Acceptability

Successful implementation of newguidelines such as Treat All requires:

– Promoting accurate KNOWLEDGE about changes within newguidelines from previous ones – including identification and correctionof myths and misconceptions – can you describe ‘what’s new?’

– Understanding and building ACCEPTABILITY among health careworkers, clients and community stakeholders of new guidelinespromoting early treatment for all PLHIV.

Before the Learning Phase Implementation of Treat All began, pre-acceptability surveys and dialogues were conducted with health careworkers and health care managers. These surveys highlighted that whilethe Treat All Strategy was largely acceptable to health care managers andproviders, there was need for clarity on exactly what new guidelinesmeant in terms of changes in practice and to answer concerns held byhealth care workers. These discussions were used to develop the TreatAll Frequently Asked Questions (FAQs) provided in Annex I.

Challenges of communicating clinical guidelines and practices have beennoted as a major cause of the “know do gap” for evidence-based practice.Front line health care providers are critical for guideline implementationsuccess.

This tool provides additional tips for improving knowledge on and acceptability of Treat All at all health facilities – both those currently implementing, and those planning to implementTreat All.

QuickDefinitions:

Acceptability: How much a treatment or recommendation is

accepted by the peoplewho are affected by it orwho are implementing it.

1. Be aware of national policy goals and the role of Treat All in reaching the 90-90-90 Goals,and Start Free – Stay Free- AIDS Free Framework.

2. Ensure all staff are familiar with current MOHCC guidelines and service delivery standards.

3. Be clear about what’s new in ‘Treat All’ guidance compared to previous guidelines.

4. Hold facility-based dialogues to identify concerns and correct myths and misconceptionsabout Treat All.

5. Use the Treat All checklist to keep track of HIV Care and Treatment goals.

Improve acceptability of the Treat Allstrategy to optimize implementation ofNational HIV Care and Treatment Guidelines

Tool 1

Tool 1: Acceptability

Although many strategies will be needed to close the book on the AIDS epidemic, one thingis certain – It will be impossible to end the epidemic without bringing HIV treatment to all

who need it.-UNAIDS

In December 2016, new Guidelines for Antiretroviral Therapy for thePrevention and Treatment of HIV in Zimbabwe were released byMOHCC. These guidelines provide detailed guidance to all healthsystem stakeholders on all aspects of HIV prevention, care andtreatment. This toolkit focuses on MOHCC recommendationsregarding initiation of ART: Treat All.

To support the operationalization of ART Guidelines, MOHCC has alsoproduced an updated Operational and Service Delivery Manual(OSDM) for the Prevention, Care and Treatment of HIV in Zimbabweand Job Aide. All health care workers in Zimbabwe should be familiarwith the content of both guidance documents as they outline boththe ‘what’ and the ‘how’ for providing HIV Care and Treatment inZimbabwe.

Do all health facilities have copies of the 2016 Guidelines, OSDM and newJob Aide? Are all health care workers sensitised on any changes inpractice? Copies of each have been provided with this Toolkit.

1. Be aware of national policy goals and the role of Treat All in reaching the 90-90-90 Goals, and Start Free – Stay Free- AIDS Free Framework

The Zimbabwe Ministry of Health and Child Care has committedto ambitious international 90-90-90 goals to end the AIDSepidemic: The goals state that by 2020,

• 90% of PLHIV are aware of their HIV status

• 90% of those diagnosed with HIV infection are ontreatment

• 90% of those on treatment are virally suppressed

Start Free, Stay Free, AIDS Free: is a super-fast-trackframework for ending AIDS among children, adolescents andyoung women by 2020.

Increasing access to HIV treatment is central to achieving 90-90-90 and Start Free, Stay Free, AIDS Free goals in Zimbabwe.Implementation of the Treat All Strategy means that all PLHIV inZimbabwe should now have access to HIV treatment regardlessof age, gender, WHO clinical stage or CD4 cell count.

“All individuals with a confirmed HIV diagnosis

are eligible for anti-retroviraltherapy (ART) irrespective ofWHO clinical stage and CD4

count level i.e. TREAT ALL.”p.21

For adults and adolescents: As apriority, initiate ART in all individualswith severe or advanced HIV clinicaldisease (WHO clinical stage 3 or 4) orCD4 count less than or equal to 350cells/ mm3.

For children: As a priority, ART should beinitiated among all children ≤ 2 yearsold or with WHO stage 3 or 4 or CD4count ≤ 750 cells/mm³ or CD percentage<25% among children younger than 5years and CD4 count ≤ 350 cells/mm³among children 5 years and older.

2. Ensure all health system staff at all levels are familiar with current MOHCC HIVtreatment and service delivery guidelines

Tool 1: Acceptability

4. Hold facility-based dialogues to identify concerns and correct myths andmisconceptions about Treat All

Acceptability surveys during the learning phasehighlighted most frequently asked questions(FAQs) and concerns regarding implementationand impact of Treat All among health care workers.These concerns were addressed in the LearningPhase, and are addressed in a number of the toolsthat you will find throughout this toolkit. A clearunderstanding of policy changes at ALL levels isvery important for the success of new guidelinerecommendations.

Hold dialogues with stakeholders at your healthfacility to provide clear information and identifyconcerns, myths and misconceptions about TreatAll. These groups might include: nurses, primarycounsellors, general hands, village health workers,PLHIV and local leaders.

If asked to educate others, how would youdescribe Treat All to PLHIV, other health careworkers or community stakeholders?

Treat All means HIV Treatment

for all PLHIV – both those newly diagnosed and clients

previously diagnosed but not on treatment.

Treat All means that ALL clients regardless

of age, gender, CD4 or WHO clinical stage should be initiated

on ART as soon as they are ready.

Evidence has shown that early HIV treatment improves the

health of PLHIV.

3. Be clear about ‘what’s new’ in Treat All guidance compared to previous guidelines

What’s New? Guidelines for Antiretroviral Therapy for the Prevention and Treatment of HIV in ZimbabweWhen to start ART in Adults and Adolescents

Change in newGuidelines?

2013 Guidelines 2016 ‘TREAT ALL’ guidelines

YES ART should be provided to all eligiblepeople with confirmed HIV diagnosisand with a CD4 count of ≤ 500cells/mm3.NEW GUIDANCE

All individuals with a confirmed HIV diagnosis are eligible for anti-retroviral therapy (ART)irrespective of WHO clinical stage and CD4 count leveli.e. TREAT ALL

When to start ART in children2013 Guidelines 2016 Guidelines ‘TREAT ALL’

NO Infants (<1yr): Treat all individuals Infants (<1yr): Treat all individuals

NO 1 year to less than 5 years: Treat allindividuals

1 year to less than 5 years: Treat all individuals

YES 5 years and above: WHO stage 3 or 4or CD4 ≤500 (CD4 ≤350 as a priority)NEW GUIDANCE

5 years and above: ART should be initiated in ALLchildren living with HIV, regardless of WHO clinical stageand at any CD4count.

Optimizing acceptability of Treat All will require increasing awareness and support among all stakeholders aboutwhat Treat All means. Stakeholders include health system managers, health promotion officers at Provincial andDistrict levels, as well as clinical and non-clinical staff at health facilities, clients, and community opinion leaders andstakeholders.

5. Use the Treat All checklist to keep track of HIV Care and Treatment goalsThe checklist below provides a list of all the sections in the Treat All Toolkit and tips found in each Tool. Identifygroups or individuals that will be important to achieving Treat All in your setting. Create an action plan and set goalsfor achieving Treat All.

Tool 1: Acceptability

Done3 Treat All Toolkit: Tips for optimizing HIV care and treatment services under Treat All.

Tool 1: Acceptability: Improve acceptability of Treat All strategy to optimize implementation of National HIV Care and Treatment Guidelines.1. Be aware of national policy goals and the role of Treat All in reaching the 90-90-90 Goals, and Start Free – Stay Free- AIDS Free Framework2. Ensure all staff are familiar with current MOHCC guidelines and service delivery standards.3. Be clear about what’s new in ‘Treat All’ guidance compared to previous guidelines.4. Hold facility-based dialogues to identify concerns and correct myths and misconceptions about Treat All.5. Use the Treat All checklist to keep track of HIV Care and Treatment goals.Tool 2: Site Preparedness: Prepare your health facility for optimal implementation of Treat All.1. Be familiar with common barriers to optimal implementation of Treat All.2. Conduct a bottleneck/root cause analysis of HIV testing, care and treatment services at your health facility to identify site-specific barriers to implementing Treat All.3. Develop a 7-point action plan to overcome identified barriers to Treat All implementation.4. Put systems in place to ensure that implementation of Treat All reduces workload and patient visits in the long term, while improving quality and efficiency of care.5. Monitor progress on site preparedness action plans.Tool 3: Communications and community mobilisation: Raise awareness and gain community support for Treat All.1. Develop a Treat All campaign strategy and brand to communicate the new treatment policy.2. Establish partnerships with community leadership, organisations and positive role models to inform communities and dispel myths and misconceptions about HIVtesting and treatment.3.Utilise health service infrastructure to positively influence behaviour to access early HIV testing and treatment.4.Incorporate a variety of promotional materials and message dissemination platforms into communication strategy.5.Meaningfully involve People Living with HIV (PLHIV) in mobilisation, awareness raising and linking clients to HIV services.Tool 4: HIV Testing Services (HTS): Keep momentum towards the First 90 under Treat All.1. Ensure that focus and attention on providing quality HTS at all health facilities increases with Treat All. 2. Offer HIV testing to ALL clients with an unknown HIV status in all entry points.3. Ensure all clients testing HIV positive after a confirmatory test undergo HIV retesting prior to ART initiation.4. Understand which groups are at greater risk to HIV infection in your area and reach out to support uptake of HIV testing and treatment services. 5. Ensure all clients testing HIV positive are linked to care and treatment and initiated on ART.Tool 5: ART Counselling & Patient Preparedness: Adequately prepare clients for ART initiation, adherence and retention.1. Always provide quality pre- and post-test counselling.2. Link clients immediately to care, treatment and support programs.3. Support client readiness before ART initiation.4. Emphasize importance of adherence and retention in care for treatment success at every visit.5. Provide enhanced adherence counselling to clients who have detectable viral load.Tool 6: ART Initiation: Optimize ART initiation for all PLHIV under Treat All1. Clearly document details of all clients testing HIV positive at your facility.2. Put SOPs in place to ensure that ALL clients testing HIV positive are successfully initiated on ART.3. Ensure all clients receive an HIV retest before ART initiation and document it appropriately.4. Establish treatment goals with clients before starting ART.5. Identify and problem solve barriers to adherence before they disrupt treatment.Tool 7: Adherence & Retention: Support clients to achieve long-term adherence and retention for sustained viral suppression.1. Agree on what adherence and retention mean and clearly describe the benefits of sustained adherence and retention for reaching treatment goals.2. Create clear expectations on specific ‘next steps’ after ART initiation to reach adherence and retention goals.3. Ensure facility-based systems are in place for generating appointment dates, identifying clients defaulting from routine care and supporting return to care.4. Use viral load testing as a tool for ART monitoring, retaining clients in care and reviewing adherence goals.5. Provide differentiated models of care to stable clients in line with MOHCC guidance.Tool 8 : Viral Load Monitoring1. Provide Viral Load Monitoring in line with MOHCC 2016 Guidelines for Antiretroviral Therapy for the Prevention and Treatment of HIV in Zimbabwe.2. Generate client demand for VL monitoring as a tool to measure progress towards treatment goals.3. Have systems in place to know which clients need VL monitoring at their next visit.4. Follow SOPs for taking samples, sample transportation and documenting processes.5. Correctly interpret VL results and action the results appropriately.Tool 9: Documentation and Reporting1. Ensure clarity about the definition of key terms for HIV testing, care and treatment documentation.2. Be aware of Provincial, District and Site-level Targets for reaching 90-90-90.3. Ensure consistent, accurate and complete documentation of client information.4. Understand how new guidelines on HIV Retesting and Treat All influence documentation of care provided and monthly return form completion.5. Place an extra focus on using registers/EPMS to identify clients defaulting from care, systems for follow-up of clients and accurate outcome documentation to ensure‘no one is left behind’.Tool 10: Looking Ahead: Reaching 90-90-90 and Start Free, Stay Free, AIDS Free1. Turn off the Tap – Reinforce combination prevention strategies in all health facilities.2. Leave no one behind – Provide tailored HIV prevention, care and treatment services for key populations3. Start Free, Stay Free, AIDS Free – Focus on ensuring that children and young people have access to the prevention and treatment services they need.

For more on 90-90-90: http://www.unaids.org/sites/default/files/media_asset/90-90-90_en_0.pdf For more on Start Free Stay Free AIDS Free Framework: http://www.unaids.org/sites/default/files/media_asset/Stay_free_vision_mission_En.pdf

Tool 3: Communications for some key tips and useful IEC materials for communicating messages about Treat All. Annex I: Treat All FAQ: to review questions raised by health care workers like YOU during the Treat All learning phase together with MOHCC answers to these questions.

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Acknowledgements: We gratefully acknowledgesupport from the President’s Emergency Plan forAIDS Relief (PEPFAR) through USAID to Families andCommunities for Elimination of HIV in Zimbabwe(AID-613-A-12-00003, FACE HIV)

For more information contact:Organization for Public Health Interventionsand Development20 Cork Road, Belgravia, Harare, Zimbabwewww.ophid.co.zw/