1. Chronic HIV Care with ART

2. CHALLENGES TO SELF-MANAGEMENT AND QUALITY CHRONIC CARE The acute care paradigm -Reactive care -Patient who is in office now -Little continuity -Diagnose and treat -No time - Competing demands -Physician centered -No system or infrastructure -Self-Management: “Not my role” Institute of Medicine & Committee on Quality of Health Care in America (2001) “Crossing the Quality Chasm: A New Health System for the 21st Century; National Academy Press

3. CHRONIC (PLANNED) CARE MODEL Acute CarePlanned Care ReactiveProactive Visit BasedPopulation Based Little ContinuityPlanned - Schedule Diagnose and TreatAssess and Support Physician Centered Directed to “Urgent” Patient Centered Directed to Major Causes Disease Wagner E, et al. (1996) Milbank Quarterly 74(4):511-544

4. Transition to good chronic HIV care Common current situation: Health services provide episodic acute care for HIV complications. [Exception: TB] Health services provide episodic acute care for HIV complications. [Exception: TB] Patient-held records for each acute episode Patient-held records for each acute episode Only organized chronic care is home-based Only organized chronic care is home-based To introduce and scale-up ART: Need to establish good chronic HIV care in facility Need to establish good chronic HIV care in facility Good care by an individual doctor or specialist does not replace the need for establishing good chronic care with a clinical team! Good care by an individual doctor or specialist does not replace the need for establishing good chronic care with a clinical team! Patient HIV care/ART record and registers, reporting forms Patient HIV care/ART record and registers, reporting forms

5. Sequence of care

10. Task Shifting Allows non-doctors to play a significant role in HIV care/ART Allows non-doctors to play a significant role in HIV care/ART both in peripheral facilities and on the district clinical team both in peripheral facilities and on the district clinical team

11. Central or Provincial Specialised referral (physicians) District Supervision and referral services provided by doctors and/or medical officers Health Centre First-line treatment and care provided by nurses, clinical officers and ART Aid on clinical team Community Support Care and support provided by treatment supporters, community health workers and care givers from within the community Community Preparedness Mobilization and sensitization to increase treatment literacy of community

12. Consider task shifts to allow scale-up Care, treatment & prevention Care, treatment & prevention Specialized physicians to doctors Specialized physicians to doctors Doctors to nurses Doctors to nurses Nurses to PLHA HIV care/ART aids—education, psychosocial support, adherence preparation and support can be taught to PLHA, other lay providers, nursing assistants Nurses to PLHA HIV care/ART aids—education, psychosocial support, adherence preparation and support can be taught to PLHA, other lay providers, nursing assistants Clinical team to patient: Clinical team to patient: Self-management Self-management Clinical team to community- for treatment support, drug refills, simple monitoring Clinical team to community- for treatment support, drug refills, simple monitoring Training Training Expert patient-trainers Expert patient-trainers PLHA on ART Present cases, provide feedback to health workers Patient tracking- treatment card to register, monthly report Patient tracking- treatment card to register, monthly report Choose those who like particular aptitude PLHA, other lay providers or nursing assistants Build functional clinical teams within a district system Build functional clinical teams within a district system

13. Technical basis for task shifts Emphasize safety Emphasize safety Validate ability to make critical decisions Validate ability to make critical decisions by validation studies (during guideline development) by validation studies (during guideline development) case review, close supervision, monitoring (during implementation) case review, close supervision, monitoring (during implementation)

14. ART Aid Increased need of HR in the context of scale up Increased need of HR in the context of scale up ART Aids (counsellors, health educators, PLWA) are often more effective than doctors and health officers/clinical officers at patient education and adherence support. ART Aids (counsellors, health educators, PLWA) are often more effective than doctors and health officers/clinical officers at patient education and adherence support. Basic ART Aid Course is designed for people with little or NO clinical background—LAY PROVIDERS can become ART Aid Basic ART Aid Course is designed for people with little or NO clinical background—LAY PROVIDERS can become ART Aid Can provide important insights during team meetings about "difficult" patients. Can provide important insights during team meetings about "difficult" patients.

15. ART Aid speaks the same language patient as the patient speaks the same language patient as the patient comes from the community to the clinical team comes from the community to the clinical team is a link with the community is a link with the community knows what is available at community level knows what is available at community level progressively learns what is needed at community level for ART and HIV care scale up progressively learns what is needed at community level for ART and HIV care scale up inform patients and the rest of the clinical team on the community services inform patients and the rest of the clinical team on the community services advocates with community stakeholders advocates with community stakeholders

16. Roles of the Basic ART Aid Adherence preparation (includes ART preparation and initiation) Adherence preparation (includes ART preparation and initiation) Monitoring and supporting patients on ART Monitoring and supporting patients on ART Post-test and on-going psychosocial support Post-test and on-going psychosocial support Patient education on HIV/AIDS, disclosure, prevention, and positive living in the context of clinical care Patient education on HIV/AIDS, disclosure, prevention, and positive living in the context of clinical care Triage Triage Peer support Peer support Community support Community support

17. WHO Basic ART Aid Training Course Index Section 1Introduction to the BASIC ART Aid course Section 2Roles and responsibilities of the ART Aid as part of the clinical team Section 3Care for HIV/AIDS Section 4Communication skills Section 5Treatment available for HIV/AIDS: cotrimoxazole and ART Section 6Adherence preparation Section 7Adherence initiation Section 8Adherence monitoring and support Section 9Prevention in the context of clinical care Section 10Disclosure Section 11Post-test and ongoing support Section 12Positive living Section 13Triage

18. What is needed to integrate community members more effectively? Lay provider needs to "formally" integrated in the health system with regular jobs as trainers and ART Aid. Lay provider needs to "formally" integrated in the health system with regular jobs as trainers and ART Aid. "Emergency" policy decisions to create new posts for LP in the context of the clinical team and for community support and education "Emergency" policy decisions to create new posts for LP in the context of the clinical team and for community support and education

19. 3 levels/approaches to community Integrated management of HIV/AIDS at facility with linked community interventions: prevention, treatment and care (IMAI/IMCI) Systems for facility-community links: home visits, trace patients, monitoring, refills, back-up to home- based care CHW training Peer support groups- trained facilitators Use of same patient education flipchart Caregiver booklet Targeted community interventions with outreach: sex workers, IDU, MSM, others Broad-based community prevention and treatment preparedness