Facilitators guide

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  • 1. Republic of Kenya Ministry of HealthAntiretroviral DrugTherapy in Kenya The ART/HMIS Training Materials (Facilitator’s Guide) National AIDS and STI Control Programme (NASCOP) August 2006
  • 2. Table of ContentsModule I: Introduction to the Course.................................................................................. 1Module II: Pre-test .............................................................................................................. 3Module III: Overview of HIV/AIDS.............................................................................. 6 Part 1: The HIV/AIDS Situation............................................................................. 6Module III: Overview of HIV/AIDS............................................................................ 10 Part 2: The ART Programme in Kenya................................................................. 10Module IV: Introduction to ART-A Conceptual Framework....................................... 12Module V: Introduction to ART Data Collection System. ............................................... 14Module VI: Data Collection ......................................................................................... 16 Part 1: Overview of Data Collection Tools........................................................... 16Module VI: Data Collection.............................................................................................. 18 Part 2: Comprehensive Care Clinic Card.............................................................. 18Module VI: Data Collection.............................................................................................. 19 Part 3: Pre-ART Register ...................................................................................... 19Module VI: Data Collection.............................................................................................. 20 Part 4: ART Register............................................................................................. 20Module VII: Aggregation and Reporting.......................................................................... 21 Part 1: Completing the Monthly Summary Sheet ................................................. 21Module VII: Aggregation and Reporting.......................................................................... 23 Part 2: Completing the Cohort Summary Sheet.................................................... 23Module VIII: ART Programme Measures ........................................................................ 24 ART/HMIS Materials - Facilitator=s Guide i
  • 3. Instructions on HMIS Training MaterialsThe Facilitator’s Guide is divided into eight (8) modules. Module I is an introduction to theCourse while Module II contains a pre-test for the participants. Module III looks at theHIV/AIDS Situation while Module IV looks at the Clinical Perspective of ART. Module Vgives an introduction to ART/HMIS while Module VI looks at the data collection tools.Module VII looks at Data Aggregation and Reporting while Module VIII covers the overviewof ART Programme Measures.Each Health Centre and Hospital staff member who comes for the course shall be giventhe following materials which should be used during the course and thereafter kept atthe facility as reference material for all staff members:1. Participant’s Notes2. Participant’s Workbook3. Procedures ManualEach District Trainer who comes for the Training of Trainers (TOT) shall be given thefollowing documents:1. Facilitator’s Guide2. Facilitator’s Workbook (To be given out at the end of the TOT)3. Participant’s Notes4. Participant’s Workbook5. Procedures ManualEach District Health Office is given the following as reference material:1. Participant’s Notes x 5 copies2. Participant’s Workbook x 5 copies3. Procedure’s Manual x 10 copies ART/HMIS Materials - Facilitator=s Guide ii
  • 4. Module I: Introduction to the CoursePURPOSE: To introduce the facilitators and the participants to each other To go through the agenda and communicate the course objectives to the participants To explain logistics arrangements To introduce the contact person for logistics affairsOBJECTIVE: Upon completion of this module, participants should be able to understand the purpose of the course and their rolesMETHOD: Short personal statement from all participants and facilitators LectureMATERIALS: Overheads/Slides ART/HMIS Training Materials: Facilitators Notes & Participants Notes Exercises: there are no exercises for this module Handout (agenda of the course) Folders, pens, paperPREPARATION: Ensure that LCD or Overhead projector is working and white board or flip chart is available Prepare set of stationery for each participant Tables and chairs set in a most suitable shape, depending on the number of participants.LEARNING ACTIVITIES 30 minutesIntroduction (20 minutes)Welcome participantsExplain that the course starts with a round of personal introductions. Ask each participant their name and function, station of work, and have them add a personal touch. (Make sure that everybody speaks loudly and clearly). Be creative; develop exercises for helping participants to get to know each other and this will help you get to know the participants. Different introduction exercises can be done for the first few days of the course; they need not be limited to the first day.Hand out and review agenda and give information on logistics arrangement, if any..Explain to the participants the agenda of the course • Emphasise the need for active participation. • Tell participants they must attend the entire course and be on time. This is important given the heavy programme and sequence of course activities. ART/HMIS Materials - Facilitator=s Guide Page 1
  • 5. • Participants who miss part of the course may not be able to understand the section that follows. • Most of the teaching materials and exercises may be handed out or can be found in the Participant’s Workbook. (Facilitators receive the Facilitator’s Workbook - a similar workbook to the participants’ – but with answers and teaching points for the exercises.) • The Participant Notes include copies of the Slide/Sheet, with space where participants can write notes. • Participants will also receive an ART/HMIS Procedures ManualLecture (4 minutes)Show Module I Slide 1 and Review the main objectives of the course Training in ART /HMIS.Explain: • The purpose of the course is to familiarise the participants with the newly developed ART Data Collection and Reporting Tools. The course will prepare members of the clinical team and district coordinators on how to complete a pre-ART register, ART register, quarterly report form and cohort analysis form using data from the Comprehensive Care Clinic Patient card. • The new ART Data Collection Tools will be the standard tools for data collection and reporting in all NASCOP registered ART sites • Introduce participants to the concept of monitoring and evaluation in antiretroviral therapy • To train members of the clinical team and district coordinators to calculate a few key indicators, analyze them, and identify and solve problems • After attending this course, participants should start using the system in their stations of work.SummaryWelcome the participants again and wish them a fruitful participation in the training programme. ART/HMIS Materials - Facilitator=s Guide Page 2
  • 6. Module II: Pre-testPURPOSE: To administer a pre-test and explain how results will be usedOBJECTIVE: Upon completion of the module: Participants should be able to understand why they are completing the pre-test Facilitators should understand how to grade the pre-test and how to use the information from the resultsMETHOD: Discussion (before test) Administer, grade and analyse test The analysis of the test results should lead to adjustments in the course set-up. More time should be spent on weak points identified in the pre-test.MATERIALS: One copy of the pre-test for each participant Pre-test answers begin on page 37 of the Facilitator’s Workbook.PREPARATIONS: Make sure you have a copy of the test for each of the participants.LEARNING ACTIVITIES 1 hour, 5 minutesLecture (2 minutes)Explain the following points to the participants: • The purpose of the pre-test is to give the facilitators an idea of what participants already know or do not know before the course. • The facilitators will use the results of the pre-test to adapt the course so that it will respond better to what the participants know and do not know. • The pre-test aims at motivating the participants, to arouse their interest. The pre-test indicates to the participants the knowledge and skills that they are expected to acquire during the course. • The participants will not be graded and the results on this test will and should not affect the participant’s participation in the course. • The participants will not be given scores and the facilitators will discuss the correct responses during the relevant modules of the course.Explain instructions for the test (3 minutes) • Everyone should work on their own • The participants do not have to put their name but put a code that only they can remember which should be the same for the post-test. • The test includes questions on mathematical skills, clinical knowledge and the use of data. No one is expected to know all the answers. ART/HMIS Materials - Facilitator=s Guide Page 3
  • 7. Hand out and collect test (45 minutes)Time allocated for the test is 45 minutes. However if it appears that many people have notfinished, give extra time so that all can complete it. It is more important to finish the pre-testthan to finish it within a certain time limit.Do not go over the answers after the test. Do not answer any questions about the test, sinceparticipants will take the same test at the end of the course.Grading the Test (time depends on # of participants)Analyze the results in the evening of the first day of the course. Each question is awarded 1point (for a totally correct answer) or 0 points (for incorrect or only partially correct answer).Remember this is not for certification; it is for you as facilitators to be able to know in whicharea your participants are weak.The test with the correct answers is indicated in bold from Page 37 of the Facilitator’sWorkbook.Here is how to analyse the pre- and post-test results. For each question, we want to find outthe percentage of correct answers. (This quickly shows us where people had difficulty; thelower the percentage, the fewer people were able to answer the question.)The formula for the percentage of correct answers is: Number of persons who got a particular question right X 100 Total Number of respondentsThis will give you the percentage of persons who got question 1, 2, 3, 4 etc. correctFor example, if 5 people got question A1 right out of 20 respondents,It will be: 5 x 100 20 = 25% of the respondents gave a correct response to question one.Then look at all the questions to find which were answered incorrectly most often. Forinstance, question B1 is on ART Indicators. If this question and the related questions have notbeen answered well, the module on ART Indicators needs to be emphasised during training.Discuss the Results (15 minutes)Discuss the results during the evening meeting for facilitators and decide whether to makeany changes in the course content, or timing based on the results. ART/HMIS Materials - Facilitator=s Guide Page 4
  • 8. The next morning tell participants in a general way how they did in the test. You may tellthem which type of questions they did well or poorly on, but do not tell them any answers oranswer any questions about test questions, since they will be taking the same test at the end ofthe course.This chart will help you organise your grading of the pre-test.Question # Covered in Module Number who % who answered answered correctly correctly (number who answered correctly /total number of respondents)A1 Module IVA2 Module IVA3 Module IVA4 Module V & VIA5 Module VIIIB1 Module VIB2 Module VIB3 Module VIB4 Module VIB5 Module VIC1 Module VIIIC2 Module IIIC3 Module IIIC4 Module IIIC5 Module V ART/HMIS Materials - Facilitator=s Guide Page 5
  • 9. Module III: Overview of HIV/AIDSPart 1: The HIV/AIDS SituationPURPOSE: • To give an overview of the HIV/AIDS situation • To brief participants on responses to the HIV/AIDS problem in Kenya.OBJECTIVES: At the end of the module, participants will be able to understand: • The HIV/AIDS situation • The implications of HIV/AIDS in Kenya • The responses to the HIV/AIDS ProblemMETHOD: LectureMATERIALS: LCD or overhead projector, white board or flip chart, markers and handouts.PREPARATION: Ensure that all materials i.e. LCD or Overhead projector are working and white board or flip chart is available, including markers.LEARNING ACTIVITIES 1 hourIntroduction (3 minutes)Explain the purpose and the objectives of the module.Show Module III Part 1 Slide 1 with objectivesTell the participants that the purpose of this module is: • To give a global and regional overview of the HIV/AIDS situation • To brief participants on responses to the HIV/AIDS problem in KenyaAt the end of the module, participants will be able to understand: • The HIV/AIDS situation • The implications of HIV/AIDS in Kenya • The responses to the HIV/AIDS ProblemIntroduce the module by saying that this module is extracted from the training materials providedduring the ART clinical training.Explain that this section is put here for the benefit of those who could have not been exposed tothe clinical training but are expected to handle ART data. ART/HMIS Materials - Facilitator=s Guide Page 6
  • 10. Lecture: HIV/AIDS Global Epidemiology (5 Minutes)Show Module III Part 1 Slide 2 and explain generally the HIV/AIDS situation.Explain that by the end of 2004, an estimated 40 million people (both children and adults) wereestimated to be living with HIV/AIDS in the world.Tell the participants some of the statistics (of adults and children) estimated to be living withHIV/AIDS worldwide in 2004 shown on the overhead/slide.Invite questions from the participants and make clarifications.Show Module III Part 1 Slide 3Explain that in 2003, fourteen thousand (14, 000) new HIV infections occurred daily of which2,000 was among children <15 years and 12,000 new HIV infections were among adults orpersons of reproductive age (15-49 years). 50% of this group (15-49 years) are women.Over 95% of these new infections occur in the developing world.In 2003, between 2.5 and 3.5 million persons died of HIV/AIDS.Lecture: HIV/AIDS in Kenya (9 Minutes)Introduce the module by giving an overview of the HIV/AIDS situation in Kenya.Show Module III Part 1 Slide 4 highlighting the HIV/AIDS situation in Kenya.Explain that HIV/AIDS is a global problem that also affects Kenya.In the early 1990s, over 200,000 HIV infections in adults were recorded per year. This numberhas since declined to below 100,000 per year now. It is estimated that 300 to 500 people in Kenyaare infected daily and about 1,000,000 (between the ages 15 to 49) are currently living withHIV/AIDS out of which 200,000 require antiretroviral treatment. It is estimated that 100,000children are living with HIV while about 60,000 people over 50 years are also living with theHIV virus.According to the Kenya Demographic and Health Survey (KDHS) carried out in 2003: • The KDHS indicates that 7% of Kenyans are infected every year. o 86,000 new infections among adults and 30,000 in children are recorded yearly. • However, in some regions the rate is as high as 30% o North Eastern province stood at 1% o Nyanza province was 15% • The HIV prevalence rate is almost twice as high in urban (10%) as in rural (6%) areas. • HIV prevalence in girls in 15-19 age group is six times higher than in males of the same age group. ART/HMIS Materials - Facilitator=s Guide Page 7
  • 11. • 150,000 deaths were recorded every year and the number is likely to rise because of the large numbers of HIV infections in the early 1990s. o 30,000 deaths among children are recorded and around 140,000 adult deaths. • 60% of the TB patients are also HIV infected.Show Module III Part 1 Slide 5Explain that in Kenya, with a population of about 32 million in 2004, 1.2 million Kenyans wereliving with HIV/AIDS.Approximately 1.6m children <15 years have been orphaned by the death of one or both parentsfrom AIDSInvite questions from the participants and make clarifications.Lecture: HIV/AIDS Implications for Kenya (6 Minutes)Show Module III Part 1 Slide 6Explain that as a result of the HIV/AIDS pandemic in Kenya, there has been a lot of sufferingjust as the saying goes, ‘If you are not infected, then you are affected’. There is a very strong linkbetween poverty and HIV. High poverty levels lead to increased HIV rates while at the same timethe pandemic worsens poverty levels. 56% of Kenyans live below the poverty line. Some of thesufferings brought about include:Sickness:Tell the participants that the increasing number of HIV/AIDS patients has also seriouslyoverwhelmed the health care services. In major hospitals for example, HIV/AIDS patients nowoccupy 50% of hospital beds.As a result of sickness of a relative, some children are unable to attend school because they attendto the sick or pupils may not attend classes if their teacher is sick or when the children themselvesare sick.There is also loss of man-hour when the worker is sick. Sickness brings about low contributionto food production which can result in hunger. Sickness also leaves a huge cost to the family bypaying for medication.Deaths:Tell the participants that deaths due to HIV/AIDS have continued to escalate, affecting the mostproductive of the population. This has resulted in increased levels of: • Poverty especially if the bread winner is the one affected (sick or dead) • Children-headed households • Orphan-hood (the number of orphans has risen from 150,000 in the early 1990s to a staggering 1.6 million in 2004). • Widowhood and • General vulnerability ART/HMIS Materials - Facilitator=s Guide Page 8
  • 12. Tell the participants that the list of implications is endless, invite questions and makeclarifications.Lecture: Response to the HIV/AIDS Situation (10 Minutes)There have been three distinct phases to Kenya’s response to the pandemic. Initially, there waswidespread denial in the late 1980s and early 1990s followed by an adoption of a multisectoralpolicy in the mid 1990s and finally strong government leadership and political commitment since2000. This was evidenced by the creation of the National AIDS Control Council and other organsat lower levels like AIDS control Units in all ministries.The first AIDS case was diagnosed in the mid 1980s.The Ministry of Health set up an AIDSControl Committee in 1987 which came up with the first5-year plan to combat AIDS. The secondplan covered 1992 – 96. Strong political will was epitomized in 1999 when AIDS was declared anational disaster by President Moi. From 1999 there has been an increase in the level ofstakeholder (local and international) involvement by way of more resources directed to the fightagainst AIDS.The national response to the pandemic in the last twenty years has shifted focus from generalprevention and supportive care to specific health services. These include testing and counselingand antiretroviral treatment.Show Module III Part 1 Slide 7Explain that not with standing the critical role of Information Education and Communication(IEC) about HIV/AIDS; other measures taken include the following:Prevention, Care, and TreatmentIn the area of prevention, the focus has been on prevention of mother to child transmission(PMTCT), Counselling and Testing, Abstinence, being faithful, condom use especially among thehigh risk groups, blood safety, and injection safety.In the area of Care, the focus is on Home Based Care.In the area of Treatment, the focus is on Anti Retroviral Therapy (ART) and the management ofopportunistic infections.Invite questions from the participants and make clarifications. (24 Minutes) ART/HMIS Materials - Facilitator=s Guide Page 9
  • 13. Module III: Overview of HIV/AIDSPart 2: The ART Programme in KenyaPURPOSE: To introduce participants to the ART programme in Kenya Introduce participants to organisation of ART services in KenyaOBJECTIVES: At the end of the module, participants will be able to understand: • The ART Programme in Kenya • The main goal of the ART Programme • Specific goals of ARV therapy • Resource limitations affecting ARV therapyMETHOD: LectureMATERIALS: LCD or overhead projector white board or flip chart, markers and handouts.PREPARATION: Ensure that all materials i.e. LCD or Overhead projector are working and white board or flip chart is available including markers.LEARNING ACTIVITIES 1 hourIntroduction (3 minutes)Show Module III Part 2 Slide 1 with objectivesExplain the purpose and the objectives of the module.Ask participants about objectives of the ART programme. List down their responses on a flipchart or white board. Then…Show Module III Part 2 Slide 2 and;Summarise that the main goal for any ART programme is to increase accessibility toantiretroviral therapy with a view of prolonging the lives of the patients infected with HIV.Lecture: ART Programme in Kenya (8 min)Introduce the lecture by giving an overview of the ART programme.Show Module III Part 2 Slide 3. ART/HMIS Materials - Facilitator=s Guide Page 10
  • 14. Explain that in Kenya, the plan by NASCOP is to scale up to all 72 districts in the country. Italso aims at building capacity of regional centres to act as referral sites and priority will begiven to high disease burden areas.The ART program is expected among other things to; • Reduce mortality and morbidity resulting from HIV/AIDS • Reduce escalating burden of AIDS orphans • Enhance national prevention efforts • Reduce HIV/AIDS related hospital admissions by 60%.Other programmes related to ART programme include PMTCT, VCT, and treatment ofOpportunistic Infections.Lecture: Target of HIV/AIDS Patients to be on ART (10 mins)Show Module III Part 2 Slide 4 and explain generally the targets set.Explain that globally, the target set for HIV/AIDS patients to be on ARVs is 3,000,000 bythe end of the year 2005. The number of ART patients in Kenya has increased 10-fold from3,000 in 2000 to more than 30,000 in 2004. The Kenyan government’s goal was to reach 50%(95,000) of the eligible people by 2005 and 78% by 2010. Currently over 200 public healthfacilities, mission and private facilities are providing comprehensive HIV care. There arecurrently over 70,000 patients on ART and thousands waiting to start treatment.Hint: To effectively measure the progress towards attaining such local and international ARTgoals, it is imperative that a monitoring and evaluation system is put in place. This systemmust answer and meet these different demands at various levels.Show Module III Part 2 Slide 5Explain to the participants that the provision of ART in the country faces several challenges.Among them are; • Cost of drugs, for instance in 2000 the cost of drugs was prohibitively high for the majority of people at $10,000 per year. Currently, the first line-regimen costs between $77 per year in the public sector and $700 in the private sector. • Integrating ART services into the existing health programs • Limited work force of health workers in the health sector • The labs need to be equipped with new equipment to provide new services to monitor HIV treatmentInvite questions from participants and make clarifications. (30 mins) ART/HMIS Materials - Facilitator=s Guide Page 11
  • 15. Module IV: Introduction to ART-A Conceptual FrameworkPURPOSE: To introduce participants to ART programme in Kenya by looking at its conceptual framework. Explain to participants the progression of the clinical manifestation and the General management of the cases.OBJECTIVES: At the end of the module, participants will be able to understand: • Procedures for commencing someone on ART • Key stages for data collection.METHOD: LecturePREPARATION: Ensure that all materials i.e. LCD or Overhead projector are working and white board or flip chart is available.LEARNING ACTIVITIES 45 MinutesIntroduction (2 Minutes)Show Module IV Slide 1.Explain the purpose of the module with emphasis that it is not designed to equip participantswith skills to provide clinical ART services. It is meant to highlight standard procedures forcommencing a patient on ART and their management thereafter. A direct relationship existsbetween the clinical processes and data collection, hence this module.Emphasise to the participants that this module must be well understood if modules V, VI andVII have to be appreciated.Lecture: The ART Conceptual Framework (18 Minutes).Show Module IV Slide 2Ask participants to locate the generic ART flow diagram in the Participants Notes and letthem turn to section 1.2 of the procedures manual and read through with them while moduleIV slide 2 is still showingExplain that the diagram presented is very generic and may not be representative ofindividual facilities. The principle on which it is based can be used at all levels.Turn to section 1.2.2 of the procedures manual for additional explanations on chart. Ensurethat before moving to section (b) participants are clear with what takes place while inPre-ART as explained in section (a). ART/HMIS Materials - Facilitator=s Guide Page 12
  • 16. Explain the following terms: • New in HIV Care B These are patients coming into HIV care without prior records of ever having been in HIV care including ART. • Transfer-Ins B These are patients who were enrolled in HIV Care from other facilities but have been officially transferred to this facility. An official transfer is that which is accompanied by referral documents with minimum data required for continuity of care.Show Module IV Slide 3.Explain that assessment for eligibility is done either clinically or via lab results of CD4 orViral Load or a combination of clinical and lab investigations. Below is the eligibility criteriaset by the Ministry of Health (NASCOP) in collaboration with stakeholders: • WHO clinical stage 1 and 2, with a CD4 count < 200/mm3 • WHO stage 3 with CD4 cell count < 350/mm3 • WHO stage 4 regardless of CD4 cell count • TLC less than 1200/mm3Explain that in August 2002, standard treatment guidelines were developed in order tostandardise care. These guidelines included standard regimens that simplify ART deliveryand commodity management and minimize procurement costs.Put back Module IV Slide 2 and continue explaining the following terms. • Not Eligible: This applies when a patient does not meet the criteria shown in module IV Slide 3. • Eligible for ART: If a patient meets the criteria outlined earlier. • Start Treatment: This means that the patient has started taking ARV drugs for the first time. Patients are commenced on first line drug combination of the first choice by the clinician. • Substitution: This involves changing one drug or two but still keeping a patient on the same family of drugs. • Switch: This involves taking a patients to a new line of drugs e.g. from 1st line to 2nd line. • Pre-ART: This is a stage in HIV care when a patient has not commenced on ART. This can be as a result of pending tests, assessment for readiness or the assessment has revealed that the patient is not eligible to commence ART. ART/HMIS Materials - Facilitator=s Guide Page 13
  • 17. Module V: Introduction to ART Data Collection System.PURPOSE: To introduce participants to the ART programme in Kenya Introduce participants to organization of ART services in Kenya.OBJECTIVES: At the end of the module, participants will be able to understand the rationale behind the ART Data Collection SystemMETHOD: Lecture and group exercisesPREPARATION: Ensure that all materials i.e. LCD or Overhead projector is working and white board or flip chart is available.LEARNING ACTIVITIES 50 MinutesIntroduction (3 Minutes)Show Module V Slide 1 with objectives.Go over the objectives of this module.Lecture: Rationale of the ART/HMIS (10 Minutes)Show Module V Slide 2Explain that the design and development of the Kenya ART/HMIS, was in response to • The need for a monitoring and evaluation framework as outlined in the national scale-up plan for ART. • Lack of an ART information system during scale-up of antiretroviral treatment to all provinces created a chaotic environment resulting in a weak and fragmented reporting structure for the government ART programme. • Standardized data capture tools to allow for patient and facility comparisons. • Response to the international reporting responsibilities such as the 3 by 5, PEPFAR etc. All these demanded for a need to develop an M&E system for public and private sector.Lecture: The Architecture of ART/HMIS (30 Minutes)IntroductionShow Module V Slide 3Explain that ART/HMIS is a paper-first-based system with an option for computerisation. Itis designed to collect bare minimum data elements for both patient management and ART/HMIS Materials - Facilitator=s Guide Page 14
  • 18. programme management. It is not a clinic system designed to improve the quality of care inindividual facilities but assists in providing minimum standards of care.Data Flow StructuresShow Module V Slide 4Explain that ART/HMIS uses several data tools.It uses registers/cards and aggregation forms • Registers: There are two registers used in ART/HMIS. One used during Pre-ART and the other used as a monthly event summary sheet for ART events. • Aggregation Forms: Monthly Summary Sheet and Cohort Summary SheetScope of ART Data Collection SystemShow Module V Slide 5Explain that ART/HMIS is not designed to answer all aspects of ART. Among others, it ismeant to do the following: • Provide history of patient visits to the facility • Provide basis for monitoring patient progress • Provide information on adverse drug events • Assists in tracking adherence to treatment • Provides information on: (i) Patients outcomes (Deaths, Lost, Stop, Substitutions, Switches, etc)A (ii) General programme performance against set goals at all levels.Show Module V Slide 6Explain that although ART/HMIS is scalable, in its current form, cannot provide information on: • Drug resistance but only warning signs of the potential or apparent resistance through drug line switches and adherence. • Staff availability • Laboratory or Pharmacy capacities or • Patient moving intra or inter facility. ART/HMIS Materials - Facilitator=s Guide Page 15
  • 19. Module VI: Data CollectionPart 1: Overview of Data Collection ToolsPURPOSE: To introduce participants to data collection To introduce participants to the ART data collection toolsOBJECTIVE: At the end of the module, participants should be able to understand the importance of data collection and correct completion of ART/HMIS data collection tools.METHOD: LectureMATERIALS: LCD or Overhead projector and white board or Flip chart HandoutPREPARATION: Ensure that LCD or Overhead projector is working and white board or flip chart is availableLEARNING ACTIVITIES 15 MinutesIntroduction (3 minutes)Show Module VI Slide 1 with objectivesExplain the objectives of the module.Lecture: Data Collection Tools (10 minutes)Show Module VI Slide 2 and explain the three general purposes of data collection which include: • to provide a record of care given to specific clients • to provide information on health status and service delivery • to provide data for planning eg drug ordering and quality improvementShow Module VI Slide 3Explain to the participants that there are three data collection tools: two register and onepatient card. Remind them that this section only presents an overview; the sections thatfollow will explain each tool in greater detail.Comprehensive Care Clinic CardAsk participants to locate the CCC card in appendix I of the Procedures Manual.Explain that this card serves as a patient’s detailed record of clinical diagnosis and treatment.It is opened when a patient enrolls into chronic HIV Care and continues to be used for ART/HMIS Materials - Facilitator=s Guide Page 16
  • 20. patients who enroll on ART. However where resources may not permit, these cards are onlyopened for patients at commencement of ART to avoid wastages.Pre ART RegisterAsk participants to locate the Pre-ART register in appendix I of the Procedures Manual.Explain that details for all patients who enroll for HIV Care are entered here. This includespatients identified within the facility and those that are referred or received from otherfacilities. The purpose of the Pre-ART Register is to provide:-(i) Information the medical status of a patient on entry into HIV Care(ii) Provide a record of patient outcome while on Pre-ART and(iii) Provide a basis for facility-level self-assessment and supervisionShow Module VI Slide 4Explain the ART register is an event-based register meant to record key monthly outcomesfor individual patients and consequently interval cohort outcome. Its specific purposesinclude(i) providing a record of patient outcome(ii) providing a track record of patients from initiation to follow up monthly visits(iii)Serving as a source of information on patient drug mixShow Module VI Slide 5 and explain the ART document flow:Explain the stages, processes, decisions and documentation used at each stage of serviceprovision. This flow is closely linked to the generic ART conceptual framework presented inmodule IV and key stages that demand data collection are highlighted on this flow chart.Follow the direction of the arrow in running through the document flow chart. ART/HMIS Materials - Facilitator=s Guide Page 17
  • 21. Module VI: Data CollectionPart 2: Comprehensive Care Clinic CardPURPOSE: To introduce participants to the Comprehensive Care Clinic CardOBJECTIVE: At the end of the module, participants should be able to understand the use and correct completion of the Comprehensive Care Clinic Card.METHOD: Lecture, demonstration on how to complete the card and exercisesMATERIALS: LCD or Overhead projector and white board or Flip chart; Handouts: Participants Workbook pages 1-9 Facilitator’s Workbook pages 1-9 Procedures Manual section 2.2.1PREPARATION: Ensure that LCD or Overhead projector is working and white board or flip chart is availableLEARNING ACTIVITIES 1 hour, 15 minutesLecture: Comprehensive Care Clinic Card (20 minutes)Refer participants to the blank samples of the Comprehensive Care Clinic Card on page 4-9of the Participants WorkbookAsk them to turn to section 2.2.1 of the ART/HMIS Procedures Manual and;Explain the following points. • Purpose of the Comprehensive Care Clinic Card • Who completes • When to completedExplain to the participants step by step the data elements required for completing theComprehensive Care Clinic Card in each part and when it is filled in.Exercise: Completing the Comprehensive Care Clinic Card (13 Minutes)Ask the participants to turn to page 1 of the Participants Workbook and do exercise 6-1.Ask participants to return to the large group. The rapporteur from each group should reportthe group’s experiences according to instructions # 4 and # 5 on page 3 of the ParticipantsWorkbookSummarise the comments and allow participants to add anything they may have forgotten tomention (40 Minutes). Ask them to use the space under each of the questions in theirWorkbooks to write down the interesting contributions of other group members. ART/HMIS Materials - Facilitator=s Guide Page 18
  • 22. Module VI: Data CollectionPart 3: Pre-ART RegisterPURPOSE: To introduce participants to the Pre-ART RegisterOBJECTIVE: At the end of the module, participants should be able to understand the use and correct completion of the Pre-ART RegisterMETHOD: Lecture, demonstration on how to complete the register through exercisesMATERIALS: LCD or Overhead projector and white board or Flip chart Handout Participants Workbook pages 10-12 Facilitator’s Workbook pages 10-12 Procedures Manual section 2.2.2PREPARATION: Ensure that LCD or Overhead projector is working and white board or flip chart is availableLEARNING ACTIVITIES 1 hour, 15 minutesLecture: Pre-ART Register (18 min)Refer participants to page 11-12 of the Participants Workbook for a blank Pre-ART RegisterRefer participants to ART/HMIS Procedure Manual section 2.2.2 and;Explain the following points. • Purpose of the Pre-ART Register • Who completes • When to completeExplain to the participants step by step the data elements required for completing thePre-ART Register in each column and when it is filled in.Exercise: Completing the Pre-ART Register (20 Minutes)Ask participants to turn to page 10 of the Participants Workbook and do exercise 6-2.Ask participants to return to the large group. Ask the rapporteur of each group to report thegroup’s experiences according to instruction # 4 on page 10 of the Participants WorkbookSummarise the comments and give chance to participants so they can add anything they mayhave forgotten to mention. Ask them to use the space under each of the questions in theirWorkbooks to write down the interesting contributions from other members (30 Minutes) ART/HMIS Materials - Facilitator=s Guide Page 19
  • 23. Module VI: Data CollectionPart 4: ART RegisterPURPOSE: To introduce participants to the ART RegisterOBJECTIVE: At the end of the module, participants should be able to understand the use and correct completion of the ART RegisterMETHOD: Lecture, demonstration on how to complete the Register and exercisesMATERIALS: LCD or Overhead projector and white board or Flip chart; Handout: Participants Workbook pages 13-16 Facilitator’s Workbook pages 13-17 Procedures Manual section 2.2.3PREPARATION: Ensure that LCD or Overhead projector is working and white board or flip chart is available.LEARNING ACTIVITIES1. Lecture: ART Register (10 min)Refer participants to page 14-16 of the Participants Workbook for a blank ART RegisterRefer participants to ART/HMIS Procedures Manual section 2.2.3 and explain the followingpoints. • Purpose of the ART Register • Who completes • When to completeExplain to the participants step by step the data elements required in completing the ARTRegister in each column and when it is filled in.Exercise: Completing the ART RegisterAsk the participants to turn to page 13 of the Participants Workbook and do exercise 6-3.Ask participants to return to the large group. Ask the rapporteur of each group to report thegroup’s experiences according to instruction # 3 on page 13 of the Participants WorkbookSummarise the comments and allow participants to add anything they may have forgotten tomention. Ask the participants to use the space under each of the questions in their Workbooksto write down the interesting contributions of other group members. ART/HMIS Materials - Facilitator=s Guide Page 20
  • 24. Module VII: Aggregation and ReportingPart 1: Completing the Monthly Summary SheetPURPOSE: To introduce Aggregation and Reporting forms to participantsOBJECTIVE: Upon completion of this module, participants will be able to recognise and correctly fill in the reporting formsMETHOD: Lecture, group discussions, demonstration on how to complete the documents and exercisesMATERIALS: LCD or Overhead projector and white board or Flip chart; Handout: Participants Workbook pages 17-24 Facilitator’s Workbook pages 18-25 Procedures Manual section 3.2PREPARATION: Ensure that LCD or Overhead projector is working and white board or flip chart is availableLEARNING ACTIVITIESIntroduction (2 minutes)Show the Module VIII Slide 1.Explain the purpose and the objectives of the module and explain that there are two dataaggregation and report forms: • Comprehensive Care Clinic Monthly Summary Sheet • Comprehensive Care Clinic Cohort Summary SheetThese forms provide a summary of information on Pre-ART and ART services provided bythe institutions.Lecture: Comprehensive Care Clinic Monthly Summary Sheet (30 min)Explain the following points.Purpose of the aggregation and reporting formsWho completesWhen to complete ART/HMIS Materials - Facilitator=s Guide Page 21
  • 25. Explain to the participants step by step the data elements required from the registers tocomplete the reporting forms.Ask participants to locate the two blank CCC Monthly Summary Sheets on page 24 of theParticipants workbook and let them turn to section 3.2 of the ART/HMIS ProceduresManual.Read with them on each of the measures on the CCC Monthly Summary Sheet • New patients enrolled within the month for HIV Care by entry point • Persons ever enrolled in HIV Care at this facility by end of this month • Patients starting ARVs within the month by WHO stage • Patients ever started on ART at this facility by end of this month • Patients currently on ARVs • Persons enrolled and eligible for ART but not yet started on ART • Patients currently on Post Exposure Prophylaxis (PEP) • Patients currently on prophylaxisNote: Before moving on to another measure, ensure that all the participants have understood.Pause after each measure and allow for questions.Exercise: Completing the Comprehensive Care Clinic Monthly Summary SheetAsk participants to turn to page 17 of the Participants Workbook and do exercise 7-1.Ask participants to return to the large group. Ask the rapporteur of each group to report thegroup’s experiences according to instruction # 5 on pages 18-19 of the ParticipantsWorkbookSummarise the comments and allow participants to add anything they may have forgotten tomention. Ask participants to use the space under each of the questions in their Workbooks towrite down the interesting contributions from other member ART/HMIS Materials - Facilitator=s Guide Page 22
  • 26. Module VII: Aggregation and ReportingPart 2: Completing the Cohort Summary SheetLecture: Comprehensive Care Clinic Cohort Summary Sheet (10 min)Ask participants to locate the two blank pages of the CCC Cohort Summary Sheets pages27-28 in the Participants Workbook and let them turn to section 3.3 of ART/HMISProcedures Manual.Read with them section 3.3 on CCC Cohort Summary Sheet with focus on the following dataelements: • Started on ART in this clinic- original cohort • Transfers in • Transfers out • Net current cohort • On original 1st-line regimen • On alternate 1st-line regimen (substituted) • On 2nd-line regimen (switched) • Stopped • Died • Lost to follow-up (DROP) • Percent of cohort alive and on ART • CD4 median or fraction ≥ 200 [of those with available CD4] (optional) • Number of persons who picked up ARVs each month for 6 months • Number of persons who picked up ARVs each month for 12 monthsEnsure that all the participants understand each of the measures discussed.Explain to the participants that this is an interval analysis form, for cohorts of patients thathave completed 6 months, 12 months, 24 months on therapy.Exercise: Completing the Comprehensive Care Clinic Cohort Summary SheetAsk participants to turn to page 25 of the Participants Workbook and do exercise 7-2.Ask participants to return to the large group. Ask the rapporteur of each group to report thegroup’s experiences according to instruction # 3 on page 25 of the Participants WorkbookSummarise the comments and allow participants to add anything they may have forgotten tomention. Ask participants to use the space under each of the questions in their Workbooks towrite down the interesting contributions from other member. ART/HMIS Materials - Facilitator=s Guide Page 23
  • 27. Module VIII: ART Programme MeasuresPURPOSE: To familiarize participants with the ART/HMIS Indicators and to provide examples of analysis and action based on information To emphasize the need for local action, using locally available knowledgeOBJECTIVE: After completion of this module, participants should be able to: • Calculate the ART/HMIS indicators • Interpret the ART/HMIS indicatorsMETHOD: Lecture, demonstration on how to calculate the indicators, and exercisesMATERIALS: LCD or Overhead projector, white board or Flip chart, markers, Handout Participants Workbook pages 29-35 Facilitator’s Workbook pages 30-36PREPARATION: Ensure that LCD or Overhead projector is working and white board or flip chart is available including markers.LEARNING ACTIVITIES 30 MINUTES1. Introduction (2 minutes)Show Module VIII Slide 1 with objectives.Explain the purpose and the objectives of the module and explain generally that there areseveral indicators in ART/HMIS for patient management, patient monitoring and monitoringthe ART programme.Show Module VIII: Overhead/Slide 2.Explain that the ART Indicators are selected based on the following: • The NASCOP Strategic Plan 2005-2010: In this plan, ART indicators are required so as to monitor the ART program. • International obligations: There are international obligation to report ART indicators by WHO, UNAIDS, or PEPFAR. • Efficiency, exclusiveness, feasibility, cost implications: Indicators are selected based on the cost to provide those indicators, how efficient it is to provide those indicators, and how feasible it is to provide those indicatorsInvite for questions and make clarifications ART/HMIS Materials - Facilitator=s Guide Page 24
  • 28. 2. Lecture: ART Indicator categories (10 min)Show Module VIII Slide 3Explain that the data to calculate these indicators are obtained from registers summarised ontally sheets and transferred to aggregation and reporting forms.Indicators are expressed in many formats. They can be absolute numbers, rates, ratios orproportions. There are three main categories of ART indicators namely: - • Measures of accessibility to HIV Care and ART • Measures of programme success • Measures of adequacy in programme support areas at all levels • Measures of HIV drugs resistance early warningBriefly describe the types and examples of the measures. Explain, step by step how tocalculate and interpret the indicators.Access to HIV Care or ARTThe following indicators relate to patients accessing HIV care or ART. a. Number enrolled in HIV care b. Number started on ART c. Number currently on ART d. Number, Proportion of persons who are enrolled and eligible for ART but have not been started on ART. e. Number, proportion of patients on both TB treatment and ART. f. Percentage of those eligible for ART in the clinic who has been started on ART.ART Programme SuccessThe following indicators measure ART Programme Success. a. Survival at 6, 12, 24, 36 months etc after initiation of ART. b. Continuation on first-line ARV regimen at 12 and 24 months after initiating treatment. c. Median CD4 at 6 and at 12 months on ART compared to baseline.HIV Drug Resistance Early WarningThe following indicators may provide a flag for potential or apparent resistance towards aspecific line of drugs (mostly first line) or towards a given combination in given family ofdrugs. It is desired that as long as it takes, patients should remain on the original 1st line drug.Below are some indicators that may point to drug resistance. ART/HMIS Materials - Facilitator=s Guide Page 25
  • 29. a. Percentage of patients who started ART 6 or 12 months ago who picked up ARV medications 6/6 or 12/12 months. b. Percentage of patients with (good) adherence to ART3. Exercise: Calculating ART IndicatorsAsk participants to turn to pages 29 of the Participants Workbook and do exercise 8-1Ask participants to return to the large group. Ask the rapporteur of each group to report thegroups experiences.Confirm their answer with the ones provided on pages 30-36 of the Facilitator’s WorkbookSummarise the comments and give participants to add anything they may have forgotten tomention. Ask the participants to use the space under each of the questions in their Workbooksto write down the interesting contributions of other member ART/HMIS Materials - Facilitator=s Guide Page 26