THE CARE AND TREATMENT PLAN

1. THE CARE AND TREATMENT PLAN

2. PART OFTHE FIRST STEPS TOWARDS PLANNING SCALE UP OF ART AT TREATMENT FACILITY. • IT IS DEVELOPED DURING SITE PREPARATION.

3. It is part of the components of the sequence that eventually empower a facility to provide care and treatment for clients. partnership commences.

4. The Care and Treatment Plan will also help you design services in line with the goal, objectives and guiding principles of the Project . • The facility should design a plan that is appropriate for it’s capacity and patient population.

5. Developing this plan will assist you to write a budget, identify areas for capacity-building, make quality improvements to your program throughout the year, and coordinate activities.

6. Who completes the Care and Treatment plan ?. • Development of the Care and Treatment Plan requires a collaborative effort of personnel from many sectors of your treatment facility.

7. Thus, it may be useful for the site to have a leader or key representative from the following areas as appropriate: • (1) clinical; (2) laboratory; (3) counseling and/or adherence support; (4) community-based health programs; (5) pharmacy; (6) medical records; and (7) finance and administration.

8. IHVN Members of staff are available to provide technical and programmatic input during the process. • The C and T plan consists of 8(eight parts) as listed on the next slides

9. Part 1: Project Overview: Structure and Management of Care • 1.1 Treatment delivery model • 1.2 Human Resource Management • 1.3 Identifying target populations for ART • 1.4 Patient Enrollment Projections • 1.5 Continuity of Care

10. Part 2: Medical Care under the ART Program • Part 3: Strengthening your adherence program • Part 4: Community Mobilization and Support for ART • Part 5: Preparing your Laboratory for ART • Part 6: Preparing your Pharmacy for ART • Part 7: Strategic Information planning • Part 8: Financial systems preparation

11. How to complete ?: • While some sections of the Care and Treatment plan are crucial for planning the site annual budget, other sections can be developed on an on-going basis throughout implementation. • It is recommended that a team of key personnel discuss part 1 in detail before completing the budget

12. Then, the key personnel should familiarize themselves with the section that pertains to their specialty (e.g. laboratory), identifying essential activities that will impact the site budget • Key personnel can continue leading on-going discussions with other relevant staff to complete the Care and Treatment Plan over time.

13. Resources: The following documents may assist you in planning: • Existing site policies and procedures • National and international ART guidelines and strategy documents • IGT (the site assessment tool)

14. Part 1: Project Overview: Structure and Management of Care • Treatment Delivery Model we recognize that no single ART delivery model has been validated as optimal for universal use in resource-constrained countries Therefore, the project supports treatment delivery modalities and solutions identified by the site that integrate into existing health care infrastructure, operate within national/international guidelines, and can achieve long-term programmatic success

15. Examples of treatment delivery models used include: • Hospital-based services provided through the out-patient department. • Home-based care centers. • Mobile VCT programs. Throughout the duration of the project, measured program success of individual approaches will be linked to prioritization for program replication, expansion, and broader scale.

16. Planning questions: • Identify your Treatment Delivery Model: • Please discuss with your team the treatment delivery model that your site plans to implement and write a brief description. We also recommend drawing a framework (e.g. with boxes and arrows) of your program to illustrate how the components will integrate into the existing health care infrastructure. Please include entry points to care as well as community support services in the description and framework.

17. 1.2 Human Resources Management: • Human resource capacity is a major constraint to scaling up comprehensive HIV/AIDS care and treatment. An ARV treatment plan that calls for significant additions in physician or nursing staff to expand the healthcare system capacity in order to provide quality care and treatment to PLWHA by definition will not be scalable. • It will be especially challenging to ensure that the necessary HIV/AIDS clinic workers are found without weakening the healthcare structure for other diseases by pulling workers out of existing programs.

18. Therefore, to strengthen the ART program, local community members will need to be recruited and trained in the details of adherence to antiretroviral and recognition of medication side effects. Once adequately trained, these new ancillary healthcare workers from local communities can dramatically increase the potential of a single physician or clinical officer to deliver ARV to their surrounding communities

19. Planning questions: • 1.Identifying theART Team: • Please describe the structure of the ART team in full detail, defining the roles and responsibilities of each member.IHVN encourages the site to make an organizational chart. *Please refer to the programmatic budget guidance for additional information regarding staff structures.

20. Members of the team • Name of the person who will be coordinating activities Responsibilities with regards to ART • Project Coordinator • Medical Officers and/or Clinical Officers. • Nurse. • Adherence counselors/Treatment Support Specialists • Community Volunteers • Pharmacy Staff. • Strategic Information staff (M&E, data entry staff, etc)

21. Laboratory staff • Finance

22. 2 Human Resource Management: • Describe the LPTF plan for hiring, retaining, and training site and community staff. • How will you recruit new staff? • Advertise and call for interviews not at present but as the programme expands. • How will you retain existing staff? • Integration into hospital scheme • What is your plan for training current and new staff, including community volunteers? • E.g. Capacity building from donors • E.g. In-house training by hospital • Step down training from those who have benefited. *Please refer to the programmatic budget guidance on training for information about the types of training that IHVN will provide.

23. 1.3 Identifying target populations for ART- Planning question: 1.Target population: Please list the sub-groups of the population targeted by the site for ART care andTreatment.

24. Sub-groups of population that ART program will targetExample:HIV positive children,Youths,Pregnant Women, People Living with HIV / Support Group.

25. Inclusion Criteria : • Please discuss with your team the medical and non-medical inclusion criteria that your site plans to implement . Please ensure that your criteria operate within the National HIV/AIDS guidelines and strategy for Nigeria.

26. Items to consider for medical criteria: clinical criteria, immune staging criteria, asymptomatic pregnant women, etc. • Items to consider for non-medical criteria: demonstrated motivation to enter care, disclosure status, substance abuse, family support, geographic criteria, socio-economic criteria, etc.

27. 3.Patients on waiting lists for ART • If your site has a waiting list of patients eligible for ART, what determines the order that patients are moved off the waiting list and placed on ART (assuming that all patients cannot be started on ART at once)?

28. 1.4 Patient Enrollment Projections • Please complete a table for patient enrollment per month for the next year. • To achieve and maintain these outcomes, consider the human resource capacity at the site, the number of ART clinic days, the number of outreach days, and the community capacity for follow-up and adherence monitoring.

29. Months • Number of adult patients initiated on ART per month of the year. • Number of pediatric patients initiated on ART per month of the year. • Eg,10 for jan,15 for feb,25 for march etc

30. 1.5 Continuity of Care • Antiretroviral therapy for AIDS has the ability to transform AIDS from a fatal acute infection to a long-term chronic condition. This transformation requires a programmatic shift from provision of acute care to a model of chronic care at many sites. Several components of the treatment model will directly support continuity of care, such as integrating the ART program into holistic HIV/AIDS approach, strengthening health care networks, expanding community mobilization.

31. Regular ART team meetings • Sites are strongly encouraged to hold regular (e.g. twice monthly) coordination meetings with key ART staff involved in patient care, including clinical officers, treatment support specialists, pharmacists, home-based care coordinators, etc. • At the meeting, the team discusses patient cases one by one in order to coordinate care plans specific to each patient. Due to time constraints, the team may decide to discuss only certain patients, such as patients in a specific catchment area, patients with adherence problems, patients preparing to start or to re-start ART, etc.

32. For each patient, the staff makes a clear follow-up plan based on the following: • What are the causes of any adherence problem that this patient is experiencing? • how can the team help this patient succeed on ART? • Is the problem serious enough to consider either changing the patient’s regimen or stopping the ARVs altogether until the problem is resolved? • What follow up actions are necessary? Who is responsible? By when? • The team also provides oversight of equitable access to care, including selection of patients who will commence ART according to criteria and specific target groups

33. 1.5.1 Patient flow:Monitoring patients on ARVs • Please describe all of the steps that will be followed in the first year to support a patient on ARV therapy to ensure continuity of care by making a flowchart illustrating the care of one patient over the course of a year. • Include the following details in the patient flow: • Entry of the person into care (what departments or organizations refer patients to AIDS care and treatment services—e.g. VCT, PMTCT, TB clinic, etc) • Initial clinical evaluation (where and by whom) • Eg:next slide

34. VCT, PMTCT, TB Clinics • Medical Officer’s evaluation • CD4 Test • Medical Officer’s evaluation criteria for ART • Treatment preparations (A/O, Counsellors)

35. 1.5.2. Coordination of patient care and communication flow • Please plan how staff will communicate patient appointments and follow up. Consider the protocol to be followed in specific situations, such as four examples outlined below:. A clinician decides to switch a patient’s regimen. How will this decision be communicated to the rest of the ART team, in particular to the adherence counselors (treatment support specialists)? Who will inform the community volunteer that supports the patient?

36. How will the ART team track what patients have missed appointments? How will the team follow up patients who have missed medical or adherence appointments? Please give a specific answer (e.g. who, when, how). • The ART team at the site discovers that a patient has adherence problems and needs more support. How and when will the ART team inform a community volunteer to follow-up with this patient?

37. A community volunteer discovers that a patient has adherence problems. How and when will the community volunteer inform the site staff about the problems faced by this patient? Who on the ART team will the community volunteer inform?

38. Part 2: Medical Care under the ART Program • Please follow your country’s National ART Guidelines when completing this section. IHVN clinical technical officers will work with the site to complete this section.

39. 2.1 Treatment Regimens • How do you determine if someone is clinically eligible.eg CD4<350. • Regimens : 1st line regimen. Alternate 1st line. regimen for pregnant women. regimen for TB patients.

40. 2.2 Safety Monitoring: • Please describe how the program will monitor for toxicity in patients who recently initiated ART. e.g. weekly appointments for the first two weeks. • How often will patients be monitored for toxicity in the short term? e.g. weekly appointment for the first 2 weeks.

41. How often will patients be monitored for toxicity over the long term?. • Who will monitor the patient for toxicity? E,g pharmacist. • Please describe how the program will monitor and address side effects of specific drugs, including nevirapine, d4T (stavudine), Alluvia, and efavirenz

42. 2.3 Laboratory Monitoring • Detail a proposed schedule for immunological and other laboratory tests required for enrollment and monitoring. • Refer to programmatic budget guidelines for information about what kinds of laboratory tests should be included in your site budget. Viral load testing is not readily available in many sites.IHVN will conduct viral load measurements to validate programmatic success and to determine some individual patient response to therapy.

43. 2.4 Linking ART to PMTCT • Many sites are currently providing PMTCT services, which are natural starting points for initiating ART to women in the 3rd trimester of pregnancy, to newborns, and to their families. Plan with members of your site team how the ART program will coordinate care of women and families between the PMTCT and ART programs.

44. Questions to discuss include the following: • How will the site screen and enroll pregnant women into the ART program? • How will care be coordinated for pregnant women participating in both the PMTCT and ART programs? • How will staff communicate with one another about patient care? (e.g. Will the patient medical record contain information from both services?) • How will the mother receive follow-up care after delivery (where, how often, who follows up?)

45. How will the child receive follow-up care after delivery? (where, how often, who follows up?)

46. Part 3: Strengthening your Adherence program (preamble) • Giving the patients the best chance to achieve success on their first line regimen is critically important, especially in light of limited viral load monitoring and limited second line treatments. In order to achieve and maintain durable viral suppression, patients must take their ARV regimen greater than 95% of the time.

47. Several psychological, social, and physical factors can influence patient adherence behavior. To address these factors, the site can strengthen specific components of the adherence program that have been shown to impact patient adherence :next slide

48. implementing on-going patient treatment preparation and adherence education • increasing the technical competence of ART program staff regarding adherence monitoring • promoting positive interpersonal relations between the patient and the ART program staff • integrating adherence support services into other services • ensuring continuity of care • expanding community participation in adherence support activities.

49. Multiple strategies to support adherence can be utilized depending on each site’s and community’s needs. Developing human resources as “adherence specialists” can be accomplished through the training of community members, hospital staff, or even patients’ family members or guardians. Once adequately trained, these new ancillary health workers can dramatically increase the potential of a single physician or clinical officer to deliver ARVs to their surrounding communities.

50. Site Planning Questions • 3.1 Treatment Preparation • Please outline the treatment preparation plan, listing specific steps that a patient will need to fulfill before starting ARVs. The treatment preparation plan should prepare the patient to adhere to ARVs and should allow the staff to determine if the patient is able to be adherent to ARVs.