Chronic HIV Care with ARTChronic HIV Care with ART

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

CHRONIC (PLANNED) CARE MODEL

Acute Care Planned Care

Reactive Proactive

Visit Based Population Based

Little Continuity Planned - Schedule

Diagnose and Treat Assess 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

Transition to good chronic HIV Transition to good chronic HIV carecare

Common current Common current situation:situation:

Health services Health services provide episodic provide episodic acute care for HIV acute care for HIV complications. complications. [Exception: TB][Exception: TB]

Patient-held records Patient-held records for each acute for each acute episodeepisode

Only organized Only organized chronic care is chronic care is home-basedhome-based

To introduce and scale-up To introduce and scale-up ART:ART:

Need to establish good Need to establish good chronic HIV care in facilitychronic HIV care in facility

Good care by an Good care by an individual doctor or individual doctor or specialist does not specialist does not replace the need for replace the need for establishing good chronic establishing good chronic care with a clinical team!care with a clinical team!

Patient HIV care/ART Patient HIV care/ART record and registers, record and registers, reporting formsreporting forms

Sequence of care Sequence of care

Task ShiftingTask Shifting

Allows non-doctors to play a significant role in Allows non-doctors to play a significant role in HIV care/ARTHIV care/ART both in peripheral facilities and on the district both in peripheral facilities and on the district

clinical teamclinical team

Centralor Provincial

Specialised referral (physicians)

DistrictSupervision and referral

services provided by doctors and/or medical officers

Health CentreFirst-line treatment and care provided by nurses,

clinical officers and ART Aid on clinical team

Community SupportCare and support provided by treatment supporters, community health workers

and care givers from within the community

Community PreparednessMobilization and sensitization to increase treatment

literacy of community

Consider task shifts to allow scale-upConsider task shifts to allow scale-up

Care, treatment & preventionCare, treatment & prevention Specialized physicians to Specialized physicians to

doctorsdoctors Doctors to nursesDoctors to nurses Nurses to Nurses to PLHA HIV care/PLHA HIV care/ART ART

aids—education, psychosocial aids—education, psychosocial support, adherence support, adherence preparation and support can preparation and support can be taught to PLHA, other lay be taught to PLHA, other lay providers, nursing assistantsproviders, nursing assistants

Clinical team to patient: Clinical team to patient: Self-managementSelf-management

Clinical team to community- for Clinical team to community- for treatment support, drug refills, treatment support, drug refills, simple monitoring simple monitoring

TrainingTraining Expert patient-trainersExpert patient-trainers

PLHA on ARTPLHA on ART Present cases, provide Present cases, provide

feedback to health workersfeedback to health workers Patient tracking- treatment Patient tracking- treatment

card to register, monthly reportcard to register, monthly report Choose those who like Choose those who like

particular aptitude particular aptitude PLHA, other lay providers or PLHA, other lay providers or

nursing assistants nursing assistants Build functional clinical teams Build functional clinical teams

within a district systemwithin a district system

Technical basis for task shiftsTechnical basis for task shifts

Emphasize safetyEmphasize safetyValidate ability to make critical decisions Validate ability to make critical decisions

by validation studies (during guideline by validation studies (during guideline development)development)

case review, close supervision, monitoring case review, close supervision, monitoring (during implementation)(during implementation)

ART AidART 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) ART Aids (counsellors, health educators, PLWA)

are often more effective than doctors and health are often more effective than doctors and health officers/clinical officers at patient education and officers/clinical officers at patient education and adherence support. adherence support.

Basic ART Aid Course is designed for people Basic ART Aid Course is designed for people with little or NO clinical background—LAY with little or NO clinical background—LAY PROVIDERS can become ART Aid PROVIDERS can become ART Aid

Can provide important insights during team Can provide important insights during team meetings about "difficult" patients.meetings about "difficult" patients.

ART AidART Aid speaks the same language speaks the same language

patient as the patient patient as the patient comes from the community to comes from the community to

the clinical team the clinical team is a link with the community is a link with the community knows what is available at knows what is available at

community levelcommunity level progressively learns what is progressively learns what is

needed at community level for needed at community level for ART and HIV care scale up ART and HIV care scale up

inform patients and the rest of inform patients and the rest of the clinical team on the the clinical team on the community services community services

advocates with community advocates with community stakeholdersstakeholders

Roles of the Basic ART AidRoles of the Basic ART Aid

Adherence preparation (includes ART Adherence preparation (includes ART preparation and initiation)preparation and initiation)

Monitoring and supporting patients on ARTMonitoring and supporting patients on ART Post-test and on-going psychosocial supportPost-test and on-going psychosocial support Patient education on HIV/AIDS, disclosure, Patient education on HIV/AIDS, disclosure,

prevention, and positive living in the context of prevention, and positive living in the context of clinical careclinical care

TriageTriage Peer supportPeer support Community supportCommunity support

WHO Basic ART Aid Training WHO Basic ART Aid Training CourseCourse

Index

Section 1 Introduction to the BASIC ART Aid course

Section 2 Roles and responsibilities of the ART Aid as part of the clinical team

Section 3 Care for HIV/AIDS

Section 4 Communication skills

Section 5 Treatment available for HIV/AIDS: cotrimoxazole and ART

Section 6 Adherence preparation

Section 7 Adherence initiation

Section 8 Adherence monitoring and support

Section 9 Prevention in the context of clinical care

Section 10 Disclosure

Section 11 Post-test and ongoing support

Section 12 Positive living

Section 13 Triage

What is needed to integrate community What is needed to integrate community members more effectively?members more effectively?

Lay provider needs to Lay provider needs to "formally" integrated in "formally" integrated in the health system with the health system with regular jobs as trainers regular jobs as trainers and ART Aid. and ART Aid.

"Emergency" policy "Emergency" policy decisions to create new decisions to create new posts for LP in the posts for LP in the context of the clinical context of the clinical team and for community team and for community support and education support and education

3 levels/approaches to communityIntegrated 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, othersBroad-based community prevention and treatment preparedness