The device works by causing scar tissue to form around the coil. This blocks the fallopian tubes and stops the egg and sperm from joining. It can take about three months for the scar tissue to grow, so it's important to use another form of birth control during this time. Then the person has to return to the doctor for a test to see if scar tissue has fully blocked the tubes. Surgical sterilization: For women, surgical sterilization blocks the fallopian tubes by cutting, tying or sealing them. It stops the egg and sperm from meeting in the tube. It is a major surgery and requires hospitalization. Sometimes, a woman having caesarean birth has the procedure done at the same time, so as to avoid having additional surgery later. For men, having a vasectomy keeps sperms from reaching the penis, so the ejaculate never has any sperm in it. A small cut is made in the upper part of the scrotum and the vas deferens is cut. It is an outpatient procedure, quick and safe. Sperms stay in the remaining portion of the vas after surgery for about 3 months. During that time, a backup form of birth control should be used to prevent pregnancy. After three months semen analysis is done to check if all the sperms are gone. Failure rates are 0.5% for female sterilization and 0.15% for male sterilization. Emergency contraception: Emergency contraception can be taken as a single pill treatment or in two doses 12 hours apart. The pills contain a high dose of hormones. It works by stopping the ovaries from releasing an egg or keeping the sperm from joining with the egg or preventing implantation of the fertilized egg. The pill should be taken as soon as possible after unprotected sex, or within 72 hours after having unprotected sex. Failure rate is around 6-10% SESSION - 3: GETTING ACQUAINTED WITH THE POLICIES, PROGRAMMES and SERVICES RELATED TO REPRODUCTIVE HEALTH CARE Learning objectives: · To learn about the policies and programmes related to reproductive health care services. · To acquaint the trainees about the availability and accessibility to existing reproductive health care services TRAININGMANUAL

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including the youth friendly health care services Duration: 50 Mins Materials to be used : White Board/Blackboard, Marker Pen and Duster/Chalk, Methodology: Case Study Discussion and Illustrative Lectures Process: Activity 1: Group Discussion · The facilitator divides the participants into three groups and assigns a programme to each group. The group

brainstorms and develops the program assigned to them. 1) Develop a programme for adolescents of India 2) Develop a programme for unwed mothers in India 3) Develop a programme for pregnant women in India · 15 minutes are given for this activity. The representative of each group presents the developed programme

and describes its details. · The facilitator clarifies any queries related to the topic and highlights the various programs and policies

available for adolescents Facilitator's Discussion: · Are you aware of these services? · Do you know where you can avail them in your locality? · Have you or anyone you know, used these services? What was your / their experience? Expected Outcome: Trainees are oriented with policies, programmes and existing health care services in India. The participants will be able to prompt the utilization of these services. Trainees will gain insight into how the policies and services are developed and the need to develop linkages with health care providers. Fact Sheet Reproductive health promoting programmes and policy in India India is committed to promoting and protecting the sexual and reproductive rights of adolescents and youth through its policies. These policies and programs recognize that reproductive rights of adolescents require urgent attention. Various policies and programs are detailed below  The National Population Policy 2000: Emphasis is on making sexual and reproductive health information, and counselling services available and easily accessible to adolescents at an affordable rate. It also underscores the need to “strengthen primary health centres and sub-centres to provide counselling, both to adolescents and also to newly-weds”. The Policy advocates use of special programs to delay age at marriage TRAININGMANUAL

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and to enforce the Child Marriage Restraint Act 1976.  The National AIDS Prevention and Control Policy 2002: It gave special attention to HIV infection and safer sex practices among youth (NACO 2002). Indeed, one of the stated objectives of the Policy is to spread information among “students, youth and other sexually active sections to generate greater awareness about the nature of its transmission and to adopt safe behavioural practices for prevention” through programmes designed especially to meet their needs.  The National Policy on Education- 1986: It emphasizes that educational programme should actively motivate and inform youth about family planning and responsible parenthood. It also stresses the need to reduce gender imbalances in school attendance and completion (MOHRD 1998). The National Policy for the Empowerment of Women 2001 identifies adolescent girls as a vulnerable group and highlights the need to address their education and nutrition needs at the same time it recognises the need to raise age at marriage and address gender-based violence (MOWCD 2001). The National Health Policy 2002 also recognises the need to address nutritional deficiencies in women and girls, and to raise awareness among school and college students about health promoting behaviour (MOHFW 2002). Adolescent Health Programs: Kishori Shakti Yojana: This programme is a key component of ICDS scheme which aims to empower adolescent girls. Adolescent girls who are unmarried and belong to families below the poverty line and school drop-outs are attached to the local Anganwadi Centres for six-months of learning and training activities. Scheme- I (Girl to Girl Approach): This scheme is for girls aged 11-15 years and belonging to families whose income level is below Rs. 6400/- per annum Scheme-II (Balika Mandal): This scheme is for girls aged 11-18 years irrespective of income levels of the family. Objectives of the program: • To improve nutritional and health status • To provide required literacy and numeracy skills through non-formal stream of education • To stimulate a desire for more social exposure and knowledge and to help them improve their decision making capabilities • To train and equip the adolescent girls to strength/ upgrade home-based and vocational skills • To promote awareness of health, hygiene, nutrition and family welfare, home management and child care • Measures to facilitate their marriage only after attaining the age of 18 years and if possible, even later • To gain a better understanding of their environment related social issues and its impact on their lives • To encourage adolescent girls to initiate various activities to be productive and useful members of the society TRAININGMANUAL

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• IFA supplementation along with deworming • Education for school dropouts and functional literacy among illiterate adolescent girls • Non-formal education to adolescent girls. Emphasis is on life education aspects including physical, developmental and sex education. Implementation of Kishori Shakti Yojana At Anganwadi Centres, a group of 20-25 girls are identified by a supervisor (Mukhya Sevika).Two girls are nominated from any anganwadi centre and sent to the Office of District Programme Officer. District Programme Officer, CDPO, officer in-charge of these sectors and NGOs organizes vocational training courses, non-formal education course, life education courses, health and nutrition education and legal literacy for these girls. Following completion of the training, the group leaders (2 adolescent girls from each Anganwadi Centre) provide training to remaining 23 adolescent girls at the anganwadi centre. Balika Samridhi Yojana: This scheme is being implemented in both rural and urban areas. Girl children belonging to families below the poverty line, who were born on or after 15th August, 1997 are given the benefits. The benefits are restricted to two girl children in a household irrespective of number of children in the household. Objectives of Balika Samridhi Yojana: • To change negative family and community attitudes towards the girl child and her mother. • To improve enrolment and retention of girl children in schools, to increase the age of marriage of girls and to assist the girl to undertake income generation activities. Benefits: a) A post birth grant amount of Rs. 500/b) For girls studying in : Class

Amount of Annual Scholarship

I-III

Rs. 300/- per annum for each class

IV

Rs. 500/- per annum

V

Rs. 600/- per annum

VI-VII VIII

Rs. 700/- per annum for each class

IX-X

Rs. 800/- per annum Rs. 1000/- per annum for each class

Procedure for obtaining the benefit • In rural areas ICDS infrastructure and in urban areas Health Department provide the benefits. Application forms are available with Anganwadi workers in the villages and with health functionaries in urban areas.

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Payment at maturity • Girl attaining 18 years of age • Certificate of GP/Municipality • The implementing agency authorizes the bank or post office Withdrawal of benefit • If a girl gets married before18yrs of age she will not be given the benefit • In case of death, all money will be withdrawn by government Reproductive and Child Health-II: Adolescent Reproductive and Sexual Health (ARSH): Services are provided to all married and unmarried adolescent girls and boys Package of Services a) Promotive services: • Focused care during antenatal period • Counselling and provision of emergency contraceptives • Counselling and provision of reversible contraceptives • Information/advice on SRH services b) Preventive services: • Services for TT and prophylaxis against nutritional anaemia • Nutritional counselling • Services for early and safe termination of pregnancy and management of post abortion complications c) Curative services: • Treatment for common RTI/STIs • Treatment and counselling for menstrual disorders related tosexual concerns of males and female adolescents ARSH Strategy in National RCH II Program Implementation Plan

Level of Care

Service Provider

Sub centre

HW(F)

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Target group

Flow of Service delivery activities

Services

Unmarried During routine • Enrolment of newly married couples male and femalesub-centre Married male clinic • Provision of spacing methods and female • Routine ANC care and institutional deliveries • Referral for early and safe abortion 1 26


• Education on prevention of RTI/STIs • Nutritional counselling on anaemia prevention and menstrual hygiene

• Immunization for pregnant adolescent mothers PHC/ CHC/ DH

HA(F)LHV or MO

Unmarr ied maleand female

Once a week teen clinic at PHC for 2hrs

• Contraceptive condom programming • Management of menstrual disorders • Education on prevention of RTI/STIs and their management • Counselling and services for pregnancy termination • Nutritional counselling and counselling for sexual problems • Immunization for pregnant adolescent mothers

(Source: Implementation Guide on RCH II ARSH Strategy, Ministry of Health and Family Welfare ) d) Referral services: • Integrated Counselling and Testing Centre • Prevention of Parent to Child Transmission e) Outreach services:

• Periodic health checkups and community camps • Periodic health education activities and co-curricular activities Adolescent Friendly Health Services (AFHS): It provides a broad range of preventive, promotiveand curative services. AFHS in India was first started by Safdarjang Hospital in New Delhi Package at AFHS: • Monitoring of growth and development • Monitoring of behaviour problems • Offer information and counselling on developmental changes, personal care and ways of seeking help TRAININGMANUAL

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• Reproductive health including contraceptives, STI treatment, pregnancy care and post abortion management • Integrated counselling and testing for HIV • Management of sexual violence • Mental health services including management of substance abuse National AIDS Control Programme (NACP) Under NACO Adolescent Education Programme has been developed which focuses primarily on prevention through awareness building. The Adolescent Education Programme is one of the key policy initiatives of NACP II. Relevant messages on safe sex, sexuality and relationships are developed and disseminated for youth via posters, booklets, panels and printed material. The Adolescence Education Programme (AEP) : • Co-curricular adolescence education in classes IX-XI • Curricular adolescence education in classes IX-XI and life skills education in classes I-VIII • Inclusion of HIV prevention education in pre-service and in-service teacher training and teacher education programmes. • Inclusion of HIV prevention education in the programmes for out-of-school adolescents and young persons, • Incorporating measures to prevent stigma and discrimination against learners/students and educators and life skills education into education policy for HIV prevention. YUVA - Youth Unite for Victory on AIDS: It comprises seven youth organisations, Nehru Yuva Kendra Sangathan, National Service Scheme, Indian Red Cross Society, National Cadet Corps, Bharat Scouts and Guides, Youth Hostels Association of India and the Association of Indian Universities. The goal is to have an “AIDS prepared Campus, AIDS prepared Community and AIDS prepared Country”. It includes prevention, education and life skills for promoting healthy, safe behaviour and practices amongst the young people.

SESSION-4: REPRODUCTIVE HEALTH: ISSUES and CONCERNS Learning objectives: · To gain information on reproductive health issues and concerns. · To improve the trainees' ability to address issues related to reproductive health. Duration: 80 Mins Materials to be used : IEC Materials like flip charts and posters, STI albums, and models for condom demonstrations, information sheet on condom usage Methodology : Group Discussion and Demonstration

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Process: Activity – 1 ·

The facilitator identifies three areas in the room where people can gather. One area indicates “I agree”, second area indicates “I disagree” and the third area indicates “Not sure”.

·

The facilitator reads out statements on HIV, STIs and RTIs. Each participant will have to move to one of the three areas depending on that he/she believes.

·

People gathered in the “I agree” area will have to convince others to come and join them by giving their reasons and vice versa.

·

Group discussion on HIV/AIDS, STI, reproductive health issues (including post partum psychosis) is lead by the facilitator. Fact sheet is used as reference material. Statements:

· HIV can be transmitted by mosquitoes · If a person gets HIV, he or she cannot live with the family. · HIV can be cured by medicines · HIV positive children should attend regular schools as they cannot pass on the infection to other children. · An HIV positive person should not get married. · An HIV positive person should not mix with people in social gatherings. · Being HIV positive is the same as having AIDS. · A person may be HIV positive and look absolutely normal and healthy for many years. · HIV cannot be transmitted by tattooing or body piercing. · Usual vegetarian diet provides enough iron to meet the needs of an adolescent girl. · Anaemia is uncommon among Indian girls. · STIs can cause infertility. · After delivery a woman may feel so depressed that she does not care for or feed her baby.

Activity – 2: Condom demonstration: · The facilitator demonstrates the right use of male condom. Each trainee is provided with one male

condom and asked to demonstrate its use if they are willing and feel comfortable by doing so. Models are provided to them for this purpose. · Myths and misconceptions about condoms, including female condoms are discussed.

Facilitator's Discussion: · How do you feel about condom demonstration? · Do you feel testing for HIV should be mandatory before marriage? TRAININGMANUAL

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· Should a couple where both partners are HIV positive, have children?

Expected Outcome: Trainees are able to address the issues related to reproductive health. They understand the mode of transmission, signs and symptoms of STI, RTI and HIV. Fact Sheet Anaemia Anaemia is a condition where red blood cells in the blood are less and is diagnosed if haemoglobin levels are below 12 gm/100 ml in non- pregnant girls above 15 years of age and below 13.5 gm/100 ml for boys. It is associated with poor nutrition, leads to a “several-fold increase in the risk of a mother dying during child birth. Anaemic girls experience tiredness, fatigue, lack of vitality, reduced physical and mental work capacity, and increased chances of contracting infections. Severe anaemia can cause cardiac failure. Anaemic women are increasingly susceptible to communicable diseases such as tuberculosis (TB) and malaria, which are associated with adverse outcomes during and after pregnancy. Anaemic women face the further risk of falling into a cycle of multiple pregnancies in their efforts to have children who survive, since nutritional deficiencies during pregnancy notably reduce the chances of infant survival. The remedial measures for anaemia include intake of foods rich in iron, vit B12, folic acid and vit C. Example spinach, beetroot, pomegranate, soya beans, nuts, beans, raisins, dates, whole grains, dals, pumpkin seeds, potatoes with skin, eggs, meat and fish. Vitamin C in the form of lemon, green chilli, tomato with meals improves iron absorption. Consumption of tea after meals has to be avoided since tannins in tea bind iron, preventing its absorption. HIV/AIDS and STD Youth constitute a large proportion of the HIV-positive population; it is estimated that over 35 percent of all reported HIV infections in India occur among young people 15–24 years of age (UNAIDS). STDs are diseases that are passed from one person to another mainly through sexual intercourse. The most common STDs are: Chlamydia, syphilis, gonorrhoea, trichomonas, genital warts, chancroids, genital herpes, hepatitis B and HIV infection. Some STDs, such as syphilis and HIV can also be transmitted through exposure to contaminated blood and from a pregnant woman to the unborn child. As many as 499 million new infections of curable sexually transmitted infections occur yearly (WHO, 2008). In pregnant women with untreated early syphilis, 21% of pregnancies result in stillbirth and 9% in neonatal death (WHO, 2011). The following are some of the symptoms of STDs: · Abnormal discharge from the penis, anus or vagina. · Burning or pain on passing urine. · Pain in the abdominal or groin area with fever. · Pain during sex. TRAININGMANUAL

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· Blisters, rash or sores on the genital organs.

HIV Infection and AIDS. In India people in the age group of 15-29 years constitute almost 25 percent of the country's population; however, they account for 31 percent of AIDS burden. This clearly indicates that young people are at high risk of contracting HIV infection. HIV (Human Immunodeficiency Virus) destroys certain white blood cells that form an important component of the immune system. The power or ability to resist infections depends on the immune system so the HIV infected individual become vulnerable to many types of infections, even those that heal quickly in people with normal immunity. The destruction of the protective white blood cells takes place gradually and therefore a person may be infected with the virus for many years without feeling unwell. This is the dormant period. Since the virus is present in the body, the person can spread the disease to others. There is no way that anyone (including doctors) could diagnose that a person is HIV positive by simply looking at him/her. The presence of HIV infection can only be confirmed by a blood test at this stage. AIDS : After a period varying from six months to as long as 10 years, the illness becomes more active and serious infections and malignancies can occur. This stage of the illness is known as AIDS (Acquired Immunodeficiency Syndrome). Almost all people infected with HIV will ultimately develop AIDS if they do not take any medication. In AIDS stage, the person develops swelling of lymph glands, fever, loose motions, loss of appetite, loss of weight, and fatigue as the body loses its battle against the virus. The complaints attributed to AIDS (fever, loose motions, loss of appetite, loss of weight, fatigue, skin lesions) are common but in AIDS they do not respond to treatment and persist for months, ending in death if untreated. HIV tests are used to detect the presence of the human immunodeficiency virus (HIV) in blood. Such tests may detect antibodies, antigens, or RNA. The commonly done tests are ELISA and Western Blot. Tests used for the diagnosis of HIV infection require a high degree of both sensitivity and specificity How is HIV transmitted? HIV infection can pass from one person to the other through the following ways: · Unprotected sexual intercourse: A person infected with HIV virus can pass it on to another when his or

her body fluids (e.g. semen, vaginal fluids or blood) enters the other person's blood stream through unprotected sexual (vaginal, anal and oral) intercourse. · Through contaminated blood or blood products: such as receiving infected blood, contaminated needles

and syringes when injecting drugs, or through skin-piercing equipment contaminated with HIV, contracting infection while handling infected and wounded persons without safety measures. The virus can enter the bloodstream through cuts, abrasions etc. on the skin or if infected fluids fall on intact mucosa. · From an HIV infected mother to the child: This could occur during pregnancy, childbirth and in infancy

through breast-milk.

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Community perceptions about HIV/AIDS Even with the current level of knowledge, HIV/AIDS generates fear and misconceptions in many people. HIV/AIDS is surrounded by many myths among people in many countries. It is important to understand how HIV/AIDS is perceived in the local community in order to develop appropriate educational messages. 1) Myth: HIV can be cured The truth is that there is no cure for HIV at this time though we have made great strides in HIV care. With today's medicine, people can reduce their viral load (amount of HIV in the blood) significantly by taking anti retroviral therapy (medicines that prevent multiplication of the virus) daily for the rest of the life of the person or as guided by the CD4 count. This helps delay the onset of AIDS and other infections. 2) Myth: One cannot get HIV from tattoos or body piercing. It is possible to get HIV from tattoo and piercing tools that are not sterilized properly between clients. The Centres for Disease Control and Prevention (CDC) says that tools that cut the skin should be used just once, then thrown away or sterilized between uses. Before getting a tattoo or body piercing, ask about sterilization of equipment and disposable needles. 3) Myth: When a person gets HIV, he/she would be able to feel it. No. A person knows if he/she has indulged in high risk behaviour like having multiple sexual partners, sharing needles, having sex with a sex worker, etc. In such cases he/she can go for a blood test for HIV to determine if there is HIV infection. There is no other way to determine if one has got HIV infection. It can take 10 years for symptoms of HIV to show up. The only way to fully protect oneself from sexually transmitted HIV is to not have sex of any kind. Using a condom correctly and every time one has sex can reduce the risk of HIV infection by 80 percent. 4) Myth: An HIV-positive pregnant woman will surely spread the disease to her baby. An untreated HIV positive pregnant woman has 25 to 30% chance of passing the infection to her baby. A woman who knows about her HIV infection early in pregnancy and is given antiretroviral treatment has about two percent chance of passing the infection to her baby. Without treatment, this risk is about 25 percent. All pregnant women should be tested for HIV. A woman with HIV should not breastfeed her baby because that is another way to pass the virus. Proper nutrition and hygiene needs to be maintained in such cases. 5) Myth: If both sexual partners have HIV they don't need to use a condom. This is not true. One still needs to practice safer sex because there are different strains (types) of HIV. The partners could be infected with different strains of HIV. Condom use would prevent infection with a different strain of the virus. One could become infected with drug-resistant strains of HIV. This can make it very hard for treatment to work. A condom should be used every time the couple has sex. 6) Myth: An HIV positive person should not start drug therapy until he/she becomes very sick. Even when a person with HIV infection is feeling great, HIV is multiplying and attacking the body. By the TRAININGMANUAL

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time the person starts feeling sick (this stage is called AIDS), HIV has already caused immense damage to the immune system. At that point, nothing can bring it fully back to normal. To protect the immune system, most experts recommend anti-HIV medication before AIDS develops. The time of starting treatment depends on the count of CD4 cells in the patient's blood. Because these drugs reduce the "viral load," or the amount of virus in the blood, they also reduce the chances of passing HIV to others. These drugs have side effects. Hence treatment is not started the moment HIV infection is diagnosed. Treatment is started later, depending on the CD4 counts. 7) Myth: Women cannot transmit HIV to men. It is much harder for men to get HIV from women, but it does happen. HIV does not live long outside the body. A man's penis is only exposed to HIV for the time that it is in the vagina. Men also may have fewer areas on the penis where the virus can enter the body. HIV can enter at the opening of the tip and through cuts or sores on the shaft. But if a partner has an untreated sexually transmitted infection (STI) like syphilis, gonorrhoea, orchlamydia, the risk is higher. 8) Myth: HIV positive is the same as AIDS. HIV is the virus that leads to AIDS. A person is said to be HIV positive when he/she is infected with HIV. After 2-10 years, when the person begins to get symptoms like long lasting fever, diahorrea, loss of weight, opportunistic infections, cancers, then he/ she is said to have AIDS. A person can have HIV for years before developing AIDS. 9) Myth : HIV/ AIDS can be easily treated No. Treatment of HIV requires intake of multiple drugs daily for the rest the person's life or as guided by the CD4 count. These drugs also have side effects. The drugs don't kill or eradicate the virus completely from the body. They just control its multiplication and hence lower the viral load. 10)Myth : You cannot live with a person who has HIV False. One can live with a person who has HIV just like one lives with a brother or a sister. Touching the person, casually shaking hands, sitting on the same chair, using same comb, bed or toilet does not transmit HIV infection. Mosquito bites, sneezing or coughing also does not transmit HIV. 11)Myth : HIV positive people should neither get married nor have children This is a matter of mutual informed consent and choice. Certainly without treatment of any sort, HIV positive mother is likely to pass on the infection to her child 25- 30% of the time. If both parents are HIV positive they would develop AIDS without treatment after a variable period of time. Their child would then require parenting care from others. Factors increasing vulnerability of young people to HIV/AIDS · Biological Vulnerability: Teenage girls are more vulnerable to STIs because their reproductive tract is

relatively underdeveloped and the defence system against infections is not mature. Male-to-female transmission of HIV and other STIs appears to be 5–7 times more efficient than female-to-male TRAININGMANUAL

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transmission. · Early marriage: In many parts of India, girls are married before they reach the age of 18 years. · Working condition: Girls and boys who are pushed into sex work are vulnerable to HIV/AIDS. Sexual

abuse, child trafficking, child labour are also risk factors. · Experimentation with drugs and alcohol: During drug injection sharing of needles is common which

increases the risk of HIV. Alcohol use also increases the risk of HIV infection because a young person may not be able to take rational decisions under its influence to safeguard himself/ herself. · Social expectation: Women are often economically dependent on their husbands. They are often unable to

negotiate on condom use. · Poor access to services and information: In rural areas of India, girls lack formal education and know

very little about their bodies, reproduction, sex, and sexuality. This is true for a large number of boys too. Treatment for HIV and NACO The aim of treatment is to prolong and improve the quality of life by maintaining maximal suppression of virus replication for as long as possible. India has embarked on structured anti-retroviral therapy. It includes the use of multiple antiretroviral drugs at the same time. There are several classes of antiretroviral agents that act on different stages of the HIV life-cycle. The use of multiple drugs that act on different viral targets is known as highly active antiretroviral therapy (HAART). HAART decreases the patient's total burden of HIV, maintains function of the immune system, and prevents opportunistic infections that otherwise often lead to death. There are several classes of drugs, which are usually used in combination, to treat HIV infection. Use of these drugs in combination is generally termed Anti-Retroviral Therapy (ART). Antiretroviral therapy should be initiated in all patients with a history of an AIDS-defining illness or with a CD4 count