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Resources Outreach Toolkit

Purpose of the Toolkit

In September 2008, BIPAI published a toolkit entitled "Implementing Care and Treatment for Children with HIV/AIDS in Resource-Limited Settings." In keeping with the urgent need to expand care and treatment for children with HIV/AIDS highlighted in the recent UNICEF report "Children and AIDS, Second Stocktaking report." 

The purpose of that toolkit was to provide a practical step-by-step guide for any group in how to plan, implement, monitor, evaluate and revise programs specifically addressing the needs of children and their families, infected and affected by HIV/AIDS and living in resource-limited settings. Included in the toolkit there was guidance on how to decentralize such efforts to outreach or rural areas of resource-limited countries. BIPAI now presents an additional "Outreach Toolkit" providing a number of tools to assist decentralization of HIV/AIDS services. In many resource-limited countries, particularly in Africa, there is a serious shortage of manpower, most notably of physicians or at least of physicians trained and experienced in the care and treatment of children with HIV/AIDS. Therefore, the toolkit also concentrates on methods to train and mentor health care professionals at outreach or primary health care sites.

Decentralization of services is usually necessary for scale up of HIV/AIDS services and BIPAI recommends that it be introduced in a gradual manner. Essentially, it is an orderly process of transferring select tasks that are delivered initially at the district hospital to the primary health centers. Services provided at the primary health center may be less comprehensive or specialized than those at the district hospital. This depends on the resources and personnel available at the primary health center and health authorities' willingness to decentralize and permit less expert personnel to care for HIV/AIDS patients.

BIPAI is currently developing extensive outreach programs in all the countries in which COEs have been established. The strategy includes both BIPAI operated satellite sites and outreach to government run primary health centers. The satellite sites will provide the same service as that at the central COE. BIPAI personnel are providing training and mentoring at the primary health centers until such time as the local staff is fully capacitated to care and treat children without outside assistance. In addition, BIPAI is providing support at existing primary health centers to allow them to treat and care for children themselves. This support takes the form primarily of training, mentoring and capacity building. Please contact BIPAI if you require advice or technical assistance in this regard. The Field Story below illustrates one of the BIPAI outreach programs.

The toolkit contained in this document consists of a series of tools developed by BIPAI personnel who have had direct experience in the implementation of outreach programs to primary health care centers of programs for the care and treatment of children with HIV/AIDS, including the provision of antiretroviral therapy. It also includes many useful tools to assist in mentoring of local health care professionals who may not have had much experience of treating children.

The toolkit is arranged in the following three sections:

  • Site assessment: The first step in pediatric HIV/AIDS care and treatment outreach is conducting a site assessment to determine the pre-existing resources and gaps.
  • Clinical mentorship: Training and mentoring of local professionals is required at primary health centres until such time as the local staff is fully capacitated to care and treat children without outside assistance.
  • Monitoring and evaluation: Monitoring and evaluation of outreach activities is critical to understanding whether outreach has been successful, and when it is appropriate to withdraw from a full functional outreach site.

The MPHATSO pilot mentorship program began in 2009 in partnership with the Ministry of Health and Clinton Foundation. MPHATSO means "gift" in Chichewa, highlighting our mission to help Malawi's HIV-positive children realize their fullest potential for a healthy generation to come. As of December 2008, there were over 17,800 children on life-saving antiretroviral (ARV) therapy in Malawi. (Malawi HIV Unit) However, the average age of treatment initiation remains high, indicating that much work lies ahead in order to save the many children who suffer early and rapidly progressing HIV/AIDS.

Missed opportunities for starting children on ARV therapy often occur due to low healthcare provider comfort in the relatively more complex methods of pediatric HIV diagnosis, care and treatment as compared to adults. MPHATSO creates two multi-disciplinary pediatric HIV mentorship teams consisting of the following staff:

  • Clinical officer
  • Nurse
  • HIV testing counselor
  • Health surveillance assistant
  • Data clerk
  • Pediatric AIDS Corps pediatrician

Teams will visit each clinic twice monthly, focusing on antiretroviral clinic and mother-infant follow-up clinic for HIV-infected mothers. A peer-to-peer mentorship approach is used to encourage open communication that may be limited within the context of medical staff hierarchy. Though more frequent visits may hold greater impact, the need for a sustainable and feasible approach for integration within the Ministry of Health support framework is essential. Following World Health Organization recommendations, we aim to incorporate mentorship as a distinct capacity building approach apart from regulatory site supervision visits.

The MPHATSO mentorship philosophy is based on the following principles:

  • Partnership. Above all we move forward in a spirit of partnership with the Ministry of Health. We aim to find mentorship solutions that are integrated within the national HIV/AIDS treatment framework.
  • Respect. Local healthcare providers know their community and patients best. Their input and guidance are highly valued.
  • Empowerment. We aim to mentor the skills and resources needed for quality pediatric HIV care at the local level. We are not a long-term staffing addition and expect local staff to remain dedicated to providing HIV services.
  • Celebrating Success. Families who leave illness behind and discover a hopeful future inspire us. We celebrate the smiles of children who can play again. We will use our successes to move us through difficult times.

MPHATSO mentors receive comprehensive training on pediatric HIV management and four target areas for site mentorship: Registration, Nutrition Assessment, Clinical Management and ARV Adherence.

Each of these domains contain a set of activities which represent a checklist of quality pediatric HIV care:

  • There is a specific clinical home for HIV-exposed and infected children
  • Exposed and infected children are identified throughout the health facility (Ward, Under-5, etc.) and referred for care
  • Pediatric HIV testing is offered to children, including those less than 18mo of age
  • Routine follow-up care is provided for all HIV-exposed or infected children whether or not they are taking ARV medications
  • Height, weight and MUAC are obtained for children at each visit
  • Nutrition status is assessed and documented
  • Clinical assessment is made
  • Cotrimoxazole preventative therapy (CPT) is provided
  • Opportunistic infections are recognized and treated
  • Children are initiated on ARVs based on current national guidelines
  • Precise number of ARV pills dispensed is recorded and interpreted for an adherence assessment
  • Disclosure counseling is provided as age-appropriate
  • Care is clearly documented in the health passport

Through on-site mentorship we aim to achieve increased access to pediatric HIV care with achievement of core quality services. Improving facility linkages between entry points of care is an essential step. Local health facilities are challenged by healthcare worker shortages, staff movement and limited supplies, requiring a focus on sustainable and grassroots solutions. MPHATSO utilizes a mentorship toolkit to achieve the goals above while implementing a feasible monitoring & evaluation approach.

Program Goals and Sample Outcome Measurements

1. Increased access to pediatric HIV services

  • Median age of children initiated on ARVs
  • % of patients on ARVs who are children
  • Reason for AVR initiation
  • Number and median age of children tested for HIV

2. Core quality pediatric HIV services provided

  • ARV elgibility correctly implemented
  • Nutritional assements made
  • % of children provided with CPT

As of mid-2009 MPHATSO has entered the mentorship phase. Baylor Children's Foundation - Malawi is looking forward to the design of a successful mentorship program that will achieve a long lasting impact for Malawi's children.

Notes

1 WHO Recommendations for Clinical Mentoring to Support Scale-Up of HIV Care, Antiretroviral Therapy and Prevention in Resource-Constrained Settings. World Health Organization, Geneva. 2006.

Tools for Outreach Clinical Mentorship in Pediatric HIV Care

The WHO recommends clinical mentorship as a method of supporting scale-up of HIV care in resource-constrained settings.

The following tools represent a collection of materials that have been developed in ongoing programs of on-site outreach clinical mentorship in pediatric HIV care to public sector facilities in resource-limited settings.

These materials represent a "generic" toolkit that can be adapted for use in a particular national setting. Specifically, national guidelines on HIV testing in children, assessment and treatment of malnutrition and antiretroviral therapy regimen and dosing differ from country to country. For most effective use, these materials should be modified to reflect specific local guidelines. As a "generic" reference, current WHO guidelines are used where there are significant differences between individual national guidelines.

These materials are concrete tools for use by clinic staff and by mentors and are designed to help clinics develop a routine and systematic approach to providing basic quality care to children exposed to or infected by HIV.

This approach to mentorship is based on the premise that pediatric HIV care can be "de-mystified" by clearly defining what needs to be done, and that conversely, if these tasks are done the result is good basic care.

The tools are divided into three main categories: site assessment and establishing mentorship, clinical mentorship (including clinical documentation and decision-making and reference materials) and monitoring and evaluation.

  • Focus on the systems level.
    In resource-limited settings challenges to good clinical care include shortages of health care workers and high staff turnover. Rather than focusing primarily on imparting clinical knowledge to individual health workers, this mentorship approach aims to help health facilities develop programs of clinical care that are systematic in their approach to children and that are sustainable despite rotation or turnover of individual staff members.
  • Support task-shifting.
    Decide what needs to get done and who can help do it. Then focus one-on-one mentorship on each cadre of worker who is part of the team.
  • Divide clinic activities into discrete "stations."
    For example: registration, nutrition assessment and triage, clinical assessment, medication dispensing and adherence assessment. Provide one-on-one mentorship to the health worker(s) at each station.
  • Use a team approach to mentorship.
    When possible, provide mentorship as a team, with at least one mentor for each "station." This facilitates effective and efficient mentorship of multiple health workers engaged in concurrent, parallel activities.
  • Use mentorship tools at each station.
    Use posted job aides, reference guides and clinical documentation and decision-making tools as relevant at each of the stations. Use these as a concrete guide for the activities and teaching at each station.
  • Use a checklist to monitor progress.
    Break down goals for clinic activities into very specific tasks. Monitor progress in proficiency and routine completion of these tasks (see example mentorship checklist) in order to determine what areas need more focus.

Site Assessment and Establishing Mentorship:

Letter of Introduction (Sample)
Send a letter of introduction to government health officers and health facility directors to explain what teaching and mentoring services will be available.

Initial Site Assessment Introduction
Present this to health facility staff at the time of the first site assessment. It explains the purpose of the site assessment and outlines expectations for an ongoing mentorship program.

Initial Site Assessment Questionnaire
Use this to gather information during a site assessment visit. The data in the section "Baseline Data" is derived using the "Data Extraction Form" (see below).

ART Data Extraction Form 
Use this to gather baseline quantitative information on existing pediatric ART care.

Ancillary Services Data Extraction Form
Use this to gather data on services that serve as referral bases for pediatric HIV care: under-5 clinic, maternity, antenatal clinic, inpatient pediatrics, HIV counseling and testing.

Checklist for Excellence in Pediatric HIV Care
Use this to gather data on services that serve as referral bases for pediatric HIV care: under-5 clinic, maternity, antenatal clinic, inpatient pediatrics, HIV counseling and testing.

Pediatric Clinical Mentorship Dates
Once a schedule for outreach mentorship has been established, write in the scheduled dates on this form and post it at the health facility. Make sure it is posted at all sites that serve as referral bases for pediatric HIV care (under-5 clinic, outpatient clinic, maternity, etc.)

Clinical Mentorship:

Reference Manual: These materials can be bound into a single guide (Reference Guide) and individual components can be posted as job aides.

Checklists for Care: These list the basic elements of routine visits for exposed infants, infected children not yet on ART, and children on ART.

HIV Testing Algorithms for Children
These algorithms diagram an approach to HIV testing based on the age of the child and types of tests available. Note: this is based on current WHO guidelines for pediatric HIV testing. Individual country guidelines will vary. Please refer to the appropriate National Testing Guidelines.

Nutrition Assessment in Children and Adolescents
Note: individual country guidelines will vary regarding definitions of moderate and severe malnutrition, and treatment guidelines for malnutrition. Please refer to the appropriate national guidelines on management of malnutrition.

WHZ tables:

WHO Clinical Staging of HIV in Children
Lists the WHO clinical staging criteria in children.

Definitions of WHO Clinical Staging Criteria in Children
Describes each of the clinical staging conditions (from:____Ref).

Criteria for Initiation of ART in Children
Outlines current WHO recommendations for initiation of children on ART based on age, clinical stage, or CD4 count/percentage. Individual country guidelines may differ. Please refer to the appropriate national guidelines for initiation of ART.

Cotrimoxazole Prophylaxis Dosing Table
Recommended dosing of cotrimoxazole prophylaxis based on age or weight.

ARV Dosing Guide
This provides dosage information for the most commonly used antiretroviral medications and formulations for children.

Adherence Calculation Sample Table
This demonstrates use of dosing table to calculate adherence.

Normal Vital Signs in Children
Specifies normal ranges for vital signs in children. Used for reference in triage or clinical review.

Developmental Warning Signs in Children
Lists important developmental milestones in children.

Clinical Documentation and Decision-Making Tools:

  • Initial Intake Form (2-sided)
    The nurse or clinician (mentee) fills this out for each new patient visit. Follow the instructions on the back to determine WHO clinical stage, ART eligibility by CD4, etc. At the bottom of the front page the user is prompted to indicate major clinical decision points: whether the child is infected or exposed, and whether the child qualifies for ART and why.
  • Exposed Infant Follow-up Form
    If an infant is determined to be exposed and not eligible for ART at this time, the nurse or clinician should fill in this form. It is used each month that the infant returns for follow-up visits. This form is used until the infant's status is known (as indicated at the bottom of the form).
  • Pediatric Mastercard
    If a child is determined to be infected but not yet eligible for ART, this form is started. One row of the table is filled in at each follow-up visit until the child starts ART. Once a child starts ART, the national form used for documenting ART patient care may be used.
  • Pediatric HIV Consultation Form
    This is used to document clinical consultations on difficult cases.

Monitoring and Evaluation:

Mentor Checklist
Checklist for all specific tasks that should be performed during a pediatric-focused clinic. At the end of each visit the completes this form, filling in one column with check marks for all tasks completed (front and back) and indicating the date at the top of the column.

Quarterly Data Extraction Tool
This tool is used to update data on pediatric ART care on a quarterly basis. It uses the same format as the "Baseline Data Extraction Tool" in the section on Site Assessment and Establishing Mentorship, above.

Quarterly Reporting Form
Summarizes key indicators for pediatric HIV care on a quarterly basis.

Pediatric Register
This register is for all exposed and infected children.

Booking Register
Write in patient names on the day of their next appointment. "Patient Present" is ticket on that appointment date when the patient comes. This register allows for rapid follow-up of patients who default on an appointment.

Certificates of Excellence in Pediatric HIV Care: These are given to individuals and sites after successful completion of a program of on-site clinical mentorship (as determined by consistent attainment of goals on the Mentorship Checklist)

  • Individual Provider
  • Site - Achievement of Excellence in Pediatric HIV Care
  • Site - Continued Provision of Excellent Pediatric HIV Care

This toolkit was prepared by former Pediatric AIDS Corps physicians Ellie Click, M.D., Ph.D. and Megan Harkless, M.D. and former BIPAI Vice President for Research and Program Evaluation, Sebastian Wanless, M.B.Ch.B., Ph.D. It is based on materials developed for use in outreach clinical mentorship programs in several of the BIPAI network countries. The following BIPAI members and collaborators are gratefully acknowledged for their contributions to development and/or review of materials used in creation of this toolkit:

Anu Agrawal, M.D.; Saeed Ahmed, M.D.; Beth Barr, Dr.P.H.; Chris Buck, M.D.; Annie Buchannan, M.D., M.P.H.; Adrienne Chan, M.D., Dignitas International, Zomba, Malawi; Chimwemwe Chitsulo, M.Sc.; Kevin Clarke, M.D.; Ellie Click, M.D., Ph.D.; Carrie Cox, M.D.; Kathy Ferrer, M.D.; Teresa Fritts, M.D.; Tony Garcia-Prats, M.D.; Carrie Golitko, M.D.; Megan Harkless, M.D.; Kebba Jobarteh , M.D.; Mark Kabue, B.D.S, M.S., M.P.H., Dr.P.H.; Peter Kazembe, M.B. Ch.B.; Maria Kim, M.D.; Sarah Kim, M.D.; Mark Kline, M.D.; Elizabeth Lowenthal, M.D., F.A.A.P.; Eric McCollum, M.D.; John Midturi, D.O., M.P.H.; Edith Mohapi, M.B.B.S.; Peter Moons, M.D., College of Medicine, Blantyre, Malawi; Jannell Routh, M.D.; Gordon Schutze, M.D.; Amy Sims, M.D.; Lineo Thahane, M.D.; Omolara Thomas, M.D.; Greg Thompson, M.D., M.P.H.; Sebastian Wanless, M.B.Ch.B., Ph.D.

Special thanks to Kevin Clarke, M.D. for preparation of the illustrative field story from Malawi.

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