5 5 yr

1. IMAI updateDr Sandy Gove for the IMAI team, WHO Department of HIV/AIDS in collaboration with many other WHO departments, regional and country offices, partners

2. Integrated primary care- WHO tools IMAI Pregnancy Adult IMPAC - Adolescent and Adult Illness - Pregnancy and Childbirth Adolescent Birth i 10 yr 1 yr 5 5 yr 2 2 mo IMCI - Childhood Illness

3. IMAI-IMCI tools build clinical teams IMAI-IMCI Delivering HIV services through primary health care • IMAI-IMCI (and IMPAC) are WHO tools for country adaptation • Support efforts to head toward universal access. Advantages: • Allows HIV scale up to strengthen rather than weaken basic services • Maximize the impact of investments in HIV interventions. • For patient-- able to provide 'one-stop-shop' or supermarket approach • For health worker-- rather than separate tools from multiple disease programmes, an integrated case management approach • Integration of prevention with treatment and care- supports more consistent delivery of prevention interventions • Health system strengthening by providing harmonized tools for integrated primary care within a district network

4. IMAI – IMCI- IMPAC strategy/tools emphasize 3 aspects:

6. Why does WHO support an integrated approach? HIV Care/ART NATIONAL LEVEL PMTCT TB/HIV PITC STI Targeted interventions Community preparedness DISTRICT LEVEL Primary care facility

7. Clinical mentors Initial emphasis ART CENTRALorREGIONAL Specialisedphysicians, paediatricians Referral, Back-Referral; Clinical mentoring; Supervision by District HIV Management Team IMAI-IMCI** DISTRICT HOSPITAL District clinicians: doctors/medical officers/clinical officers IMAI- IMCI*** HEALTH CENTRE Clinical care- nurses, medical assistants ; lay counsellors (ART aid) IMAI-IMCI** COMMUNITY Treatment supporters, community health workers, peer support groups, CBOs, treatment and prevention literacy Drugs, diagnostics, commodities, logistic support National, Regional and District ART Management

8. WHO IMAI- IMCI- IMPAC integrate: Acute Care Palliative Care: Symptom Management Chronic Care • General principles • Chronic HIV Care • with ART and Prevention Not disease specific All ages For all patients: HIV+, HIV- PITC When to suspect TB Management main symptoms IMAI adolescent, adult IMCI child Prevention integrated with care and treatment (by age, serostatus) Support for healthy pregnancy & childbirth Infant, child nutrition & development 'MCH + men'

9. WHO IMAI- IMCI- IMPAC integrate: Acute Care Palliative Care: Symptom management Chronic Care HIV+, HIV- PITC TB casefinding OI's Cough, difficult breathing STI's Diarrhoea Skin problems Mental health, alcohol Neurological problems Fever/malaria • General principles • Chronic HIV Care • with ART and Prevention • PreART care, ART • PMTCT • Prevention with Positives • TB-HIV Co-Management • MDR TB- draft • Diabetes- in development Not disease specific All ages OI symptom management ART side effects End-of-life care Prevention integrated with care and treatment (by age, serostatus- all) Support for healthy pregnancy & childbirth (IMPAC) Infant, child nutrition & development (IMCI-HIV)

10. IMAI-IMCI tools build clinical teams IMAI-IMCI IMAI-IMCI learning programmes >> training • Ongoing learning over time • Accomodates new interventions, knowledge • Strong emphasis on clinical mentoring and supportive supervision after training • Casebooks for continued practice • Follow-on short training courses (on-site, weekends, distance learning) • Second level learning programme for district hospital clinicians

11. IMAI-IMCI tools build clinical teams Integrated primary care 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-sponsorship by national programmes – shared programme of work • Efficient management for patient (single clinic visit) and • clinical team: • TB-HIV co-management • PMTCT interventions integrated with antenatal, L&D, post-partum and newborn care • IDU integrated with HIV care and ART within primary care  IMAI tools to support this expanded integration of services

12. IMAI-IMCI strategies to address severe human resource constraints: Task shifting Pre-service education: provide HIV content for a public health approach Expansion of clinical teams providing HIV services with trained and paid PLHIV Interventions to retain health workers: attention to HW safety personal support and on-going learning through clinical mentoring attention to burn-out

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

14. Train and hire PLHIVs to be Expert Patient-Trainers • Who are the EPTs? • Literate patients on ART • Often half of the IMAI faculty! • Can later be incorporated on clinical team as lay counsellor • Trained to present cases and give feedback during skill station sessions (replaces most role plays) • Participate in classroom discussions • Extensive experience (> 20 countries) • Full curriculum, trained facilitators IMAI-IMCI tools empower patients and communities

15. Flipcharts for patient education • Chronic care approach prepares clinical teams to partner with the patient • Patient self-management is supported by: • Education and booklets • Preparation of treatment • supporters for ART and TB • Technically sound home-based care • Low literacy training courses for CHWs- in development Patient self-management and caregiver booklets, cards for each ART regimen IMAI-IMCI tools empower patients and communities

16. IMAI-IMCI tools build clinical teams Facilitate serious scale up by training strategy: • First train regional/district management teams • Set up for core IMAI training courses for HIV scale up can be demanding: • all materials- clinical and patient monitoring • hire, train EPTs • 3 to 4 simultaneous classrooms • Able to train 10 teams at once • Avoid single training courses- organize back to back training wherever possible • Capable of training all clinical teams in a region in 2 months • Increasing integration: TB-HIV, integrated PMTCT

17. IMAI-IMCI tools build clinical teams IMAI-IMCI Serious WHO commitment to clinical mentoring • WHO guidelines • Clinical mentor pocket guide- draft • Participatory training materials • Adding paediatric module • Mentor's role to support basic primary care services, prevention, TB-HIV, PMTCT– not just ART • Working with many partners and countries now seriously into mentoring • Still, no country has a national clinical mentoring plan for all sites

18. Strengthening management and logistics supports: scale up of HIV services and health system strengthening • Support large scale decentralization of HIV services to health centre level • Draft Operations Manual – management/leadership, infrastructure, supply management, lab, integration and linkages of services- facility and community, patient and programme monitoring, quality management (full draft, district-level review, early country use: imaimail@who.int) • District management • District HIV coordinators’ course • Manual for district HIV managers • Quality assurance tools • National and regional: • Adaptation guide • Strategic and operational planning, budgeting IMAI-IMCI tools strengthen management & logistics

19. > 35 countries; all districts: Uganda, Ethiopia, Lesotho, Swaziland IMAI scale up Scale up training and follow-up after training TOT, initial scale up limited to few districts or pilot Adaptation in progress

20. IMAI-IMCI HIV statusScale up training-mentoring-supervise sitesIntroduction, TOT Few Early, Sites all To large Adaptation Limited States, expanding districts number sites Provinces health centres Nigeria Kenya Botswana Burkino Faso PNG Haiti Indonesia Uganda Lesotho Swaziland Guyana Senegal Ethiopia Tanzania Mozambique Seychelles GuineaConakry Benin Nepal Myanmar Laos Columbia Peru Others Zimbabwe Ghana Namibia Yemen Zambia Burundi China India RSA Sudan Somalia

21. IMAI-IMCI tools build clinical teams IMAI-IMCI IMAI review/report from 25 countries: • PLHIV expert patient-trainers 21/25 • MOH national patient monitoring system • based on WHO illustrative system 16/25 • (often multiple parallel partner systems) • Builds on IMCI (already adapted in country) 23/25 • Expanding beyond acute OI; chronic HIV care, ART; PITC • Adaptation of TB-HIV co-management • and TB infection control in progress 12/25 • IMAI-IMPAC Integrated PMTCT training Just released • ART delivery within ANC, L&D, PP/newborn care • Renewed emphasis on palliative care

22. If we aim for universal access to HIV prevention, care, and treatment, we must ensure that all health-care professionals are properly educated. Therefore, the timely integration of adequate and regularly updated comprehensive HIV training into pre-service curricula of all cadres of health-care professionals is of paramount importance. Not only redesigning training curricula but also upgrading faculties and providing support for empowerment in teaching HIV content to students is needed. Continuing collaboration between WHO, partners, and ministries to rapidly produce and continuously update strong HIV content for pre-service education and continuing medical education is needed. LancetVol 372 July 26, 2008