1. IMAI Sequence of Care Task shifting, division of labor, and the role of non-clinicians on the care team

2. The Care Team Clinical Officers, nurses and midwives Medical Doctor ART Aids (NAs, Counsellors, Health assistants COMMUNITY SERVICES Patient Designated MD with substantial ART experience (first months)

3. ART Aid MD, MO District Outpatient Clinical Team RN, medical aid (CO) RN, medical aid (CO) ART Aid Consult, refer, back-refer, visit Health centre

4. Who does what at the clinic? Nurse Offer HIV testing and provide pre- test counselling Offer HIV testing and provide pre- test counselling ANC and PMTCT ANC and PMTCT Clinical review of symptoms and signs Clinical review of symptoms and signs Determine HIV clinical stage and functional status Determine HIV clinical stage and functional status Assess adherence to medications Assess adherence to medications Drawing and processing of blood samples Drawing and processing of blood samples Manage symptoms according to Acute Care guidelines Manage symptoms according to Acute Care guidelines Pre-screen for ART eligibility; refer for ART initiation Pre-screen for ART eligibility; refer for ART initiation Completion of HIV Care/ART Follow-up Form Completion of HIV Care/ART Follow-up Form Community Counsellor HIV testing and post-test counselling HIV testing and post-test counselling Register new patients in the Pre- ART register Register new patients in the Pre- ART register Discuss disclosure Discuss disclosure Explain treatment, follow-up care Explain treatment, follow-up care Support chronic HIV care Support chronic HIV care Assess and support adherence to prophylaxis and ART Assess and support adherence to prophylaxis and ART Prevention education (safer sex, condoms) Prevention education (safer sex, condoms) Link with community services Link with community services Update Pre-ART and ART registers Update Pre-ART and ART registers

5. Sequence of Care—11 steps 1. Triage 2. Education and support 3. Assess 4. Review pregnancy status 5. Review TB status 6. Provide clinical care 7. Give prophylaxis 8. ART 9. Manage chronic problems 10. Arrange 11. Prevention

6. Sequence of care Non-cliniciansClinicians

7. Members of the Care Team Clinicians Clinicians Doctor Doctor Health Officer Health Officer Nurse Nurse Non-clinicians (potentially filled by PLHA) Non-clinicians (potentially filled by PLHA) ART Aid Triage/receptionist Data clerk

8. Triage/Data Clerk When patients come to the clinic, someone greets them, locates their HIV Care/ART card, finds out why they have come, and weighs them. After the evaluation, this person can transfer the relevant data from the HIV Care/ART Card to the register. When patients come to the clinic, someone greets them, locates their HIV Care/ART card, finds out why they have come, and weighs them. After the evaluation, this person can transfer the relevant data from the HIV Care/ART Card to the register.

9. Sequence of care Triage/Receptionist

10. ART Aid Given the importance of patient education and the time required for effective adherence support, it is advisable to have one or more additional team members who can work as ART Aids. A specialized counsellor is not necessary; an ART Aid can be a nursing assistant or PLHA or other lay provider who has gone through the IMAI ART Aid course. Given the importance of patient education and the time required for effective adherence support, it is advisable to have one or more additional team members who can work as ART Aids. A specialized counsellor is not necessary; an ART Aid can be a nursing assistant or PLHA or other lay provider who has gone through the IMAI ART Aid course.

11. Sequence of care ART Aid

12. Nurse/midwife In the IMAI approach, these cadres do clinical staging, monitor adherence, provide patient education, and recommend or initiate first-line treatment in uncomplicated patients under the supervision of a health officer/clinical officer or a doctor. In the IMAI approach, these cadres do clinical staging, monitor adherence, provide patient education, and recommend or initiate first-line treatment in uncomplicated patients under the supervision of a health officer/clinical officer or a doctor.

13. Sequence of care Nurse/midwife

14. Doctor Even if not stationed at the facility, a doctor needs to take responsibility for the care, make frequent visits to supervise, be a clinical mentor (reviewing cases, answering questions, etc), be available for consultation on cases, and be responsible for substitutions and for switches to second-line treatment. Even if not stationed at the facility, a doctor needs to take responsibility for the care, make frequent visits to supervise, be a clinical mentor (reviewing cases, answering questions, etc), be available for consultation on cases, and be responsible for substitutions and for switches to second-line treatment.

15. Health Officer/Clinical Officer Provides supervision to the rest of the care team, initiate first-line treatment and manage adverse effects under the supervision of the doctor. Provides supervision to the rest of the care team, initiate first-line treatment and manage adverse effects under the supervision of the doctor.

16. Sequence of care Doctor or Health Officer/Clinical Officer

17. Dispenser In a small health centre, dispensing may be done by a clinician. In a larger health centre or a district hospital, dispensing is often done by a pharmacist technician, supervised by a pharmacist. In a small health centre, dispensing may be done by a clinician. In a larger health centre or a district hospital, dispensing is often done by a pharmacist technician, supervised by a pharmacist.

18. Sequence of care Dispenser

19. 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.

20. ART Aid speaks the same language patient as the patient comes from the community to the clinical team is a link with the community knows what is available at community level 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 advocates with community stakeholders

21. 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

22. 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

23. Task Shifting Improves team efficiency, which: Improves team efficiency, which: Is more convenient for the patient Is more convenient for the patient Increases the number of patients that can be cared for by one team Increases the number of patients that can be cared for by one team Decreases costs Decreases costs For optimal team efficiency: For optimal team efficiency: # of non-clinicians > # of clinicians

24. Triage Acute Care vs. Chronic HIV Care Quick circuit vs. Regular circuit

25. Regular Circuit For: For: Patients with OI's Patients with OI's Patients starting or recently starting ART Patients starting or recently starting ART Patients with ART toxicity Patients with ART toxicity Triage → ART Aid → Nurse → [HO/CO if necessary] → Dispenser Triage → ART Aid → Nurse → [HO/CO if necessary] → Dispenser 40-60 minutes 40-60 minutes

26. Sequence of care Regular Circuit

27. Quick Circuit For: For: Stable patients in Chronic HIV Care needing refills of cotrimoxazole Stable patients in Chronic HIV Care needing refills of cotrimoxazole Stable patients with > 3 months of ART without toxicity or OI's Stable patients with > 3 months of ART without toxicity or OI's Triage → ART Aid → Dispenser Triage → ART Aid → Dispenser 10-15 minutes 10-15 minutes

28. Sequence of care Quick Circuit

29. Community-based Refills and Monitoring For: For: Stable patients in Chronic HIV Care or ART who live far away from the health facility. Stable patients in Chronic HIV Care or ART who live far away from the health facility. Refill and counselling provided by a community health worker or community volunteer Refill and counselling provided by a community health worker or community volunteer Coordinated by someone at the health facility Coordinated by someone at the health facility Decrease patient load within health facility, but requires time and resources to train and coordinate community volunteers Decrease patient load within health facility, but requires time and resources to train and coordinate community volunteers

30. Sequence of care Community-based refills and monitoring

31. Which cadre will be: Providing first-level facility HIV care/ART- nurses, clinical officers, medical assistants, other…? Will they be initiating first-line ART or only recommending? Providing first-level facility HIV care/ART- nurses, clinical officers, medical assistants, other…? Will they be initiating first-line ART or only recommending? Providing patient education and support, adherence preparation and support (ART counselling)—lay providers on clinical team, nursing assistants, nurses, other… Providing patient education and support, adherence preparation and support (ART counselling)—lay providers on clinical team, nursing assistants, nurses, other… District MD/MO on clinical team District MD/MO on clinical team