Dr Sandy Gove, IMAI Technical Coordinator WHO IMAI Technical Working Group

1. Integrated Management of Adolescent-Adult Illness (IMAI):A Primary Health Care Approach to TB-HIV Care in Low Resource Settings Dr Sandy Gove, IMAI Technical Coordinator WHO IMAI Technical Working Group 22 Departments and Regional Offices including: Stop TB HIV/AIDS Management of Non-Communicable DiseaseChild and Adolescent Health Health Service Provision Mental Health and Substance Dependence Evidence for Health Policy Roll Back Malaria AFRO Regional Office IMAI International Working Group Zimbabwe, Uganda, Zambia, many other institutions/organizations/individuals

2. IMAI Pregnancy IMPAC s r B a i r e t Y h 0 1 5 Years 2 Months 1 Week IMCI Integrated Management of Pregnancy and Childbirth Integrated Management of Childhood Illness Integrated Management of Adolescent/Adult Illness

3. IMAI PAL TB DOTS TB DOTS STI HIV Integrated Content for Primary Health Care

4. TB-HIV within Integrated Management of Adolescent/Adult Illness (IMAI) • TB and HIV care integrated within primary health care • For first-level facility health workers in low resource settings • both district outpatient clinics and peripheral health centres • both rural and urban • Complements MD/senior clinician guidelines for ARV treatment and TB-HIV care • Integrates care and prevention

5. National and District Planning: TB, HIV, STI and other Programmes; General Medical Services Inpatient Clinicians in outpatient clinics Nurses Peer educators/ support staff/ counselors District Nurses Peer educators/ support staff/ counselors Health centres, clinics IMAI Community Home-based care: caregiver education in palliative care TB case detection TB and ARV treatment supporters Link with community organizations, NGOs

6. Intensified TB case detection Ask & observe for cough in all acute patients Send sputums in acute pneumonia Broader criteria--> special attention/referral if: suspicious nodes severe undernutrition or weight loss abdominal pain persistent fever Consider TB: on follow-up visits after acute care at each HIV care visit during home-based palliative care How IMAI can contribute to TB control

7. How IMAI can contribute to TB control TB treatment closer to home • Contributes to continuing expansion of DOTS to enable first-level facilities to initiate treatment in smear + patients and monitor care • TB treatment supporters in the community • Effective training using MANAGEMENT OF TUBERCULOSIS: Training for Health Facility Staff Few IMAI additions (for nurses also trained in HIV and acute care): • When to refer to clinician for consideration ART • Cotrimoxazole prophylaxis and pyridoxine in all TB-HIV patients • Treat peripheral neuropathy with amitriptyline • Manage acute illness (using IMAI Acute Care)

8. IMAI Acute Care module • Care for both HIV+ and HIV- patients • When to suspect HIV and TB • HIV testing & counselling in context of clinical care (using lay counsellors) • Preventive interventions linked with all care • Enables the nurse to provide most acute care, as in IMCI • Same format as IMCI--> efficiencies in training, care, and clinic and district management

9. pneumonia diarrhoea fever undernutrition and anaemia genito-urinary: STIs, UTIs, menstrual problems oral problems- candida, ulcers peripheral neuropathy, headaches, other neurological skin infections pyomyositis depression harmful alcohol use Integrated with preventive interventions IMAI Acute Care includes care for:

10. IMAI General Principles of Good Chronic Care Supports introduction of an effective approach to chronic care (lifelong care): • treatment partnership with the patient • respect for patient’s right to choose • emphasis on patient education, self-management, and active support for adherence (with reminders, treatment supporters...) • team approach • inclusion of “expert patients”/peer educators and support staff on clinical team

11. IMAI HIV Care module • Introduction of an efficient approach to chronic care • With or without ARV treatment • Prophylaxis- cotrimoxazole, INH, fluconazole • Patient education and psychosocial support • Adherence preparation and support • Clinical monitoring • Support for disclosure & other interventions to prevent transmission

12. IMAI HIV Care module • Focus on nurses and peer (lay)educators/support staff- working in a clinical team with the clinician • Close collaboration with community volunteers and organizations • Complements ARV & TB-HIV clinician guidelines • Based on general principles of good chronic care (applicable in other chronic diseases) • For use in range of facilities to allow scale up: • Government • Private • NGO • Mission

13. Palliative Care Guidelinesfor clinical management, home care recommendations, back-up to home-based care Caregiver Education Booklet to prepare patients, families and community-based carers to provide effective home care Line drawings Locally adapted Essential, quality palliative care within home care To improve management of pain and other symptoms within home-based care Support oral morphine use at home Both medical and non-medical interventions Simplified, standardized approach Public health approach- capable of achieving wide coverage IMAI Palliative Care:Symptom Management and End-of-Life Care

14. Adolescent Job Aid • How to make the facility and health worker adolescent-friendly, to allow access • Special considerations in treating adolescents • For use with IMAI, IMPAC (pregnancy guidelines), Family Planning, STI guidelines • Essential to allow integrated adolescent and adult guidelines

15. IMAI: tools for rapid expansion of TB-HIV care Generic tools for country adaptation and implementation: • simplified evidence-based guidelines for health workers • simplified job aids for lay staff • training materials • cards/booklets for patients and community carers • materials to support country adaptation and implementation

16. IMAI: tools for rapid expansion of TB-HIV care Several alternative training methods are needed with: • Efficient methods • skill stations • video presentation of cases and skills • combine initial distance learning with clinical practice and short workshops or on-site training • build on IMCI skills for acute care training • Early introduction into preservice education

17. Shift responsibility for much outpatient adult care to nurses and other first-level facility health workers Expand staff: involve lay counsellors and “expert patients” on clinical team Involve community in case detection and care delivery Preserve staff by providing ARV treatment Aim: rapid expansion of human resources for TB-HIV care and prevention while providing skills and clinic capacity to manage other acute and chronic illnesses

18. Status of IMAI modules relevant to TB-HIV care • When ready for country adaptation and fieldtesting/phased implementation with close monitoring : • HIV Care Now • Palliative Care Now • Caregiver Education Booklet Now • General Principles of Good Chronic Care August • Acute care- in validation studies October • Collaborators with resources needed: • further review and expert input • another acute care validation study site • fieldtesting and early implementation with close monitoring- working with IMAI team • Few IMAI additions (for use by nurses trained in HIV Care) to the TB training materials- for review.

19. Further development of IMAI • Iterative process • Need further input from as many low resource settings as possible- both by review and fieldtesting • Further guideline simplification- needs to be evidence-based • hope to eliminate clinical signs from acute care algorithm based on validation results • Need help in the development of effective and efficient training materials

20. IMAI country adaptation will include rapid ethnographic methods to culturally modify interventions: • to improve adherence (by understanding beliefs about medications) • to explore how the association of TB with HIV affects case detection • to renew and expand prevention efforts linked with new availability of HIV treatments • to tailor more effective communication methods

21. Quick Check and Emergency Treatments Brief interventions for key risk factors Smoking Poor diet Physical inactivity Harmful alcohol use Diabetes Integrated approach to cardiovascular disease RF/RHD secondary prophylaxis Epilepsy Leprosy Asthma COPD …... IMAI modules of less relevance to TB-HIV control

22. Acute Care Acute TB case detection TB Care- IMAI additions to TBReference Booklet Long but time- limited Harmful Alcohol Use Smoking Physical Inactivity Poor diet Increase testing: HIV+ Manage acute problems Case detection Case detection CTX prophylaxis, when to refer to clinician Diabetes Care, other chronic diseases HIV Care Palliative Care Chronic Symptom management End-of-life care Chronic Care and Risk Reduction: general principles of good chronic care

23. First-level facility care: outpatient or peripheral health centres VCT (freestanding) TB Medical care for sick adolescent/ adult HIV testing within clinical care FP Home-based care Antenatal care: recruited via PMTCT activities Labour and delivery Special FP, STI, HIV, TB clinics Severely ill patients in ED, inpatient