Clinical Mentorship in Public Health Settings

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Documented and Designed bySAATHIIin association withNew Concept Information Systems Pvt. Ltd.Website: www.newconceptinfo.com

Copyright: 2009 TANSACS & SAATHII

ACKNOWLEDGEMENTS

1. I-TECH team2. ART medical ofcers

3. TNFCC programme partners4. TNFCC clients5. TANSACS and SAATHII team


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In the ght against HIV/AIDS, Tamil Nadu has achieved a signicant reduction in the prevalence,providing an example to other states of how well-planned and comprehensive programmes canhelp control the epidemic. One such effort is the Clinical Mentorship Programme implemented byTamil Nadu AIDS Control Society (TANSACS) as part of the 3-year (2005-08) Tamil Nadu FamilyCare Continuum Programme, in three government hospitals.

The technical assistance and capacity building inputs from SAATHII were crucial to the successof the programme. I-TECH, added to the quality of the training and mentorship component.

The aim of the clinical mentorship programme was to signicantly increase the skills of medicalofcers in the management of HIV/AIDS; the approach was participatory, based on the principlesof adult learning. Highly skilled and experienced clinicians were designated as mentors to guidethe ART medical ofcers. Programme components which ensured effectiveness were needsassessment, training, both face-to-face and distance mentoring, and on-going monitoring andevaluation.

The programme has been remarkably successful in ensuring the mentees improved skills.Evaluation has demonstrated improved learnings, improved clinical outcomes and improveddocumentation. Successful clinical mentorship has been followed by three other programmes:

counseling mentorship for hospital and eld counselors; home-based care mentorship foroutreach workers; and child services mentorship for child counselors.

TANSACS acknowledges SAATHII for its technical assistance to the program, Duke University formonitoring and evaluation, The Childrens Investment Fund Foundation for funding support, and allthe TNFCC-associated ART centers, eld NGOs and hospital NGOs for effective implementation.

On behalf of TANSACS, I take this opportunity to express our appreciation of hospitals and theMedical Ofcers contribution to the success of the clinical mentorship programme.

Dr S. Vijayakumar, IAS

Project Director

FOREWORD


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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


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HIV Clinical Mentorship - In a public health context 1

Overview

The revised estimate of people living with HIV inIndia (July 2007) puts India in third place in the listof countries with the largest number of people livingwith HIV. Of the estimated 2-3.1 million peoplewith HIV in India 39% are women and 3.8 % arechildren.

The transmission route is predominantly sexual(87.4%) from high-risk groups to bridge populations(clients of sex workers, truckers) and then to thegeneral population.

Globally, the availability of new resources hasaccompanied a push for greater access to treatment,care and support. Never before has the worldattempted, on such a large scale, to bring broad-basedchronic disease management to resource-limitedsettings. India, like other countries, has embarkedon aggressive campaigns to control the epidemic.

National response to the AIDS epidemic has been todecentralize the programme to the state and districtlevels to enhance commitment, coverage, andeffectiveness. The goal is to reverse the HIV epidemicby 2015, and to improve quality of life for peopleliving with HIV/AIDS (PLHIV) through increasedaccess to care and support services and, in particular,Anti Retroviral Therapy (ART).

The national response also recognizes the importanceof maintaining strong prevention efforts. Prevention iscritical in countries, like India, where HIV prevalenceremains low in the wider population and whereopportunities still exist to prevent an exponential risein transmission. Where transmission occurs mainly

through risky behaviors, it is critical to continue toemploy robust behavior change intervention effortsto stem the epidemic.

Care and Treatment Models

Family-centered and comprehensive care models arerecognized as appropriate strategies for mitigatingthe impact of AIDS. Access to therapy, nutritionassistance, and treatment for Opportunistic Infections(OI) and other health issues that complicate orexacerbate HIV infection are all integral componentsof a comprehensive care model.

It is thus recognized that medical treatment alone isnot sufcient. Programmes offering care and supportto HIV-affected families should integrate psychosocialservices in the treatment process, as well as supportiveservices such as nancial support, family counselling,nutritional aids, and palliative care where necessary.ART programmes should also address the mentalhealth-related aspects of disease management, and

HIV Prevention, Care andSupport in India


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provide access to psychotropic medications wherepossible. Palliative carein combination with and asan adjunct to home-based care also has a role toplay in improving medical care, symptom control, andmortality from the disease. Appropriate palliative carealso addresses psychosocial issues experienced byfamilies and surviving children, supports care giversand communities, and encourages future patients tocome forward earlier in the disease.

National Strategy

Following the detection of the rst case of AIDS inIndia in 1986, several measures, both governmentaland non-governmental, were taken throughout thecountry to curtail the spread of HIV and protectthe rights of People Living with HIV/AIDS (PLHIV).At present, the National AIDS Control Organisation(NACO) provides leadership to HIV/AIDS controlprogrammes in India through 35 HIV/AIDS Preventionand Control Societies.

The overall goals of NACP-III (National AIDS ControlProgramme) is to halt and reverse the epidemicin India over the next ve years by integratingprogrammes for prevention, care and support, andtreatment [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 generalpopulation.

l Provide greater care, support, and treatment tolarger numbers of PWLHA.

l Strengthen the infrastructure, systems, andhuman resources in prevention, care, support,and treatment programmes at district, state, andnational levels.

l Strengthen the nationwide Strategic InformationManagement System.

The specic target of NACP-III is to reduce the rateof incidence by 60 percent in the rst year of theprogramme in high prevalence states to obtain thereversal of the epidemic, and by 40 percent in thevulnerable states to stabilise the epidemic.

Care, Support, and Treatmentunder NACP-III

NACPIII seeks to implement HIV services across thecontinuum of care. Accordingly, prevention will gohand-in-hand with access to prophylaxis, managementof opportunistic infections, and ART. Given the lowlevels of coverage, focus will also be on assuring


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universal access to rst line Anti Retroviral drugs(ARVs) in the rst instance. To ensure drug adherence,the Community Care Centers will be recongured as abridge between the patient and the ART centers and

provide psychosocial support, counselling throughstrong outreach services, referrals, and palliativecare. Home-based care will be an integral part of thisstrategy.

Care, support, and treatment services includemanagement of opportunistic infections includingcontrol of TB in PLHIV, ART, safety measures, positiveprevention, and impact mitigation. By 2011, theprogramme will be able to treat 320,000 OI episodesin a year, provide TB referrals to 2.8 million PLHIV,and ART treatment to 300,000 PLHIV, including39,000 children. The component related to Care,Support, and Treatment is proposed to be allocatedan 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 (September2005 to August 2008) being implemented by TamilNadu State AIDS Control Society (TANSACS) inpartnership with Solidarity and Action Against theHIV Infection in India (SAATHII). SAATHII, a non-prot agency headquartered in Chennai, India,provides technical assistance and capacity-buildingto government and non-government HIV serviceproviders, and has been helping strengthen and scaleup services in the country since 2000.

In 2005, The Childrens Investment Fund Foundation,UK (CIFF, UK) awarded funding to TANSACS to expandART, with SAATHII designated as the provider oftechnical, operational, and logistical assistance.

Tamil Nadu Family CareContinuum (TNFCC) Programme

Clinical Mentorship is being carried out in partnershipwith International Training and Education Center onHIV/AIDS (I-TECH). External Monitoring and Evaluationis being conducted by Duke University, USA.

TNFCC is one of the rst and largest public-private partnerships for HIV care in India. Itserves approximately 14,178 PLHIV, 9,393 familieswith children, 13,104 adults, and 1,074 infectedand 10,253 affected children at the end of threeyears (September 2005 to August 2008). It hasdemonstrated success in reducing HIV-relatedmorbidity and mortality, and improving quality-of-life, by providing ART to children and familiesinfected and affected by HIV/AIDS in the urban andrural areas of Tamil Nadu.

Of particular note is the fact that TNFCC is one of therst government programmes to give free 2 nd line ARTdrugs. Out of the 65,000 PLHIV in Tamil Nadu, around35% requires 2nd line ART. Second line ART is moreexpensive (Rs. 6,00012,000, averaging 10,000 permonth) than 1 st line ART (Rs. 6502,000, dependingon regimen, government procurement rates maybe between Rs. 5001,500). One of the biggestachievements of the TNFCC clinical mentorshipprogramme is streamlined 2nd line initiation. Thisprocess will be discussed later in the document.

TNFCC Programme Objectives:l To develop and evaluate a multi-sectoral model

involving government hospitals, NGOs, CBOs, andpositive networks in providing a comprehensivecontinuum of care and treatment to includemedical, psychosocial and nutrition services,treatment of opportunistic infections, andprovision of ART.



l To develop and evaluate an integrated family-centred continuum of care and treatment modelfor HIV positive families.

l To develop successful linkages throughpartnerships among various stakeholdersincluding government, NGOs, CBOs, and PLHIV.

l To integrate community-led treatmentpreparedness and literacy programmes with care,support, and services.

l To evaluate the impact of nutrition support andcounselling on morbidity and mortality in childrenand 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 andVillupuram.

l Govt. Mohan Kumaramangalam Medical College

Hospital (Salem cluster) - Salem, Erode,Dharmapuri, and Perambalur.

l Govt. Medical College Hospital (Tirunelvelicluster) - Tirunelveli, and Tuticorin.

Hospital Activities

The three government medical college hospitalsfunction as hospital programme sites and are responsiblefor coordinating and providing comprehensive care,support, and treatment services.

The hospital-based services are provided byhospital staff, government appointed doctors, andrepresentatives of community based organizations.

Hospital and NGO Partners of the TNFCC programme

Hospital Districts covered Hospital NGO Field NGOs, CBOs and

Positive NetworksGovernment KilpaukMedical CollegeHospital, Chennai

Chennai, Tiruvallur,Kanchipuram, andVillupuram

Community HealthEducation Society (CHES)

SIP+, MSDS, and ACD

Government MohanKumaramangalamMedical CollegeHospital, Salem

Salem, Erode,Dharmapuri, andPerambalur

Young WomenChristian Association(YWCA), Salem

YWCA, HILLS,SEARCH, and INDO

Government MedicalCollege Hospital,Tirunelveli

Tirunelveli, Tuticorin,and Kanniyakumari Gramodhaya SocialService Society PWST+, St. JosephLeprosy Hospital



For each ART Center, TANSACS has recruited andtrained 2 ART medical ofcers, 12 counsellors,1 lab technician, 1 pharmacist, 1 community carecoordinator, and 1 data entry operator. While thisstafng pattern is similar to that of ART Centersacross the country, TNFCC sites were established withsupplemental stafng in the form of a trained NGOsupport team, consisting of the following personnel:l 1 Project Coordinatorl 12 Counsellorsl 12 Nutritionistsl 12 Nurse Case Mangersl 2 Nursing Aidesl 1 Pharmacistl 1 Accountant/Data Entry Operatorl 1 Sanitary Worker

After the second year of operation, the NGO staff wereslowly phased out once the ART staff were added, asper the revisions in national ART centre operationalguidelines. The NGO staff numbers have varied acrossthe three centers, in accordance with the prevailingclient load.

Field Activities

Community services provided by NGOs in each ofthese ten districts are as follows:l Identication of HIV clients and motivation of

patients for hospital registration and monthlyfollow-up visits

l Conducting support groups near the patientsresidence

l Identication and training of peer educators andcare givers

l Provision of home-based care that includesopportunistic infections diagnosis and referrals,as well as ongoing adherence counselling

l Referrals and linkages to various services likehousing, 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 810Outreach Workers of the eld NGOs afliated with therespective ART Centers.



SAATHI (Solidarity and Action Against The HIVInfection in India) has served as technical assistancepartner for TNFCC, providing training, support visits,coordination, networking, ongoing technical updates,and mentorship.

TrainingTANSACS and SAATHII conducted training for variousstakeholders on the following topics (target traineepopulation shown in parentheses):l Clinical Management of HIV/AIDS (counsellors, lab

technicians, nutritionists, pharmacists, sanitaryworkers, project coordinators, community healthnurses, child counsellors, and outreach workers)

l Home-based Care (nurses, counsellors, projectcoordinators, nutritionists, outreach workers,community health nurses)

l Adherence Counselling (hospital and eldcounsellors and coordinators, community healthnurses, and outreach workers)

l Child Counselling (ART counsellors and eld childcounsellors)

l Life-skills Training (eld project coordinators,child counsellors)

l Financial Management (project head, projectcoordinators, accountants)

l Training on Organization Development/ Management, Leadership, and Communication(NGO heads and project coordinators)

l Induction and advanced training fornutritionists

l Training and mentorship to hospital and eldcounsellors and outreach workers on generalcounselling with a component on HIV/AIDS(disclosure, safe sex, and stigma)

TNFCC - TechnicalAssistance and Capacity Building

l Home-based care mentorship training forcommunity project coordinator, child counsellors,and community health nurse for mentoringoutreach workers

l Child Services training for the community childcounsellors

l Training for ART medical ofcers (see below).

ART medical ofcers were trained at the start of theTNFCC programmefour days in Tambaram Sanatoriumand six days in YRG Care. The Tambaram trainingcomplied with NACO Guidelines and covered OI, ART,side effects, documentation and reporting, monitoring,clinical rounds, and pediatric HIV care. The trainingat YRG covered second line drugs, system-wide HIVclinical management, hospital-waste management,universal work precautions, clinical rounds, and casestudies. Tools were adapted from the Clinical MentoringToolkit developed by the International Training andEducation Center on HIV (I-TECH).

The contents of induction training were repeatedduring Years II and III because of high staff



turnover. The training was made specic and target-focused in order to ensure that participants attainedthe necessary level of competence. All trainingprogrammes were conducted within the rst threeyears since TNFCCs inception.

SAATHII provides technical updates during supportvisits and programme coordination meetings at ARTcenters where hospital ART team and communityNGO teams interface. Discussions focus on the issuesarising out of the daily work of programme staff,especially outreach workers. Technical assistanceto NGOs helps in identifying eld-based solutionsthrough monthly monitoring visits and ongoing need-based support. For instance, several outreach workershave difculties in talking about sex, ART treatment,and disclosure so SAATHII conducts regular follow-upon the trainings provided.

Mentorship Initiatives

There are four Mentorship programmes under theTNFCC:l Clinical Mentorship to ART medical ofcers

(provided by SAATHII and I-TECH)

l Counselling Mentorship to hospital and eldcounsellors (SAATHII)

l Home-based Care Mentorship to outreach workers(SAATHII and Field NGO Core Team: ProjectCoordinator, Child Counsellor, Community HealthNurse)

l Child Services Mentorship to child counsellors(SAATHII)

The clinical mentorship programme was the rstof its kind in the programme, and in the country,and its success resulted in launching of mentorshipinitiatives in the other domains listed above. Theclinical mentorship programme will be presented indetail in the following section.

For the counselling mentorship programme, four daysof training were provided (two days each, in tworounds from January to March 2008). In addition,one-day visits were made twice to the hospitals.These visits involved counselling and observationsin the morning, and case study discussions amonghospital and eld counsellors, in the afternoon. Thementorship activities were implemented by SAATHIIwith initial assistance from external experts.

Initial home-based care mentorship was provided bySAATHII. However, due to an increased number ofoutreach workers in the third year (around 100), amentorship training was conducted by SAATHII forselected eld staff (2025 total, two to three fromeach community NGO) who then constituted the coreeld team. This helped broaden and decentralize thepool of mentors.

The child services mentorship was provided by SAATHIIto the community NGO-based child counsellors.Training covered life skills education, recreation,education and referrals, and linkages to additionalservices.



Background and Partners

A signicant need addressed through the TNFCCprogramme was capacity enhancement of the localhealth institutions in HIV care and treatment,especially in management of complicated andchallenging cases in relation to OIs, and ART (rstand second line drugs). SAATHII identied clinicalmentoring as an appropriate strategy to developthis expertise among local health care providers.Structured clinical mentoring, using adult learningprinciples, helped bridge the training gap betweentraditional didactic trainings and practice in theclinical setting.

SAATHII identied the International Training andEducation Center on HIV/AIDS (I-TECH) as thetechnical partner to develop the Clinical MentorshipProgramme for TNFCC. I-TECH is a global AIDS trainingprogramme working at the invitation of ministries ofhealth and the U.S. government to increase humanand institutional capacity for care and treatment incountries hardest hit by the HIV and AIDS epidemic.

The Clinical MentorshipProgramme Overview

I-TECH is collaboration between the University ofWashington, Seattle, and University of California,San Francisco.

I-TECHs model of Clinical Mentorship

I-TECHs primary objectives for clinicalmentoring are consistent with the World HealthOrganizations public health approach to scalingup HIV care and ART. These objectives include:l Supporting decentralized delivery of HIV care,

ART and prevention, as well as continuousimprovement of patient outcomes at all ARTdelivery sites.

l Promoting application of classroom learningto clinical settings.

l Improving the quality of clinical care andpatient outcomes in resource-constrainedsettings.

l Building capacity of primary care providersto provide comprehensive and integratedcare using on-site clinical collaboration,consultation, and directed support

SAATHII collaborated with I-TECH in curriculumadaptation, mentor programme design andimplementation.

Geographical SitesThe Clinical Mentorship Programme has been implementedin ART centers in three districtsGovernment KilpaukMedical College Hospital in Chennai, Government MohanKumaramangalam Medical College Hospital in Salem,and Government Medical College Hospital in Tirunelveli.These three sites cater to families from three focal andseven surrounding districts.



Who is a Clinical Mentor?As dened by WHO: A clinical mentor in theantiretroviral therapy context is a clinician with

substantial expertise in antiretroviral therapy andopportunistic infections who can provide ongoingmentoring to less-experienced HIV clinical providersby responding to questions, reviewing clinical cases,

providing feedback and assisting in case management.This mentoring occurs during site visits as well asvia ongoing phone and e-mail consultation. Clinicalmentoring is critical to building successful districtnetworks of trained health care workers for HIV careand treatment in resource-constrained settings .

The Clinical Mentorship Programme involves two mentorsfrom I-TECH, one mentor from SAATHII, and sevenmentees, who are medical ofcers at the ART Centersthat were included in the TNFCC programme. Whenmentorship was initiated in April 2007, the menteesalready had a case load of around 12,000 HIV/AIDSpatients altogether at three sites, including over 4,000patients on ART, of whom 80 are on 2 nd line drugs.

The mentors possess clinical knowledge, training andinterpersonal communication skills. Key mentoringstrategies included building rapport, giving feedbackeffectively, identifying teaching moments, teachingat the bedside, and addressing systemic issues.

For greater details on the Clinical Mentors TrainingCurriculum, refer to www.go2itech.org

Mentorship Methodology

Mentorship is an ongoing process whereby thementor assists and assesses the patients conditionand line of treatment both directly during visits andthrough distance mentorship to ART medical ofcersbased on details provided via email or telephone.Mentorship includes, at a minimum, the followingcomponents:l Orientation of external mentor by SAATHI

mentorl Planning and tool development by mentorsl Training and needs assessment of the ART medical

ofcers by SAATHII mentorl Reliance on adult learning principlesl On-site two-day hospital visits by mentors to

each of the hospitals every three monthsl Long-distance mentorship

Onsite MentorshipThe mentor makes quarterly visits to the hospitalsand engages directly with the doctors and thepatients identied by the mentee as case studies. Inaddition, the mentor examines individual patients asrequested by the mentee. Onsite mentorship entailsthe following:l Onsite review of medical practices at the hospitals

with the doctorsl Identifying training needs and areas for

strengtheningl Mentoring the doctors by the various methods

elaborated below:l Modelingl Facilitation of various case studies and

discussionsl Hands-on trainingl Additional clinical training using adult learning

principlesl Sharing of supplementary reading materials from

peer-reviewed journals.l Advocacy with mentees for systematized case-

management, laboratory investigations anddocumentation

l Facilitating data collection, best practicessharing, and clinical research



Distance MentorshipThis component of the mentorship programme isprobably the most pragmatic, as it ensures continuousand adaptive learning. The mentees call or emailthe mentors periodically, enabling timely treatmentof patients, and establishing open communicationbetween mentor and mentee.

Distance Mentorship entails the following:l Ongoing consultation with doctors by phone and

email l Exchange of case sheets, scans, and other relevant

documentsl Sharing of reference material to enhance

learningFocus Areas of Mentor Involvementl Routine clinical care for HIV and associated

medical conditions

Mentoring Strategies

Modeling Facilitate Discussions Additional ClinicalTraining

Support

l Greeting patientswarmly

l Sensitive patientexamination

l Multidisciplinaryteam approach

l Shadow/observe

l Difcult andcomplex cases

l Ethical issuesl Patient owl Clinic set-upl Patient triagel Quality of Care

l Case Studiesl Mini-Teaches based

on needs of clinic

l Serve as an advocatel Cheerlead

l Listen/validatework of doctors

l Coachcommunicationtechniques

(source: www.go2itech.org)

l Progress assessment of patients on ART (side-effects, toxicities, management)

l OI management of non-ART patientsl HIV-TB co-infection managementl Second line initiation, regimen selection, and

monitoringl Improving doctor-patient interaction through

effective communicationl Post-Exposure Prophylaxis (PEP)

Results

Findings and outcomes of the mentorship programmewere gathered through initial training needsassessment, personal observations by the mentors,patient interviews, and focus group discussions withthe hospital staff and through mentees self reporting.Results are presented in the following sections.



The Mentees

A needs-assessment of the seven mentees was conductedat the beginning of the mentorship. The followingsynopsis reects the experience in all three centers:

1. Prior experience in the HIV/AIDS eldWork experience varied among doctors, with twohaving less than two years of experience, and therest ve either 24 years, 46 years, or 810 years.

All but one had previous AIDS-related work experiencein hospitals, private clinics, or with NGOs.

2. Patients treated per monthHospital PLHIV PLHIV on ART Tirunelveli 1,000 250300Kilpauk MedicalCollege Hospital

2,100 530

Salem 4,500 1,500Average 2,533 768

3. Previous trainingsAll of the doctors had attended previous HIV-relatedtrainings. These include:l GHTM NACO 4 attendees l YRG Care 4 attendeesl HIV-TB/ATT-RNTCP 4 attendeesl Dr. MGR Medical University 1 attendee l International Conference, University of

Hyderabad 1 attendee l CME, Karigiri 1 attendeel CME, YRG 2 attendees l WHO IMAI training, St. Johns Bangalore

1 attendee l Clinton Foundation IMA doctors training

1 attendee

Clinical Mentorship Programme Training Needs Assessment

4. Training formatsl The most preferred training formats were: t Conferences

t Printed materials (journals, newsletters, etc.) t Skill building workshops t Case presentation seminarsl The least preferred training format was weekend

case discussions.l Each doctor listed a separate preference for

frequency of ongoing trainings.l Most of the doctors agreed that one working day

a month could be dedicated to training, either asfour hours each day for two days, or one day ofeight hours.

l Internet access: Tirunelveli and Salem hadunrestricted access to internet use, but KMCHonly received access towards the mid-mentorshipperiod.



5. Barriers to trainingl The most commonly cited barrier to training was

long travel times to Chennai.Suggested solutions:

t Make Madurai or Tiruchi the centre fortrainings

t Conduct trainings at all three sites, on arotating basis

l Salem indicated that both ART medical ofcerscould not attend at the same time.

Suggested solution: Assign an alternate/additionalART medical ofcer

l KMCH cited lack of access to internet as abarrier.

Suggested solution: Printed materials and CDs

Training Needs Assessment

Doctors were presented with a set of HIV-relatedtopics, and asked to indicate their level of skill ineach and their learning interest (as high, mediumor low).

The doctors expressed the highest learning interest intopics listed below. Items that are starred are thosein which they also indicated low levels of skill.

1. Lab Diagnosis of HIV Infection Therapeuticdiagnosesl HIV RNA PCRl CD4 Count testingl Other markers*l Culture and resistance*

2. Opportunistic Infections and Co-Infectionsl Clinical presentationl Lab and clinical diagnosis of OIsl Differential diagnosisl Treatmentl GIT manifestationsl Dental manifestations*l Ophthalmic manifestations*l Neurological manifestationsl Tuberculosis*

3. Pediatric HIVl Growth and development parametersl Lab diagnosis (



Site-specic needsTirunelveli KMCH SalemClinical Topicsl Radiotherapy in HIV patientsl HIV/TBl Role of Immuno-

Modulators in HIVl Natural Medicines/Herbs/

Ayurveda/Siddha and HIVl Neurological case presentation

other than common CNS OIl Immunity: Innate, Acquired,

and HIV Pathogenesis

Other Topicsl Need for separate

e-forum for ART MOl Legal implications

and advocacyl Administration skill

development and leadershipqualities improvement

l Financial managementof ART centers

Clinical Topicsl Resistance testing methodsl Mutations (diagnostic,

prevention, treatment 2nd line) and dry selectionaccording to mutations

l Algorithms for specictoxic effects of ARVs

l Psychosocial assessment scales for specic conditions,adult scales, child scales

l Prevention: breast feeding,education of adolescents,ARV eligibility

l ART: second lines, integraseinhibitors, maturationinhibitors, any viricidals?

l Vaccines: trials, typesl Recent research studiesl HIV and other elds

Clinical Topicsl Non-HIVrelated

co-infectionl Management of chronic and

recurrent diarrhoea

l Technical update on ARTinitiation and re-initiation

l Management of OIin ART patient likeImmune ReconstitutionInammatory Syndrome

l Changing patient attitudesand positive prevention(i.e., more womengetting pregnant)



As described in Section IV, Overview, the TNFCCClinical Mentorship Programme incorporates threeprimary learning components use of adult learningprinciples, onsite and Distance Mentorship. Trainingtools were adapted from the Clinical MentoringToolkit developed by I-TECH. (For additionalinformation on the I-TECH training curriculum, seeAnnexure - I)

The following section explores these components ingreater detail.

Adult Learning as Basic Approach

The clinical mentorship programme is designedon the premise that adult learning techniques arethe most effective in skills transfer. Adult learningprinciples emphasize that adults come to learningenvironments with:l their own experience and expertisel an expectation that they will be respected and

guidedl and a focused motivation to learn based on

specic needs to accomplish job-related tasksmore effectively

The experience at Tirunelveli provides a case study onthe use of these learning principles within the clinicalmentorship programme. Dr. Narayana Srinivasan,Senior Medical Ofcer at the Government MedicalCollege Hospital, Tirunelveli, calls this a uniqueprogramme because it was developed in response to apersonal needs-assessment. The mentors rst questionwas what are your expectations? The mentor seeksto identify strengths and weaknesses and providesassistance accordingly. The mentors work beside thedoctors and not above them. The center has a caseload of 250 patients a day. The mentor recognizes the

The Clinical Mentorship Programme Learning Methodology

challenges faced by the doctors and the staff, as wellas the demands made upon them.

The mentors have been very willing to shareinformation. The doctor calls the mentor everyday onthe I-TECH hotline to discuss any problems or doubtshe may have. These conversations cover a range ofissues including drug adjustment, availability ofdrugs, and drug dosage. A recent example is thatof a patient with renal failure the mentee soughtguidance regarding on how to assess changing levelsof kidney functions, and the need to adjust ARVdosages accordingly.

Moreover, the mentorship is not purely clinical -- thementors urge the doctors to use interpersonal skillswhich enhance their role as a doctor, such as how toelicit information from reluctant/hesitant patients orhow to counsel them on behavior change.



Mentorship through On-Site Visits

The rst round of On-site Mentorship for the ART medicalofcers of three TNFCC centers was implemented duringthe rst quarter of the grant period. This round followeda tools development for mentors and training needsassessment of the ART medical ofcers (mentees). On-site visits proceeded as follows:(a) The mentor outlined the objectives/purpose of

the visit to the medical ofcer: to improve theskills of the ART medical ofcer. The mentor alsoreviewed the principles of mentorship and thespecics of the two-day schedule.

(b) On the rst days morning session, observationwas used to assess the medical ofcers clinicalknowledge, skills, attitudes, and practices. Mentorssat with the medical ofcers at the ART clinic.

(c) In the afternoon, discussions/trainings wereconducted to share observations, explorechallenging cases, review national guidelines,and discuss the feasibility of implementation.Mentors also shared their work experiences inother settings as a way to discuss best practices.In addition, the following issues were covered indetail: ART toxicities, substitution of ARVs, privacyof examination, ow of patients at the ART centre,the role of the nurse case manager at the ARTcentre, and HIV/TB co-infection management.

(d) On the second day, apart from mentoring in theoutpatient department, the mentor:

l Performed ward rounds and hands-on-trainingon the wards

l led detailed case discussions on second line

drugs using actual case studies from the ARTcentre

l addressed gaps in case management and inthe documentations of second line cases;and, made suggestions as to how to rectifythe problems using the check list, a draftcopy of which was handed out

l demonstrated how to use the Stanford guidein interpreting the genotype resistance studyresults using the appropriate web site

l using case records, stressed how important itis for the medical ofcer to examine patientson second line drugs

l explained the importance of documentationrelated to death and other interesting cases

l gave the medical ofcers important web sitesfor reference, and shared articles related toareas of interest

Recommendations were made to all three sites basedon the rst round of visits. See box below. The tool formentorship assessment is provided in Annexure - II

Distance MentorshipDistance Mentorship in this programme has beenactively encouraged and a hotline between thedoctors and the mentor allows for open and regularcommunication. Several doctors said that they wouldcall the mentors 34 times a day. Distance Mentorshipincluded:(e) Ongoing consultation with the doctors through

various communication modes like phone callsand e-mails

(f) Monthly follow-up meetings with TechnicalAssistance (TA) and Implementer

(g) Quarterly eld visits by the mentor. On theseoccasions, special cases are directly presentedto the mentor. In addition, observations anddiscussions with mentees give the mentor anopportunity to observe any other infrastructureneeds doctors may have. (See more about On-Sitementorship above).



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

l Appropriate instruments and logistics for systematic clinical examination to be provided to improveclinical examination.

l Appropriate laboratory tests for better clinical care to be made available at all the centers for testingselected and needed cases.

l The doctors shall follow the NACO guidelines in care and treatment.l There is a need to arrange experience-sharing and review meetings and update sessions with interesting

and difcult case studies.l The ART medical ofcers of three centers should rotate for experience sharing and case discussions. They

can also visit other centers during mentorship visits (cross-mentorship).l Documentation should be improved in case sheets and ART card.

To improve the documentation practices in the case sheets:l Medical Ofcers shall conduct audit of the reported deaths among the ART team to discuss and identify

the probable cause and also use it for programme improvementl Death

(a) Doctors shall mention the associated conditions that led to patients 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 patients condition during his/her last visit and discuss withthe doctor based on the same.

l SECOND LINE DRUGS:

(a) Appropriate initiation of second line drugs A committee consisting of TA team, I-TECH and TANSACSshould decide on the appropriate regimen to be chosen. Other technical members shall be includedin the committee as required by TANSACS.

(b) The ART medical ofcers should ll the second line case sheet attached as annexure and send thesame to the committee for deciding the second line.

(c) ART medical ofcers should collect all the details from the referral doctors regarding previoustreatment 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 mentors 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.l All the basic lab tests for management of HIV including second line drugs as per the NACO guidelines are

available. Below is the list of lab tests not available:

Tirunelveli KMC SalemHBsAg Anti- HCV HBsAgAnti-HCV S.Lipase Anti-HCVS.Amylase S.TriglyceridesS.LipaseS.Triglycerides



TANSACS shall suggest TA and ART medical ofcers to follow-up on the above lab tests.l The pharmacy assessment report shows majority of the basic drugs especially Cotrimoxazole (Septran)

and Fluconazole are available for treatment and the drugs not available are listed with the reasons below.The starred drugs are not available under regular hospital supply, and hence will be purchased using theOI 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 byI-TECH and SAATHII, in partnership with TANSACS,has demonstrated success in1. Improved learning;2. Improved clinical outcomes;3. Improved documentation.

1. Improved Learning

The most signicant emerging practice in the ClinicalMentorship Programme is the culture of new andcontinued learning for the entire team of health careprofessionals 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 signicant impact onthe approach to HIV care and treatment, and laid astrong foundation for continuous and renewed adultlearning.

Dr.Thennarasu from Kilpauk Medical Hospital afrms,The Clinical Mentorship has shaped me! Thementorship programme has brought him in contactwith senior professionals and has improved hisknowledge and skills in dealing with patients. Afocus group discussion with the project coordinator,nutritionist, nurse, and lab technician at GovernmentMohan Kumaramangalam Medical College Hospitalin Salem revealed that even though they have notinteracted with Dr. Manoharan (the mentor) directly,they are aware of his expertise and knowledge. Theprocess of continuous learning has had a ripple

The Clinical Mentorship Programme Findings, Feedback and Outcomes

effect. They have learnt when to change the regimenand are more comfortable with preparing nutrientsfor special cases, and making home visits. Health careprofessionals in Salem indicate that their knowledgeof HIV has increased not only in care and treatment,but in counselling as well.

Mentorship programme enhances the menteesexisting expertiseThis enhanced expertise translates into higher jobsatisfaction for doctors and, ultimately, into higherpatient satisfaction rates. For example, Mr.Rajan(name changed)a 35-year-old lorry driver who hasbeen coming to Tirunelveli since 2005was awarethat when the new drug prescribed did not agreewith him, it was changed in consultation with anexternal doctor.

This alternative route to learning has set a precedentin the programme to foster an open environmentwhere there is easy access to information andenhanced communication and collaboration at all



levels. Besides this, the process of continued learningis a new experience for the doctors who are used toattending trainings that are either too didactic ortoo short to address the complexities of HIV care andtreatment. Simple standardized guidelines for caredo not t in many cases. The nuances of managingdrug interactions and toxicities against the backdropof underlying liver disease and co-infections arechallenges the medical world is trying to meet atevery turn. It requires expertise and a progressiveapproach, which a mentorship programme providesfor both the mentor and the mentee.

Clinical mentors help the mentees translatetheoretical knowledge into practical clinical skillsDr. Thennarasu at Kilpauk Medical Hospital admitsthat his knowledge of HIV/AIDS prior to the launch ofmentorship was quite limited. His specialization is inophthalmology, and there was no component of HIV/ AIDS in his medical curriculum. It was only throughthe Clinical Mentorship programme that he becameaware of diagnostic challenges and other clinicalconsiderations that steer the line of treatment. Thementor advises him on when to run viral load andresistance tests, and when to start 2 nd line ART. Dr.Sentha Krishna from Salem Government Hospitalexplains, I am more condent about handling casesnow. She now treats complications like Cryptococcalmeningitis and Zidovudine anemia (caused by ARTtoxicity) because of the knowledge she gainedthrough mentorship.

The mentors have been very willing to shareinformation, and they give the doctor tips on how toelicit information from reticent patients. The doctorscall the mentors regularly on the I-TECH hotline foradvice on drug adjustment, dosage, and availability.Detailed case histories are sent through email, whileX-rays, CT scans, and photographs are couriered atleast 23 times a month.

2. Improved Clinical OutcomesKey outcomes of the clinical mentorship programmehave included streamlining of 2 nd line ART initiation

and improved management of complicated casesincluding kidney, liver and CNS issues.

TNFCC was one of the rst initiatives in the country tomake 2nd line ART drugs available. Out of the 65,000PLHIV in Tamil Nadu, around 5% require 2nd line ART.NACO started 2nd line ART recently.

As Dr Sathish puts it, one of the biggestachievements of clinical mentorship is streamlined2nd line initiation. The complexity of managingdifcult cases means that standard protocols andstraightforward algorithms cannot always be applied.Individual clinical judgment needs to be supportedthrough mentoring, referral, and consultation supportuntil clinicians become comfortable in knowing whento start, stop or change therapies. The mentorshipprogramme enhances the quality of both short-termand long-term patient care and health outcomes.

Prior to the mentorship programme, complicatedcases were referred to other hospitals or sent tolarger towns. Dr Sentha Krishna, from Salem, saysthat referrals to Tambaram have come down and thepatients reiterate it, Tambaram care is availablehere! The programme has also raised the hospitalsprole in the eyes of patients. Patients from otherdistricts have also started visiting these hospitalsbecause of accessibility and quality treatment.Complicated cases are treated in the hospital eitherthrough electronic or telephonic consultations orthe case is presented to the mentor on the day ofhis visit.

Another signicant clinical outcome of this programmeis the timely intervention in peripheral and symptomaticconditions like kidney and liver malfunction, centralnervous system problems. Earlier these cases werereferred to other departments or hospitals causingdelays in the patients treatment, which in some caseswere fatal. For instance, a patient with Zidovudineanemia in Salem hospital showed no improvementeven after eight bottles of blood transfusion. Onmentors suggestion, an erythropoietin injection wasadministered and the patient, who had severe anemia


27/58



may help minimize any misunderstandings. It isimportant to match the mentees expectations in orderto foster an effective mentoring relationship. Therewere cases where a mentee would have preferred amore senior mentor who better matched his ownconsiderable experience and knowledge.

The mentorship programme needs to focus beyondclinical management of HIV. The spectrum of HIVrelated care is much broader and the patient load insome of these centers is very high (the doctors aretreating around 12,75013,000 HIV/AIDS patientsat three sites, more than 4,300 of whom are onART, including 100 on 2nd line drugs). Counselling,stigmatization, and behavioral changes are some ofthe issues that need to be addressed.

The mentorship programme is too focused on clinicalcare and management of HIV/AIDS. It should includecounselling, nutrition and home based care.

Some doctors felt that the mentors quarterly visitswere not enough, especially if they delayed/missed avisit. A more exible itinerary may be more effective.Most doctors felt that it would be a good idea toinstitutionalize the mentorship programme.

Mentorship outcomes and ndings

Mentorships Positive Impact on Care as perMentorsOobservationsl Comprehensive medical assessmentl Improved safer sex education and family

counsellingl Privacy during medical examination and

counsellingl Diagnosis and treatment of complex medical

conditions including crypotococcal meningitis,TB meningitis, TB pleural effusion, AZT-inducedchronic diarrhoea and ascites among others

l Timely initiation of ART for TB co-infectedpatients

l Use of correct dosages of ART for childrenl Diagnosis and treatment of co-morbidities such

as diabetes, hypercholesterolemia, and liverdisease

l Accurate identication and treatment of failurecases

l Referral to appropriate medical services which areavailable onsite

l Frequent referencing to national guidelines andprotocols

l Quality of care documentationl Reduction of overcrowding at the clinics by

shifting certain tasks to nurse managersl Diagnosis of various medical conditions through

use of medical equipment that was previously notavailable onsite

In the course of a focus group discussion withART team other than doctors, to share and analyzeoutcomes of the mentorship programme, pointsdiscussed included:l Paramedical staff (excluding the Project

Coordinator) knew about the mentors visits.l There is not enough space and time to control the

high patient turn over. Given the opportunity, theywould like to spend more time on counselling.

l Improvement in infrastructure, like provisionof generators, would facilitate the free ow ofservices, especially in the labs.

l To help practice universal precautions, coats,shoes, and gloves have been provided and areavailable.

Feedback from Different Stakeholders:

The clinical mentorship programme has been receivedfavourably in all the centers and feedback reectsthis. Its reach has, in some cases, extended topersons not directly participating in the programme.For example, at one ART centre, staff who had notinteracted directly with the mentor was familiar withhis work in the hospital.

Direct feedback obtained from the different groupsreects a generally favorable reaction to thementorship programme.


29/5823HIV 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 planl Retain the same medical ofcers at the ART centersl Advocate for more, but appropriate, lab tests and drugs at the ART centersl Advocate for more collaboration between hospital departments

Mentees l The clinical mentorship programme is very useful for doctors, especially in centers with onlyone doctor, who would otherwise not have the chance to discuss patients with colleagues

l Helpful for those recently graduated from medical schoolsl Need for an intensive training on 2 nd line ART and annual refresher/orientation programmes

Paramedical l Pre-ART care is also an essential feature of the programmel 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 510 minutes

because the patients who are waiting become impatient. Given that these sessions

usually address health and hygiene, micro/macro nutrition, and other positive livingtopics, 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 fastpatient 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 childrens attendance at school.l Few patients prefer counsellors to make home visitsl 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 efciently and a months supply of OI drugs isavailable. In addition, concerned hospital staff provides patients with information andanswers their questions in detail. For these reasons, patients dont mind spending thewhole 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 mentorand mentee is the foundation of effective mentoringpractice. This section includes suggestions on howto initiate and build a strong relationship of mutualrespect between the mentor and the mentee, and howto provide constructive feedback and encouragementwithin the mentoring relationship.

Strategies for MentoringMentors work in a variety of settings in which theyface a wide range of constraints and challenges.Developing strategies and approaches to effectivelycarry out mentoring activities within different settingspresents a unique set of challenges. The documentsin this section provide mentors with suggestions andideas on various approaches to mentoring, includinghow to conduct bedside teaching, conduct site visits,mentoring in the face of heavy patient loads, andstrategies for addressing a wide range of systemsissues.

Monitoring and Evaluation Tools

This section includes tools and resources for amentor to use to assess the skills of providers andto assess facility issues. Observation checklistsin this section help the mentor to track providers

I-TECH Clinical MentorsTraining Curriculum

improvement in their delivery of clinical care overtime. Facility checklists enable monitoring of systemsimprovements at a site. The tools included have beendeveloped by I-TECH projects around the world, andcan be adapted to t a mentors particular situationand area of focus.

Training Health Care Workers

The ultimate goal of a clinical mentoring programme isto build the skills of local clinicians. Clinical mentorsmay provide one-on-one mentoring to a health careprovider during a patient consultation, conduct stand-alone sessions for clinical staff on various clinicaltopics, lead discussions highlighting the managementof complex cases, and accompany staff on rounds.This section includes resources for mentors on how touse case studies and clinical vignettes to guide thetraining of health care workers.

I-TECH Curricula

This section contains I-TECH training curricula on avariety of topics related to HIV and AIDS that canbe 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. Clinicalmentors are free to adapt and change these materialsas needed. This section includes twelve completecurricula (multiday trainings with several slide sets)and four workshops (shorter sessions appropriate foran hour or two of training on a focused topic). All ofthe curricula included here have been pilot tested byI-TECH country programmes.



Tool for mentoshipassessment

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 stafnglevel?

Very well staffedAdequately staffedUnderstaffed

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)

Currentlyfunctioning

(Yes/No)

Last used /available

(Date)

Reasons fornot using/nonavailability onday of visit

(*see codesbelow)

Final code

(To be codedlater)

ElectricityRunning waterCommunicationfacilities (phone, fax,internet access)

Private room forcondential consults

Seating for patientswhile waitingDisp. glovesDisp. masksStethoscopeDisinfectantsAppropriateexamining tableAdequate lightingBP cuff Reex hammerSpeculumMicroscopy

*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 ling 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 alsoconsults a traditional and/or alternative healer?

%

Dont knowProviders dont ask

2. What are the general characteristics of yourpatient/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 HIVtransmission?

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 bloodspecimens frozen at 20-70 o 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?

Inuenza

Pneumococcus

Hepatitis A and B

6. What barriers do you experience in providingcare 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 condentiality

Issues of cultural competency

Other (specify) ____________________

V. PRACTICE SET-UP

1. Physical space to accommodate and patient privacy (tick one):

Inadequate, major barrier1.

Minimal 2.

Adequate3.2. Does triage promote efciency and patient safety?

None, totally ad hoc1.

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

Triage occurs (guidelines in place)3.

Efcient triage system practiced4.3. 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 ow between members of the team is effective and efcient:

Patients movement among providers is inefcient1.

Patient spends time with different team members makes some sense2.

Patients receive maximum benet from moving among providers3.



Is patient education incorporated into patient care?Physician Nurse Councellor NutriotionistNo Yes No Yes No Yes No Yes

General HealthAdherenceRisk reduction

Is continuum of care routinely practiced?No Rarely Sometimes Routinely

OI prophylaxisOI treatmentTB treated/monitoredSTIs treatedPain reduction methods offered

Is continuum of care routinely practiced?Yes No Yes No

Data capturing forms/registersCase sheets - initial (Yes/No)Report forms (Yes/No)Clinical document forms

Pain 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 patientsfollow through on care and/or service referrals?

Always

Almost always

Sometimes

Never

What is the most common reason patients cite for lack offollow 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 practicedYes No Yes No

Data capturing forms/registersCase sheets - initial (Yes/No)Report forms (Yes/No)Clinical document forms

Pain reduction methods offered

Hand hygieneAvailable Reported

available,

not seen

Not Available Notes

Sink or basin withrunning waterBucket of waterwith cup next tosink or basin

Antibacterial soapis available inward/on siteAlcohol-basedsolution for handwashing availableDry Soap in dishnear sink/basinComments:



Aseptic techniqueEquipment/

Supply

Available Reported available,

not seen

Not Available Notes

Supply of steriletubes for ICD

procedure availableAlcohol rub (i.e.antiseptics) availablefor sterilizationof patientDisposable sterilesyringes availableOther sterileequipment (pleasespecify)

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 UPMethods Observed Reported available,

not seen

Not Available Notes

MDRTB+ patientsplaced separatelyfrom HIV+ patientsTB- patientsseparated from TB+Comments

Immunization and exposure managementMethods Observed Reported done,

not seenNo procedureconducted/observedwith needle

Notes

MDRTB+ patientsplaced separatelyfrom HIV+ patientsHealth care staffused needle destroyerimmediately afteruse (i.e. did notrecap needle)Comments

Number of doctors reporting completing Hepatitis B vaccine course:

Doctors:



VII. LABORATORY

Can your laboratory perform the following tests?

Lab testsrecommendedby NACO

Yes No Maybe Remarks

Haemogram:Hb%TCDCESRPlatelet countTLC

Urine tests:SugarAlbuminDepositsOther tests

Liver function tests:S.BilirubinSGOTSGPTSAPTotal proteinAlbumin

Renal function tests:Blood urea

Sputum for AFBMantoux testChest X ray

Blood sugar

Blood VDRLTPHA

HBsAgAnti-HCV

CD4 count/CD4%

CD8 count, ratio

Viral load



S.AmylaseS.Lipase Culture SputumUrine

BloodCSF Stool

Fluid analysis CSF,pleural, peritonealetc. CSF India ink S.Cholesterol proleS.Total cholesterol TriglyceridesLDL,VLDLHDL S.LactateLDH

Stool examination

Motion ova, cystStool for AFB Toxoplasma serology StainsLeishmansMethenamine silverZN

GramGiemsaModied acid fast

FNAC USG scanCT scanMRI scan



VIII. PHARMACY

Category Currently available/ not available

(A/NA)

Last used/ available(if currently notavailable)

Whether available inthe OP or hospital

Reasons fornot using/nonavailability onday of visit

AntibioticsCiprooxacinNoroxacinCo-trimoxazoleErythromycinDoxycyclineAzithromycinAmoxicillinNaladixic acid

ClarithromycinSpectinomycinAqueousPenicillin (Inj)Clindamycin 300 mgSulphadiazine500 mgLevooxacinAntifungalsFluconazole.TFluconazole. InjNystatinKetoconazoleAmphotericin BItraconazole5-FlucytosineClotrimazole topical Antivirals:Acyclovir .T

Acyclovir.InjGancyclovir

Antiamoebics:MetronidazoleAntihelminths:AlbendazoleMebendazoleNitazoxanide

Antidiarrheals:ORSLoperamide



Antiemetics:MetoclopramideDomperidone Dermatologicalpreparations:Gentian violetWhiteeld ointmentTopical antifungalsLiquid parafn

Other drugs:NitrofurantoinDapsoneT. SulfadiazinePyrimethamineFolinic acidParacetamol AspirinIbuprofenCodeineChlorpheniramineDexamethasoneHydrocortisoneAmitriptyline

Carbamazepine

ATTIsoniazidRifampinEthambutolPyrazinamideStreptomycin

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 lled in after the observation]

Known HIV-positive person1. Chief complaints (check all that apply)

Skin lesions

Difculty breathing

Cough

Weight loss

Fever

Oral ulcers

Persistent diarrhea

Night sweats

Difculty 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 patients 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 mouth4.5 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 infectionMalaria

Diarrhoeal illness

Cold/u

Oral candida

TB

Herpes zoster

PID

Cryptococcal meningitisSyphilis

Pneumonia (non-specic)

Gonorrhea

Pneumonia (PCP)

Chlamydia

Herpes simplex virus

Depression

AIDS stage

Other ________________________

No presumptive diagnosis made

Dont know

8. Treatment prescribed

8.1 Yes8.2 No

8.3 Dont 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 notication

11.1 Partner notication recommended

11.2 Partner notication 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 historyComponent (Did physician obtainthe following information?)

Check those observed Where not observed, provideexplanation where possible

When/how was DX of HIVrst establishedCurrent symptoms andconcerns of patientPast illnesses and treatment givenSymptoms of TB and/ or treatment for TBPast or present symptoms of STIPossibility of Pregnancy

ImmunizationsSocial habits & sexual history


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Demonstrated knowledge/skills CommentsART doctor conducts focused, thorough discussion withpatient of pertinent omissions or errorsDoctor emphasizes team approach (shares informationwith nurse, efcient interaction, lack of duplication ofeffort)

Doctor underscores need for adequate physical exam (inrelation to history and current complaint)Doctor comments on accuracy of assessment and diagnoses(including WHO staging) of patientART adherence, tolerance, side-effects addressedAppropriateness of recommended drug treatment (ART& OI)Appropriate involvement of patient in development of afocused management planAppropriateness of recommended labsPatient education on sexual and other risk behaviors(including secondary infection)Emotional/social support needs/possibilities discussedDevelops appropriate follow-up scheduleIntroduced self and objective appropriately(name, where from, credentials, what this is all about )Negotiated interaction in the presence of the patientDoctor made the patient comfortable (no tension,preceptee not defensive)

Listens and observes patiently(avoids unnecessary interruptions)

Recommendations to improve this doctors skills to mentor independently

Examples of information shared that might improve this doctors skills to mentor independently



Clinical Mentor Scale for individual doctor 1 2 3 4 5Puts 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 condentiality measures were followed Universal precautions were taken



First VisitRecommendations basedon the initial assessment

Second Onsite mentorshipvisit-October 2007

Third visit - February 2008 Fourth Visit -April 2008

"1. Needs to be provided

with an examination tableand aprivate room for thoroughphysical examinationincluding examination

of abdomen andsensitive parts."

Both the doctors are

examining patients in 2separate rooms, therebyprivacy is ensured. Theexamination table willbe provided soon.

Now there are 3 doctors

and one senior doctor ishaving a separate roomand other 2 doctors areexamining patients inthe other room. Butthe privacy is takencare of. The exminationtable is available andbeing put to use.

"Same practice is being

followed. If there is onemore room for thirdmedical ofcer, privacyfor patients may beappropriate."

"2. Needs more medical

personnel to take thoroughhistory especially sensitiveand sexual histories counselling regardingsafe sex, familycounselling etc."

Medical ofcers need

to complement thecounselling done bycounsellors by providingsafe sex and familycounselling.This wasalso highlighted duringthe discussions

"Now there is one more

new Medical Ofcer. Thepresence of an additionaldoctor has really improvedthe time spent in casemanagement. All threedoctors also participated inthe 'basics of counselling'training.All the doctors areobserved providing safesex counselling and

family counselling forappropriate cases."

Same practice is

being followed.

Note: Counsellors providesafe sex counselling

Sample Mentorship Report



"3. Doctor needs trainingon second line drugsand ongoing updates inmanaging HIV patientswith CNS manifestations.( Training on the topic

is given during theafternoon hours)"

"It was noticed that theMedical ofcers' knowledgeand skills in managingpatients with rst linetreatment failure hasincreased. They were ableto prescribe appropriatesecond line drugs, identifytoxicities correctly and alsomaintain appropriate caserecords for second linepatients.There were lot ofdiscussions related to CNSopportunistic infectionsduring the mentorship B1"

"It was observed thatduring the intervalbetween second and thirdvisits, the senior ARTmedical ofcer (SMO)was able to identifytreatment failure casesand also made correctinterpretations using thechecklists and Stanfordwebsite on genotypicresistance testing analysis.C3The second doctor wasalso found to identifytreatment failure casesbut her involvement in theinterpretation on secondline options, was notobserved by the mentor.

Discussions on CNSopportunistic infectionshappened during thementorship and it wasobserved that the CNSOI cases were managedappropriately. (One caseof Toxoplasmosis waspresented to the mentorat the time of mentorshipwhich demonstrated

their skills in correctdiagnosis and managementof the case)+C1"

"The knowledge and skillof senior ART MedicalOfcer (SMO) on managingtreatment failure cases andproviding second line drugshas improved. If furthertraining on second linedrugs is given to him, hewill become an asset tothe ART centre.The other two doctorsneed to learn from seniormedical ofcer abouttreatment failure andinitiation of second linepatients.OIs involving CNS werediscussed and the doctorsknowledge seem to have

improved compared tothe last visit.D8"

4. The two medical ofcersare examining around200 patients a day. TheSMO is also involved inadministrative help toother staff of ART centreand coordination withhospital departments and

management. Both ofthem are taking care of 21inpatients also. If supportis provided in this regard,his skills in ART care andsupport will improve.

The Nurse caseman+B3ager (supportiverole) was involved inactive patient care alongwith the Medical Ofcers.It was noticed that theNurse case manager,under the supervision of

ART Medical Ofcer wasable to manage this taskreasonably well. Becauseof her involvement thedoctors were able to spendmore time with difcultcases. The supervision shallcontinue until the Nurseis adequately trained.

"There was a third MedicalOfcer now and this hasimproved not only thepatient care but alsothe counselling aspect.The third Medical ofcerthough not attendedNACO training, was able

to manage cases throughsupport from other 2Medical Ofcers.The nurse casemanager still assistin providing care. "

The three Medical Ofcerswork in unison so that thecare and support activitiesare appropriate. It wasobserved that one doctoris taking care of inpatientsand other 2 doctors aretaking care of OP patients.

All the 3 doctors discussthe problem cases amongthemselves and arrive ata consensus of opinionregarding the management.

5. Both the doctorscan communicate with

mentors and other expertsin the eld to improvetheir knowledge.

Both the doctors usedto communicate with

mentor regularly

Both the doctors usedto communicate with

mentor regularly

All the 3 doctorscommunicate with the

mentor regularly.



6. Frequent references toNACO guidelines, keepthe guidelines handy

"The NACO guidelines wereseen on the doctors' tableand it was referred towhenever necessaryThe WHO clinical stagingposters ( adults andchildren) and the ARTdosage charts for adultsand children were providedfor their reference duringthis mentorship"

Now the doctors wereable to manage casesappropriately withoutlooking into the guidelineswhich showed theirunderstanding of theguideline components.

Doctors were ableto manage the casesappropriately. They werereferring to the guidelineswhenever necessary. .During the mentorship theywere observed looking atthe growth chart in thePaediatric guidelines formanaging a child withgrowth retardation.

7. I-TECH handbookreference

"The I-TECH Handbookseen on the doctors' tableand it was referred towhenever necessary.The doctors were using asmall handbook on ARTand other drug interactions

also . If they are providedwith the small pocketbookon all drug interactionsrelated to HIV , it will bevery useful.Several other materials,study articles of relevanceare given to the doctorsby mail and hard copiesduring the visit e.g.. ARTdrug interactions, drug

dosing in various medicalconditions, second linepaediatric dosage etc."

They are referringfor appropriate casemanagement whenevernecessary (during thementorship, the doctorswere observed referring acase of chronic myeloid

leukemia and anothercase of lymphoma to theappropriate higher centresfor further treatment)

Frequent referenceswere made

8. Need based callsand mails to I-TECH

During the period betweenrst and second onsitementorship, TA wasprovided in managing 5difcult cases and brieffollow-up calls were made

During the period betweensecond and third onsitementorship, TA wasprovided in managing6 difcult cases andfollow-up calls and emaildiscussions were made

During the period betweenthird and fourth onsitementorship, TA wasprovided in managing3 difcult cases andfollow-up calls and emaildiscussions were made

Clinical Mentorship in Public Health Settings

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