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Printed by the WHO Document Production Services, Geneva, Switzerland WHO Basic ART Clinical Training Course─Participant Manual Introduction....................................................3 Chapter 1 Introduction to chronic HIV care including ARV therapy.............................. 5 Chapter 2 Introduction to HIV/AIDS and opportunistic infections............................ 13 Chapter 3 HIV and antiretroviral drugs.........................27 Chapter 4 Adherence and resistance.......................... 39 Chapter 5 Assess (clinical review of symptoms and signs, medication use, side effects, complications) and provide clinical care............................43 Chapter 6 Use the HIV Care/ART card..........................57 Chapter 7 Prophylaxis...................................... 75 Chapter 8 Adherence preparation.............................81 Chapter 9 Initiate first-line ARV regimen at first-level facilities in patients without complications............ 93 Chapter 10 Four first
o Veerle Huyst, Institute for Tropical Medicine, Antwerp o Russ Glasgow, expert in 5As and chronic care o Mr Hannington, TASO Uganda o Mary Lyn Field, Family Health International o Patricia Whitesell-Shirey, ACT International, Atlanta, Georgia, USA o Jane Lucas, Consultant o People Designs, Durham, NC, USA o Moher Downing, ITech (U Washington/UCSF) o WHO IMAI team: Sandy Gove and Francesca Celletti, JoAnne Epping, Mona Bhatt Shah, Anna Eden, David Miller and others from the WHO IMAI technical working group Input of materials from MSF (through Alexandra Calmy), MTCT+, and Mildmay Uganda is also gratefully acknowledged. They are part of the training working group but were unable to attend the December working meeting.
Line drawings by Jovan Bahizi, Uganda Revised after the Masaka and Hoima, Uganda trainings.
Please ask for the most up-to-date version of this course prior to use and provide feedback, so we can continue to improve both the IMAI guidelines and these training materials. Work is ongoing to translate into several languages. Please send comments to firstname.lastname@example.org.
This is the participant manual which includes written exercises. Participants should also
have copies of:
Flip chart for educating patients (basic ART, positive living, prevention)
Copies of 2-sided recording forms (a copy is in Annex 1):
o Front: Clinical review; assess pregnancy/FP, TB, functional status, clinical stage o Back: 7 requirements to initiate ART at first-level facility HIV Care/ART card Expert patient cases for each skill station session Photo booklet
Additional facilitator course materials:
o Facilitator guide o Laminated wall charts for exercises o Cards for card sorts o Expert patient training guide o Clinical training videos 2 Introduction to IMAI Lack of access to ARV drugs has been declared a global health emergency.
Universal access to ARV therapy is considered a human right and an initial target has been set by WHO of ensuring that three million people are on treatment by the end of 2005.
During the last 20 years, Ministries of Health, NGOs and private providers have been working in collaboration with WHO, UNAIDS, bilateral donors, and other local and international partners to establish comprehensive care programmes for HIV infected people. ART is now being added to this in certain health units.
We hope that this training course, based on a country (or project) adaptation of the IMAI Chronic HIV Care with ARV Therapy, will contribute to this, both in the district hospital outpatient clinic and down to ART delivery through health centres at community level.
What is IMAI?
IMAI is the Integrated Management of Adolescent and Adult Illness.
These simplified and standardized WHO guidelines support the delivery of ARV therapy within the context of primary health care, based at first-level health facilities or in district outpatient clinics. The guidelines are based on the standardization and simplification of ARV regimens presented in Scaling Up Antiretroviral Therapy in Resource-Limited Settings1. IMAI provides tools (standardized guidelines and training courses to teach these guidelines). The module are for country adaptation and use in their efforts to achieve the 3 by 5 goals.
The guideline modules cover Chronic HIV care with ARV Therapy, Acute care (including the management of opportunistic infections and when to suspect HIV, linking to testing and counselling), Palliative Care (symptom management at home), and General Principles of Good Chronic Care (to support the health system transition from acute to chronic care). Each module can be used alone or as an integrated package. The pocket-size guideline modules are intended to be used both as learning aids (during this training course) and as job aids (for reference during clinical care). The modules are cross-referenced between each other; however, other national guidelines can be substituted if necessary.
See Annex A for a short description of the 4 IMAI modules that are relevant to the continuum of care for HIV. Course participants will be given all 4 guideline modules and will learn to use them. The course this week focuses on the clinical part of Chronic HIV Care including ARV Therapy guideline module.
Target groups for this Basic ART Clinical Training course This course is intended for first-level facility health workers who work in a district outpatient clinic or in peripheral health centres and clinics, in rural or urban
areas, in low resource settings. We have divided the training to support the Chronic HIV Care including ART into two short courses−this clinical training course and a counselling course.
Clinical training in the use of these simplified guidelines will hopefully provide an efficient introduction to chronic HIV care and to ART. This will allow key tasks to be shifted from doctors to nurses, clinical officers, medical aids and other multipurpose health workers within a clinical team. The goal is efficient quality ARV therapy (ART) based on a solid chronic care model.
Medical officers or doctors can also go through this course more rapidly for an introduction to chronic HIV care and ART and to make them thoroughly familiar with the care provided by others on the clinical team, which they will need to supervise. This course would then need to be followed by more advanced ART and OI training.
The Basic ART Aid Training Course addresses triage, patient education, and psychosocial support, prevention, and adherence preparation and support guidelines. These guidelines have been designed so they can be implemented by PLHA and other lay providers working on the clinical team2. An important potential source for the increase in human resources required to rapidly expand access to ART can come from PLHA and other community members who both join clinical teams and support treatment and other care in the community.
Management of common opportunistic infections is important prior to starting ART. An additional short course is available to prepare first-level facility health workers to recognize and treat key common opportunistic infections in preparation for ART. It is possible that you already know how to provide acute care and to manage opportunistic infections as an outpatient and to refer when necessary. If this is the case, you may be able to skip the Opportunistic Infection/Acute Care course and take only this course that teaches Chronic HIV Care with ARV Therapy.
Symptom management (palliative care) remains important throughout acute and chronic HIV care, during ART, and if ART needs to be stopped. This is summarized in the Palliative Care module. These guidelines prepare the health worker to teach patients, families and community caregivers to provide effective care at home, using the Caregiver Booklet. A short training course is available.
2 This is different from a Community Health Worker who is a trained lay provider based in the community, not based on the clinical team in the health facility.
4 Chapter 1: Introduction to chronic HIV care including ARV therapy Comprehensive care for people living with HIV/AIDS requires both clinical care based at the health facility and home-based care involving the patient, family and friends, community health workers, other community-based caregivers, traditional practitioners, and community-based organizations, NGOs and FBOs.
The sequence of clinical care presented on pages H6 to H7 of the Chronic HIV Care with ARV Therapy module is centred around community care and treatment support. This course concentrates on clinical care, which is an important component of comprehensive care but not the only one.
The Chronic HIV Care with ARV Therapy guidelines start with a positive HIV test and the patient accepting care. For some patients, there will be a gap between testing positive and coming to a health facility for care.
Acute and chronic HIV care and prevention To improve the comprehensive care of PLHA at health centres and at the district or hospital outpatient clinic, it is important to be able to provide both good acute and chronic care and prevention at the health facilities and to link with home-based care.
Think about the care that you provide now in your clinic or health centre. Is it mostly acute care or chronic care? Most care that we deliver is usually acute care. Acute care includes the management of the common illnesses that are problems for adolescents and adults. These include common bacterial infections, skin, neurological and mental health problems. In countries with a high prevalence of HIV infection, more and more of these acute problems are due to opportunistic infections based on immunodeficiency from the HIV infection. HIV infection causes a chronic disease but if we only care for the patient during episodes of acute illness, then we are only providing acute care.
We are not yet providing good chronic care.
Because most health care systems developed in response to acute problems, they are designed to address urgent health care needs and to diagnose, relieve symptoms, and expect cure. Health care for chronic conditions is different from health care for acute problems.
To better manage chronic conditions including HIV/AIDS, health care needed to be organized and delivered in a different way. Acute care will always be necessary (even chronic conditions have acute episodes), but at the same time health care must be able to care for long-term health problems.
Introduction to the General Principles of Good Chronic Care Good chronic care recognizes the fact that the patient must understand and learn to manage his or her own chronic condition. HIV infection and its slow progression to AIDS require much education and support to give patients the skills to self-manage (manage their own condition). Although the clinical team and others at home and in the community can help, it is the patient that needs to learn to cope with their infection, to disclose to those that they trusts in order to get further help, to learn to practice prevention and positive living, and to understand and use prophylaxis and ART and other treatments. This requires much education and support but the result is important.
The following principles can be used in managing many diseases or risk conditions, including HV/AIDS. We will learn about these gradually throughout this course. (They will appear in various chapters.)
1. Develop a treatment partnership with your patient
2. Focus on your patient's concerns and priorities
3. Use the 5 A's— Assess, Advise, Agree, Assist, Arrange
4. Support patient self-management
5. Organize proactive follow-up
6. Involve “expert patients,” peer educators and support staff in your health facility
7. Link the patient to community-based resources and support
8. Use written information - registers, Treatment Plan, and treatment cards - to document, monitor, and remind
9. Work as a clinical team
10. Assure continuity of care
A general principle of good chronic care: