Stakeholder Input and Adaptation Process

1. Scaling-up HIV PreventionCare and Antiretroviral Therapyat Primary Health Centres:A WHO/PEPFAR Collaboration Stakeholder Input and Adaptation Process

2. Scaling-up HIV PreventionCare and Antiretroviral Therapyat Primary Health Centres:A WHO/PEPFAR Collaboration WHO and PEPFAR coordinated support for a MOH-led, multi-partner collaboration

3. Scaling-up HIV Prevention, Careand ART at Primary Health Centres Why Adaptation? • Each element of the “generic” Operations Manual was selected to be applicable to MOST country situations. • Adaptation is needed to produce a manual that can be directly applied to a primary health centre in a specific country. • For example, specific adaptations needed for: • National supply management system • Essential lab tests for basic primary care • Staffing requirement for basic primary care

4. Scaling-up HIV Prevention, Careand ART at Primary Health Centres Why Adaptation? • Many countries have already adapted IMCI/IMAI clinical guidelines or the WHO Patient Monitoring Systems for HIV care/ART and TB. • These tools may need to be “re-adapted” to reflect recent developmental work at the global level • Integration of TB and PMTCT into IMAI clinical guidelines • Broadening of Patient Monitoring Systems to include ANC/PMTCT • HIV variables added to TB patient monitoring system

5. National level requirements to support a decentralized, integrated approach for scale up at health centre level: Key policy decisions (task shifting, lay counselors on clinical team, TB can be treated in HIV clinics, TB infection control, etc) Adaptation of the tools -- MOH, USG partners, other partners and stakeholders Agreements between national programmes on shared programme of work Agreements on responsibility for implementation support (regionalization, etc)

6. * "District clinicians" providing outpatient and inpatient care at district hospital, depending on country Doctors, Medical officers, GPs* Health officers, Clinical officers* Nurses Midwives, MCH nurses TB clinic nurses Physicians Paediatricians IMAI task shifting for HIV care and ART: clinical management Nursing assistants, Counsellors, Lay counsellors: PLHIV on clinical team PLHIV (self-management) CHWs, other community- based practitioners Community volunteers (PLHIV and others) Family caregivers

7. Scaling-up HIV Prevention, Careand ART at Primary Health Centres The Adaptation Process • Initial meeting of national stakeholders convened by Ministry of Health, with support from WHO, USG, other partners • Decision on whether adapted Operations Manual would help country scale-up; what clinical tools need to be updated • Then series of adaptation workshops focused by technical area

8. Scaling-up HIV Prevention, Careand ART at Primary Health Centres The Adaptation Process • Series of adaptation workshops focused by technical area • Operations Manual- several streams of work, by chapter • Updated IMCI/IMAI clinical guidelines and tools • Tanzania very up-to-date on IMAI Chronic HIV Care- already integrates TB-HIV co-management, ART in pregnancy and other PMTCT interventions, prevention by PLHA, psychosocial support for children • IMCI 'classic' to IMCI Chart Booklet for High HIV Settings • Use these to review, adapt adult, paediatric intervention lists (chapters 1 and 2) • Consider additional 'new' interventions or changes based on new normative guidelines and/or data

9. Operations Manual Adaptation Process • Multiple streams of work- examples • Patient monitoring systems for health centre: • HIV care/ART • HIV variables into TB monitoring system • PMTCT system • Laboratory at health centre: • SOPs for lab tests • System for sending out CD4 and DBS for infant HIV diagnosis • Supply management • Fit to national system and health centre essential drug list- stock cards, etc

10. Country-adapted Operations Manual and Clinical Tools • National standardized guidelines, training materials, job aids, recording and reporting forms • What services should be at health centre • Clinical guidelines, job aids • Laboratory support • Supply management • Infrastructure • HR: staffing, training, health worker protection, mentoring • Patient monitoring systems • Quality management- approach, tools, supportive supervision • Operations Manual is not stand-alone. Sits next to clinical tools

11. Scaling-up HIV Prevention, Careand ART at Primary Health Centres Summary of PEPFAR Countries • Adaptation of IMCI: all (15/15) • Adaptation of IMAI: Uganda, South Africa (E. Cape, Mpumalanga..), Zambia, Ethiopia, Tanzania, Haiti, Botswana, Nigeria, Kenya, Guyana, Namibia, Mozambique (12/15) • Adaptation of HIV care/ART Patient Monitoring System: Uganda, South Africa, Ethiopia, Tanzania, Nigeria, Kenya, Guyana, Namibia (8/15)

12. Scaling-up HIV Prevention, Careand ART at Primary Health Centres Inputs into the Adaptation Process • Draws upon existing development work and implementation experience by partners in the country • New evidence and updated global normative guidelines for PMTCT, PITC, infant testing, etc  updated national guidelines  tools for health centre • Policy and regulatory work to expand roles of cadres • Task shifting experiences from other countries • Scale up is substantially advanced - modifications and new tools to support decentralization, expanded integration, accelerated prevention etc.

13. Scaling-up HIV Prevention, Careand ART at Primary Health Centres The Adaptation Process • Includes all partners active at the health centre level: • USG and non-USG • MOH, NGO, FBO • HIV care/ART focused plus TB, maternal and child health, palliative care, etc • PLHIV expert patient groups (involved in training, lay providers on clinical team)

14. Scaling-up HIV Prevention, Careand ART at Primary Health Centres The Adaptation Process • Adaptation Guides are being developed to: • Standardize the adaptation process • Evidence base for recommendations in the Operations Manual and IMAI clinical tools • Guidance for selection of possible adaptations • Substance of possible adaptations- for example, trigger forms for TB screening

15. Scaling-up HIV Prevention, Careand ART at Primary Health Centres Outputs of Adaptation Process • Boxed set of field-ready tools. Country-adapted: • Operations manual • IMCI/IMAI clinical guidelines • Training materials • Patient monitoring cards and registers • QA tools • Patient education tools (IEC materials) • Consensus by the Ministry of Health, other organizations and partners to support scale-up at the health centre level using a single strategy.

16. Scaling-up HIV Prevention, Careand ART at Primary Health Centres Outputs of Adaptation Process • Consistent with increased interest by Ministries of Health for a “standard package” of technical assistance to primary health centers: • Ethiopia • Tanzania • Nigeria • Uganda, etc.

17. Standardized guidelines, training, management toolsShare training, mentors, patient monitoring system within a district or region MOH, other partners Workplace HIV services USG partners, NGO or FBO Private providers Military services  Scale up toward universal access is more feasible, sustainable

18. National standardized package to support HIV services • For all health centres: • Government • FBO-sponsored clinics

19. Scaling-up HIV PreventionCare and Antiretroviral Therapyat Primary Health Centres:A WHO/PEPFAR Collaboration The Implementation Process

20. Scaling-up HIV Prevention, Careand ART at Primary Health Centres A Powerful Combination • Joint support for implementation by USG agencies/implementing partners • WHO/Ministries of Health support for standards and policy changes to facilitate decentralized scale-up • Other partners

21. Scaling-up HIV Prevention, Careand ART at Primary Health Centres The Implementation Process • Opportunity to increase cooperation through endorsement of Ministry of Health strategy • Between partners • Between partners and the Ministry of Health • Coordinated health systems strengthening • Standardized approach to training/mentoring • QA • Patient monitoring

22. Scaling-up HIV Prevention, Careand ART at Primary Health Centres The Implementation Process • Training & support after training - health center staff • Essential laboratory tests for health center • Facility management • Use of patient monitoring systems • Etc. • Training & support after training - district teams • Use of QA tools • Patient monitoring - annual monitoring review, analysis, reporting to national level • Etc.

23. Scaling-up HIV Prevention, Careand ART at Primary Health Centres Role of WHO at Country Level • Strengthen MOH with seconded staff (NPOs) • Work with MOH to coordinate adaptation process • Quality assurance - minimum standards for IMAI/IMCI training, QA after training with partners • Promote technical experts and managers within the MOH at central, regional and district level, other national institutions, NGOs/FBOs – will also be able to support neighboring MOH (south to south capacity)

24. Scaling-up HIV Prevention, Careand ART at Primary Health Centres Role of USG Partners at Country Level • Build on relationship previously developed with the Ministry of Health • Full participation in adaptation process • Strengthen support for regional, district and facility management in all targeted sites • Support implementation of adapted tools in assigned regions or sites- training, mentoring, quality assurance, supplies, lab, infrastructure support etc

25. Scaling-up HIV Prevention, Careand ART at Primary Health Centres • Speed of implementation, number of primary health centres, patient targets, responsibility for regions – should be a collaborative decision involving Ministry of Health and all stakeholders • During implementation period, each primary health center will be supported using QA tools and evaluated on all the elements included in the country-adapted Operations Manual

26. Scaling-up HIV Prevention, Careand ART at Primary Health Centres: Tanzania • Strong MOH commitment to integrated models of care (e.g. IMCI) • MOH already has simplified patient monitoring systems and IMAI guidelines, curriculum for health centre scale up • Close collaboration with USG partners – division of input by regions

27. IMCI Chart Booklet Tanzania

30. Logistics, management Clinical guidelines Complements Operations Manual- Health Centre Supplies, lab, infrastructure, QA, patient monitoring, human resources, fiscal management

31. Integrated approach better serves HIV clients with other diseases (TB) or conditions (pregnancy, IDU) • Clinical co-management • Co-supervision by district teams (HIV, TB, MCH) • Co-sponsorshipby national programmes- • shared programme of work • Efficient management for patient (single clinic visit) • and clinical team: • TB-HIV co-management • ART or ARV prophylaxis and other PMTCT interventions integrated in antenatal, L&D, post-partum and newborn care

32. Scaling-up HIV Prevention, Careand ART at Primary Health Centres: Tanzania • Scale up of HIV services to district hospitals in 2006 • Plan to scale up to 540 health centres in 2007-8 • USG partners, WHO, 1 representative MOH had introductory meeting in July • Next step: stakeholders meeting/ workshop for OM, new or updated clinical tools

33. Mozambique • Introductory meeting on the collaboration and Operations Manual with MOH, USG partners, WHO in August • All interested in updated IMAI tools and adapting Operations Manual to support health centre scale up • Translating current IMAI/IMCI tools into Portugese • Hoping for date soon for adaptation workshop

34. Operations Manual Health centre tools for scaling up HIV services integrated with basic health care- in a country using IMAI Bench Aid Malaria plus Other aids District Addendum to the Operations Manual Forms: Patient Monitoring, Other IMAI Adaptation Guide Operations Manual and District Addendum Adaptation Guide IMCI Adaptation Guide: Section C, updates For national programme managers, experts, partners or other national primary care guidelines

35. Operations Manual assumptions for the generic • High HIV prevalence, generalized epidemic • Resource constraints. • Basic primary health care and prevention services • HIV prevention, care and treatment services are integrated in their delivery and with these primary care services. • For large or small health centres: • Large: limited number L&D beds, few inpatient beds for severe malaria or emergency surgery; catchment up to 20,000 • Small: 10,000. • Management of up to 750 PLHIV in chronic HIV care, with 30 to 50% on ART. • No surgical or specialized reproductive health services such as female sterilization, vasectomy, or adult male circumcision • Limited essential lab on site with few tests sent out • No refrigeration, other than vaccine cold chain • Water supply • Some electricity (variable source) • Communication- at least mobile phone • All routine health centre sites (not sentinel, research sites).

36. Primary target audiences of tools • Adaptation Guide (evidence base, possible adaptations): • National programme managers, technical experts from universities, partners, NGOs/FBOs • District addendum: • District management team • Operations Manual: • Health centre team • (already country-adapted, standard guidelines, tools)

37. District addendum(use with updated district HIV coordinators' training course) • Supervisory checklist • QA, routine evaluation tools • Tools to assess site readiness and to reassess, examine service availability • Case management observation • Exit interviews • Record audit: DRAT, IMAI rapid assessment • How to support patient monitoring system • Annual monitoring review • Supervision/QA/support (stains) for health centre laboratories • Waste management

38. Chapter 1: Assessment and Planning • Assess services which are currently provided • Where are we at now? • What more can we do? • What more is needed to support this? • Determine HIV service needs in health centre catchment area • Number need testing with PITC push • HIV+, ART • clinical visit frequency •  estimates in Infrastructure, HR chapters based on 100, 250, 500, 750 in HIV care • Need further input to forecast health centre needs to support scale up of PITC • ? add costing (or in District addendum)

39. What HIV and basic health services are available (SAM)? Quality assessment and improvement: checklist, observation, patient satisfaction, etc What HIV and basic health services are available (SAM)? Quality assessment and improvement: checklist, observation, patient satisfaction, etc • Assess and plan • Where are we at now? • What do we want to add? • What more is needed to support this? What HIV and basic health services are available (SAM)? Quality assessment and improvement: checklist, observation, patient satisfaction, etc • Assess and plan • Where are we at now? • What do we want to add? • What more is needed to support this? What HIV and basic health services are available (SAM)? Quality assessment and improvement: checklist, observation, patient satisfaction, etc • Assess and plan • Where are we at now? • What do we want to add? • What more is needed to support this? • Assess and plan • Where are we at now? • What do we want to add? • What more is needed to support this? What laboratory tests? How many? Reagent supplies adequate? Quality assure lab tests What laboratory tests? How many? Reagent supplies adequate? Quality assure lab tests What laboratory tests? How many? Reagent supplies adequate? Quality assure lab tests What laboratory tests? How many? Reagent supplies adequate? Quality assure lab tests What infrastructure and equipment? Equipment upkeep and quality check for scales, other equipment Color-coded waste disposal, handwashing at all care sites? TB infection control in place? What infrastructure and equipment? Equipment upkeep and quality check for scales, other equipment Color-coded waste disposal, handwashing at all care sites? TB infection control in place? What infrastructure and equipment? Equipment upkeep and quality check for scales, other equipment Color-coded waste disposal, handwashing at all care sites? TB infection control in place? What infrastructure and equipment? Equipment upkeep and quality check for scales, other equipment Color-coded waste disposal, handwashing at all care sites? TB infection control in place? What supplies and commodities? How much? Check stock cards Use supply checklists What supplies and commodities? How much? Check stock cards Use supply checklists What supplies and commodities? How much? Check stock cards Use supply checklists What supplies and commodities? How much? Check stock cards Use supply checklists What human resources? How to protect them? Staff positions filled? PEP, other HW safety in place?terventions available What human resources? How to protect them? Staff positions filled? PEP, other HW safety in place?terventions available Manage and assure quality What human resources? How to protect them? Staff positions filled? PEP, other HW safety in place?terventions available Manage and assure quality What human resources? How to protect them? Staff positions filled? PEP, other HW safety in place?terventions available Manage and assure quality Manage and assure quality Are services well integrated and linked? Is each type of patients efficiently co-managed? Effective links with hospital, community, services offered by others? E Are services well integrated and linked? Is each type of patients efficiently co-managed? Effective links with hospital, community, services offered by others? E Are services well integrated and linked? Is each type of patients efficiently co-managed? Effective links with hospital, community, services offered by others? E Are services well integrated and linked? Is each type of patients efficiently co-managed? Effective links with hospital, community, services offered by others? E Manage implementation Assure quality Solve problems Manage implementation Assure quality Solve problems Manage implementation Assure quality Solve problems How are patients monitored? All forms and registers present and used correctly? Review patient monitoring data. Manage implementation Assure quality Solve problems How are patients monitored? All forms and registers present and used correctly? Review patient monitoring data. How are patients monitored? All forms and registers present and used correctly? Review patient monitoring data. How are patients monitored? All forms and registers present and used correctly? Review patient monitoring data. Is leadership and management sufficient? Is leadership and management sufficient? Is leadership and management sufficient? Is leadership and management sufficient?

40. Chapter 2: HIV services • Lists of interventions- for country adaptation: • Basic essential (?consensus possible; survey who/how) • Desirable • Intensified • Includes basic primary care services for children and adults • Cannot delivery HIV services when basic services are weak • Matrix to help assess current services, what to add • Then detailed planning for each new service- back to chapter 1 • Need to edit down, consistent level of detail. • No "how to" • From Chapter 3 on: How to .. • ? also define linked community interventions?

41. Chapter 7 Patient monitoring • Most data for treatment and care; few variables go up • 3 linked patient monitoring systems: • TB (decades old; has just finalized few new HIV variables) • HIV care/ART: 2004- standardized minimum data set, illustrative forms • PMTCT- simplified paper-based system still in development- urgent completion, consensus needed

42. Chapter 7 Patient monitoring • Quarterly cross-sectional reports: few new variables being considered- PMTCT, TB-HIV • Annual monitoring review by district/regional team to collect: • ART cohort data • sample of cards for TB screening data, HIV care/ART and PMTCT data Simple tally sheet in development