Copyright: 2009 TANSACS & SAATHII

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2 Copyright: 2009 TANSACS & SAATHII ACKNOWLEDGEMENTS 1. I-TECH team 2. ART medical officers 3. TNFCC programme partners 4. TNFCC clients 5. TANSACS and SAATHII team Documented and Designed by SAATHII in association with New Concept Information Systems Pvt. Ltd. Website:

3 foreword In the fight against HIV/AIDS, Tamil Nadu has achieved a significant reduction in the prevalence, providing an example to other states of how well-planned and comprehensive programmes can help control the epidemic. One such effort is the Clinical Mentorship Programme implemented by Tamil Nadu AIDS Control Society (TANSACS) as part of the 3-year ( ) Tamil Nadu Family Care Continuum Programme, in three government hospitals. The technical assistance and capacity building inputs from SAATHII were crucial to the success of the programme. I-TECH, added to the quality of the training and mentorship component. The aim of the clinical mentorship programme was to significantly increase the skills of medical officers in the management of HIV/AIDS; the approach was participatory, based on the principles of adult learning. Highly skilled and experienced clinicians were designated as mentors to guide the ART medical officers. Programme components which ensured effectiveness were needs assessment, training, both face-to-face and distance mentoring, and on-going monitoring and evaluation. The programme has been remarkably successful in ensuring the mentees improved skills. Evaluation has demonstrated improved learning s, improved clinical outcomes and improved documentation. Successful clinical mentorship has been followed by three other programmes: counseling mentorship for hospital and field counselors; home-based care mentorship for outreach workers; and child services mentorship for child counselors. TANSACS acknowledges SAATHII for its technical assistance to the program, Duke University for monitoring and evaluation, The Children s Investment Fund Foundation for funding support, and all the TNFCC-associated ART centers, field NGOs and hospital NGOs for effective implementation. On behalf of TANSACS, I take this opportunity to express our appreciation of hospitals and the Medical Officers contribution to the success of the clinical mentorship programme. Dr S. Vijayakumar, IAS Project Director

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5 Contents 1. HIV Prevention, Care and Support in India 1 2. Tamil Nadu Family Care Continuum (TNFCC) Programme 4 3. TNFCC - Technical Assistance and Capacity Building 7 4. The Clinical Mentorship Programme - Overview 9 5. The Clinical Mentorship Programme - Training Needs Assessment The Clinical Mentorship Programme - Learning Methodology The Clinical Mentorship Programme Findings, Feedback and Outcomes 19 Annexure I - I-TECH Clinical Mentors Training Curriculum 24 Annexure II - Tool for Mentorship Assessment 25 Annexure III - Sample Mentorship Report 43 Annexure IV - Case Sheet Documentation for treatment failure 48

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7 HIV Prevention, Care and Support in India 1 Overview The revised estimate of people living with HIV in India (July 2007) puts India in third place in the list of countries with the largest number of people living with HIV. Of the estimated million people with HIV in India 39% are women and 3.8 % are children. The transmission route is predominantly sexual (87.4%) from high-risk groups to bridge populations (clients of sex workers, truckers) and then to the general population. through risky behaviors, it is critical to continue to employ robust behavior change intervention efforts to stem the epidemic. Care and Treatment Models Family-centered and comprehensive care models are recognized as appropriate strategies for mitigating the impact of AIDS. Access to therapy, nutrition assistance, and treatment for Opportunistic Infections (OI) and other health issues that complicate or exacerbate HIV infection are all integral components of a comprehensive care model. Globally, the availability of new resources has accompanied a push for greater access to treatment, care and support. Never before has the world attempted, on such a large scale, to bring broad-based chronic disease management to resource-limited settings. India, like other countries, has embarked on aggressive campaigns to control the epidemic. National response to the AIDS epidemic has been to decentralize the programme to the state and district levels to enhance commitment, coverage, and effectiveness. The goal is to reverse the HIV epidemic by 2015, and to improve quality of life for people living with HIV/AIDS (PLHIV) through increased access to care and support services and, in particular, Anti Retroviral Therapy (ART). It is thus recognized that medical treatment alone is not sufficient. Programmes offering care and support to HIV-affected families should integrate psychosocial services in the treatment process, as well as supportive services such as financial support, family counselling, nutritional aids, and palliative care where necessary. ART programmes should also address the mental health-related aspects of disease management, and The national response also recognizes the importance of maintaining strong prevention efforts. Prevention is critical in countries, like India, where HIV prevalence remains low in the wider population and where opportunities still exist to prevent an exponential rise in transmission. Where transmission occurs mainly HIV Clinical Mentorship - In a public health context 1

8 provide access to psychotropic medications where possible. Palliative care in combination with and as an adjunct to home-based care also has a role to play in improving medical care, symptom control, and mortality from the disease. Appropriate palliative care also addresses psychosocial issues experienced by families and surviving children, supports care givers and communities, and encourages future patients to come forward earlier in the disease. The overall goals of NACP-III (National AIDS Control Programme) is to halt and reverse the epidemic in India over the next five years by integrating programmes for prevention, care and support, and treatment [2]. This will be achieved through a fourpronged strategy: Prevent infections through saturation of coverage of high-risk groups with targeted interventions (TIs) and scaled up interventions in the general population. Provide greater care, support, and treatment to larger numbers of PWLHA. Strengthen the infrastructure, systems, and human resources in prevention, care, support, and treatment programmes at district, state, and national levels. Strengthen the nationwide Strategic Information Management System. The specific target of NACP-III is to reduce the rate of incidence by 60 percent in the first year of the programme in high prevalence states to obtain the reversal of the epidemic, and by 40 percent in the vulnerable states to stabilise the epidemic. Care, Support, and Treatment under NACP-III NACP III seeks to implement HIV services across the continuum of care. Accordingly, prevention will go hand-in-hand with access to prophylaxis, management of opportunistic infections, and ART. Given the low levels of coverage, focus will also be on assuring National Strategy Following the detection of the first case of AIDS in India in 1986, several measures, both governmental and non-governmental, were taken throughout the country to curtail the spread of HIV and protect the rights of People Living with HIV/AIDS (PLHIV). At present, the National AIDS Control Organisation (NACO) provides leadership to HIV/AIDS control programmes in India through 35 HIV/AIDS Prevention and Control Societies. 2 HIV Clinical Mentorship - In a public health context

9 provide psychosocial support, counselling through strong outreach services, referrals, and palliative care. Home-based care will be an integral part of this strategy. universal access to first line Anti Retroviral drugs (ARVs) in the first instance. To ensure drug adherence, the Community Care Centers will be reconfigured as a bridge between the patient and the ART centers and Care, support, and treatment services include management of opportunistic infections including control of TB in PLHIV, ART, safety measures, positive prevention, and impact mitigation. By 2011, the programme will be able to treat 320,000 OI episodes in a year, provide TB referrals to 2.8 million PLHIV, and ART treatment to 300,000 PLHIV, including 39,000 children. The component related to Care, Support, and Treatment is proposed to be allocated an amount of Rs crores accounting for 16.9% of the total project outlay. HIV Clinical Mentorship - In a public health context 3

10 2 Tamil Nadu Family Care Continuum (TNFCC) Programme Overview Tamil Nadu Family Care Continuum (TNFCC) Programme for HIV+ Families is a 3-year programme (September 2005 to August 2008) being implemented by Tamil Nadu State AIDS Control Society (TANSACS) in partnership with Solidarity and Action Against the HIV Infection in India (SAATHII). SAATHII, a nonprofit agency headquartered in Chennai, India, provides technical assistance and capacity-building to government and non-government HIV service providers, and has been helping strengthen and scale up services in the country since In 2005, The Children s Investment Fund Foundation, UK (CIFF, UK) awarded funding to TANSACS to expand ART, with SAATHII designated as the provider of technical, operational, and logistical assistance. Clinical Mentorship is being carried out in partnership with International Training and Education Center on HIV/AIDS (I-TECH). External Monitoring and Evaluation is being conducted by Duke University, USA. TNFCC is one of the first and largest publicprivate partnerships for HIV care in India. It serves approximately 14,178 PLHIV, 9,393 families with children, 13,104 adults, and 1,074 infected and 10,253 affected children at the end of three years (September 2005 to August 2008). It has demonstrated success in reducing HIV-related morbidity and mortality, and improving qualityof-life, by providing ART to children and families infected and affected by HIV/AIDS in the urban and rural areas of Tamil Nadu. Of particular note is the fact that TNFCC is one of the first government programmes to give free 2 nd line ART drugs. Out of the 65,000 PLHIV in Tamil Nadu, around 3 5% requires 2 nd line ART. Second line ART is more expensive (Rs. 6,000 12,000, averaging 10,000 per month) than 1 st line ART (Rs ,000, depending on regimen, government procurement rates may be between Rs ,500). One of the biggest achievements of the TNFCC clinical mentorship programme is streamlined 2 nd line initiation. This process will be discussed later in the document. TNFCC Programme Objectives: To develop and evaluate a multi-sectoral model involving government hospitals, NGOs, CBOs, and positive networks in providing a comprehensive continuum of care and treatment to include medical, psychosocial and nutrition services, treatment of opportunistic infections, and provision of ART. 4 HIV Clinical Mentorship - In a public health context

11 To develop and evaluate an integrated familycentred continuum of care and treatment model for HIV positive families. To develop successful linkages through partnerships among various stakeholders including government, NGOs, CBOs, and PLHIV. To integrate community-led treatment preparedness and literacy programmes with care, support, and services. To evaluate the impact of nutrition support and counselling on morbidity and mortality in children and adults. Expected Outcomes: Prevent children being orphaned. Reduce HIV related mortality and morbidity among families. Achieve 90% adherence among adults receiving ARV therapy. Improve quality of life among families. Programme Overview Sites Three hospital sites cater to ten districts: Kilpauk Medical College Hospital (Chennai cluster) - Chennai, Tiruvallur, Kanchipuram and Villupuram. Govt. Mohan Kumaramangalam Medical College Hospital (Salem cluster) - Salem, Erode, Dharmapuri, and Perambalur. Govt. Medical College Hospital (Tirunelveli cluster) - Tirunelveli, and Tuticorin. Hospital Activities The three government medical college hospitals function as hospital programme sites and are responsible for coordinating and providing comprehensive care, support, and treatment services. The hospital-based services are provided by hospital staff, government appointed doctors, and representatives of community based organizations. Hospital and NGO Partners of the TNFCC programme Hospital Districts covered Hospital NGO Field NGOs, CBOs and Positive Networks Government Kilpauk Chennai, Tiruvallur, Community Health SIP+, MSDS, and ACD Medical College Kanchipuram, and Education Society (CHES) Hospital, Chennai Villupuram Government Mohan Salem, Erode, Young Women YWCA, HILLS, Kumaramangalam Dharmapuri, and Christian Association SEARCH, and INDO Medical College Perambalur (YWCA), Salem Hospital, Salem Government Medical Tirunelveli, Tuticorin, Gramodhaya Social PWST+, St. Joseph College Hospital, and Kanniyakumari Service Society Leprosy Hospital Tirunelveli HIV Clinical Mentorship - In a public health context 5

12 After the second year of operation, the NGO staff were slowly phased out once the ART staff were added, as per the revisions in national ART centre operational guidelines. The NGO staff numbers have varied across the three centers, in accordance with the prevailing client load. Field Activities For each ART Center, TANSACS has recruited and trained 2 ART medical officers, 1 2 counsellors, 1 lab technician, 1 pharmacist, 1 community care coordinator, and 1 data entry operator. While this staffing pattern is similar to that of ART Centers across the country, TNFCC sites were established with supplemental staffing in the form of a trained NGO support team, consisting of the following personnel: 1 Project Coordinator 1 2 Counsellors 1 2 Nutritionists 1 2 Nurse Case Mangers 2 Nursing Aides 1 Pharmacist 1 Accountant/Data Entry Operator 1 Sanitary Worker Community services provided by NGOs in each of these ten districts are as follows: Identification of HIV clients and motivation of patients for hospital registration and monthly follow-up visits Conducting support groups near the patient s residence Identification and training of peer educators and care givers Provision of home-based care that includes opportunistic infections diagnosis and referrals, as well as ongoing adherence counselling Referrals and linkages to various services like housing, income generation, legal services, etc. Child counselling and related services All services are provided by the Project Coordinator, Child Counsellor, Community Health Nurse, and 8 10 Outreach Workers of the field NGOs affiliated with the respective ART Centers. 6 HIV Clinical Mentorship - In a public health context

13 TNFCC - Technical Assistance and Capacity Building 3 SAATHI (Solidarity and Action Against The HIV Infection in India) has served as technical assistance partner for TNFCC, providing training, support visits, coordination, networking, ongoing technical updates, and mentorship. Training TANSACS and SAATHII conducted training for various stakeholders on the following topics (target trainee population shown in parentheses): Clinical Management of HIV/AIDS (counsellors, lab technicians, nutritionists, pharmacists, sanitary workers, project coordinators, community health nurses, child counsellors, and outreach workers) Home-based Care (nurses, counsellors, project coordinators, nutritionists, outreach workers, community health nurses) Adherence Counselling (hospital and field counsellors and coordinators, community health nurses, and outreach workers) Child Counselling (ART counsellors and field child counsellors) Life-skills Training (field project coordinators, child counsellors) Financial Management (project head, project coordinators, accountants) Training on Organization Development/ Management, Leadership, and Communication (NGO heads and project coordinators) Induction and advanced training for nutritionists Training and mentorship to hospital and field counsellors and outreach workers on general counselling with a component on HIV/AIDS (disclosure, safe sex, and stigma) Home-based care mentorship training for community project coordinator, child counsellors, and community health nurse for mentoring outreach workers Child Services training for the community child counsellors Training for ART medical officers (see below). ART medical officers were trained at the start of the TNFCC programme four days in Tambaram Sanatorium and six days in YRG Care. The Tambaram training complied with NACO Guidelines and covered OI, ART, side effects, documentation and reporting, monitoring, clinical rounds, and pediatric HIV care. The training at YRG covered second line drugs, system-wide HIV clinical management, hospital-waste management, universal work precautions, clinical rounds, and case studies. Tools were adapted from the Clinical Mentoring Toolkit developed by the International Training and Education Center on HIV (I-TECH). The contents of induction training were repeated during Years II and III because of high staff HIV Clinical Mentorship - In a public health context 7

14 turnover. The training was made specific and targetfocused in order to ensure that participants attained the necessary level of competence. All training programmes were conducted within the first three years since TNFCC s inception. SAATHII provides technical updates during support visits and programme coordination meetings at ART centers where hospital ART team and community NGO teams interface. Discussions focus on the issues arising out of the daily work of programme staff, especially outreach workers. Technical assistance to NGOs helps in identifying field-based solutions through monthly monitoring visits and ongoing needbased support. For instance, several outreach workers have difficulties in talking about sex, ART treatment, and disclosure so SAATHII conducts regular follow-up on the trainings provided. Mentorship Initiatives There are four Mentorship programmes under the TNFCC: Clinical Mentorship to ART medical officers (provided by SAATHII and I-TECH) Counselling Mentorship to hospital and field counsellors (SAATHII) Home-based Care Mentorship to outreach workers (SAATHII and Field NGO Core Team: Project Coordinator, Child Counsellor, Community Health Nurse) Child Services Mentorship to child counsellors (SAATHII) The clinical mentorship programme was the first of its kind in the programme, and in the country, and its success resulted in launching of mentorship initiatives in the other domains listed above. The clinical mentorship programme will be presented in detail in the following section. For the counselling mentorship programme, four days of training were provided (two days each, in two rounds from January to March 2008). In addition, one-day visits were made twice to the hospitals. These visits involved counselling and observations in the morning, and case study discussions among hospital and field counsellors, in the afternoon. The mentorship activities were implemented by SAATHII with initial assistance from external experts. Initial home-based care mentorship was provided by SAATHII. However, due to an increased number of outreach workers in the third year (around 100), a mentorship training was conducted by SAATHII for selected field staff (20 25 total, two to three from each community NGO) who then constituted the core field team. This helped broaden and decentralize the pool of mentors. The child services mentorship was provided by SAATHII to the community NGO-based child counsellors. Training covered life skills education, recreation, education and referrals, and linkages to additional services. 8 HIV Clinical Mentorship - In a public health context

15 The Clinical Mentorship Programme Overview 4 Background and Partners A significant need addressed through the TNFCC programme was capacity enhancement of the local health institutions in HIV care and treatment, especially in management of complicated and challenging cases in relation to OIs, and ART (first and second line drugs). SAATHII identified clinical mentoring as an appropriate strategy to develop this expertise among local health care providers. Structured clinical mentoring, using adult learning principles, helped bridge the training gap between traditional didactic trainings and practice in the clinical setting. SAATHII identified the International Training and Education Center on HIV/AIDS (I-TECH) as the technical partner to develop the Clinical Mentorship Programme for TNFCC. I-TECH is a global AIDS training programme working at the invitation of ministries of health and the U.S. government to increase human and institutional capacity for care and treatment in countries hardest hit by the HIV and AIDS epidemic. I-TECH is collaboration between the University of Washington, Seattle, and University of California, San Francisco. I-TECH s model of Clinical Mentorship I-TECH s primary objectives for clinical mentoring are consistent with the World Health Organization s public health approach to scaling up HIV care and ART. These objectives include: Supporting decentralized delivery of HIV care, ART and prevention, as well as continuous improvement of patient outcomes at all ART delivery sites. Promoting application of classroom learning to clinical settings. Improving the quality of clinical care and patient outcomes in resource-constrained settings. Building capacity of primary care providers to provide comprehensive and integrated care using on-site clinical collaboration, consultation, and directed support SAATHII collaborated with I-TECH in curriculum adaptation, mentor programme design and implementation. Geographical Sites The Clinical Mentorship Programme has been implemented in ART centers in three districts Government Kilpauk Medical College Hospital in Chennai, Government Mohan Kumaramangalam Medical College Hospital in Salem, and Government Medical College Hospital in Tirunelveli. These three sites cater to families from three focal and seven surrounding districts. HIV Clinical Mentorship - In a public health context 9

16 Mentorship Methodology Who is a Clinical Mentor? As defined by WHO: A clinical mentor in the antiretroviral therapy context is a clinician with substantial expertise in antiretroviral therapy and opportunistic infections who can provide ongoing mentoring to less-experienced HIV clinical providers by responding to questions, reviewing clinical cases, providing feedback and assisting in case management. This mentoring occurs during site visits as well as via ongoing phone and consultation. Clinical mentoring is critical to building successful district networks of trained health care workers for HIV care and treatment in resource-constrained settings. The Clinical Mentorship Programme involves two mentors from I-TECH, one mentor from SAATHII, and seven mentees, who are medical officers at the ART Centers that were included in the TNFCC programme. When mentorship was initiated in April 2007, the mentees already had a case load of around 12,000 HIV/AIDS patients altogether at three sites, including over 4,000 patients on ART, of whom 80 are on 2 nd line drugs. The mentors possess clinical knowledge, training and interpersonal communication skills. Key mentoring strategies included building rapport, giving feedback effectively, identifying teaching moments, teaching at the bedside, and addressing systemic issues. For greater details on the Clinical Mentors Training Curriculum, refer to Mentorship is an ongoing process whereby the mentor assists and assesses the patients condition and line of treatment both directly during visits and through distance mentorship to ART medical officers based on details provided via or telephone. Mentorship includes, at a minimum, the following components: Orientation of external mentor by SAATHI mentor Planning and tool development by mentors Training and needs assessment of the ART medical officers by SAATHII mentor Reliance on adult learning principles On-site two-day hospital visits by mentors to each of the hospitals every three months Long-distance mentorship Onsite Mentorship The mentor makes quarterly visits to the hospitals and engages directly with the doctors and the patients identified by the mentee as case studies. In addition, the mentor examines individual patients as requested by the mentee. Onsite mentorship entails the following: Onsite review of medical practices at the hospitals with the doctors Identifying training needs and areas for strengthening Mentoring the doctors by the various methods elaborated below: Modeling Facilitation of various case studies and discussions Hands-on training Additional clinical training using adult learning principles Sharing of supplementary reading materials from peer-reviewed journals. Advocacy with mentees for systematized casemanagement, laboratory investigations and documentation Facilitating data collection, best practices sharing, and clinical research 10 HIV Clinical Mentorship - In a public health context

17 Mentoring Strategies Modeling Facilitate Discussions Additional Clinical Training Greeting patients Difficult and Case Studies warmly complex cases Mini-Teaches based Sensitive patient Ethical issues on needs of clinic examination Patient flow Multidisciplinary Clinic set-up team approach Patient triage Shadow/observe Quality of Care (source: Support Serve as an advocate Cheerlead Listen/validate work of doctors Coach communication techniques Distance Mentorship This component of the mentorship programme is probably the most pragmatic, as it ensures continuous and adaptive learning. The mentees call or the mentors periodically, enabling timely treatment of patients, and establishing open communication between mentor and mentee. Distance Mentorship entails the following: Ongoing consultation with doctors by phone and Exchange of case sheets, scans, and other relevant documents Sharing of reference material to enhance learning Focus Areas of Mentor Involvement Routine clinical care for HIV and associated medical conditions Progress assessment of patients on ART (sideeffects, toxicities, management) OI management of non-art patients HIV-TB co-infection management Second line initiation, regimen selection, and monitoring Improving doctor-patient interaction through effective communication Post-Exposure Prophylaxis (PEP) Results Findings and outcomes of the mentorship programme were gathered through initial training needs assessment, personal observations by the mentors, patient interviews, and focus group discussions with the hospital staff and through mentees self reporting. Results are presented in the following sections. HIV Clinical Mentorship - In a public health context 11

18 5 Clinical Mentorship Programme Training Needs Assessment The Mentees A needs-assessment of the seven mentees was conducted at the beginning of the mentorship. The following synopsis reflects the experience in all three centers: 1. Prior experience in the HIV/AIDS field Work experience varied among doctors, with two having less than two years of experience, and the rest five either 2 4 years, 4 6 years, or 8 10 years. All but one had previous AIDS-related work experience in hospitals, private clinics, or with NGOs. 2. Patients treated per month Hospital PLHIV PLHIV on ART Tirunelveli 1, Kilpauk Medical 2, College Hospital Salem 4,500 1,500 Average 2, Previous trainings All of the doctors had attended previous HIV-related trainings. These include: GHTM NACO 4 attendees YRG Care 4 attendees HIV-TB/ATT-RNTCP 4 attendees Dr. MGR Medical University 1 attendee International Conference, University of Hyderabad 1 attendee CME, Karigiri 1 attendee CME, YRG 2 attendees WHO IMAI training, St. John s Bangalore 1 attendee Clinton Foundation IMA doctors training 1 attendee 4. Training formats The most preferred training formats were: t Conferences t Printed materials (journals, newsletters, etc.) t Skill building workshops t Case presentation seminars The least preferred training format was weekend case discussions. Each doctor listed a separate preference for frequency of ongoing trainings. Most of the doctors agreed that one working day a month could be dedicated to training, either as four hours each day for two days, or one day of eight hours. Internet access: Tirunelveli and Salem had unrestricted access to internet use, but KMCH only received access towards the mid-mentorship period. 12 HIV Clinical Mentorship - In a public health context

19 5. Barriers to training The most commonly cited barrier to training was long travel times to Chennai. Suggested solutions: t t Make Madurai or Tiruchi the centre for trainings Conduct trainings at all three sites, on a rotating basis Salem indicated that both ART medical officers could not attend at the same time. Suggested solution: Assign an alternate/additional ART medical officer KMCH cited lack of access to internet as a barrier. Suggested solution: Printed materials and CDs Training Needs Assessment Doctors were presented with a set of HIV-related topics, and asked to indicate their level of skill in each and their learning interest (as high, medium or low). The doctors expressed the highest learning interest in topics listed below. Items that are starred are those in which they also indicated low levels of skill. 1. Lab Diagnosis of HIV Infection Therapeutic diagnoses HIV RNA PCR CD4 Count testing Other markers* Culture and resistance* 2. Opportunistic Infections and Co-Infections Clinical presentation Lab and clinical diagnosis of OIs Differential diagnosis Treatment GIT manifestations Dental manifestations* Ophthalmic manifestations* Neurological manifestations Tuberculosis* 3. Pediatric HIV Growth and development parameters Lab diagnosis (<18 months) ART Second line regimen ART and ATT ART in women (pregnancy and PMTCT) Immune Reconstitution Syndrome When to change treatment (resistance and treatment failures) 5. HIV and Psychiatry 6. HIV Virology Mechanism of resistance 7. HIV and Gynecology* 8. HIV and Wasting* 9. HIV and Nutrition* Nutritional counselling 10. Legal, Ethical, Cultural Issues* The doctors expressed low skill but only moderate learning interest in the following: Economic, health care, and socio-cultural issues impacting patients. Current trends in epidemiology India, Global Palliative care Structured treatment interruptions HIV Clinical Mentorship - In a public health context 13

20 Site-specific needs Tirunelveli KMCH Salem Clinical Topics Clinical Topics Clinical Topics Radiotherapy in HIV patients Resistance testing methods Non-HIV related HIV/TB Mutations (diagnostic, co-infection Role of Immuno- prevention, treatment Management of chronic and Modulators in HIV Natural Medicines/Herbs/ 2nd line) and dry selection according to mutations recurrent diarrhoea Ayurveda/Siddha and HIV Algorithms for specific Technical update on ART Neurological case presentation toxic effects of ARVs initiation and re-initiation other than common CNS OI Psychosocial assessment Management of OI Immunity: Innate, Acquired, and HIV Pathogenesis scales for specific conditions, adult scales, child scales Prevention: breast feeding, in ART patient like Immune Reconstitution Inflammatory Syndrome Other Topics education of adolescents, Changing patient attitudes Need for separate ARV eligibility and positive prevention e-forum for ART MO ART: second lines, integrase (i.e., more women Legal implications and advocacy inhibitors, maturation inhibitors, any viricidals? getting pregnant) Administration skill Vaccines: trials, types development and leadership Recent research studies qualities improvement HIV and other fields Financial management of ART centers 14 HIV Clinical Mentorship - In a public health context

21 The Clinical Mentorship Programme Learning Methodology 6 As described in Section IV, Overview, the TNFCC Clinical Mentorship Programme incorporates three primary learning components use of adult learning principles, onsite and Distance Mentorship. Training tools were adapted from the Clinical Mentoring Toolkit developed by I-TECH. (For additional information on the I-TECH training curriculum, see Annexure - I) The following section explores these components in greater detail. Adult Learning as Basic Approach The clinical mentorship programme is designed on the premise that adult learning techniques are the most effective in skills transfer. Adult learning principles emphasize that adults come to learning environments with: their own experience and expertise an expectation that they will be respected and guided and a focused motivation to learn based on specific needs to accomplish job-related tasks more effectively The experience at Tirunelveli provides a case study on the use of these learning principles within the clinical mentorship programme. Dr. Narayana Srinivasan, Senior Medical Officer at the Government Medical College Hospital, Tirunelveli, calls this a unique programme because it was developed in response to a personal needs-assessment. The mentor s first question was what are your expectations? The mentor seeks to identify strengths and weaknesses and provides assistance accordingly. The mentors work beside the doctors and not above them. The center has a case load of 250 patients a day. The mentor recognizes the challenges faced by the doctors and the staff, as well as the demands made upon them. The mentors have been very willing to share information. The doctor calls the mentor everyday on the I-TECH hotline to discuss any problems or doubts he may have. These conversations cover a range of issues including drug adjustment, availability of drugs, and drug dosage. A recent example is that of a patient with renal failure the mentee sought guidance regarding on how to assess changing levels of kidney functions, and the need to adjust ARV dosages accordingly. Moreover, the mentorship is not purely clinical -- the mentors urge the doctors to use interpersonal skills which enhance their role as a doctor, such as how to elicit information from reluctant/hesitant patients or how to counsel them on behavior change. HIV Clinical Mentorship - In a public health context 15

22 Mentorship through On-Site Visits The first round of On-site Mentorship for the ART medical officers of three TNFCC centers was implemented during the first quarter of the grant period. This round followed a tools development for mentors and training needs assessment of the ART medical officers (mentees). Onsite visits proceeded as follows: (a) The mentor outlined the objectives/purpose of the visit to the medical officer: to improve the skills of the ART medical officer. The mentor also reviewed the principles of mentorship and the specifics of the two-day schedule. (b) On the first day s morning session, observation was used to assess the medical officer s clinical knowledge, skills, attitudes, and practices. Mentors sat with the medical officers at the ART clinic. (c) In the afternoon, discussions/trainings were conducted to share observations, explore challenging cases, review national guidelines, and discuss the feasibility of implementation. Mentors also shared their work experiences in other settings as a way to discuss best practices. In addition, the following issues were covered in detail: ART toxicities, substitution of ARVs, privacy of examination, flow of patients at the ART centre, the role of the nurse case manager at the ART centre, and HIV/TB co-infection management. (d) On the second day, apart from mentoring in the outpatient department, the mentor: Performed ward rounds and hands-on-training on the wards led detailed case discussions on second line drugs using actual case studies from the ART centre addressed gaps in case management and in the documentations of second line cases; and, made suggestions as to how to rectify the problems using the check list, a draft copy of which was handed out demonstrated how to use the Stanford guide in interpreting the genotype resistance study results using the appropriate web site using case records, stressed how important it is for the medical officer to examine patients on second line drugs explained the importance of documentation related to death and other interesting cases gave the medical officers important web sites for reference, and shared articles related to areas of interest Recommendations were made to all three sites based on the first round of visits. See box below. The tool for mentorship assessment is provided in Annexure - II Distance Mentorship Distance Mentorship in this programme has been actively encouraged and a hotline between the doctors and the mentor allows for open and regular communication. Several doctors said that they would call the mentors 3 4 times a day. Distance Mentorship included: (e) Ongoing consultation with the doctors through various communication modes like phone calls and s (f) Monthly follow-up meetings with Technical Assistance (TA) and Implementer (g) Quarterly field visits by the mentor. On these occasions, special cases are directly presented to the mentor. In addition, observations and discussions with mentees give the mentor an opportunity to observe any other infrastructure needs doctors may have. (See more about On-Site mentorship above). 16 HIV Clinical Mentorship - In a public health context

23 Mentor Recommendations at the end of initial visits, from all three centers - Appropriate instruments and logistics for systematic clinical examination to be provided to improve clinical examination. Appropriate laboratory tests for better clinical care to be made available at all the centers for testing selected and needed cases. The doctors shall follow the NACO guidelines in care and treatment. There is a need to arrange experience-sharing and review meetings and update sessions with interesting and difficult case studies. The ART medical officers of three centers should rotate for experience sharing and case discussions. They can also visit other centers during mentorship visits (cross-mentorship). Documentation should be improved in case sheets and ART card. To improve the documentation practices in the case sheets: Medical Officers shall conduct audit of the reported deaths among the ART team to discuss and identify the probable cause and also use it for programme improvement Death (a) Doctors shall mention the associated conditions that led to patient s death and document in the case sheets (b) Doctors shall mention the probable cause of death if outreach workers are giving the details of the patients either by discussions with the doctor or in a form of short note. (c) Field staff should convey information to doctors during their visit to hospital during informationsharing days like Write a note on the patient s condition during his/her last visit and discuss with the doctor based on the same. SECOND LINE DRUGS: (a) Appropriate initiation of second line drugs A committee consisting of TA team, I-TECH and TANSACS should decide on the appropriate regimen to be chosen. Other technical members shall be included in the committee as required by TANSACS. (b) The ART medical officers should fill the second line case sheet attached as annexure and send the same to the committee for deciding the second line. (c) ART medical officers should collect all the details from the referral doctors regarding previous treatment before starting second line drugs. (d) Doctors need second line drugs training sooner as there are around 75 patients on second line therapy. (e) Doctors shall document all the second line cases in the case sheet attached (Annex 5) for improving the quality of services as per the mentor s feedback. (f) The basic lab tests for management of HIV including second line drugs as per the NACO guidelines are available. The lists of unavailable lab tests are shown below. All the basic lab tests for management of HIV including second line drugs as per the NACO guidelines are available. Below is the list of lab tests not available: Tirunelveli KMC Salem HBsAg Anti- HCV HBsAg Anti-HCV S.Lipase Anti-HCV S.Amylase S.Triglycerides S.Lipase S.Triglycerides HIV Clinical Mentorship - In a public health context 17

24 TANSACS shall suggest TA and ART medical officers to follow-up on the above lab tests. The pharmacy assessment report shows majority of the basic drugs especially Cotrimoxazole (Septran) and Fluconazole are available for treatment and the drugs not available are listed with the reasons below. The starred drugs are not available under regular hospital supply, and hence will be purchased using the OI drug funds. At present, all the drugs needed for the opportunistic infections treatment are procured centrally by TANSACS for distribution to all ART centres. Tirunelveli Reasons Azithromycin 500 mg Inadequate hospital supply Clarithromycin 500 mg No request made due to no need so far Clindamycin 300 mg OI drugs purchase can be done * Fluconazole-T. and Inj. Nitazoxanide 500 mg Inj. Amphotericin B 50 mg Inj. Acyclovir 250 mg No request made Inj. Gancyclovir 500 mg Cap.Gancyclovir 250 mg Dapsone Sulphadiazine, Sulphadoxine Pyrimethamine Folinic acid No request made Salem Clindamycin 300 mg Nitazoxanide 500 mg Dapsone Sulphadiazine, Sulphadoxine Pyrimethamine Folinic acid Inj. Acyclovir 250 mg Inj. Gancyclovir 500 mg Cap. Gancyclovir 250 mg Reasons KMC Azithromycin 500 mg Clarithromycin 500 mg Clindamycin 300 mg Inj. Fluconazole Nitazoxanide 500 mg Inj. Amphotericin B 50 mg Inj. Acyclovir 250 mg Inj. Gancyclovir 500 mg Cap. Gancyclovir 250 mg Dapsone Sulphadiazine, Sulphadoxine Pyrimethamine Folinic acid Reasons 18 HIV Clinical Mentorship - In a public health context

25 The Clinical Mentorship Programme Findings, Feedback and Outcomes 7 The Clinical Mentorship Programme, implemented by I-TECH and SAATHII, in partnership with TANSACS, has demonstrated success in 1. Improved learning; 2. Improved clinical outcomes; 3. Improved documentation. effect. They have learnt when to change the regimen and are more comfortable with preparing nutrients for special cases, and making home visits. Health care professionals in Salem indicate that their knowledge of HIV has increased not only in care and treatment, but in counselling as well. 1. Improved Learning The most significant emerging practice in the Clinical Mentorship Programme is the culture of new and continued learning for the entire team of health care professionals in the three hospitals: (a) Government Kilpauk Medical College Hospital, Chennai (b) Government Mohan Kumaramangalam Medical College Hospital, Salem (c) Government Medical College Hospital, Tirunelveli Based on the pedagogical principles of adult learning, the programme has made a significant impact on the approach to HIV care and treatment, and laid a strong foundation for continuous and renewed adult learning. Mentorship programme enhances the mentees existing expertise This enhanced expertise translates into higher job satisfaction for doctors and, ultimately, into higher patient satisfaction rates. For example, Mr.Rajan (name changed) a 35-year-old lorry driver who has been coming to Tirunelveli since 2005 was aware that when the new drug prescribed did not agree with him, it was changed in consultation with an external doctor. This alternative route to learning has set a precedent in the programme to foster an open environment where there is easy access to information and enhanced communication and collaboration at all Dr.Thennarasu from Kilpauk Medical Hospital affirms, The Clinical Mentorship has shaped me! The mentorship programme has brought him in contact with senior professionals and has improved his knowledge and skills in dealing with patients. A focus group discussion with the project coordinator, nutritionist, nurse, and lab technician at Government Mohan Kumaramangalam Medical College Hospital in Salem revealed that even though they have not interacted with Dr. Manoharan (the mentor) directly, they are aware of his expertise and knowledge. The process of continuous learning has had a ripple HIV Clinical Mentorship - In a public health context 19

26 levels. Besides this, the process of continued learning is a new experience for the doctors who are used to attending trainings that are either too didactic or too short to address the complexities of HIV care and treatment. Simple standardized guidelines for care do not fit in many cases. The nuances of managing drug interactions and toxicities against the backdrop of underlying liver disease and co-infections are challenges the medical world is trying to meet at every turn. It requires expertise and a progressive approach, which a mentorship programme provides for both the mentor and the mentee. Clinical mentors help the mentees translate theoretical knowledge into practical clinical skills Dr. Thennarasu at Kilpauk Medical Hospital admits that his knowledge of HIV/AIDS prior to the launch of mentorship was quite limited. His specialization is in ophthalmology, and there was no component of HIV/ AIDS in his medical curriculum. It was only through the Clinical Mentorship programme that he became aware of diagnostic challenges and other clinical considerations that steer the line of treatment. The mentor advises him on when to run viral load and resistance tests, and when to start 2 nd line ART. Dr. Sentha Krishna from Salem Government Hospital explains, I am more confident about handling cases now. She now treats complications like Cryptococcal meningitis and Zidovudine anemia (caused by ART toxicity) because of the knowledge she gained through mentorship. The mentors have been very willing to share information, and they give the doctor tips on how to elicit information from reticent patients. The doctors call the mentors regularly on the I-TECH hotline for advice on drug adjustment, dosage, and availability. Detailed case histories are sent through , while X-rays, CT scans, and photographs are couriered at least 2 3 times a month. 2. Improved Clinical Outcomes Key outcomes of the clinical mentorship programme have included streamlining of 2 nd line ART initiation and improved management of complicated cases including kidney, liver and CNS issues. TNFCC was one of the first initiatives in the country to make 2 nd line ART drugs available. Out of the 65,000 PLHIV in Tamil Nadu, around 5% require 2 nd line ART. NACO started 2nd line ART recently. As Dr Sathish puts it, one of the biggest achievements of clinical mentorship is streamlined 2 nd line initiation. The complexity of managing difficult cases means that standard protocols and straightforward algorithms cannot always be applied. Individual clinical judgment needs to be supported through mentoring, referral, and consultation support until clinicians become comfortable in knowing when to start, stop or change therapies. The mentorship programme enhances the quality of both short-term and long-term patient care and health outcomes. Prior to the mentorship programme, complicated cases were referred to other hospitals or sent to larger towns. Dr Sentha Krishna, from Salem, says that referrals to Tambaram have come down and the patients reiterate it, Tambaram care is available here! The programme has also raised the hospital s profile in the eyes of patients. Patients from other districts have also started visiting these hospitals because of accessibility and quality treatment. Complicated cases are treated in the hospital either through electronic or telephonic consultations or the case is presented to the mentor on the day of his visit. Another significant clinical outcome of this programme is the timely intervention in peripheral and symptomatic conditions like kidney and liver malfunction, central nervous system problems. Earlier these cases were referred to other departments or hospitals causing delays in the patients treatment, which in some cases were fatal. For instance, a patient with Zidovudine anemia in Salem hospital showed no improvement even after eight bottles of blood transfusion. On mentor s suggestion, an erythropoietin injection was administered and the patient, who had severe anemia 20 HIV Clinical Mentorship - In a public health context

27 with heart failure, improved dramatically and his hemoglobin, is now 12%. 3. Documentation In many healthcare programmes implemented by the government and NGOs, documentation processes and quality are compromised due to a high patient load, lack of documenting skills, and a single-minded focus on care and treatment. Although doctors are fully aware that documentation is a critical contributor to assessment and follow-up in patient care, the documents they produce are usually perfunctory and sketchy. The mentorship programme is based on long distance communication and quarterly visits, making accurate and detailed case studies imperative in order to determine the line of treatment and follow-up. The programme s well-defined documentation processes are now being followed by all the staff. Reports, detailed records, maintaining registers, death analysis, 2 nd line ART documentation, and pediatric records have improved and mentors have been extremely encouraging in teaching new documentation skills. In addition, the mentors have introduced the doctors to some online learning models to expose them to international formats and even shared a model of the Stanford Guide from their curriculum. Bridging Gaps in the Mentorship Programme Though there has been a significant scaling up of HIV care and treatment through the clinical mentorship programme, there are still some gaps that need to be addressed. The mentors are well respected doctors and their commitment to the programme has helped make it a success. But the mentees did not have exposure to all the mentors because there was no rotation, and some of the doctors felt that they would have benefitted from other mentors. Successful mentoring involves a dynamic process and it is often wise to consider establishing a discrete time period as a trial basis to determine whether the mentoring relationship is working. This HIV Clinical Mentorship - In a public health context 21

28 may help minimize any misunderstandings. It is important to match the mentees expectations in order to foster an effective mentoring relationship. There were cases where a mentee would have preferred a more senior mentor who better matched his own considerable experience and knowledge. The mentorship programme needs to focus beyond clinical management of HIV. The spectrum of HIV related care is much broader and the patient load in some of these centers is very high (the doctors are treating around 12,750 13,000 HIV/AIDS patients at three sites, more than 4,300 of whom are on ART, including 100 on 2 nd line drugs). Counselling, stigmatization, and behavioral changes are some of the issues that need to be addressed. The mentorship programme is too focused on clinical care and management of HIV/AIDS. It should include counselling, nutrition and home based care. Some doctors felt that the mentors quarterly visits were not enough, especially if they delayed/missed a visit. A more flexible itinerary may be more effective. Most doctors felt that it would be a good idea to institutionalize the mentorship programme. Mentorship outcomes and findings Mentorship s Positive Impact on Care as per Mentor soobservations Comprehensive medical assessment Improved safer sex education and family counselling Privacy during medical examination and counselling Diagnosis and treatment of complex medical conditions including crypotococcal meningitis, TB meningitis, TB pleural effusion, AZT-induced chronic diarrhoea and ascites among others Timely initiation of ART for TB co-infected patients Use of correct dosages of ART for children Diagnosis and treatment of co-morbidities such as diabetes, hypercholesterolemia, and liver disease Accurate identification and treatment of failure cases Referral to appropriate medical services which are available onsite Frequent referencing to national guidelines and protocols Quality of care documentation Reduction of overcrowding at the clinics by shifting certain tasks to nurse managers Diagnosis of various medical conditions through use of medical equipment that was previously not available onsite In the course of a focus group discussion with ART team other than doctors, to share and analyze outcomes of the mentorship programme, points discussed included: Paramedical staff (excluding the Project Coordinator) knew about the mentor s visits. There is not enough space and time to control the high patient turn over. Given the opportunity, they would like to spend more time on counselling. Improvement in infrastructure, like provision of generators, would facilitate the free flow of services, especially in the labs. To help practice universal precautions, coats, shoes, and gloves have been provided and are available. Feedback from Different Stakeholders: The clinical mentorship programme has been received favourably in all the centers and feedback reflects this. Its reach has, in some cases, extended to persons not directly participating in the programme. For example, at one ART centre, staff who had not interacted directly with the mentor was familiar with his work in the hospital. Direct feedback obtained from the different groups reflects a generally favorable reaction to the mentorship programme. 22 HIV Clinical Mentorship - In a public health context

29 Mentors Mentees Paramedical Patients From the implementation point of view, the following challenges need to be addressed: To plan and execute the mentorship as per the plan Retain the same medical officers at the ART centers Advocate for more, but appropriate, lab tests and drugs at the ART centers Advocate for more collaboration between hospital departments The clinical mentorship programme is very useful for doctors, especially in centers with only one doctor, who would otherwise not have the chance to discuss patients with colleagues Helpful for those recently graduated from medical schools Need for an intensive training on 2 nd line ART and annual refresher/orientation programmes Pre-ART care is also an essential feature of the programme Rapid patient turnover presents many challenges. Space is inadequate and limited staff capacity does not allow for patients to receive the desired care and attention. For example, counsellors are forced to keep counselling sessions to 5 10 minutes because the patients who are waiting become impatient. Given that these sessions usually address health and hygiene, micro/macro nutrition, and other positive living topics, more time is required to discuss these essential matters. Doctors are also not able to spend enough time with patients due to the need for fast patient turnover. Overall, quality of treatment is good. Waiting hours are too long because of high client load. Long waiting times interrupt family obligations such as children s attendance at school. Few patients prefer counsellors to make home visits Would like to see more services and education on wound care and treatment. In comparison to other centers (those not under TNFCC), the process moves faster. Care and support facilities are provided efficiently and a month s supply of OI drugs is available. In addition, concerned hospital staff provides patients with information and answers their questions in detail. For these reasons, patients don t mind spending the whole day at the hospital. HIV Clinical Mentorship - In a public health context 23

30 Annexure - I I-TECH Clinical Mentors Training Curriculum Reference: To equip the mentors with mentoring skills the threeday training focuses on: Relationship Building A trusting, two-way relationship between the mentor and mentee is the foundation of effective mentoring practice. This section includes suggestions on how to initiate and build a strong relationship of mutual respect between the mentor and the mentee, and how to provide constructive feedback and encouragement within the mentoring relationship. Strategies for Mentoring Mentors work in a variety of settings in which they face a wide range of constraints and challenges. Developing strategies and approaches to effectively carry out mentoring activities within different settings presents a unique set of challenges. The documents in this section provide mentors with suggestions and ideas on various approaches to mentoring, including how to conduct bedside teaching, conduct site visits, mentoring in the face of heavy patient loads, and strategies for addressing a wide range of systems issues. Monitoring and Evaluation Tools This section includes tools and resources for a mentor to use to assess the skills of providers and to assess facility issues. Observation checklists in this section help the mentor to track providers improvement in their delivery of clinical care over time. Facility checklists enable monitoring of systems improvements at a site. The tools included have been developed by I-TECH projects around the world, and can be adapted to fit a mentor s particular situation and area of focus. Training Health Care Workers The ultimate goal of a clinical mentoring programme is to build the skills of local clinicians. Clinical mentors may provide one-on-one mentoring to a health care provider during a patient consultation, conduct standalone sessions for clinical staff on various clinical topics, lead discussions highlighting the management of complex cases, and accompany staff on rounds. This section includes resources for mentors on how to use case studies and clinical vignettes to guide the training of health care workers. I-TECH Curricula This section contains I-TECH training curricula on a variety of topics related to HIV and AIDS that can be used by a clinical mentor to conduct more formal, classroom-based training of health care workers. Each curriculum includes sets of PowerPoint slides, facilitator guides, and participant handbooks. Clinical mentors are free to adapt and change these materials as needed. This section includes twelve complete curricula (multiday trainings with several slide sets) and four workshops (shorter sessions appropriate for an hour or two of training on a focused topic). All of the curricula included here have been pilot tested by I-TECH country programmes. 24 HIV Clinical Mentorship - In a public health context

31 Annexure - II Tool for mentoship assessment Clinical Mentorship - Assessment Questionnaire Date: Site: Site Reviewer: I. STAFFING What types and numbers of providers do you have at this clinic? Physician Nurse case manager Lab technician Nurse aid/assistant Pharmacist Nutritionist Number Number Councelor Project coordinator Data entry operator Sanitary worker Pharmacist Other (specify) 1. How would you describe your overall staffing level? Very well staffed Adequately staffed Understaffed 2. How much staff turnover do you experience? High turnover Moderate turnover Low turnover Where among your staff is the greatest turnover? Comments: HIV Clinical Mentorship - In a public health context 25

32 II. SPACE AND EQUIPMENT How many consulting or counseling rooms are present in the centre? 1. Injection material: Facilities and supplies (Tick all that apply) 4. Record keeping: 1.1 Multiple use needles provided 1.2 Single use disposable needles provided If YES 4.1 Record HIV-related illnesses in register 4.2 Patient medical records kept by patient 4.3 Paper patient medical records kept on-site 4.4 Electronic medical records Needles recapped before disposal Needles recapped one handed Needles deposited directly Needle cutter used Sharps containers available 5. Availability of written material/posters on HIV/ AIDS/STDs to educate patients: Yes No 2. Methods for disinfecting reusable medical equipment: 2.1 Autoclave 2.2 Steam sterilization 2.3 Boiling and chemicals 2.4 Chemicals only 2.5 Boiling only 2.6 Other 6. Material/internet access for doctors on: 6.1 NACO ART adult guidelines 6.2 Paediatric guidelines 6.3 OI guidelines 6.4 PEP 6.5 PPTCT guidelines 6.6 Second line drugs 6.7 Others 2.7 Use disposables only 3. Disposal of contaminated items: 3.1 Burned in incinerator 3.2 Burned in open pit 3.3 Burned and buried 3.4 Thrown in trash/open pit 3.5 Thrown in pit latrines 3.6 Removed off site 3.7 Other 26 HIV Clinical Mentorship - In a public health context

33 Category Capability Currently functioning Last used / available Reasons for not using/non availability on day of visit Final code (Yes/No) (Yes/No) (Date) (*see codes below) (To be coded later) Electricity Running water Communication facilities (phone, fax, internet access) Private room for confidential consults Seating for patients while waiting Disp. gloves Disp. masks Stethoscope Disinfectants Appropriate examining table Adequate lighting BP cuff Reflex hammer Speculum Microscopy *Codes: 1. Equipment failure 2. Lack of or inadequate supplies 3. Absence or non-availability 4. No request made of trained staff 5. Other (specify) Do you also have the following available for use in the clinic? 1. Weighing scale (tick) Yes No Maybe 2. Furniture (tick) Yes No Maybe 3. Lockable filing cabinet (tick) Yes No Maybe 4. Thermometer (tick) Yes No Maybe 5. Waiting benches (tick) Yes No Maybe 6. Computer (tick) Yes No Maybe Comments: HIV Clinical Mentorship - In a public health context 27

34 III. PATIENT DEMOGRAPHICS Number of HIV/AIDS patients seen/day in OPD: Number of patients on ART: 1. What percentage of your HIV+ patients also consults a traditional and/or alternative healer? 2. What are the general characteristics of your patient/client population? Race Ethnicity Gender Age Health priorities Sexual orientation Other What have you observed among your patients/ clients as the most common mode(s) of HIV transmission? % Don t know Providers don t ask IV. CLINIC SERVICES 1. What types of services do you have at your clinic site and hospital setting? Mental Health Care Alcohol/Substance Abuse Treatment Pharmacy Services Family Planning Services Dental Care Patient Education HIV/STD/Hepatitis B& C Screening HIV/AIDS Care and Treatment reatment Pharmacy Services Family Planning Services Dental Care Patient Education HIV/STD/Hepatitis B& C Screening 2. Does the clinic perform blood draws? Yes 3. Does your lab have the capacity to keep blood specimens frozen at o C below HIV/AIDS Care No Yes No 4. Where do you send blood specimen to run the following tests? 28 HIV Clinical Mentorship - In a public health context

35 Viral load testing Resistance assays CD4 counts Hepatitis screening 5. Which of the following immunizations do you provide? 6. What barriers do you experience in providing care to HIV-infected patients/clients? Influenza Pneumococcus Hepatitis A and B Limited resources Inadequate reimbursement Inadequate access to HIV medications Lack of provider expertise Lack of provider interest Patients/clients not aware of services Issues of confidentiality Issues of cultural competency Other (specify) V. PRACTICE SET-UP 1. Physical space to accommodate and patient privacy (tick one): Inadequate, major barrier Minimal 3. Adequate 2. Does triage promote efficiency and patient safety? None, totally ad hoc Some effort at triage (no guidelines in place) Triage occurs (guidelines in place) 4. Efficient triage system practiced 3. Communication among HIV/ART team None Minimal discussion among some team members Some regular discussion of information shared by team members Regular information sharing about most key things occur 5. Highly functioning team communication practiced regularly 4. Patient flow between members of the team is effective and efficient: Patients movement among providers is inefficient Patient spends time with different team members makes some sense Patients receive maximum benefit from moving among providers HIV Clinical Mentorship - In a public health context 29

36 Is patient education incorporated into patient care? Physician Nurse Councellor Nutriotionist No Yes No Yes No Yes No Yes General Health Adherence Risk reduction Is continuum of care routinely practiced? No Rarely Sometimes Routinely OI prophylaxis OI treatment TB treated/monitored STIs treated Pain reduction methods offered Is continuum of care routinely practiced? Data capturing forms/registers Case sheets - initial (Yes/No) Report forms (Yes/No) Clinical document forms Pain reduction methods offered Yes No Yes No Patient connection with community Yes No Comments Adherence CD4 Viral load Patient functioning (QOL) Decrease in patient suffering Weight gain OI prophylaxis given To the best of your knowledge, how often do patients follow through on care and/or service referrals? Always Almost always Sometimes Never What is the most common reason patients cite for lack of follow through on referrals? 30 HIV Clinical Mentorship - In a public health context

37 Medical Care Yes Who provides this service? No Where are people referred for medical care? Pharmacy services Yes Who provides this service? No Under what circumstances--and to whom--do you refer HIV+ patients? Where are people referred for medical care? VI. SAFETY & HYGIENE Universal precautions practiced Data capturing forms/registers Case sheets - initial (Yes/No) Report forms (Yes/No) Clinical document forms Pain reduction methods offered Yes No Yes No Hand hygiene Available Reported Not Available Notes available, not seen Sink or basin with running water Bucket of water with cup next to sink or basin Antibacterial soap is available in ward/on site Alcohol-based solution for hand washing available Dry Soap in dish near sink/basin Comments: HIV Clinical Mentorship - In a public health context 31

38 Aseptic technique Equipment/ Available Reported available, Not Available Notes Supply not seen Supply of sterile tubes for ICD procedure available Alcohol rub (i.e. antiseptics) available for sterilization of patient Disposable sterile syringes available Other sterile equipment (please specify) Number of intravenous lines inserted using aseptic technique: Doctors: Nurses: Nursing Assistants: Sanitary Workers: Other (please specify): No procedure observed Number of sterile syringes used during a procedure: No procedure observed Patient placement related to UP Methods Observed Reported available, Not Available Notes MDRTB+ patients placed separately from HIV+ patients TB- patients separated from TB+ Comments not seen Immunization and exposure management Methods Observed Reported done, not seen MDRTB+ patients placed separately from HIV+ patients Health care staff used needle destroyer immediately after use (i.e. did not recap needle) Comments No procedure conducted/observed with needle Notes Number of doctors reporting completing Hepatitis B vaccine course: Doctors: 32 HIV Clinical Mentorship - In a public health context

39 VII. LABORATORY Can your laboratory perform the following tests? Lab tests recommended by NACO Haemogram: Hb% TC DC ESR Platelet count TLC Yes No Maybe Remarks Urine tests: Sugar Albumin Deposits Other tests Liver function tests: S.Bilirubin SGOT SGPT SAP Total protein Albumin Renal function tests: Blood urea Sputum for AFB Mantoux test Chest X ray Blood sugar Blood VDRL TPHA HBsAg Anti-HCV CD4 count/cd4% CD8 count, ratio Viral load HIV Clinical Mentorship - In a public health context 33

40 S.Amylase S.Lipase Culture Sputum Urine Blood CSF Stool Fluid analysis CSF, pleural, peritoneal etc. CSF India ink S.Cholesterol profile S.Total cholesterol Triglycerides LDL,VLDL HDL S.Lactate LDH Stool examination Motion ova, cyst Stool for AFB Toxoplasma serology Stains Leishmans Methenamine silver ZN Gram Giemsa Modified acid fast FNAC USG scan CT scan MRI scan 34 HIV Clinical Mentorship - In a public health context

41 VIII. PHARMACY Category Currently available/ not available (A/NA) Last used/ available (if currently not available) Whether available in the OP or hospital Reasons for not using/non availability on day of visit Antibiotics Ciprofloxacin Norfloxacin Co-trimoxazole Erythromycin Doxycycline Azithromycin Amoxicillin Naladixic acid Clarithromycin Spectinomycin Aqueous Penicillin (Inj) Clindamycin 300 mg Sulphadiazine 500 mg Levofloxacin Antifungals Fluconazole.T Fluconazole. Inj Nystatin Ketoconazole Amphotericin B Itraconazole 5-Flucytosine Clotrimazole topical Antivirals: Acyclovir.T Acyclovir.Inj Gancyclovir Antiamoebics: Metronidazole Antihelminths: Albendazole Mebendazole Nitazoxanide Antidiarrheals: ORS Loperamide HIV Clinical Mentorship - In a public health context 35

42 Antiemetics: Metoclopramide Domperidone Dermatological preparations: Gentian violet Whitefield ointment Topical antifungals Liquid paraffin Other drugs: Nitrofurantoin Dapsone T. Sulfadiazine Pyrimethamine Folinic acid Paracetamol Aspirin Ibuprofen Codeine Chlorpheniramine Dexamethasone Hydrocortisone Amitriptyline Carbamazepine ATT Isoniazid Rifampin Ethambutol Pyrazinamide Streptomycin Others - specify 36 HIV Clinical Mentorship - In a public health context

43 IX. Physician assessment: QUALITY CARE ASSESSMENT PATIENT CHARACTERISTICS 1. Sex (male=1; female=2) 2. Type of visit (initial=1; follow-up=2) 2. A. If follow-up visit date of previous visit to facility ) 3. HIV status (positive=1; negative=2; unknown=3) [Note to interviewer Q2 and Q3 can be filled in after the observation] Known HIV-positive person 1. Chief complaints (check all that apply) Skin lesions Difficulty breathing Cough Weight loss Fever Oral ulcers Persistent diarrhea Mental status change PID Genital discharge Genital ulcer Lower abdominal pain Abnormal test Pregnancy Other (specify) Night sweats Difficulty swallowing Fatigue 2. Symptoms (check all that apply) 2.1 Determined if they were recurrent 2.2 Asked about duration 3. Risk factors (for new cases)(check all that apply) 3.1 Asked patient s occupation 3.2 Asked about unprotected sex 3.3 Asked about IV drug abuse 3.4 Asked about sex with men (men only) 3.5 Asked about previous STIs 3.6 Asked about alcohol use 3.7 Asked about spouse/family symptoms 3.8 Asked about spouse/family risk behavior 3.9 Asked if previously tested for HIV 2.3 Asked about severity 2.4 Probed further about other symptoms 4. Physical exam (check all that apply) 4.1 Vitals measured or reviewed 4.2 Weighed or reviewed patient wt. 4.3 Visually inspected eyes 4.4 Visually inspected mouth 4.5 Visually inspected skin 4.6 Listened to chest 4.7 Palpated abdomen 4.8 Referred-gynec/STD exam 4.9 Pelvic examination 4.10 Speculum examination 4.11 External genital examination 4.12 No exam performed HIV Clinical Mentorship - In a public health context 37

44 5. Diagnostic tests available to physician for review 5.1 Chest x-ray 5.2 Culture results (bacterial/viral infections) 5.3 AFB smear (TB test) 5.4 VDRL/RPR results 5.5 Pregnancy test result 5.6 HIV test results 5.7 CD4 count 5.8 Viral load 5.9 Other 5.10 None 6. Diagnostic tests ordered 6.1 Chest x-ray 6.2 Culture (bacterial/viral infections) 6.3 AFB smear (TB test) 6.4 VDRL/RPR 6.5. Haemogram 6.6 CD4 count 6.7 LFT 6.8 RFT 6.9 Others 6.9 None 7. Presumptive diagnosis (check all that apply) Skin infection Malaria Diarrhoeal illness Cold/flu Oral candida TB Herpes zoster PID Cryptococcal meningitis Syphilis Pneumonia (non-specific) Gonorrhea Pneumonia (PCP) Chlamydia Herpes simplex virus Depression AIDS stage Other No presumptive diagnosis made Don t know 8. Treatment prescribed 8.1 Yes 8.2 No 8.3 Don t know 9. Conditions of consultation 9.1 Private consultation with doctor 9.2 Hands washed/gloves changed 9.3 Time spent with patient mins 10. Partner notification 11.1 Partner notification recommended 11.2 Partner notification not discussed 11. Staging Stage I Stage II Stage III Stage IV Patient not staged 38 HIV Clinical Mentorship - In a public health context

45 12. Patient is on ART Yes 12.2 No 12.1 For patients on ART (regimen) 13. Patient referred to a support group/+ Persons network? 13.1 Yes 13.2 No Already involved with group Asked about adherence Asked about side-effects Ordered ART follow-up labs ART adherence counselling 12. Patients not on ART ART not discussed OI prophylaxis prescribed OI drugs adherence counseling provided OI drug side effects discussed 14. Counseling 14.1 Provided counseling-living w/hiv 14.2 Referred to counseling [family/vct] 14.3 Provided counseling on safe sex 14.4 Provided counseling on nutrition 14.5 None mentioned Comments: Patient medical history Component (Did physician obtain the following information?) When/how was DX of HIV first established Current symptoms and concerns of patient Past illnesses and treatment given Symptoms of TB and/ or treatment for TB Past or present symptoms of STI Possibility of Pregnancy Immunizations Social habits & sexual history Check those observed Where not observed, provide explanation where possible HIV Clinical Mentorship - In a public health context 39

46 Patient exam Component Check those observed Comments Weight Temperature Oropharyngeal mucosa Lymph nodes Chest (incl. x-ray) Cardiovascular system Abdomen Genitourinary system Skin CNS Accuracy of diagnosis WHO staging OI Temperature Comments on those that apply Appropriateness of labs ordered What lab tests were ordered? What lab tests were not ordered (although available) that should have been? Comments on those that apply Accuracy of treatment ARV Rx OI Rx Other Follow up recommended Comments on those that apply Accuracy of treatment ARV Rx OI Rx Other Follow up recommended Comments on those that apply General Observations Were universal precautions respected? Basic privacy/confidentiality practices followed? Is a team approach being used to treat and monitor patient progress? 40 HIV Clinical Mentorship - In a public health context

47 Demonstrated knowledge/skills ART doctor conducts focused, thorough discussion with patient of pertinent omissions or errors Doctor emphasizes team approach (shares information with nurse, efficient interaction, lack of duplication of effort) Doctor underscores need for adequate physical exam (in relation to history and current complaint) Doctor comments on accuracy of assessment and diagnoses (including WHO staging) of patient ART adherence, tolerance, side-effects addressed Appropriateness of recommended drug treatment (ART & OI) Appropriate involvement of patient in development of a focused management plan Appropriateness of recommended labs Patient education on sexual and other risk behaviors (including secondary infection) Emotional/social support needs/possibilities discussed Develops appropriate follow-up schedule Introduced self and objective appropriately (name, where from, credentials, what this is all about ) Negotiated interaction in the presence of the patient Doctor made the patient comfortable (no tension, preceptee not defensive) Listens and observes patiently (avoids unnecessary interruptions) Comments Recommendations to improve this doctor s skills to mentor independently Examples of information shared that might improve this doctor s skills to mentor independently HIV Clinical Mentorship - In a public health context 41

48 Clinical Mentor Scale for individual doctor Puts patient at ease and makes patient comfortable Respects patient Assesses complaints/symptoms/risk factors Reviews necessary medical history Ensures that vital signs are taken Complete physical exam completed Orders appropriate lab tests Provides correct/appropriate diagnosis Appropriate follow-up for ART (appropriateness of prescription, description of side effects, importance of adherence stressed) Safe sex education Provides patient education as needed Appropriate referrals were made Develops follow-up schedule Involves patient in decision-making and medical care Team approach was used Privacy and confidentiality measures were followed Universal precautions were taken 42 HIV Clinical Mentorship - In a public health context

49 Annexure - III Sample Mentorship Report First Visit Recommendations based on the initial assessment Second Onsite mentorship visit-october 2007 Third visit - February 2008 Fourth Visit -April 2008 "1. Needs to be provided with an examination table and a private room for thorough physical examination including examination of abdomen and sensitive parts." Both the doctors are examining patients in 2 separate rooms, thereby privacy is ensured. The examination table will be provided soon. Now there are 3 doctors and one senior doctor is having a separate room and other 2 doctors are examining patients in the other room. But the privacy is taken care of. The exmination table is available and being put to use. "Same practice is being followed. If there is one more room for third medical officer, privacy for patients may be appropriate." "2. Needs more medical personnel to take thorough history especially sensitive and sexual histories counselling regarding safe sex, family counselling etc." Note: Counsellors provide safe sex counselling Medical officers need to complement the counselling done by counsellors by providing safe sex and family counselling.this was also highlighted during the discussions "Now there is one more new Medical Officer. The presence of an additional doctor has really improved the time spent in case management. All three doctors also participated in the 'basics of counselling' training. All the doctors are observed providing safe sex counselling and family counselling for appropriate cases." Same practice is being followed. HIV Clinical Mentorship - In a public health context 43

50 "3. Doctor needs training on second line drugs and ongoing updates in managing HIV patients with CNS manifestations. ( Training on the topic is given during the afternoon hours)" "It was noticed that the Medical officers' knowledge and skills in managing patients with first line treatment failure has increased. They were able to prescribe appropriate second line drugs, identify toxicities correctly and also maintain appropriate case records for second line patients. There were lot of discussions related to CNS opportunistic infections during the mentorship B1" "It was observed that during the interval between second and third visits, the senior ART medical officer (SMO) was able to identify treatment failure cases and also made correct interpretations using the checklists and Stanford website on genotypic resistance testing analysis. C3The second doctor was also found to identify treatment failure cases but her involvement in the interpretation on second line options, was not observed by the mentor. Discussions on CNS opportunistic infections happened during the mentorship and it was observed that the CNS OI cases were managed appropriately. (One case of Toxoplasmosis was presented to the mentor at the time of mentorship which demonstrated their skills in correct diagnosis and management of the case)+c1" "There was a third Medical Officer now and this has improved not only the patient care but also the counselling aspect. The third Medical officer though not attended NACO training, was able to manage cases through support from other 2 Medical Officers. The nurse case manager still assist in providing care. " "The knowledge and skill of senior ART Medical Officer (SMO) on managing treatment failure cases and providing second line drugs has improved. If further training on second line drugs is given to him, he will become an asset to the ART centre. The other two doctors need to learn from senior medical officer about treatment failure and initiation of second line patients. OIs involving CNS were discussed and the doctors knowledge seem to have improved compared to the last visit.d8" 4. The two medical officers are examining around 200 patients a day. The SMO is also involved in administrative help to other staff of ART centre and coordination with hospital departments and management. Both of them are taking care of 21 inpatients also. If support is provided in this regard, his skills in ART care and support will improve. The Nurse case man+b3ager (supportive role) was involved in active patient care along with the Medical Officers. It was noticed that the Nurse case manager, under the supervision of ART Medical Officer was able to manage this task reasonably well. Because of her involvement the doctors were able to spend more time with difficult cases. The supervision shall continue until the Nurse is adequately trained. The three Medical Officers work in unison so that the care and support activities are appropriate. It was observed that one doctor is taking care of inpatients and other 2 doctors are taking care of OP patients. All the 3 doctors discuss the problem cases among themselves and arrive at a consensus of opinion regarding the management. 5. Both the doctors can communicate with mentors and other experts in the field to improve their knowledge. Both the doctors used to communicate with mentor regularly Both the doctors used to communicate with mentor regularly All the 3 doctors communicate with the mentor regularly. 44 HIV Clinical Mentorship - In a public health context

51 6. Frequent references to NACO guidelines, keep the guidelines handy "The NACO guidelines were seen on the doctors' table and it was referred to whenever necessary The WHO clinical staging posters ( adults and children) and the ART dosage charts for adults and children were provided for their reference during this mentorship" Now the doctors were able to manage cases appropriately without looking into the guidelines which showed their understanding of the guideline components. Doctors were able to manage the cases appropriately. They were referring to the guidelines whenever necessary.. During the mentorship they were observed looking at the growth chart in the Paediatric guidelines for managing a child with growth retardation. 7. I-TECH handbook reference 8. Need based calls and mails to I-TECH 9. Tongue depressor, knee hammer, tuning fork, X-Ray lobby to be provided for better clinical examination. 10. Doctor shall start referring for special tests like HBsAg and HCV To initiate with few patients and then increase to more numbers. "The I-TECH Handbook seen on the doctors' table and it was referred to whenever necessary. The doctors were using a small handbook on ART and other drug interactions also. If they are provided with the small pocketbook on all drug interactions related to HIV, it will be very useful. Several other materials, study articles of relevance are given to the doctors by mail and hard copies during the visit e.g.. ART drug interactions, drug dosing in various medical conditions, second line paediatric dosage etc." During the period between first and second onsite mentorship, TA was provided in managing 5 difficult cases and brief follow-up calls were made They are referring for appropriate case management whenever necessary (during the mentorship, the doctors were observed referring a case of chronic myeloid leukemia and another case of lymphoma to the appropriate higher centres for further treatment) During the period between second and third onsite mentorship, TA was provided in managing 6 difficult cases and follow-up calls and discussions were made Frequent references were made During the period between third and fourth onsite mentorship, TA was provided in managing 3 difficult cases and follow-up calls and discussions were made To be provided To be provided Orders had been placed for X-Ray lobby and by the end of mentorship, the X-ray lobby was purchased and doctors started using them. The other logistics were made available. Steps taken for the purchase of kits by the Microbiology department/discuss with the blood bank To discuss with the implementers for necessary steps and check with the follow-up steps. Appropriate advocacy measures have to be taken by the authorities for the provision of these facilities HIV Clinical Mentorship - In a public health context 45

52 11. Patient flow needs to be studied and streamlined to avoid overcrowding in front of doctors room. Because of the usage of separate rooms for each doctor and also because of the assistance provided by Nurse case manager, the patient flow was smooth. Patient flow is smooth Though the patient flow is smooth the available space was not sufficient during morning hours especially between 9.30 to The ART centre was overcrowded. More space is needed for the appropriate service providers and patients. "The co-morbid conditions were discussed during mentorship. The Medical Officers were also looking for general medical conditions like Diabetes Mellitus, Congestive cardiac failure,anaemia and others. The Medical Officers made appropriate referrals to the following departments: Internal Medicine, Neurology, Thoracic Medicine, General Surgery, Ophthalmology, Paediatrics, Clinical Pathology, Microbiology, Biochemistry, STD. A post graduate student of Medicine dept was also posted in the ART centre for one week." The training was completed. Subsequent to that, the academic materials related to behaviour change and counselling were provided to the Medical Officers for further reading. They can discuss with the counselling mentor for coordination and clarifications. The death auditing was discussed in the monthly ART centre review meeting. They also conduct periodic death reviews during their internal staff meetings. Unable to do it regularly due to time constraints. 12. During the feedback session on the second day, the doctors mentioned more training related to Non-HIV comorbid conditions. Discussed during mentorship and it will be covered during future case discussions and conference call once in 15 days It was observed that the team manages the comorbid medical conditions appropriately but they need still more training on managing the comorbid conditions. They were able to diagnose the co-morbid conditions but need support in the management. Appropriate referrals were made. (a case of cirrhosis liver with portal hypertension on ART was diagnosed and managed appropriately) 13. The doctors wanted more training on behavior change communication. Will be covered with technical update for counsellors Both the senior doctors were trained and the effect of the training was felt during the mentorship.** "Other recommendations: 1. Documentation - Death and second line cases" The doctors shall document the death regularly for all reported deaths as per the previous recommendations and also fill the case sheets for all old second line initiated cases so that the case record shall have all information for tracking. The case records were complete as far as the death records are concerned. (Screened 40 case records during the mentorship.) The doctors were requested to analyse the baseline characteristics of mortality and they were also requested to discuss these cases in the weekly review meetings. 46 HIV Clinical Mentorship - In a public health context

53 2. Initiation of second line cases 3. During the weekly team meetings important case studies may be discussed As per the previous It is being followed recommendations, all new second line cases before initiation shall be documented in the second line/treatment failure case sheet like before and send to mentor, TANSACS and TA for mentor's opinion, program and budget related process documentation. 3. During the weekly team meetings important case studies may be discussed including death auditing. New Recommendations To maintain the growth chart of children upto 12 years To develop a checklist for the follow-up of second line patients To develop case studies for e-meetings and tele conferencing. The documentation of new cases started on second line drugs were complete but the old cases with second line drugs need to be completed. Important case studies were being discussed in their weekly staff meetings including poor adherence, treatment preparedness and others. The growth charts for children upto 18 years were provided to the Medical Officers for documentation Checklist given to the doctors on second line lab tests "A case of toxoplasmosis was discussed with the e-group and the same was discussed at the ART MO meeting. The 3 Medical Officers have provided appropriate answers for the questions (quiz) posted at the e-group." HIV Clinical Mentorship - In a public health context 47

54 Annexure - IV Case Sheet Documentation for treatment failure Note: This case sheet is being designed for documenting the patient details before initiating first line alternate regimen and second line regimen. Name of the patient: Age: Sex: District: Name of the TNFCC -ART centre: Referred by: NGO follow-up: Pre-ART No.: ART No: 1. Date of HIV diagnosis: 2. Reason for diagnosis: 3. Stage at diagnosis: 4. Date of ART initiation: 5. Criteria for ART initiation: a. Clinical stage IV b. CD4 < 200 c. CD4<350 and stage III 6. Date of registration at TNFCC-ART Centre: 7. When developed failure? - Is it clinical, immunological or virological failure? T staging 8. Resistance testing done yes or no? 48 HIV Clinical Mentorship - In a public health context

55 9. ART treatment details: S.No Period* Regimen with duration ( months) Place of treatment CD4 count/% with date Viral load with date Cause for change in regimen** Adh % T Stage Wt Ht (in children) OIs Drug side effects Imp. lab values Remarks*** * - If date not available, please mention month and year or year only. **- ARV drug side effects/toxicity / substitution / stopped Rx / treatment failure - immunological/clinical/virological failure etc. *** -Remarks - please mention reasons for poor adherence, drug/rx stopped, any medical and social factors which are appropriate. Please go through private doctor s prescriptions (if patient is taking ART with private doctor) for adherence and regimen type (mono/dual/triple drug and name of drugs) HIV Clinical Mentorship - In a public health context 49

56 10. If done, resistance testing reports (provided resistance testing is done when the patient is on ART drugs) 11. Analysis of resistance testing and interpretation of resistance test report: 12. Appropriate second line drug regimen: 13. Appropriate lab tests done before second line ART initiation Yes/No If yes, please mention the lab values. 50 HIV Clinical Mentorship - In a public health context

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