WHO/IMAI Orientation and Briefing

1. WHO/IMAI Orientation and Briefing

2. Challenges of rapid scale-up of ART • HIV: multi-system disease • Requires shift to chronic care • Comprehensive care: acute, chronic, palliative; with/without, before/after ART • Clinical team approach

3. Clinical interventions for public health • Standardized generic guidelines for country adaptation • Focus on priority problems • Provides tools (guidelines, training, patient monitoring, management materials) for country adaptation and use • Simplified for use at district and health centre level (first-level outpatient facilities) • Symptom-based but also integrates important, available lab tests

4. HIV-relevant pocket guides (guideline modules)

5. Key Features of IMAI • Flexible service delivery model • Supports rapid scale up—aimed at achieving broad coverage of key interventions—required for scaling-up • Harmonization, simplification and standardization • Simple and practical but comprehensive • Coherent & consistent, rather than fragmented & inconsistent—package

6. Based on WHO ART guidelines: (Product of global consultation) HIV/AIDS STANDARD TREATMENT GUIDELINES

7. Scaling-up HIV services ART

8. Tony Harries, Malawi:The “medicalised model” in Africa • Doctors to deliver ARV treatment • Choice of multiple ARV regimens • Mandatory laboratory monitoring • “LFTs, FBC, CD4-counts” • Computers to track patient follow-up will preclude rapid and massive scale up

9. Chronic HIV Care ART

10. PMTCT

11. Spectrum of HIV related services HIV uninfected HIV infected Not sexually active Sexually active Asymptomatic   Advanced + Home based & Palliative care + ART and OI management + ARV for Prevention (MTCT) Psychosocial care, livelihood support, P4P + Info, prevention and care services (Pregnancy, STI, substance use and PEP) HIV testing Information, life skills & community based interventions to: raise awareness of HIV, reduce IDU & stigma & promote services

12. Testing and Counselling

13. Basic prevention for ALL: • Safer sex/condoms • STI screen, get treated • Dual protection FP • Test and get family/ • partners tested Integrated Management of Prevention, Care and Treatment In the community PLHA support Positive prevention Peer outreach sex workers, IDU, adolescents Focused prevention Treatment Preparedness Strengthen prevention Treatment Supporters Prevention HIV T&C Know your status Illness: HIV negative and positive IMAI Acute Care At first-level health facility IMAI Chronic HIV Care with ART Severe illness IMAI/IMCI: Second level ART/OI & HIV inpatient management At district hospital

14. Basic prevention for ALL • delivered in community: • Safer sex/condoms • STI screen, get treated • Promote dual protection FP • Test and get family/ • partners tested Integrated Management of Prevention, Care and Treatment in the community • PLHA: • Prevention for positives • Prevention by positives • Peer groups for • treatment support • Patient Education • Flipchart on HIV • prevention section CHWs: Treatment support Prevention Patient Treatment Cards–prevention on back Adolescents Sex Workers IDU Community-based preparation of Treatment Supporters by CHWs Prevention Client- Initiated T&C: Know your status Peer outreach/Focused prevention Treatment Preparedness: Community education on ART; Community adherence support Strengthen prevention WHO IMAI Patient Self- Management & Caregiver Booklet

15. Pregnant women FP visits Palliative Adult illness: HIV negative and positive Adult illness: HIV negative and positive Acute Sex worker Adoles- cent Routine HIV T&C Routine HIV T&C IDU Job Aid Routine HIV T&C Reproductive Health Child illness: HIV negative and positive Routine HIV T&C Routine HIV T&C TB: HIV negative and positive Chronic- all ages Routine HIV T&C Integrated Management of Prevention, Care and Treatment At first-level health facility PLHA IMAI Acute Care PMTCT: FP: dual protection For positives: Reproductive choice Return to sexuality IMAI TB Care with TB-HIV Co-Management PMTCT: Infant feeding counselling IMCI-HIV Adaptation ARV prophylaxis- Taught within Chronic HIV Care with ART IMAI Palliative Care IMAI Chronic HIV Care with ART PMTCT integrated within Antenatal, Post-partum Care Safer Labour & Deliver

16. Basic prevention for ALL: • Safer sex/condoms • STI screen, get treated • Dual protection FP • Test and get family/ • partners tested Pregnant Women with complications Clinical mentoring Referral/back-referral Severe adult illness Acute & chronic Routine HIV T&C Routine HIV T&C PMTCT: Safer labour and delivery in hospital Severe child illness Reproductive Health TB disease Regular Clinical Supervision/ Communication by MD/ MO on clinical team Integrated Management of Prevention, Care and Treatment At district hospital IMAI/IMCI: Second level ART/OI – MD/MO & HIV inpatient management- MD/MO; nursing TB treatment by MD/MO- Co-treatment decisions, etc.

17. Extending HIV Care/ART beyond the hospital • HIV/AIDS care and treatment should be made available as close to the patient’s homes as possible—for equity, access, adherence • Most OIs can be treated in primary care facilities • IMAI Acute Care prepares for non-hospital management of non-severe pneumonia, oral & some oesophageal thrush, most skin infections, persistent diarrhoea, peripheral neuropathy, etc

18. Clinic HIV testing and counselling Education and counselling PMTCT Chronic HIV Care (OI prophylaxis and ART) Preparation for ART Initiation of ART in uncomplicated patients ART dispensing and follow-up Record-keeping of all the above activities Health centre and hospital Initiation of ART in sick and hospitalized patients Management of complicated OI cases Management of treatment failure and adverse effects Management of complications of ART Record-keeping of all the above activities Decentralization of HIV services

19. IMAI principles for scaling up integratedHIV prevention, treatment and care • Establish good chronic HIV care with clinical teams working within a district network (linking the several levels of care). • Strong PLHA and community involvement. • Empower patients for self-management. • Adapt and broadly implement a coherent, standardized package of interventions. • Decentralize most interventions to the health centre and community to head toward universal access. This involves further simplification and operationalization of guidelines, harmonized training materials, and emphasis on follow-up after training (both clinical mentoring and supportive supervision). • Rigorous and coordinated approach to adherence. - by clinical team, community, and one-to-one treatment support in the home. • Integrate prevention with treatment and care in the facility. • Use broad-based community interventions for prevention, treatment preparedness, and to promote use of services. • Target prevention efforts where most transmission occurs. This requires peer outreach and special, friendly health services for high risk and vulnerable groups. • Emphasis on management training at support at district, regional and national level.

20. Uganda* Swaziland* Eritrea* Senegal* Sudan* South Africa (Eastern Cape Province)* Ethiopia* Zambia* Lesotho* Burkina Faso* Guinea-C* Tanzania* India China Somalia Mozambique Burundi Cameroon Zimbabwe Ghana Namibia Botswana PNG Nigeria Indonesia Haiti Kenya Myanmar * adaptation complete Countries which have started IMAI adaptation

21. IMAI/IMCI tools to support service delivery Example of operational tools: Integrated Management of HIV/AIDS at Facility with Linked Community Interventions (based on IMAI/IMCI/IMPAC) • Home: • Positive prevention • Universal precautions • ART, TB one-to-one treatment support • Psychosocial support • Home-based palliative care • Home: • Positive prevention • Universal precautions • ART, TB one-to-one treatment support • Psychosocial support • Home-based palliative care Levels of interventions Patient self-management tools; caregiver booklet • Community (above plus): • CHWs: adherence,monitor, refill ART, TB, OI prophylaxis; prevention: safer sex, condoms, FP; nutritional support • HIV testing and counseling (CITC/VCT) • Targeted interventions (outreach)—SW, IDU, other • Broad-based prevention (emphasis on youth) • Community mobilization for prevention, treatment preparedness, use of services CHW training; peer groups Education flipchart TB Care with TB-HIV Co-Management, Chronic HIV Care with ART, Acute Care-adult, child (IMCI) Harmonized short courses • Health centre (above plus): • Provider-initiated T&C • PMTCT • STI detection and treatment • Special care: IDU, sex worker; youth-friendly • Initiate first-line ART in uncomplicated patients • TB treatment, TB-HIV Co-management • Treat most OIs • PEP—occupational, non-occupational • Safe medical injections Second-level ART/OI training, Clinical mentoring • Integrate prevention with treatment, care • Hospital (above plus): • Blood safety • ART in complicated patients, second-line, IRIS, severe toxicity • TB: smear negative, extrapulmonary, TB-ART co-management • Complicated OIs • IDU: drug substitution

22. 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