Chronic hiv care_art Emmanuel Ngabirano 2011 Correspondence engabirano@idi.co.ug

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Advancing HIV treatment and administering ART

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  • Cultural shift towards chronic care. HIV, unlike other communicable diseases, is a chronic disease. Less like cholera than diabetes.
  • Clinical staging: with and without CD4
  • 7 requirements needed to start ART: not just another drug
  • Clear, practical explanation of how to treat HIV within national guidelines.
  • Chronic hiv care_art Emmanuel Ngabirano 2011 Correspondence engabirano@idi.co.ug

    1. 1. Chronic HIV Care with ART Presented by Emmanuel Ngabirano College of American Pathologies Infectious Diseases Institute-Mulago Hospital
    2. 2. CHALLENGES TO SELF-MANAGEMENT AND QUALITY CHRONIC CARE <ul><li>The acute care paradigm </li></ul><ul><li>- Reactive care </li></ul><ul><li>- Patient who is in office now </li></ul><ul><li>- Little continuity </li></ul><ul><li>- Diagnose and treat </li></ul><ul><li>- No time </li></ul><ul><li>- Competing demands </li></ul><ul><li>- Physician centered </li></ul><ul><li>- No system or infrastructure </li></ul><ul><li>- Self-Management: “Not my role” </li></ul>BCMIPA Institute of Medicine & Committee on Quality of Health Care in Uganda (2009) “ Crossing the Quality Chasm: A New Health System for the 21st Century ; National Academy Press
    3. 3. CHRONIC (PLANNED) CARE MODEL Ngabirano E, et al. (2008) HIV care 74(4):511-544 Acute Care Planned Care Reactive Proactive Visit Based Population Based Little Continuity Planned - Schedule Diagnose and Treat Assess and Support Physician Centered Directed to “Urgent” Patient Centered Directed to Major Causes Disease
    4. 4. Transition to good chronic HIV care <ul><li>Common current situation: </li></ul><ul><li>Health services provide episodic acute care for HIV complications. [Exception: TB] </li></ul><ul><li>Patient-held records for each acute episode </li></ul><ul><li>Only organized chronic care is home-based </li></ul><ul><li>To introduce and scale-up ART: </li></ul><ul><li>Need to establish good chronic HIV care in facility </li></ul><ul><li>Good care by an individual doctor or specialist does not replace the need for establishing good chronic care with a clinical team! </li></ul><ul><li>Patient HIV care/ART record and registers, reporting forms </li></ul>
    5. 5. Sequence of care
    6. 10. Task Shifting <ul><ul><li>Allows non-doctors to play a significant role in HIV care/ART </li></ul></ul><ul><ul><ul><li>both in peripheral facilities and on the district clinical team </li></ul></ul></ul>
    7. 11. Central or Provincial Specialised referral (physicians) District Supervision and referral services provided by doctors and/or medical officers Health Centre First-line treatment and care provided by nurses, clinical officers and ART Aid on clinical team Community Support Care and support provided by treatment supporters, community health workers and care givers from within the community Community Preparedness Mobilization and sensitization to increase treatment literacy of community
    8. 12. Consider task shifts to allow scale-up <ul><li>Care, treatment & prevention </li></ul><ul><li>Specialized physicians to doctors </li></ul><ul><li>Doctors to nurses </li></ul><ul><li>Nurses to PLHA HIV care/ ART aids—education, psychosocial support, adherence preparation and support can be taught to PLHA, other lay providers, nursing assistants </li></ul><ul><li>Clinical team to patient: </li></ul><ul><ul><li>Self-management </li></ul></ul><ul><li>Clinical team to community- for treatment support, drug refills, simple monitoring </li></ul><ul><li>Training </li></ul><ul><li>Expert patient-trainers </li></ul><ul><ul><li>PLHA on ART </li></ul></ul><ul><ul><li>Present cases, provide feedback to health workers </li></ul></ul><ul><li>Patient tracking- treatment card to register, monthly report </li></ul><ul><ul><li>Choose those who like particular aptitude </li></ul></ul><ul><ul><li>PLHA, other lay providers or nursing assistants </li></ul></ul><ul><li>Build functional clinical teams within a district system </li></ul>
    9. 13. Technical basis for task shifts <ul><li>Emphasize safety </li></ul><ul><li>Validate ability to make critical decisions </li></ul><ul><ul><li>by validation studies (during guideline development) </li></ul></ul><ul><ul><li>case review, close supervision, monitoring (during implementation) </li></ul></ul>
    10. 14. ART Aid <ul><li>Increased need of HR in the context of scale up </li></ul><ul><li>ART Aids (counselors, health educators, PLWA) are often more effective than doctors and health officers/clinical officers at patient education and adherence support. </li></ul><ul><li>Basic ART Aid Course is designed for people with little or NO clinical background—LAY PROVIDERS can become ART Aid </li></ul><ul><li>Can provide important insights during team meetings about &quot;difficult&quot; patients. </li></ul>
    11. 15. ART Aid <ul><li>speaks the same language patient as the patient </li></ul><ul><li>comes from the community to the clinical team </li></ul><ul><li>is a link with the community </li></ul><ul><li>knows what is available at community level </li></ul><ul><li>progressively learns what is needed at community level for ART and HIV care scale up </li></ul><ul><li>inform patients and the rest of the clinical team on the community services </li></ul><ul><li>advocates with community stakeholders </li></ul>
    12. 16. Roles of the Basic ART Aid <ul><li>Adherence preparation (includes ART preparation and initiation) </li></ul><ul><li>Monitoring and supporting patients on ART </li></ul><ul><li>Post-test and on-going psychosocial support </li></ul><ul><li>Patient education on HIV/AIDS, disclosure, prevention, and positive living in the context of clinical care </li></ul><ul><li>Triage </li></ul><ul><li>Peer support </li></ul><ul><li>Community support </li></ul>
    13. 17. IDI Basic ART Aid Training Course Index Section 1 Introduction to the BASIC ART Aid course Section 2 Roles and responsibilities of the ART Aid as part of the clinical team Section 3 Care for HIV/AIDS Section 4 Communication skills Section 5 Treatment available for HIV/AIDS: cotrimoxazole and ART Section 6 Adherence preparation Section 7 Adherence initiation Section 8 Adherence monitoring and support Section 9 Prevention in the context of clinical care Section 10 Disclosure Section 11 Post-test and ongoing support Section 12 Positive living Section 13 Triage
    14. 18. What is needed to integrate community members more effectively? <ul><li>Lay provider needs to &quot;formally&quot; integrated in the health system with regular jobs as trainers and ART Aid. </li></ul><ul><li>&quot;Emergency&quot; policy decisions to create new posts for LP in the context of the clinical team and for community support and education </li></ul>
    15. 19. 3 levels/approaches to community <ul><li>Integrated management of HIV/AIDS at facility with linked community interventions : prevention, treatment and care (IDI/BIPA) </li></ul><ul><ul><li>Systems for facility-community links: home visits, trace patients, monitoring, refills, back-up to home-based care </li></ul></ul><ul><ul><li>CHW training </li></ul></ul><ul><ul><li>Peer support groups- trained facilitators </li></ul></ul><ul><ul><li>Use of same patient education flipchart </li></ul></ul><ul><ul><li>Caregiver booklet </li></ul></ul><ul><li>Targeted community interventions with outreach: sex workers, IDU, MSM, others </li></ul><ul><li>Broad-based community prevention and treatment preparedness </li></ul>

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