Documented and Designed by mentorship in Public...of the programme. I-TECH, added to the quality of the training and mentorship component. The aim of the clinical mentorship programme

Documented and Designed by SAATHII

in association with

New Concept Information Systems Pvt. Ltd.

Website: www.newconceptinfo.com

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

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 (2005-08) 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

fOrEWOrD

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 12

6. The Clinical Mentorship Programme - Learning Methodology 15

7. 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

CONTENTS

HIV Clinical Mentorship - In a public health context 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 2-3.1 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.

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).

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

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.

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

HIV Prevention, Care and Support in India 1

2 HIV Clinical Mentorship - In a public health context

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.

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.

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 four-

pronged strategy:

l Prevent infections through saturation of coverage

of high-risk groups with targeted interventions

(TIs) and scaled up interventions in the general

population.

l Provide greater care, support, and treatment to

larger numbers of PWLHA.

l Strengthen the infrastructure, systems, and

human resources in prevention, care, support,

and treatment programmes at district, state, and

national levels.

l 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

3HIV Clinical Mentorship - In a public health context

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

provide psychosocial support, counselling through

strong outreach services, referrals, and palliative

care. Home-based care will be an integral part of this

strategy.

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. 1953 crores accounting for 16.9%

of the total project outlay.


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 non-

profit 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 2000.

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.

Tamil Nadu Family Care Continuum (TNFCC) Programme 2

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 public-

private 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 quality-

of-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 2nd line ART

drugs. Out of the 65,000 PLHIV in Tamil Nadu, around

3–5% requires 2nd line ART. Second line ART is more

expensive (Rs. 6,000–12,000, averaging 10,000 per

month) than 1st line ART (Rs. 650–2,000, depending

on regimen, government procurement rates may

be between Rs. 500–1,500). One of the biggest

achievements of the TNFCC clinical mentorship

programme is streamlined 2nd line initiation. This

process will be discussed later in the document.

TNfCC Programme Objectives:l 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.


l To develop and evaluate an integrated family-

centred continuum of care and treatment model

for HIV positive families.

l To develop successful linkages through

partnerships among various stakeholders

including government, NGOs, CBOs, and PLHIV.

l To integrate community-led treatment

preparedness and literacy programmes with care,

support, and services.

l To evaluate the impact of nutrition support and

counselling on morbidity and mortality in children

and adults.

Expected Outcomes:l Prevent children being orphaned.

l Reduce HIV related mortality and morbidity

among families.

l Achieve 90% adherence among adults receiving

ARV therapy.

l Improve quality of life among families.

Programme Overview

SitesThree hospital sites cater to ten districts:l Kilpauk Medical College Hospital (Chennai

cluster) - Chennai, Tiruvallur, Kanchipuram and

Villupuram.

l Govt. Mohan Kumaramangalam Medical College

Hospital (Salem cluster) - Salem, Erode,

Dharmapuri, and Perambalur.

l 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

Medical College

Hospital, Chennai

Chennai, Tiruvallur,

Kanchipuram, and

Villupuram

Community Health

Education Society (CHES)

SIP+, MSDS, and ACD

Government Mohan

Kumaramangalam

Medical College

Hospital, Salem

Salem, Erode,

Dharmapuri, and

Perambalur

Young Women

Christian Association

(YWCA), Salem

YWCA, HILLS,

SEARCH, and INDO

Government Medical

College Hospital,

Tirunelveli

Tirunelveli, Tuticorin,

and Kanniyakumari

Gramodhaya Social

Service Society

PWST+, St. Joseph

Leprosy Hospital


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:

l 1 Project Coordinator

l 1–2 Counsellors

l 1–2 Nutritionists

l 1–2 Nurse Case Mangers

l 2 Nursing Aides

l 1 Pharmacist

l 1 Accountant/Data Entry Operator

l 1 Sanitary Worker

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

Community services provided by NGOs in each of

these ten districts are as follows:

l Identification of HIV clients and motivation of

patients for hospital registration and monthly

follow-up visits

l Conducting support groups near the patient’s

residence

l Identification and training of peer educators and

care givers

l Provision of home-based care that includes

opportunistic infections diagnosis and referrals,

as well as ongoing adherence counselling

l Referrals and linkages to various services like

housing, income generation, legal services, etc.

l 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.


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):

l Clinical Management of HIV/AIDS (counsellors, lab

technicians, nutritionists, pharmacists, sanitary

workers, project coordinators, community health

nurses, child counsellors, and outreach workers)

l Home-based Care (nurses, counsellors, project

coordinators, nutritionists, outreach workers,

community health nurses)

l Adherence Counselling (hospital and field

counsellors and coordinators, community health

nurses, and outreach workers)

l Child Counselling (ART counsellors and field child

counsellors)

l Life-skills Training (field project coordinators,

child counsellors)

l Financial Management (project head, project

coordinators, accountants)

l Training on Organization Development/

Management, Leadership, and Communication

(NGO heads and project coordinators)

l Induction and advanced training for

nutritionists

l 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)

TNFCC - Technical Assistance and Capacity Building 3

l Home-based care mentorship training for

community project coordinator, child counsellors,

and community health nurse for mentoring

outreach workers

l Child Services training for the community child

counsellors

l 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


turnover. The training was made specific and target-

focused 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 need-

based 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:

l Clinical Mentorship to ART medical officers

(provided by SAATHII and I-TECH)

l Counselling Mentorship to hospital and field

counsellors (SAATHII)

l Home-based Care Mentorship to outreach workers

(SAATHII and Field NGO Core Team: Project

Coordinator, Child Counsellor, Community Health

Nurse)

l 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.


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.

The Clinical Mentorship Programme – Overview 4

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:

lSupporting decentralized delivery of HIV care,

ART and prevention, as well as continuous

improvement of patient outcomes at all ART

delivery sites.

lPromoting application of classroom learning

to clinical settings.

lImproving the quality of clinical care and

patient outcomes in resource-constrained

settings.

lBuilding 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 SitesThe 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.


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 e-mail 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 2nd 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 www.go2itech.org

Mentorship Methodology

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 email or telephone.

Mentorship includes, at a minimum, the following

components:

l Orientation of external mentor by SAATHI

mentor

l Planning and tool development by mentors

l Training and needs assessment of the ART medical

officers by SAATHII mentor

l Reliance on adult learning principles

l On-site two-day hospital visits by mentors to

each of the hospitals every three months

l Long-distance mentorship

Onsite MentorshipThe 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:

lOnsite review of medical practices at the hospitals

with the doctors

lIdentifying training needs and areas for

strengthening

lMentoring the doctors by the various methods

elaborated below:

lModeling

lFacilitation of various case studies and

discussions

lHands-on training

lAdditional clinical training using adult learning

principles

lSharing of supplementary reading materials from

peer-reviewed journals.

lAdvocacy with mentees for systematized case-

management, laboratory investigations and

documentation

lFacilitating data collection, best practices

sharing, and clinical research


Distance MentorshipThis component of the mentorship programme is

probably the most pragmatic, as it ensures continuous

and adaptive learning. The mentees call or email

the mentors periodically, enabling timely treatment

of patients, and establishing open communication

between mentor and mentee.

Distance Mentorship entails the following:

lOngoing consultation with doctors by phone and

email

lExchange of case sheets, scans, and other relevant

documents

lSharing of reference material to enhance

learning

Focus Areas of Mentor Involvement lRoutine clinical care for HIV and associated

medical conditions

Mentoring Strategies

Modeling facilitate Discussions Additional Clinical Training

Support

l Greeting patients

warmly

l Sensitive patient

examination

l Multidisciplinary

team approach

l Shadow/observe

l Difficult and

complex cases

l Ethical issues

l Patient flow

l Clinic set-up

l Patient triage

l Quality of Care

l Case Studies

l “Mini-Teaches” based

on needs of clinic

l Serve as an advocate

l Cheerlead

l Listen/validate

work of doctors

l Coach

communication

techniques(source: www.go2itech.org)

lProgress assessment of patients on ART (side-

effects, toxicities, management)

lOI management of non-ART patients

lHIV-TB co-infection management

lSecond line initiation, regimen selection, and

monitoring

lImproving doctor-patient interaction through

effective communication

lPost-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.


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 fieldWork 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 1,000 250–300

Kilpauk Medical

College Hospital

2,100 530

Salem 4,500 1,500

Average 2,533 768

3. Previous trainingsAll of the doctors had attended previous HIV-related

trainings. These include:

lGHTM – NACO – 4 attendees

lYRG Care – 4 attendees

lHIV-TB/ATT-RNTCP – 4 attendees

lDr. MGR Medical University – 1 attendee

lInternational Conference, University of

Hyderabad – 1 attendee

lCME, Karigiri – 1 attendee

lCME, YRG – 2 attendees

lWHO IMAI training, St. John’s Bangalore –

1 attendee

lClinton Foundation – IMA doctors training

– 1 attendee

Clinical Mentorship Programme – Training Needs Assessment5

4. Training formatslThe most preferred training formats were:

t Conferences

t Printed materials (journals, newsletters, etc.)

t Skill building workshops

t Case presentation seminars

lThe least preferred training format was weekend

case discussions.

lEach doctor listed a separate preference for

frequency of ongoing trainings.

lMost 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.

lInternet access: Tirunelveli and Salem had

unrestricted access to internet use, but KMCH

only received access towards the mid-mentorship

period.


5. Barriers to traininglThe most commonly cited barrier to training was

long travel times to Chennai.

Suggested solutions:

tMake Madurai or Tiruchi the centre for

trainings

tConduct trainings at all three sites, on a

rotating basis

lSalem indicated that both ART medical officers

could not attend at the same time.

Suggested solution: Assign an alternate/additional

ART medical officer

lKMCH 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 diagnoseslHIV RNA PCR

lCD4 Count testing

lOther markers*

lCulture and resistance*

2. Opportunistic Infections and Co-InfectionslClinical presentation

lLab and clinical diagnosis of OIs

lDifferential diagnosis

lTreatment

lGIT manifestations

lDental manifestations*

lOphthalmic manifestations*

lNeurological manifestations

lTuberculosis*

3. Pediatric HIVlGrowth and development parameters

lLab diagnosis (<18 months)

lART

lSecond line regimen

lART and ATT

lART in women (pregnancy and PMTCT)

lImmune Reconstitution Syndrome

lWhen to change treatment (resistance and

treatment failures)

5. HIV and Psychiatry

6. HIV Virology lMechanism of resistance

7. HIV and Gynecology*

8. HIV and Wasting*

9. HIV and Nutrition* lNutritional counselling

10. Legal, Ethical, Cultural Issues*

The doctors expressed low skill but only moderate

learning interest in the following:

lEconomic, health care, and socio-cultural issues

impacting patients.

lCurrent trends in epidemiology – India, Global

lPalliative care

lStructured treatment interruptions


Site-specific needs

Tirunelveli KMCH Salem

Clinical TopicslRadiotherapy in HIV patients

lHIV/TB

lRole of Immuno-

Modulators in HIV

lNatural Medicines/Herbs/

Ayurveda/Siddha and HIV

lNeurological case presentation

– other than common CNS OI

lImmunity: Innate, Acquired,

and HIV Pathogenesis

Other TopicslNeed for separate

e-forum for ART MO

lLegal implications

and advocacy

lAdministration skill

development and leadership

qualities improvement

lFinancial management

of ART centers

Clinical TopicslResistance testing methods

lMutations (diagnostic,

prevention, treatment

– 2nd line) and dry selection

according to mutations

lAlgorithms for specific

toxic effects of ARVs

lPsychosocial assessment

– scales for specific conditions,

adult scales, child scales

lPrevention: breast feeding,

education of adolescents,

ARV eligibility

lART: second lines, integrase

inhibitors, maturation

inhibitors, any viricidals?

lVaccines: trials, types

lRecent research studies

lHIV and other fields

Clinical TopicslNon-HIV–related

co-infection

lManagement of chronic and

recurrent diarrhoea

lTechnical update on ART

initiation and re-initiation

lManagement of OI

in ART patient like

Immune Reconstitution

Inflammatory Syndrome

lChanging patient attitudes

and positive prevention

(i.e., more women

getting pregnant)


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:

ltheir own experience and expertise

lan expectation that they will be respected and

guided

land 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

The Clinical Mentorship Programme – Learning Methodology 6

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.


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). On-

site 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:

lPerformed ward rounds and hands-on-training

on the wards

lled detailed case discussions on second line

drugs using actual case studies from the ART

centre

laddressed 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

ldemonstrated how to use the Stanford guide

in interpreting the genotype resistance study

results using the appropriate web site

lusing case records, stressed how important it

is for the medical officer to examine patients

on second line drugs

lexplained the importance of documentation

related to death and other interesting cases

lgave 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 e-mails

(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).


Mentor recommendations at the end of initial visits, from all three centers -

lAppropriate instruments and logistics for systematic clinical examination to be provided to improve

clinical examination.

lAppropriate laboratory tests for better clinical care to be made available at all the centers for testing

selected and needed cases.

lThe doctors shall follow the NACO guidelines in care and treatment.

lThere is a need to arrange experience-sharing and review meetings and update sessions with interesting

and difficult case studies.

lThe 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).

lDocumentation should be improved in case sheets and ART card.

To improve the documentation practices in the case sheets:

lMedical 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

lDeath

(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 information-

sharing days like – “Write a note on the patient’s condition during his/her last visit and discuss with

the doctor based on the same”.

lSECOND 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.

lAll 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 HBsAgAnti-HCV S.Lipase Anti-HCVS.Amylase S.TriglyceridesS.LipaseS.Triglycerides


TANSACS shall suggest TA and ART medical officers to follow-up on the above lab tests.

lThe 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 reasonsAzithromycin 500 mg Inadequate hospital supplyClarithromycin 500 mg No request made due to no need so farClindamycin 300 mg OI drugs purchase can be done *Fluconazole-T. and Inj. OI drugs purchase can be done*Nitazoxanide 500 mg OI drugs purchase can be done*Inj. Amphotericin B 50 mg OI drugs purchase can be done*Inj. Acyclovir 250 mg No request madeInj. Gancyclovir 500 mg OI drugs purchase can be done*Cap.Gancyclovir 250 mg OI drugs purchase can be done*Dapsone OI drugs purchase can be done*Sulphadiazine, Sulphadoxine OI drugs purchase can be done*Pyrimethamine OI drugs purchase can be done*Folinic acid No request made

Salem reasonsClindamycin 300 mg OI drugs purchase can be done*Nitazoxanide 500 mg OI drugs purchase can be done*Dapsone OI drugs purchase can be done*Sulphadiazine, Sulphadoxine OI drugs purchase can be done*Pyrimethamine OI drugs purchase can be done*Folinic acid OI drugs purchase can be done*Inj. Acyclovir 250 mg OI drugs purchase can be done*Inj. Gancyclovir 500 mg OI drugs purchase can be done*Cap. Gancyclovir 250 mg OI drugs purchase can be done*

KMC reasonsAzithromycin 500 mg OI drugs purchase can be done*Clarithromycin 500 mg OI drugs purchase can be done*Clindamycin 300 mg OI drugs purchase can be done*Inj. Fluconazole OI drugs purchase can be done*Nitazoxanide 500 mg OI drugs purchase can be done*Inj. Amphotericin B 50 mg OI drugs purchase can be done*Inj. Acyclovir 250 mg OI drugs purchase can be done*Inj. Gancyclovir 500 mg OI drugs purchase can be done*Cap. Gancyclovir 250 mg OI drugs purchase can be done*Dapsone OI drugs purchase can be done*Sulphadiazine, Sulphadoxine OI drugs purchase can be done*Pyrimethamine OI drugs purchase can be done*Folinic acid OI drugs purchase can be done*


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.

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.

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

The Clinical Mentorship Programme – Findings, Feedback and Outcomes 7

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.

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


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 2nd 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 email, 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 2nd 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 2nd line ART drugs available. Out of the 65,000

PLHIV in Tamil Nadu, around 5% require 2nd line ART.

NACO started 2nd line ART recently.

As Dr Sathish puts it, “one of the biggest

achievements of clinical mentorship is streamlined

2nd 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


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,

2nd 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


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 2nd 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’sOobservationslComprehensive medical assessment

lImproved safer sex education and family

counselling

lPrivacy during medical examination and

counselling

lDiagnosis and treatment of complex medical

conditions including crypotococcal meningitis,

TB meningitis, TB pleural effusion, AZT-induced

chronic diarrhoea and ascites among others

lTimely initiation of ART for TB co-infected

patients

lUse of correct dosages of ART for children

lDiagnosis and treatment of co-morbidities such

as diabetes, hypercholesterolemia, and liver

disease

lAccurate identification and treatment of failure

cases

lReferral to appropriate medical services which are

available onsite

lFrequent referencing to national guidelines and

protocols

lQuality of care documentation

lReduction of overcrowding at the clinics by

shifting certain tasks to nurse managers

lDiagnosis 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:

l Paramedical staff (excluding the Project

Coordinator) knew about the mentor’s visits.

l 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.

l Improvement in infrastructure, like provision

of generators, would facilitate the free flow of

services, especially in the labs.

l 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.

23HIV Clinical Mentorship - In a public health context 23

Mentors From the implementation point of view, the following challenges need to be addressed:

l To plan and execute the mentorship as per the plan

l Retain the same medical officers at the ART centers

l Advocate for more, but appropriate, lab tests and drugs at the ART centers

l Advocate for more collaboration between hospital departments

Mentees l 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

l Helpful for those recently graduated from medical schools

l Need for an intensive training on 2nd line ART and annual refresher/orientation programmes

Paramedical l Pre-ART care is also an essential feature of the programme

l 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.

l 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.

l Doctors are also not able to spend enough time with patients due to the need for fast

patient turnover.

Patients l Overall, quality of treatment is good.

l Waiting hours are too long because of high client load. Long waiting times interrupt

family obligations such as children’s attendance at school.

l Few patients prefer counsellors to make home visits

l Would like to see more services and education on wound care and treatment.

l 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.


reference:

To equip the mentors with mentoring skills the three-

day 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’

I-TECH Clinical Mentors’ Training CurriculumAnnexure - I

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 stand-

alone 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.


Tool for mentoship assessmentAnnexure - II

Clinical Mentorship - Assessment Questionnaire

Date: ______________________________________________

Site: _______________________________________________

Site Reviewer: ________________________________________

I. STAFFING

What types and numbers of providers do you have at this clinic?

Number Number

Physician ______ Nurse case manager ______ Lab technician ______ Nurse aid/assistant ______ Pharmacist ______ Nutritionist ______

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:


II. SPACE AND EQUIPMENT

How many consulting or counseling rooms are present in the centre? _____

Facilities and supplies (Tick all that apply)

1. Injection material:

1.1 Multiple use needles provided

1.2 Single use disposable needles

provided

If YES

1.2.1 Needles recapped before disposal

1.2.2 Needles recapped one handed

1.2.3 Needles deposited directly

1.2.4 Needle cutter used

1.2.5 Sharps containers available

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 ____________________

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 ______________________________

4. Record keeping:

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

5. Availability of written material/posters on HIV/AIDS/STDs to educate patients:

Yes

No

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


Category Capability

(Yes/No)

Currently functioning

(Yes/No)

Last used / available

(Date)

Reasons for not using/non availability on day of visit

(*see codes below)

Final code

(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: ______________________________________________________________________


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?

%

Don’t know Providers don’t ask

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?

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 •

HIV/AIDS Care •

2. Does the clinic perform blood draws? Yes•

No•

3. Does your lab have the capacity to keep blood specimens frozen at 20-70o C below

Yes•

No•

4. Where do you send blood specimen to run the following tests?


Viral load testing•

Resistance assays•

CD4 counts•

Hepatitis screening•

5. Which of the following immunizations do you provide?

Influenza•

Pneumococcus•

Hepatitis A and B•

6. What barriers do you experience in providing care to HIV-infected patients/clients?

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 barrier1.

Minimal2.

Adequate3.

2. Does triage promote efficiency and patient safety?

None, totally ad hoc 1.

Some effort at triage (no guidelines in place) 2.

Triage occurs (guidelines in place) 3.

Efficient triage system practiced 4.

3. Communication among HIV/ART team

None1.

Minimal discussion among some team members2.

Some regular discussion of information shared by team members3.

Regular information sharing about most key things occur4.

Highly functioning team communication practiced regularly5.

4. Patient flow between members of the team is effective and efficient:

Patients movement among providers is inefficient1.

Patient spends time with different team members makes some sense2.

Patients receive maximum benefit from moving among providers3.


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?

Yes No Yes No

Data capturing forms/registers

Case sheets - initial (Yes/No)

Report forms (Yes/No)

Clinical document formsPain reduction methods offered

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?


Medical Care Yes•

Who provides this service?•

No•

Where are people referred for medical care?•

Pharmacy services Yes•

Who provides this service?•

No•

Where are people referred for medical care?•

Under what circumstances--and to whom--do you refer HIV+ patients?

VI. SAFETY & HYGIENE

Universal precautions practiced

Yes No Yes No

Data capturing forms/registers

Case sheets - initial (Yes/No)

Report forms (Yes/No)

Clinical document formsPain reduction methods offered

Hand hygiene

Available Reported

available,

not seen

Not Available Notes

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:


Aseptic technique

Equipment/

Supply

Available Reported available,

not seen

Not Available Notes

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 seen

Not Available Notes

MDRTB+ patients placed separately from HIV+ patients

TB- patients separated from TB+

Comments

Immunization and exposure management

Methods Observed Reported done, not seen

No procedure conducted/observed with needle

Notes

MDRTB+ patients placed separately from HIV+ patients

Health care staff used needle destroyer immediately after use (i.e. did not recap needle)

Comments

Number of doctors reporting completing Hepatitis B vaccine course:

Doctors:


VII. LABORATORY

Can your laboratory perform the following tests?

Lab tests recommended by NACO

Yes No Maybe Remarks

Haemogram:

Hb%

TC

DC

ESR

Platelet count

TLC

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


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


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


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


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

Night sweats

Difficulty swallowing

Fatigue

Mental status change

PID

Genital discharge

Genital ulcer

Lower abdominal pain

Abnormal test

Pregnancy

Other (specify)_________________

2. Symptoms (check all that apply)

2.1 Determined if they were recurrent

2.2 Asked about duration

2.3 Asked about severity

2.4 Probed further about other symptoms

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

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


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


12. Patient is on ART

12.1. Yes

12.2 No

12.1 For patients on ART

12.1.1 __________(regimen)

12.1.2 Asked about adherence

12.1.3 Asked about side-effects

12.1.4 Ordered ART follow-up labs

12.1.5. ART adherence counselling

12. Patients not on ART

12.2.1 ART not discussed

12.2.2 OI prophylaxis prescribed

12.2.3 OI drugs adherence counseling provided

12.2.4 OI drug side effects discussed

13. Patient referred to a support group/+

Persons network?

13.1 Yes

13.2 No

13. 3 Already involved with group

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?)

Check those observed Where not observed, provide explanation where possible

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


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 Comments on those that apply

WHO staging

OI

Temperature

Appropriateness of labs ordered Comments on those that apply

What lab tests were ordered?

What lab tests were not ordered (although available) that should have been?

Accuracy of treatment Comments on those that apply

ARV Rx

OI Rx

Other

Follow up recommended

Accuracy of treatment Comments on those that apply

ARV Rx

OI Rx

Other

Follow up recommended

General Observations

Were universal precautions respected?

Basic privacy/confidentiality practices followed?

Is a team approach being used to treat and monitor patient progress?


Demonstrated knowledge/skills Comments

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)

Recommendations to improve this doctor’s skills to mentor independently

Examples of information shared that might improve this doctor’s skills to mentor independently


Clinical Mentor Scale for individual doctor 1 2 3 4 5

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


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."

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.

Note: Counsellors provide safe sex counselling

Sample Mentorship ReportAnnexure - III


"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"

"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.

"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 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.


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

"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."

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)

Frequent references were made

8. Need based calls and mails to I-TECH

During the period between first and second onsite mentorship, TA was provided in managing 5 difficult cases and brief follow-up calls were made

During the period between second and third onsite mentorship, TA was provided in managing 6 difficult cases and follow-up calls and email discussions were made

During the period between third and fourth onsite mentorship, TA was provided in managing 3 difficult cases and follow-up calls and email discussions were made

9. Tongue depressor, knee hammer, tuning fork, X-Ray lobby to be provided for better clinical examination.

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.

10. Doctor shall start referring for special tests like HBsAg and HCV–To initiate with few patients and then increase to more numbers.

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


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 11.30. The ART centre was overcrowded. More space is needed for the appropriate service providers and patients.

12. During the feedback session on the second day, the doctors mentioned more training related to Non-HIV co-morbid 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 co-morbid medical conditions appropriately but they need still more training on managing the co-morbid 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)

"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."

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.**

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.

"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.

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.


2. Initiation of second line cases

As per the previous 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.

It is being followed The documentation of new cases started on second line drugs were complete but the old cases with second line drugs need to be completed.

3. During the weekly team meetings important case studies may be discussed

3. During the weekly team meetings important case studies may be discussed including death auditing.

Important case studies were being discussed in their weekly staff meetings including poor adherence, treatment preparedness and others.

New Recommendations

To maintain the growth chart of children upto 12 years

The growth charts for children upto 18 years were provided to the Medical Officers for documentation

To develop a checklist for the follow-up of second line patients

Checklist given to the doctors on second line lab tests

To develop case studies for e-meetings and tele conferencing.

"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."


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?

Case Sheet Documentation for treatment failureAnnexure - IV


9. A

RT t

reat

men

t de

tails

: 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***

1

2

3

4

5

6

7

* -

If d

ate

not

avai

labl

e, p

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e m

enti

on m

onth

and

yea

r or

yea

r on

ly.

•**

- AR

V dr

ug s

ide

effe

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city

/ s

ubst

itut

ion

/ st

oppe

d Rx

/ t

reat

men

t fa

ilure

- im

mun

olog

ical

/clin

ical

/viro

logi

cal f

ailu

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tc.

***

-Rem

arks

- p

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enti

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easo

ns f

or p

oor

adhe

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rug/

Rx s

topp

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and

soc

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acto

rs w

hich

are

app

ropr

iate

.Pl

ease

go

thro

ugh

priv

ate

doct

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pres

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and

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ono/

dual

/tri

ple

•dr

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nd na

me

of d

rugs

)


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.



Documents

Documented and Designed by mentorship in Public...of the programme. I-TECH, added to the quality of the training and mentorship component. The aim of the clinical mentorship programme